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HI 







THE 
COMMONHEALTH 



VOLUME 14 ^V JAN.-FEB.-MAR. 

NO. 1 - ■dMim 1927 




Maternal and Child Hygiene 



4 



\f^ MASSACHUSETTS 

DEPARTMENT OF PUBLIC HEALTH 

GEORGE H. BIGELOW, M.D., COMMISSIONER 



THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of Public Health. 
Sent Free to any Citizen of the State. 

Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 



PAGE 

Maternal Mortality, by Robert L. DeNormandie, M.D 1 

Nutrition of the Mother and Baby, by Lou Lombard, S.B 1 

Essentials of Physical Examination of the Pre-schoo! Child, Two to Six Years 

Old, by Fritz B. Talbot, M.D 3 

Certain Aspects of the Psychology of the Pre-school Child, by Rose S. 

Hardwick, Ph.D 5 

May Day and the Summer Round-Up, by Merrill Champion, M.D. . . 7 

The Common Communicable Diseases — Protection for the Infant and Pre- 
school Child, by Clarence L. Scamman, M.D 9 

The Importance of First Teeth, by Eleanor B. Gallinger, S.B.. ... 10 

Sunlight for Babies 12 

The Maternal and Child Hygiene Activities of the Massachusetts Depart- 
ment of Public Health, by Susan M. Coffin, M.D 15 

Report of First Six Months of a Breast Feeding Demonstration, by Lela M. 

Cheney, R.N 18 

Activities of the Massachusetts Department of Public Health . . . . 21 

Barnstable County Health Department, by A. P. Goff, M.D 26 

Editorial Comment: 

Current Health Legislation 28 

The Summer Round-Up 29 

Barnstable County Health Department 29 

The State Cancer Program 30 

Testimonial Exercises to Dr. Charles V. Chapin 30 

Health Bulletin Service 31 

Summer Course at Eyannis 31 

Report of Division of Food, and Drugs, October, November, and December, 

1926 .,.'.*.' 32 



1 

MATERNAL MORTALITY 



By Robert L. DeNormandie, M.D., Boston, Mass. 

A SERIES of studies by the Massachusetts Department of Public Health on 
984 maternal deaths has brought out some most interesting facts. Chief 
among them is the number of deaths that occur in Massachusetts from puer- 
peral septicemia and puerperal albuminuria and convulsions. There are£ other 
points that are well worth studying in these investigations, but these two causes of 
death, which are recognized as to a great extent preventable, make us ask the 
question, "Is the medical profession, doing its complete duty to the community?" 
It is fair to say that practically all sepsis arises from infection from without. The 
technique of delivery is in some way at fault. The deaths from puerperal albu- 
minuria are due in a great measure to a lack of proper co-operation between the 
patient and the physician. For the first cause the physician is largely responsible, 
but for the second the physician and the patient are equally responsible. 

If the physician is largely responsible for the first cause, wherein lies the trouble? 
Is the physician properly taught, or does he fail to carry out what he has been 
taught? The latter, I think, is the real cause. He has been taught thoroughly 
the principles of asepsis. Yet he continues to have these deaths from sepsis which 
must be regarded as preventable. 

The teaching in operative obstetrics unquestionably is far from satisfactory in 
the medical schools, and until this can be materially improved we shall continue 
to have deaths from this cause. The teaching of the delivery of normal cases is 
thorough, satisfactory, and accurate, but it is because physicians do not live up to 
what they are taught that this high preventable death rate, which in Massachusetts 
amounts to nearly a quarter of the deaths, continues. 

The second cause of which I have spoken can be materially reduced with intelli- 
gent co-operation and medical supervision. Here again physicians have been taught 
the danger signals of toxemia of pregnancy, yet they fail to treat these cases effi- 
ciently from the beginning of the toxemia, and when an eclampsia occurs they rush 
to some operative procedure which gives them a high mortality. 

Here are two causes of maternal mortality which account for at least 50% of 
our deaths in obstetrics — two preventable causes. Is there any more fertile 
field in which physicians can help? 

NUTRITION OF THE MOTHER AND BABY 



By Lou Lombard, S.B., Consultant in Nutrition, 
Massachusetts Department of Public Health 



THE mother stands between her baby and nutritional disaster. During preg- 
nancy and the nursing period the material to build the baby comes from either 
the mother's food or from the stores she has accumulated in her own body. 
The foods needed during these periods differ from those of any other time. The 
mother's food must not only maintain and repair her body, furnish energy for her 
work, but it must also provide for the growth of the baby and maintain his body 
temperature, muscular activities and body weight. The baby's first need, however, 
during the period of pregnancy is material for growth; that is, protein, minerals, 
and the vitamins. In case these are not supplied in sufficient amounts to meet the 
needs of both mother and baby, the mother's body suffers first. Since the teeth 
are most readily affected they usually show first the disastrous results of an inade- 
quate diet at such a time. 

To protect the mother from such results the right kind of food is necessary. 

The right foods are milk, eggs, green leafy vegetables, and fruit. They, because 

of their vitamin and mineral content, safeguard both the mother and baby. The 

quantities of these foods needed to furnish the necessary protection during the 

period of pregnancy are stated as follows, in one of the Children's Bureau leaflets: — 

1 quart of rnflk 1 citrous fruit or tomato 

1 raw vegetable salad 1 cooked green leafy vegetable 

1 egg 1 serving of whole grain cereal or bread 



These foods will furnish approximately the first 1,000 calories of the diet and to 
these can be added such other food to make up the necessary amount to meet the 
demands for energy. This amount will, as at any other time, depend upon the 
age, weight for height, and activity of the individual. The following menus for 
a day are suggestive of the amounts of food needed to meet the requirements of the 
average pregnant woman. 



Breakfast Mid-Morning 


Lunch 




Orange 1 1 glass of milk 


Baked macaroni and cheese 


Kcup 


Rolled oats % cup 


Lettuce and French dressing 




with top milk 


Bran muffins and butter 


2 


Graham toast 2 slices 


Apple sauce 


Hcup 


Butter 1 tbsp. 


Ginger cookies 


2 


Cocoa 1 cup 


Milk 


1 glass 


(made with whole milk) 






Dinner 






Lamb chop 


1 




Creamed potato 


Yl cup 




Buttered spinach 


X A cup 




Graham bread and butter 2 slices 




Baked custard 


3^ cup 





The general rule of eating moderately of simple, well-cooked easily digested 
foods holds true during this period as at any other time. Foods known to disagree, 
and fried foods should be avoided. Sometimes four or five small meals during 
the day are found to agree better than three full meals. If so, a glass of milk could 
be taken in the middle of the morning and the middle of the afternoon. 

It has been the experience of obstetricians that excessive gain in weight is unde- 
sirable during the period of pregnancy from the standpoint of ease of delivery. 
Consequently the weight of the patient has been added to the prenatal observations. 

The average woman of normal weight should not gain more than 20 pounds 
during the period of pregnancy and the overweight woman would be better for 
gaining much less. Therefore, over-eating must be guarded against carefully. 
The overweight woman should be sparing in her use of potato, bread, cereal, sugar, 
sweets of all sorts, cream and butter. A feeling of satisfaction can be produced 
without adding materially to the caloric value of the diet if plenty of fruit and 
leafy vegetables such as spinach, cabbage, lettuce, endive, celery, and beet greens 
are used. These furnish bulk and are of low caloric value. A suggestive meal 
plan for the overweight pregnant woman follows: 



Breakfast 
Orange 1 

Graham bread, 1 slice 
Butter 1 tsp. 

Cocoa 1 cup 

(Made with whole milk) 



Mid-Morning 
1 glass of milk 



Lunch 
Large serving cabbage salad, 

French dressing 
Bran muffin 1 

Butter 1 

Milk 1 



Dinner 
Lamb chop 
Graham bread 
Butter 
Spinach 
Baked custard 



tsp. 
glass 



1 

1 slice 

1 tsp. 

1 large serving 

Mcup 



It is frequently necessary for the doctor to eliminate meat entirely from the 
diet during pregnancy, and in such case eggs may be substituted. 

After the birth of the baby the mother's chief need is, as far as the nutrition of 
the child is concerned, to maintain an adequate supply of breast milk. Her ability 
to do this depends a great deal upon her physical and mental well-being, as well as 
her determination to nurse the baby. Proper habits of eating and living will do 
much to maintain a good state of physical and mental health. Rest is most 
necessary, and the life of the mother should be so ordered that she is protected as 
much as possible from fatigue and strain. 



3 

Recent experimental work in feeding human milk to rats at the University of 
Wisconsin showed that the milk from a woman who^had been exposeed to the rays 
of a mercury quartz lamp, developed certain antirachitic properties which the 
milk from the same woman before exposure did not have. This suggests the 
desirability and advisability of the nursing mother, because of the effect upon her 
milk, getting out into the sunshine every day if it is possible. As during the period 
of pregnancy, simple, well-cooked, easily digested foods are desirable during the 
nursing period. Exactly the same type of foods, i.e., those which provide ample 
mineral and vitamin and the right kind of protein should be included. A quart 
of milk, leafy vegetables, raw fruit and egg, whole grain cereal or bread must be 
included. Larger quantities of food, however, may be needed to meet the addi- 
tional demand upon the mother. If the mother is active, perhaps doing housework, 
she may need half again as much food during lactation as she did before or during 
pregnancy. 

Even the breast-fed baby will require foods other than milk early in his life if he 
is to have the best development. Cod Liver Oil is considered desirable and is 
often given as early as one month. Usually the beginning dose is one-half tea- 
spoonful twice a day. This can be gradually increased up to one and one-half 
teaspoonfuls twice a day. It is well to keep up the Cod Liver Oil through the 
second year. If the baby gets out in the sun every day the oil is not absolutely 
necessary. Orange juice also is given as early as one month. It furnishes one of 
the necessary vitamins for growth. One tablespoonful of juice in an equal quantity 
of water should be given daily at first. This amount should be increased rapidly to 
two tablespoonfuls. If orange juice can not be had tomato juice, either fresh or 
canned, may be used. The oil and fruit juice are usually given one-half hour before 
nursing. Cod Liver Oil and orange juice cause a more complete utilization of the 
breast milk and the baby's bones and teeth grow in the best possible way. 

At six months of age strained cooked cereals can be given. Dry bread crust or 
unsweetened zweiback also are given for the baby to chew on as these help to 
bring the teeth through the gums. At the same time vegetables in the form of 
vegetable soup should be added. The mild flavored vegetables such as carrots, 
spinach, peas, etc., are best. By the time the baby is weaned, around the ninth 
or tenth month, he should be having in addition to his milk, cereal, fruit juices, 
vegetables, and crisp dry toast. 

Nutrition is a big problem of pregnancy and lactation. The choice of food during 
these periods should be directed by the brain rather than by the taste, if adequate 
amounts of the necessary growth factors — protein, minerals, and vitamins, are 
to be supplied. 



ESSENTIALS OF PHYSICAL EXAMINATION OF THE PRESCHOOL 
CHILD TWO TO SIX YEARS OLD 



By Fritz B. Talbot, M.D., Boston 



THE importance of the physical examination of the pre-school child can not be 
over-emphasized, since it will detect at this time preventable physical handi- 
caps which if allowed to progress may later develop into serious diseases; 
will demonstrate disease conditions already present, and will give a record of the 
physical condition of the child which will be of value in later life. A single exami- 
nation is very valuable, but repeated examinations give more important data which 
can only be collected in this way. A record should be made of those facts in his 
history which might influence his future development and health. 

The physical fitness should first be estimated by visual inspection of the nude 
body — many defects are covered by clothes. The child should look healthy and 
full of life, the cheeks should have a clear pink color and the skin should be fine and 
soft without eruptions. The body should be well covered with subcutaneous fat, 
and the child should have the air of elasticity and vitality characteristic of the age. 
Measurements of the height and weight should be taken to give a check of the 
clinical estimation of physical development but such measurements can never give 
the sort of data obvious to the eye of the trained observer. Since they are so easy 



4 
to make too much emphasis has been given to them and the possible errors of 
interpretation neglected. They should never be used as the final criterion of 
physical fitness. Of more importance are. the subsequent records of height and 
weight which give an accurate record of the skeletal and physical growth. 

Body Mechanics. The physical efficiency of the individual depends in large 
part on good body mechanics or posture. When it is incorrect muscles and tendons 
undergo strain and a load is carried by the individual which causes fatigue and 
handicaps Ms health and efficiency, thus making him more susceptible to disease. 
The feet should be examined for pronation and fallen arches. These should be 
corrected whenever found. Curvature of the spine will be shown by an examina- 
tion of the back. When the abdomen protrudes and hangs down like a bag, the 
chest becomes flat and the airspace within it is diminished. If the upper spine is 
bent forward the scapulae protrude behind like wings, and the general appearance 
of fatigue and old age is obvious. Improper body mechanics is the background 
and foundation of many diseases. 

Teeth. The teeth should be examined for caries, a source of infection to the 
body and to the teeth themselves. Caries should be corrected even in the first 
teeth in order to prevent infection of the permanent teeth. When the teeth do 
not approximate normally food cannot be chewed properly and as a result may not 
be thoroughly digested. Teeth that are crowded together because of narrowing of 
the jaw are cleaned with great difficulty and are easily infected. 

Tonsils and Adenoids. Enlargement of the adenoids are rarely recognized by 
visual inspection and most physicians do not consider it necessary to make a 
digital examination. It is not always a safe procedure except with strict aseptic 
precautions. The criteria upon which the diagnosis of enlargement of the adenoids 
is based are the symptoms they cause, such as mouth breathing, ansemia, and ear 
trouble. 

Enlarged tonsils can be easily seen. If these tonsils are not causing any symp- 
toms they need not of necessity be removed. Here also the trouble they cause is 
of more importance than the way they look. The most important symptoms, are 
difficulty in swallowing, frequent colds, enlargement of the glands at angle of jaw, 
and other general indications of local infection. Symptoms often appear even when 
the tonsils look small. In such cases the pillars of the fauces are adherent to the 
tonsil, prevent free drainage, and cause greater absorption. Such tonsils often do 
more harm than those which look much larger. 

Peripheral Glands. The glands at the back of the neck are usually not of 
great importance. They drain the scalp and if enlarged are usually due to infec- 
tion, or irritation of the skin. Sometimes there is a slight general enlargement of 
the glands of the body which is associated with malnutrition. The glands back of the 
sternocleidomastoid muscle drain the ear and posterior pharynx; glands below or in 
front of it drain the tonsils ; glands in front of these drain the mouth. Enlargement of 
the glands in the axilla and groins, when only on one side, usually mean infection 
in some part of the extremities. Bilateral enlargement, on the other hand, may 
mean a systemic blood disease, such as leukaemia. 

In the pre-school age enlargement of the epitrochlear glands have very little 
special significance. Enlargement of the glands of the chest are suggested by the 
D'Espine sign, which can be recognized with the stethoscope but can only be 
definitely proven by X-ray. The glands in the abdomen can sometimes be recog- 
nized by X-ray but usually not until they are calcified. X-ray examination is only 
indicated in rare cases, and does not form a part of the usual routine examination. 

Chest. The heart size may be determined by percussion. In children of this 
age the left border of the heart is just outside of the left nipple line, and the right 
border is about two and one-half centimeters to the right of the midsternum. The 
action should be regular, and the pulse rate somewhere between 80 and 90. Mur- 
murs should be recorded but most of the murmurs in this age are functional and 
are not organic. 

Lungs. Percussion of the thymus is unreliable. Routine X-ray of the thymus 
has been adopted by some hospitals before performing any surgical operation. 
Percussion of the lungs will show any area of solidification, while auscultation will 
show any change in the respiratory murmur and presence of rales. In the majority 
of instances, pathology is found mainly in children suffering with the acute diseases. 



5 

Malformation of the ribs and beading due to rickets is rare, except in the healing 
stage. Deformities of the chest are occasionally so severe that the lungs show signs 
of compression. 

Abdomen. Umbilical and inquinal hernia should always be examined for — 
the latter is often overlooked. Masses in any part of the abdomen may be due to 
tubercular glands, and are most frequently found in the right lower quadrant. 

An infected appendix is unusual and difficult to diagnose at this age. Whenever 
there is suspicion of appendicitis, a rectal examination should be made. Other 
masses should be felt for and recorded. 

The edge of the liver when enlarged is felt and the distance it lies below the edge 
of the ribs recorded in order that future examinations may tell whether the size of 
the liver is increasing or diminishing. The same is true of the spleen. 

Genitalia. The genitalia should be examined for defects or congenital abnor- 
malities, discharge, or irritation. An adherent prepuce may result in discomfort 
and thus handicap the health of the child. 

Hair. The hair should be examined for nits. A very coarse, sparse hair should 
lead to the suspicion of hyperthyroidism. 

Skin. The skin should show no rash; it should not be coarse and dry, nor should 
it be too moist. 

Endocrine Abnormalities. The early recognition of endocrine abnormalities 
is of great importance, especially since methods of treatment are becoming more and 
more successful in the different tj'pes. Coarse, sparse hair is suggestive of cretin- 
ism. Overgrowth of hair on other parts of the body is said to have some relation- 
ship to the pituitary gland. 

A dry skin is evidence of hyperthyroidism. Over-development of the breasts 
in the male is evidence of underaction of the anterior part of the pituitary gland. 
Great growth suggests overaction of this gland. 

Under-development of the genitalia may be found in cretinism, Frohlich's 
Syndrome, and Mongolianism. Enlargement of the thyroid is rare in childhood 
and is usually temporary. In rare instances, it is evidence of Grave's disease. 

Obesity may be due to overeating, or hypothyroidism, or Frohlich's Syndrome. 

The body proportions are of importance when abnormal. Short arms and legs 
are found in hypothyroidism, great growth in over-activity of the anterior-pituitary, 
and very long arms and legs in underaction of the gonads. 



CERTAIN ASPECTS OF THE PSYCHOLOGY OF THE PRE-SCHOOL 

CHILD 



By Rose S. Hardwick, Ph.D., Head Psychologist of Habit Clinics, 
Division op Mental Hygiene, Massachusetts Department of 
Mental Diseases 



FROM the point of view of mental hygiene the special interest of the pre-school 
years, that is, from two to six, lies in the fact that during that period the foun- 
dations of an individual's social development should be laid. Since man is 
the pre-eminently social animal, this means, in no slight degree, laying the founda- 
tions of personality. 

The child of two years has acquired two powerful instruments of investigation, 
namely, locomotion and language, and with these he starts out to explore and 
exploit and to feel his way to an adjustment with his environment, both physical 
and social. Later on, when he enters school, comes the period of mass activities, 
in which the individual is merged in the group. Still later the gang appears, the 
smaller groups, formed by conscious selection. The boy and the girl have their 
chums, their "special friends". Adolescence brings the highly organized and 
differentiated group activities which we know as "team" work and play._ By the 
time the individual reaches maturity he has served a varied apprenticeship to life, 
and if all goes well he should not be unready to meet serious responsibilities. 

But all these later phases presuppose the initiation of the pre-school years. At 
two years he already recognizes other people as important elements in his universe, 
as often making or marring his satisfaction. By the time he enters school he should 



6 

have learned the technique of the simpler social situations, so that he moves with 
confidence and dignity in his own little world. 

The importance of this social technique will bear emphasis. Many a bit of 
childish naughtiness is traceable to ignorance of technique. A child may "take 
things" because he does not understand when and how to ask for them. He may 
bungle a message because he does not know the correct formula. He may he and 
sulk because he does not know how to own up and apologize. By the time he is 
six years old he should have learned all these things and many others. He should 
have mastered the technique of borrowing and lending, as well as of giving and 
receiving, the courtesies of ordinary conversation, and the essentials of table 
etiquette. He should understand how to lead and how to follow. He should 
recognize the lawful authorities to whom prompt obedience is due, and should have 
learned to discriminate between a request that may be refused, a suggestion that 
may be discussed, and a command that must be obeyed. He should know when 
and how to ask for explanations. He should have begun at least to distinguish 
fact from fancy and to recognize that each has its appropriate place. At the same 
time, he should learn to think of truth telling as a fine art, an achievement, an 
accomplishment. That is what it really is, and we take all the fun out of it and 
needlessly discourage the child when we treat it as an easy thing, to be mastered at 
the first attempt. 

Needless to say, all these things must be taught gradually, here a little explana- 
tion, there a bit of an object lesson, and here a moment's careful rehearsal. Many 
negligences and ignorances must be overlooked, especially at first. But if the 
adults concerned are at all tactful, the child will respond with genuine interest and 
effort. For these things belong to the dramatic aspect of life, and the little child 
loves drama and ceremony. Also, he craves a place in the social picture, and he 
quickly recognizes that these things give him a place that is his, not by tolerance, 
but by right. 

During these pre-school years, then, let him enter into as many and as varied 
social relations as possible, having due regard for his childish hmitations. Let 
him "help", that he may learn the technique of helping as well as the joy of it. 
Let him take Ms part, but no more than his part, in the family pleasures and 
responsibilities. He is far too young to be given a daily task which he is to "re- 
member" to do regularly. He has as yet no facilities for such remembering. But 
he has a good deal of aesthetic and dramatic sense, and long before he is six he will 
put away hat and coat, fold his napkin and put his chair in place, not at all because 
he "remembers" to do these things, but because he senses the situation and feels 
the fitness of doing just these things at the moment. As for dressing and undress- 
ing himself, combing his hair and the like, a normal child delights in the feeling of 
independence and actually prefers to struggle with the "hard button" rather than 
let anyone help him. 

It is true that habit and conditioned reactions play an important part in the 
establishment of socially satisfactory types of behavior. But that the aesthetic 
feeling is also important and may often be the determining factor any good observer 
may easily see himself. 

In giving psychological examinations, for example, one is often tempted to speed 
up the process by merely shoving aside the material for each test to make room for 
the next, instead of taking the extra minute or two required to put each away in 
orderly fashion. It is generally a false economy for two reasons. First, anything 
like disorder tends to distract the child's attention, and second, if the natural 
rhythm of attention is to be utilized there must be, not only the arousal of interest 
by the presentation of new material, and the mounting excitement that accompanies 
the child's reaction to it, but also a chance for this emotional wave to subside. 
That is provided in a natural way if a moment is taken to put all in order. The 
best effect is obtained when the child does this himself, or helps someone to do it, 
but, if that is impossible, he likes to watch the process. One can often detect the 
relaxing tension and sometimes a long breath which is almost a sigh of satisfaction, 
as the cycle is completed, and the child turns spontaneously to the next thing. 
When due regard is paid to this sort of rhythm a little child will co-operate with 
relish and without fatigue for a much longer time than is generally supposed. 



7 

Parallel with this social development, and closely related to it, goes the growth in 
motor skills. Here again it is the smaller units of technique which are being 
acquired. The child is much too immature to endure prolonged and systematic 
drill or to do anything very ambitious in the way of carrying out projects, but he 
loves to manipulate and to experiment. He learns by trial and error to balance his 
blocks in different positions and different combinations. After many failures he 
learns to keep his own little fist out of the way when packing the blocks into their 
box again. 

Taken out for a walk, he worries his escort by all sorts of fanciful modes of pro- 
gression, stepping on alternate bricks only, or splashing through every mud puddle. 
Table manners suffer because he needs must find out, by actual experiment, just 
how far he can tip his mug without spilling, and, since childish hands are unsteady, 
he generally spills a bit before he is satisfied. A sharp reproof only makes matters 
worse for then he jumps and spills a great deal. Of course he must not be allowed 
to form uncouth habits, but mother should understand when his motives are 
innocent, her reproofs should be quiet and good tempered, and she should see to 
it that the child has ample opportunity to satisfy his scientific curiosity when time 
and place are suitable, by experimenting to his heart's content with water, and 
sand, and spoons, and cups, and all the other crude tools and materials that children 
love. 

Turning to the field of language we find a similar process going forward, a steady 
gain in control of the smaller units of verbal expression. It is not only that the 
child is learning new words every day, but what is far more important, he is learn- 
ing the significance of different kinds of words. As his own thoughts become more 
clearly defined and differentiated, he begins to take an interest in verbal expres- 
sions of relation, prepositions, adverbs and the like, and thus the way is paved for 
control of the longer sentences and the more involved constructions which he will 
require later. 

The control of the vocal organs is likewise improving. Articulation ceasesto 
be of the infantile type. The child plays with his voice, experimenting with high 
notes and low, loud and soft, as well as with many nameless vocalizations. There 
is much to be said in favor of letting him get a smattering of one or two foreign 
languages at this time, if it can be done without diverting too much energy and 
attention from the mother tongue. The child who chatters French with his nurse 
today may have forgotten every word of that language five years hence, but he will 
retain a better control of his vocal organs, and a greater confidence in the use of 
them which will stand him in good stead if he ever takes up a foreign language 
seriously, and which, in any case, should enable him to speak his mother tongue 
more pleasingly. 

What is it that we really desire for these youngsters between the cradle and the 
schoolroom? Surely there can be no serious doubt. On the one hand, we wish 
them to enjoy to the full their swiftly passing childhood, and, on the other hand, 
we wish them to lay the foundations for personalities that will be adequate to the 
demands of adult life. Too often we have hastily assumed that these ideals were 
incompatible. With a better understanding of the situation may we not hope to 
arrive at a higher synthesis, and so to guide the little ones that they may have the 
satisfaction of expressing the childish self of the moment and, at the same time, 
build for the larger self of the years to come? 



MAY DAY AND THE SUMMER ROUND-UP 



By Merrill Champion, M.D., Director, Division of Hygiene 
Massachusetts Department op Public Health 



THE Summer Round-Up is an "intriguing" term applied to a very important 
movement in child hygiene. Child hygiene, as we all know, is largely a 
matter of education, and educational things to many people have an element 
of vagueness. There is nothing vague about the Summer Round-Up. It repre- 
sents the principles of education applied in the most concrete manner to the pro- 
motion of good health in the child. Here is what it is all about. 



For many years some people have realized to a greater or lesser extent the 
importance of a periodic looking-over for young children. It began first, perhaps, 
with the baby who had to have his feeding supervised. The habit of going to the 
physician once established, was likely to carry over in the case of certain far-sighted 
people to the pre-school child. For twenty-one years in Massachusetts we have 
had legal provision for the periodic examination of school children. 

In spite of all this, however, most people have never had their children of pre- 
school age looked over by a physician excepting at times of illness. The child has 
gone to school accompanied by his physical defects the correction of which has 
been left until after the school physician had detected them and urged their impor- 
tance upon the family. This method is obviously a wasteful one for two reasons. 
In the first place it delays until the age of six or later, the correction of physical 
defects which may leave their mark upon the child for fife, and secondly, this 
method sends children into school poorly prepared to take advantage of the educa- 
tional opportunities which the community is offering them at great cost. The 
Summer Round-Up proposes to change all this. 

The Summer Round-Up as a definite entity first appeared two years ago. The 
term was a clever idea of the National Congress of Parents and Teachers. It 
simply means a movement which would bring to a physical examination in the 
spring all of the children about to enter school in the fall. Physical defects would 
be discovered which would be corrected during the summer before the school time 
came around. 

This idea of the Summer Round-Up met with instant favor amongst public 
health workers and had the backing of the Federal Bureau of Education. An 
attempt was made to fink up the idea of the Summer Round-Up with the equally 
appealing one started by the American Child Health Association of May Day as 
Child Health Day. On Child Health Day the community is made to realize the 
importance of health to the child and methods by which he may obtain health. 
The interest thus aroused finds a concrete outlet in the work of the Summer Round- 
Up. The work of the Summer Round-Up in turn leads to an interest in all phases 
of child health the year round. 

This year an unusually strong effort will be made in Massachusetts to capitalize 
all this interest in child health. May Day will be celebrated as Child Health Day 
we hope, in every city and town in the State. An organization has been perfected 
whereby each community will have a Child Health Committee pledged to further 
the plans for the celebration of May Day as Child Health Day, and pledged to 
make real the Summer Round-Up. 

It is hoped that schools will give special recognition to health work on May 2nd 
since May 1st falls on Sunday. Setting aside this day will offer the schools an 
opportunity to take an inventory of the year's work and to have some kind of a 
celebration in the school as a climax to the health educational program. We are 
suggesting that every school, regardless of its size, choose a May King and Queen. 
Three boys and girls should be picked by the school doctor, school nurse and 
superintendent of schools and their names voted on by the children. The Depart- 
ment is distributing a simple health play that can be used at this time featuring 
the girl and boy who have been chosen as having the best health habits. If the 
school is too small to produce a play a general exhibit of posters on health work 
that has been done throughout the year is recommended. Larger schools may 
put on more elaborate outdoor May Day festivals, including the good old-time 
May Pole dancing and games. Suggestions have been prepared to help the super- 
intendent of schools and the local chairman in arranging for the type of May Day 
program that is most suitable for each community. 

May Day gives the communitj?- as well as the schools a splendid opportunity to 
focus attention on the health of the school child. In this waj r we hope that it will 
be a climax for the health work done throughout the year for the school child as 
well as the starting point for the Summer Round-Up of the pre-school children. 

May Day coming on Sunda3^ this year, we hope the ministers will preach it 
from their pulpits. The radio will carry the message of May Day as Child Health 
Day to the remotest farmhouse which has a radio set. Parent-Teacher Associa- 
tions affiliated with the Massachusetts Parent-Teacher Association, and through 
that association with the national organization, will compete with each other for 



9 
the honor of the best Summer Round-Up and a prize which is offered by the Na- 
tional Congress of Parents and Teachers. Other Communities will put on the 
Summer Round-Up anyway. 

A prize is needed to make a^ human being do anything. The prize may be 
money or it may be something far less intangible. It may be the respect of our 
neighbors or it may be a sense of well-being which comes from doing a good job 
well. In the case of the Summer Round-Up there is a prize for everyone in the 
sense that every child examined and with defects corrected stands as the most 
hopeful tiling in the civilization of today. It exemplifies the old dictum of "a 
sound mind in a sound body" which, it is needless to say, will be the essential factor 
in the successful community of tomorrow. 



THE COMMON COMMUNICABLE DISEASES 
PROTECTION FOR THE INFANT AND PRE-SCHOOL CHILD 



By Clarence L. Scamman, M.D., Director, Division of Communicable Diseases 
Massachusetts Department of Public Health 



^HE so-called contagious diseases of childhood are familiar to all of us. What 
can we do to protect infants and children in the pre-school age from these 
diseases? 

Chicken-pox, mumps and german measles are with us always. There is no 
specific protective measure which can be used against them. Fortunately, under 
the age of adolescence, there is almost never a complication and seldom a fatality 
in a person sick with these diseases. 

Diphtheria. We have in toxin-antitoxin a safe and sure method of protection. 
The best time to have a child immunized is shortly after it is six months old. Everjr 
child should be so protected before it reaches its first birthday. The majority of 
cases and deaths from this disease occur in little children. Have your physician 
protect your child now. 

Scarlet Fever. The use of Dick toxin for the protection of children against 
this disease holds out great promise. Proper doses of toxin properly spaced will 
give a certain amount of immunity to scarlet fever. Because of the possibility of 
disappointing or embarrassing results, it seems unwise at this time to urge this 
method of protection popularly. The curative value of scarlet fever antitoxin 
is unquestioned. Unless the circumstance is exceptional, scarlet fever antitoxin 
should not be used as a prophylactic measure. 

Measles. In the age group which is being considered, measles is a serious 
disease. Our special endeavor then, should be to postpone the disease beyond the 
age of three or four if possible. Protection by means of convalescent measles 
serum has been used successfully to prevent or modify this disease. It is given 
during the seven days after the first exposure. If protection is complete, immunuy 
lasts about a month. In a single outbreak of measles this is usually time enough. 
In cases modified by the use of convalescent serum, the disease is mild and has no 
complications. Furthermore, these mild cases acquire a lasting immunity. A 
serious drawback to this method is the difficulty of getting serum. 

Recent work makes us hope that the organism causing measles has been discov- 
ered. If this is so, we may have a protective serum or vaccine for this disease 
which will give lifelong immunity. 

Smallpox. Though few people realize it, before the days of vaccination small- 
pox was as much a disease of childhood as is measles today. Vaccination against 
this disease was first done by Edward Jenner more than one hundred and thirty 
years ago. Its value as a protective measure against smallpox has been proved. 
The best time to vaccine a child is when he is two months old. The child lies 
quiet in his bed and cannot injure Ms arm in play. The arm will not be so sore at 
tMs age. The immumty of the child should be retested when he enters school. 
The best place to vaccinate is the skin on the left arm (in right handed persons) 
over the insertion of the deltoid muscles. The improved methods of vaccination 
leave scars so small and superficial that they are rarely unsightly. The "multiple 
pressure of prick" method, sometimes called the Kinyoun method, has been de- 



10 
scribed by Leake, White and others. There are several advantages to this method, 
among them its painlessness. 

Whooping Cough. This disease, among children at tender years, is decidedly 
serious. Unfortunately, we have no method of control which is efficacious in the 
prevention of this disease. We do have, however, a vaccine against this disease 
which has given more or less promising prophylactic results. With the newer 
interest aroused in the perfection of this vaccine as a protective agent, there is 
hope that children may be immunized against this disease. 

Common Colds. These are undoubtedly contagious and should be so con- 
sidered. There are those parents who never kiss their children on the mouth. 
Many people refrain from intimate contacts with children when suffering from 
colds. There is hope of controlling the spread of common colds, when parents and 
public realize that an infected person by means of his discharges may spread 
disease to an uninfected person. 

Although children have many individual upsets, the cheapest possible insurance 
against serious disease is to call a competent physician at once whenever your 
child is sick. Before you call the doctor and at the first indications of illness, put 
the child to bed, or at least isolate the child so that if he is found suffering from a 
contagious disease you may have saved your own as well as your neighbor's children 
from infection. 

Bear in mind finally that children under five } r ears should not be intentionally 
exposed to disease. More than fifty per cent of the deaths from diphtheria, 
measles and whooping cough take place in those children who are sick of these 
diseases before they reach their fifth birthday. 

THE IMPORTANCE OF FIRST TEETH 



By Eleanor B. Gallinger, S.B., D.H., Consultant in Dental Hygiene and 
Health Education, Massachusetts Department of Public Health 



NO discussion of Maternity and Infant Hygiene would be quite complete 
without one more plea for "those baby teeth". For years it has been a 
popular tradition to consider the first set of teeth of little importance. 
"They don't matter for they will all come out sooner or later" has been the cry. 
As in years past the dental profession has done little to stop this, each j r ear it has 
become more firmly implanted in the consciousness of the general public. Mothers 
have passed it on to their daughters, their relatives and to their neighbors until 
it has become so well established that it will take years of effort to break down the 
wall of prejudice. 

This is the situation that faces us — a disregard for first teeth, no matter how 
badly decayed or even abscessed. It is everywhere. Children with "intelligent 
parents", well able to take care of the matter financially, are being neglected as 
well as the poorer ones. 

The Massachusetts Department of Public Health has taken up the slogan 
"Look out for those baby teeth" and is passing it on to groups of nurses, doctors, 
health workers, students and parents. This message must be carried into each 
town by the public health workers before any real impression will be made. 

How to Interest Parents in First Teeth 

A real appreciation of the importance of first teeth depends on two things: 
the ability of the person to visualize the relation of the two sets of teeth in the jaws 
so that the arguments concerning spacing, straightness of second teeth, etc., will 
seem clear and reasonable; or the interest of this person in the condition of a certain 
child's teeth. 

In the first case, when talking to groups of mothers or lecturing to nurses and 
other field workers, we have found that the use of charts or slides to show the 
second dentition just below the first is one of the best ways of making the story 
clear and real. 

In the second case the opportunity is of a different kind. At well child confer- 
ences, at clinics or in the home, wherever the worker has the child near at hand, 
she can use the actual condition in the child's mouth as an illustration of the general 



11 

message she is trying to get across. Using a narrow arch that has been caused 
by thumb sucking or a decayed molar as a starting point, an earnest appeal for the 
babjr teeth can be made and it will be listened to with considerably more interest 
than if the worker was speaking from a platform. This second method gives one 
a chance to show the mother where the six year molar will arrive and to urge her 
to watch for it. 

Parents are very likely to take for granted that there is nothing wrong with the 
child's teeth because he does not complain of pain. Unfortunately there is no 
warning signal for trouble in the baby teeth. The nerve is small and it decays 
easily. This decay may progress to the point of an abscess with no one knowing of 
it unless someone has sufficient interest in that child to look into his mouth and 
watch out for such conditions. 

When the children get to school some "outsider" (school dentist, dental hygienist 
or school nurse) will discover neglected conditions and report them to the parents, 
but during the pre-school age parents are the ones who must take the initiative in 
most cases. 

Why are First Teeth Important? 

What are the simple, outstanding facts about first teeth? 

1. First of all, first teeth are important because they chew food. They are all 
the child has to chew with for the first six years of his life. This includes 
around 6,570 meals during the most important years of growth. If the 
baby teeth are decayed the child will swallow his food whole. What 
follows? Poor digestion, poor assimilation and poor growth; the child 
does not gain properly, has little energy and is more likely to catch minor 
infections. 

2. Proper chewing is necessary to develop the jaws. The phrase "develop the 
jaws" usually means very little to most mothers for they do not realize 
how very plastic the bony material of the jaw is at this period and how 
much the arches must be expanded to hold the permanent teeth. Chewing 
is exercise. It brings blood to the bones of the jaw and helps them to 
grow. 

3. Each baby tooth holds a space for the second tooth that is forming below it in 
the jaw. If a baby tooth is allowed to deca}^ and has to be extracted the 
bony process shrinks leaving the space considerably smaller than it was 
in the first place. This means crowded second teeth and crowded second 
teeth throw the whole masticating machine out of gear and therein lies 
the cause for a great deal of pyorrhea. 

4. If a baby tooth is lost the second tooth has no guide and it may come in 
crooked. A chart or diagram is best to illustrate this point. It will show 
the permanent tooth hying in a socket just under the roots of the baby 
teeth. It will be clear that as the second tooth pushes forward the roots 
of the first tooth are absorbed. These roots are the guide-posts for the 
permanent teeth. If they are gone the second tooth wanders, usually 
coming through the gum in a very aimless fashion, tipping one way or the 
other. 

5. Decayed baby teeth may become infected at the root and may be responsi- 
ble for a host of ills such as rheumatism, arthritis, heart trouble and so on. 

Methods of presentation may vary but these facts are fundamental and a great 
deal of talking in this direction is needed to offset the old traditional prejudices 
concerning first teeth and the ever present inertia on the part of the parents. 

Formation of the First Teeth 

Very few mothers realize that a baby is born with the enamel of his first set of 
teeth completely formed. Here again we find charts are very useful, showing how 
the teeth begin to form as early as the tliird month of pregnancy, for a good intro- 
duction for a general discussion of the type of prenatal diet that will insure good 
teeth. The substances to form the teeth, lime, phosphorus and vitamines must be 
supplied by the mother during this period. 



12 
The Care of the Mother's Teeth 

The care of the mother's teeth also has a direct bearing on this subject. She 
should go to the dentist for a general examination as early as the third month of 
pregnancy, if possible. She should follow this up by monthly visits so that he 
can give her advice as how to keep her gums and teeth in good condition during 
this period. A postnatal examination is also recommended, for at this time the 
dentist can do extensive fillings or necessary extractions which might not have 
been advisable during pregnancy. This will protect the mother and the next 
baby. 

Importance of Breast Feeding 

Breast feeding is a safeguard for good teeth for two reasons. Under normal 
conditions it provides the necessary building material for the teeth for the first 
few months at least. In the second place it aids in the development of the baby's 
jaws, face and throat muscles as the position of the baby's mouth when nursing 
is more conducive to a well-formed arch than when he is feeding from a bottle. 

Care of the First Teeth 

It might be well to note here that it is considered wisest not to use anything in 
the baby's mouth before the teeth are out. As soon as they do appear they should 
be brushed with a small soft toothbrush after meals. 

Bad Habits 

Thumb and finger sucking are very harmful habits as they are apt to deform the 
baby's jaws and face for life. To help overcome this habit we recommend an elbow 
cuff (made of cardboard covered with cloth and tied with tapes) that is tied around 
the child's elbow, thus keeping his hands away from his face. Use of a pacifier 
and breathing through the mouth also tend to deform the jaws. 

Proper Dental Treatment 

If it is possible, take the baby to a dentist interested in children's work at the 
age of three. He will examine the baby molars for tiny defects and will fill them 
as carefully as he would second teeth. This will prevent decay and is therefore 
very important. It has been discovered that 85% of all molars come through the 
gum with cracks or fissures in the surface. This is because the enamel was not 
formed perfectly when the tooth was developing. As a fissure is no larger than 
one bristle of a toothbrush it is obvious that brushing cannot keep it clean. Food 
immediately gets into the crack and decay starts. This is one of the most impor- 
tant messages we can give our mothers as it applies to first and second teeth and is 
one of the best ways of preventing decay that we now know. This early attention 
is, of course, only the first step. To insure against further trouble of all kinds the 
teeth should be examined every six months. 

Summary 

It is evident that there is a great need for spreading information in favor of first 
teeth. These simple facts must be made as vivid as possible to attract the interest 
of parents. When it is possible this information should be illustrated by conditions 
of the teeth of the child at hand. 

The subject of first teeth includes all the phases of preventive dentistry and good 
dental hygiene, the diet and care of the mother's teeth during the prenatal period, 
value of breast feeding, diet for the infant and the early treatment of pits and 
fissures in the first and second teeth as soon as they appear. 

SUNLIGHT FOR BABIES 

[Folder No. 5, Children's Bureau] 

Sunlight and Growth 

SUNLIGHT is a most important factor in the life of a growing child, especially 
a baby. Although this has been known in a general way for a long time, it 
has not been given sufficient attention until recent years, during which 
knowledge of the effect of sunlight on the growth of children has become more 
specific. 



13 
Normal growth of bone is dependent not only on the food that the child eats 
but also upon the direct sunlight that he receives, for the sunlight provides the 
body with the power to utilize the food. If a baby is constantly deprived of direct 
sunlight his bones will not develop normally, his muscles will be flabby, and his 
skin will be pale. He will probably have rickets. 

Rickets Caused by Lack of Sunlight 

Rickets is a disease of growth, affecting the whole body, but most strikingly the 
bones. In hot climates, where children are outdoors in the sun throughout the 
year, rickets is little known; in temperate climates, where children are indoors a 
large part of the year, rickets is prevalent. Since rickets is a disease resulting 
primarily from lack of sunlight it can be prevented or cured by sunlight. 

To ward off rickets preventive measures must be begun very early in an infant's 
life, for rickets makes its appearance in very young infants. These preventive 
measures are the giving of sun baths and the administering of cod-liver oil, the so- 
called "bottled sunshine." 

Window Glass Bars Ultra-Violet Rays 

When the sun's rays are analyzed by a physicist it is found that some of them 
produce light that when passed through a prism divides into the well-known 
spectrum of colors — red, orange, yellow, green, blue, and violet. Beyond each 
end of this visible spectrum are invisible rays, at one end the infrared rays that 
produce heat, and at the other end the beneficial ultra-violet rays that have a 
powerful effect on living matter — destroying bacteria and healing tuberculosis 
and rickets. 

When sunlight passes through window glass the visible rays and the heat rays 
pass through, but the ultra-violet rays do not. In the same, way heat rays may 
penetrate clothing but ultra-violet rays do not. 

Spring and Summer Sun Most Beneficial 

The ultra-violet light coming from sun to the earth varies in its intensity with 
the seasons. This variation probably depends on the distance the rays have 
traveled through the atmosphere to reach the earth. The greater the distance the 
rays travel the less intense is the ultra-violet light that reaches the earth. 

To reach the North Temperate Zone the rays must travel a much greater dis- 
tance in winter when the sun is in the south than in summer when it is in the north. 
When the sun's rays reach the earth at nearly a right angle to the earth's surface, 
in May, June, and July, the ultra-violet content of the sunlight is at its height, and 
when the rays are oblique, in the winter months, it is lowest. 

Sunlight Good for Baby 

It has long been a tradition that babies are delicate and must be carefully pro- 
tected from direct sunlight. When a baby was put outdoors he was bundled up in 
many clothes and wraps, and the hood of the baby carriage was pulled up to keep 
out every ray of sunlight. The carriage might be placed in the sun, but the ultra- 
violet rays could not penetrate the hood and the clothes to reach the baby. 
- It has also been believed that a baby's eyes are weak and sensitive to light. 
The sun does not cause inflammation, however, when the baby's eyes are closed or 
when his head is turned so that the eyes are not in the direct line of the rays. 

Traditions such as these, handed down from generation to generation, are founded 
more on hearsay than on fact. 

Direct Rays Essential 

The beneficial effect of sunlight is not obtained unless the rays reach the skin 
directly. The interposition of clothing or window glass keeps out the ultra-violet 
rays. It is only when the skin begins to be tanned that any benefit may be ex- 
pected. 

Sun baths in the direct sunlight are the simplest method of giving the baby enough 
ultra-violet light. An older child, who has learned to walk, naturally seeks the 
sunny part of the playground, but a baby is dependent on others to put him in the 
sun. 

Give Sun Baths Early 

In the North Temperate Zone it is usually possible for normal babies to begin to 
have outdoor sun baths by the middle of March or the first of April, provided that 



14 

the place selected for the sun bath is protected from the wind. 

Sun baths should be begun when the baby is about 3 or 4 weeks old. A baby- 
born in the spring or summer, therefore, can have outdoor sun baths earlier than 
a fall or winter baby. The exact date when sun baths may be begun varies with 
the latitude and the weather. 

Beginning the Sun Bath 

On the first sunny day in early spring the baby may be put in the direct sun- 
light with the hood of the carriage and the baby's cap pushed well back so that 
the sun will shine directly on his cheeks. He should be turned first on one side 
and then on the other so that both cheeks will be exposed to the sun and yet the 
eyes will be kept away from the direct rays. On this first day the baby's hands 
should be exposed to the direct sun for a few minutes. Care must be taken not 
to burn the skin. 

A slight reddening of the skin each day will gradually bring about pigmentation 
or tanning. Unless the baby is accustomed to the sunlight through exposure at 
an open window the first outdoor sun bath should be for 10 or 15 minutes only. 
Each day thereafter the exposure to the sun should be increased by 3 to 5 minutes. 

Every few days the amount of body surface exposed should be increased, at 
first slowly, but as the days grow warmer, more rapidly. 

Baby Should Have a Coat of Tan 

After the face and hands are used to the sun the arms may be bared, at first one 
at a time, later both together. They should be bared for only a few minutes at 
first, and the time increased daily. Soon the legs also may be bared, at first one 
at a time, and later both together. Gradually the baby gets used to the sun, and 
by the middle of May or the first of June sun baths may be given the whole body. 
When the face, arms, and legs are tanned the shirt should be taken off for a short 
time daily, and finally the band and diaper. The sun baths may be lengthened 
until the baby lies in the sun an hour in the morning and an hour in the afternoon. 
In July and August sun baths should be given before 11 a.m. and after 3 p.m. 
On very hot days the baby should not be given sun baths between these hours. 
If he is outdoors at that time his head should be protected. The face and hands 
should be well tanned by the middle of April, the arms and legs by the middle of 
May, and the whole body in June. A good tan is evidence that the ultra-violet 
rays are being effective. 

Winter Babies Need Sunlight 

In cold parts of the temperate zones extensive outdoor sun baths cannot be given 
between the middle of November and the middle of March. However, on bright 
winter days the baby can be put outdoors to get whatever sunlight there is. Many 
mothers think that in cold weather a baby may not be put outdoors, not realizing 
that in the sun the thermometer may register 40 or 50 degrees more than in the 
shade. If the baby is protected from wind the sun will keep him warm. 

Indoor Sun Baths at Open Window 

A sun bath can be given indoors at a window opened at top or bottom, the baby 
being placed in the patch of sunlight coming through the open space. It is thus 
possible to produce tanning. If the room is heated the baby need not be wrapped 
up warmly. It may not be possible to expose the whole body to the sun; but the 
face, hands, and legs can be exposed daily for increasing periods. The periods of 
exposure should be longer than the summer outdoor periods, and they should be 
between 10 a.m. and 1 p.m., when the rays are most intense. 

Winter and fall babies need long sun baths, as they are more \ike\y to develop 
severe rickets than those born in the spring and summer. If a baby is used to 
indoor sun baths he can be started on outdoor ones bj' the first of March, or even 
earlier, depending on the climate and the weather. 

Cod-Liver Oil is "Bottled Sunshine" 

In the temperate zones sunlight must be supplemented with cod-liver oil, espe- 
cially in fall and winter. X-ray studies have shown that either sunlight or cod-liver 
oil, or better, both together would cure rickets or prevent it. 



15 
Rickets affects about 90 per cent of the babies in the North Temperate Zone. 
Even though a baby is born in the spring and receives sun baths throughout his 
first summer he should also be given cod-liver oil. A winter baby cannot get 
enough outdoor sunshine, so he especially needs cod-liver oil. It should be given 
to every baby through the first two years of fife, beginning at 2 weeks of age, 
whether he is breast fed or artificial^ fed. 

Daily Amounts of Cod-Liver Oil 

2 to 6 weeks, 3^ teaspoonful twice a day. 

6 weeks to 3 months, 1 teaspoonful twice a day. 

3 to 4 months, l}/£ teaspoonfuls twice a day. 

4 months to 2 years, V/i to 2 teaspoonfuls twice a day. 

Give Sun Bath and Cod-Liver Oil Daily 

How to Give Cod-Liver Oil to Baby 

With the babjr on your lap, pour the cod-liver oil into a spoon held in your right 
hand. With your left hand open the baby's mouth by pressing his cheeks together 
between your thumb and fingers. Pour the oil little by little into his mouth. 
If his mouth is not held open until the oil is entirely swallowed he will spit out what 
is left in his mouth. It is rare for a baby actually to vomit oil. Cod-liver oil will 
not upset a baby's digestion. Older babies may be given orange juice with the 
cod-liver oil, or after it. It is best however to teach them to take it directly, 
unmixed with anything else. 

Sun Baths for Older Children 

Though sun baths are of primary importance for the baby they are also of great 
value for the "runabout" and the pre-school child. Sun bathing is more important 
for the child than sea bathing, and it is accessible everywhere in spring and summer. 
Clothing for sun baths should be low in the neck, short in the legs, and without 
sleeves. An ordinary bathing suit or bathing trunks, a sleeveless slip, or a set of 
cotton underwear may be worn. 

Sun baths may be given in the fields, in a city back yard, on a roof, or on a porch, 
as well as on a beach. Care must be taken not to let the child's skin become sun- 
burned severely. The best time for sun baths is the morning. 

Tanning is the goal for which to strive, and the process must be gradual. The 
exposure should begin with the face and arms and increase slowly in duration and 
in the extent of body surface exposed, until the whole body is exposed for two 
hours a day. 

Sunlight and Cod-Liver Oil Prevent Rickets 

THE MATERNAL AND CHILD HYGIENE ACTIVITIES OF THE MASSA- 
CHUSETTS DEPARTMENT OF PUBLIC HEALTH 



By Susan M. Coffin, M.D., Pediatrician Massachusetts Department 
of Public Health 



MASSACHUSETTS handles the greater part of its child hygiene problem 
through the Division of Hygiene in the State Department of Public 
Health. So far as possible the child hygiene program is correlated with 
that of adult hygiene since it is realized that it is impossible as well as impracticable 
to isolate the child from his home enviromnent. The Division of Hygiene possesses 
no supervisory authority; it is an advisory body only. 

The child hygiene activities of the Massachusetts Department of Public Health 
are as follows : 

Maternal and Infant Hygiene 

This is in charge of a full time physician and four full time public health nurses 
whose work is as follows: 

(a) The State is divided into four districts each in charge of one of the nurses 
mentioned above. It is the nurse's duty to keep in constant touch with the local 
nurses both municipal and private, carrying on child hygiene activities. In addi- 
tion to regular visits to these local nurses in their own communities, a certain 



16 

number of district conferences are held for groups of nurses. These four nurses 
also assist in working up and conducting our well child conferences. 

(b) Demonstration well child conferences are held in various parts of the State 
from time to time, at the request of interested organizations or boards of health. 
These conferences are strictly for demonstration and diagnostic purposes, no 
treatment whatsoever being given. Reference is always made to the family 
physician and a copy of the findings of the examination in each case is sent to him. 
The conferences are carried on in as simple a manner as possible, one of the objects 
being to show the local communities how possible it would be for them to carry 
on similar activities. 

(c) The maternal and child hygiene staff assist in gathering material and pre- 
paring papers dealing with such subjects as maternal and infant mortality, breast 
feeding, pre-school hygiene and allied topics. 

WORK DONE IN 1926 

1. Prenatal Work 

Prenatal work has been largely through the prenatal letters and other printed 
material. A set of ten posters, very simple in design, outlining fundamental points 
in prenatal hygiene, are used at the clinics. A delineascope film, "A Message to 
Mothers" is used with prenatal talks. The Baby Book is being revised at the 
present time. Meantime "Your Baby" published by the American Medical 
Association and the Child Health Association is being distributed in large numbers. 

Massachusetts with a population of 3,852,356 used 65,000 prenatal letters in 
1925. 5,186 new requests were received during the year. This is a large number 
as compared with several other states with a similar number of inhabitants. 

In our State requests for the letters come in from local nurses, Visiting Nurse 
Associations, hospitals, a few from physicians, and a considerable number from 
mothers themselves. The greatest number comes from hospitals and from nursing 
associations. A large correspondence is carried on directly with the mothers also, 
as they write the Department to ask questions in connection with the letters. 
Much additional printed matter is sent out with the letters, and in answer to 
requests for more information. The service is purely educational. Every mother 
is urged to go regularly to her family physician for advice and to take her baby or 
young child to him for examination and correction of defects. 

2. Study of Maternal Mortality 

A statistical summary of maternal deaths occurring in Massachusetts in 1925 
was made by our statistician, Miss Hamblen. It is intended that tins summary 
be made every year. Studies of causes of early infant deaths have been begun, 
using the infant death records received through the courtesy of the City of Boston 
Department of Health. 

It might be noted in passing that the Children's Bureau offers a carefully worked 
out form for those states desiring to make a detailed study of their maternal deaths. 
It is expected that many states will take up this study in 1927. 

MATERNAL DEATHS IN MASSACHUSETTS DURING 1925 
A Statistical Summary 

The death certificates for 1925 show 501 deaths listed as due to puerperal causes. 
These deaths occurred in 100 towns. The causes of death were summarized as 
follows : — 

Causes of Death (Reg. Rep.) 
Accidents of pregnancy .45 



Abortion 

Actopic gestation . 

Others 
Puerperal hemorrhage 
Other accidents of labor 

Csesarean section 



Other surgical operation and instrumental delivery 6 
Others under this title 44 



24 
10 
11 

64 
. 68 
18 



17 



Puerperal septicemia . . .$ 140 

Puerperal phlegmasia alba dolens, embolus, sudden death 60 

Puerperal albuminuria and convulsions 120 

Following childbirth (not otherwise defined) ..... 2 

Puerperal diseases of the breast 2 

375 occurred in a hospital. 

A special summary of the deaths recorded as due to septicemia has been made 
from the reports of 116 doctors from 48 towns. 

The number of sepsis deaths reported, according to towns, is as follows: — 
Boston 36, Springfield 13, Fall River 7, Lynn 7, Worcester 6, New Bedford 5, 
LoweU 4, Brockton 4, Cambridge 3, Holyoke 3, Maiden 3, Quincy 3, Somerville 
3, Beverly 2, Chelsea 2, Gardner 2, Haverhill 2, Methuen 2, North Adams 2, 
Salem 2, Waltham 2. The remaining 26 towns reported one each. It seems un- 
likely that 255 towns had no maternal deaths in 1925. 

3. Well Child Conferences 

Well Child Conferences have been of two types, those in which all children from 
six months to six years are examined, and those in which only children who will 
enter school during the year are seen. 

In 1926, 62 conferences were held in 59 towns requesting them. 1,907 children 
from 1,187 families were examined, an average of 31 children per conference. In 64 
towns in which conferences were held in 1925-26, follow up work with the children 
is being done. This means interested nurses and interested and co-operative parents 
and doctors. Some towns still have no nursing service, so, of course, follow up 
cannot be as thorough as is desirable. 

Written reports of the children examined have been received from the local 
nurses in several towns and verbal reports from many more. 

Permanent conferences were established by the local organizations following the 
state demonstration conference in five towns in 1926, two with a physician in 
charge. Several more are to be started in the spring of 1927. In all the children 
are referred to the family physician for advice in regard to defects found and 
regular yearly examination is strongly recommended to the parents. 

At the Well Child Conferences, in addition to the prenatal posters mentioned, 
posters on habits and nutrition are displayed. Duplicate sets of these posters are 
also loaned constantly to local well child conferences. 

Printed matter on diet and habit training is distributed at the conferences to 
every mother or sent home to her when she is unable to come with the child. This 
is an important item, particularly as we have seldom been able to have the much- 
needed nutrition worker at the conference to talk with the mothers. The coming 
year it is expected that a nutritionist will be available for the conferences. 



DEFECTS FOUND AT WELL CHILD CONFERENCES 

The final summary of defects has been made concerning the 1,907 children 
examined at the Well Child Conferences in 1926, and is as follows: — 

Number of children without defects 
Dental defects 
Posture .... 
Flat feet 

Bow legs .... 
Definite diagnosis of rickets . 
Eye defects 
Defective hearing 
Discharging ears . 
Defective nasal breathing- 
Enlarged tonsils 
Skin defects . 
Miscellaneous 

The end results of rickets — poor posture, flabby muscles and generally poor 
nutrition — were evident in a very large number of children examined. Only one 



No. 


Per Cent 


298 


15.6 


637 


33.4 


123 


6.4 


55 


2.9 


47 


2.5 


35 


1.8 


34 


1.8 


8 


0.4 


10 


0.5 


168 


8.8 


570 


29.9 


169 


8.9 


51 


2.7 



18 
case of scurvy has been seen at the conferences so far and that was in an ignorant 
foreign family where the child had had no food except condensed milk since birth. 
This child has made a good recovery under proper treatment. 

Prenatal Care in Hospitals throughout Massachusetts 

During 1926 the Department sent out a questionnaire to 219 hospitals in the 
State to get an idea of prenatal service in those doing obstetric work and giving 
prenatal care. 141 hospitals taking maternity patients replied. 105 of these give 
no prenatal care to out patients. The remaining 36 give prenatal care, and of 
these prenatal care is supervised by a doctor in 34. In one instance prenatal care 
is supervised bjr a "social nurse", in the other by a "graduate nurse". 

The per cent of cases cared for that were delivered in the hospitals varied from 
50% in one hospital to 100% in eighteen hospitals. It is somewhat surprising to 
find that so many of this group, 16 in all, give prenatal care to mothers not planning 
to have hospital delivery, but, of course, in some of the large city hospitals externe 
obstetrics service is maintained. 

Now, as to what the hospital requires of the mothers. They are, in the 33 
hospitals replying to this question requested to report monthly, in most instances, 
until the later months of pregnancy, and then every two weeks. Urinalysis is 
requested at every visit in 31 hospitals. 

Information as to the time in pregnancy that patients registered for prenatal 
care was too meagre to be of much value. 14 did state "at the sixth or seventh 
month." The impression was that early registration was still unpopular and this 
was amply borne out by our previous maternal death study. 

An effort was made to get an outline of what "routine prenatal care" covered 
and the following brief tabulation gives the information obtained. It will be noted 
that in all of the 36 hospitals reporting, history is taken and urinalysis done, and 
that blood pressure and measurements are done in all but one. 
Routine prenatal care covered: 

History 36 

Complete physical examination 32 

Weight 24 

Urinalysis 36 

Measurements 35 

Blood pressure .... .... 35 

Wassermann .... 17 

"Routine if indicated" 13 

This is, of course, a very limited report of a very small group of hospitals but so 
far as it goes it is important and of considerable interest. 

To give the hospitals and the physicians a fair chance earlier registration of 
maternity patients would be most desirable. Probably no one can do more to 
further this than the community nurse. To give the patient all the chance possible 
for a normal delivery routine prenatal care should cover all the points outlined. 
Both parents and physicians still need to be taught to feel the importance of early 
and adequate prenatal care. 

The mother who dies at childbirth with a history of little or no prenatal care is 
in the same category as the child who dies of diphtheria without benefit of toxin- 
antitoxin. Ignorance and indifference still besiege our gates, but a growing interest 
in improving conditions for mothers and babies is evident in many quarters. 

REPORT OF FIRST SIX MONTHS OF A BREAST FEEDING 
DEMONSTRATION 



By Lela M. Cheney, R.N., formerly Consultant in Public Health Nursing 
Massachusetts Department of Public Health 



Local Picture 
Town: Northbridge, Massachusetts. 
Population: 10,051. 
Type: Industrial, manufacturing, machinery, paper, silk and cotton. 



19 

Racial distribution: 38% of the population are foreign born whites. Of these 
one third are French-Canadian; one half are distributed among Irish, Dutch, 
Armenian, English and Polish. Of the 62% born in this country a large pro- 
portion are the children of foreign born parents of the above named nationali- 
ties. 

Medical and nursing resources: 1 hospital; 11 physicians; Village Relief 
Association, employing 2 public health nurses; 1 school nurse; 2 industrial 
nurses. 

Duration of demonstration: This preliminary report covers all cases admitted 
during the first six months of the demonstration, i.e. from December 1, 1925, 
to May 30, 1926. The demonstration will end May 30, 1927. 

Procedure 

• 1. Village Relief Association consented to carry on a breast feeding demonstra- 
tion as proposed by the Massachusetts Department of Public Health. - 

2. State Consultant in Public Health Nursing interviewed all local physicians 
(except one who was out of the country and two who did no obstetrical work). 
The object of the interviews was to explain the proposed demonstration, and to 
enlist the support of the local medical group. Without exception, but with vary- 
ing degrees of enthusiasm, they approved the plan as outlined and promised their 
co-operation. 

3. The printed material used included a bulletin of breast feeding for nurses; 
a pamphlet on breast feeding for mothers; individual record cards; four form letters 
for mothers, with reply blanks to accompany each. These were provided by the 
State Department of Public Health. 

4. Information regarding registered births was obtained each week from the 
town clerk by the Village Relief Association nurses. 

5. Instructive home visits were made by the Village Relief Association nurses 
when a baby was two weeks old and again when he was four weeks old. The object 
of these visits was: 

(a) To impress on the mother the importance of breast feeding, and to 
encourage her to nurse her baby. 

(b) To teach the important factors in maintaining breast milk: regular, 
complete emptying of the breasts, preferably by a vigorous baby; sufficient 
rest, exercise, fresh air; a well balanced diet; a cheerful mental attitude and a 
desire to breast feed the baby. 

The original plan was to teach manual expression and the use of complementary 
feedings under the direction of the private physician in all cases where the breast 
milk was insufficient. As it actually has been carried out, however, manual ex- 
pression was used in comparatively few instances, the chief reliance being placed 
on the factors mentioned above, especially on encouraging the mother to continue 
breast feeding when she was about ready to give up. When manual expression 
was practiced it was a means of increasing the quantity of milk and restoring milk 
to apparently dry breasts. 

6. A form letter enclosing a reply blank and a stamped, addressed envelope, 
was sent at the end of- the second, third, fourth, and fifth months. If no reply was 
received, or if the reply indicated any difficulty in maintaining breast feeding, a 
home visit was made. Otherwise the last home visit was made at the end of the 
sixth month when the record was closed. Inability to supervise a large number 
of babies with limited nursing service was the reason for discontinuing the super- 
vision at six months rather than continuing throughout the normal nursing period. 

Statistical Studies 

A. 
Length of Breast Feeding 

Breast fed 6 months or more 57 

Breast milk only 47 

Breast milk and complementary feeding 10 



Breast fed less than 6 months 
Breast fed 53^ months 



20 



2 weeks - 1 month 
less than 2 weeks 



Never breast fed 
Total 



B. 



40 



100 



Reasons for discontinuing breast feeding 




Advised by physician 












20 


Breast abscess 


3 


(month of weaning) 


1,1,4 




Milk no good 




(< 


It 


tt 


1 




Mother nervous 




a 


It 


it 


1 




Cracked nipples 




K 


tt 


it 


1 




Twins 




It 


ft 


a 


2 




Baby vomiting 




il 


ti 


tt 


2 




Insufficient milk 


3 


It 


a 


a 


2,3,4 




Baby not gaining enough 




tt 


a 


a 


2 




Mother had a cold 




It 


it 


a 


3 




Mother had a gallstone 














attack 




ti 


a 


it 


3 




No reason stated 




tt 


ti 


a 


1,4 




Diabetes 




It 


it 


a 


3 




Pregnancy 




" 


a 


tt 


5 




Pneumonia death 




It 


(( 


n 


2 weeks 




Without advice of physician . 












20 


Insufficient milk 










. 11 




Mother unwilling to continue breast feeding 




. 6 




Baby refused to nurse 










1 




Malnutrition of baby 










. 1 




Mother went to work 










. 1 




Total 












40 



Mother unwilling 



C. 

Reasons for Never Breast Feeding 



D. 

Racial Factors 
Mothers who breast fed baby 6 months or more, 26 % were French Canadian 
Mothers who discontinued breast feeding before 

the sixth month, 55 % were French Canadian 

Mothers who refused to breast feed the baby, 6Q%% were French Canadian. 

Analysis of "Failures" 

An analysis of the reasons given for discontinuing breast feeding, and a knowl- 
edge of the case histories, would lead one to believe that at least one half of these 
babies should have had the benefit of more breast milk. Underlying the "reasons" 
given was frequently an unwillingness on the part of the mother to continue breast 
feeding in some cases. "Insufficient milk" can hardly be considered a real reason 
for depriving a baby of what breast milk he might get, although that was given 
as a reason in fourteen instances. 

On the other hand the proportion of breast fed cases is no doubt higher than 
it would have been without the intensive work done by the Village Relief Associa- 
tion nurses, for in many instances they were able to help the mothers to maintain 
or to restore breast milk. 



21 
A Few of the Successes 

Baby M. at four weeks of age weighed less than at birth. The mother apparently 
had quantities of breast milk, but it looked "blue and watery". The physician 
ordered a complementary feeding; but baby M. had his own ideas about the proper 
diet at one month of age and steadily refused to take anything but breast milk. 
At the age of three months he weighed less than a pound and a half above his 
birth weight. The nurse suggested that with as large a quantity of milk possibly 
the baby was not getting the "strippings" containing the most fat. So the mother 
was taught to express the first ounce or so of milk before putting the baby to the 
breast. That week he gained 8 ounces, and continued to grow rapidly. Now, at 
eight months he is slightly above average weight, healthy and happy as every 
normal baby should be. 

SUMMARY 

1. With intensive supervision 57% of the babies admitted during the first six 
months of the demonstration were breast fed for at least six months. 

2. One half of those discontinuing breast feeding did so without the advice of 
their physician; one half with Ms advice. 

3. Of the various reasons for discontinuing breast feeding "insufficient milk" 
was the leading one. In these particular cases manual expression and comple- 
mentary feedings were not tried. 

4. In instances of insufficient milk where manual expression and complementary 
feedings were used, the quantity of breast milk was increased so that it was unnec- 
essary to wean the baby. No doubt a more general use of this method would 
raise the proportion of breast feeding considerably. 

5. The highest percentage of failures in breast feeding were among the French 
Canadians. 

6. Although the proportion of breast feeding was lower than we should expect 
from results obtained in similar demonstrations outside of Massachusetts, never- 
theless, for a community where breast feeding has not been popular, we consider 
this a very good beginning. We anticipate that the results of the second half of 
the demonstration will be even more gratifying. 

7. If other communities, learning of tins pioneer work, focus their efforts more 
intently on the promotion of breast feeding, the demonstration in Northbridge will 
have accomplished its primaiy purpose. 

ACTIVITIES OF THE MASSACHUSETTS DEPARTMENT OF PUBLIC 

HEALTH 

The following series of articles form a brief summary of the many activities of 
the State Department of Public Health. As the work of the various divisions is 
constantly changing "The Commonhealth" is taking this opportunity to present 
this problem with a brief statement of the work now being done. — Ed. 

DIVISION OF ADMINISTRATION 

THE Division of Administration has as its director the Commissioner. Its 
duties are those which its name implies: the centralization of all Depart- 
mental activities, including the many and varied administrative problems 
arising in a Department which includes eight divisions, various subdivisions and 
four state sanatoria, with a personnel for the entire Department totalling well over 
eight hundred. 

The most important work of the Division is the monthly meeting of the Com- 
missioner and Public Health Council, at which all official decisions are reached and 
hearings held. Special meetings, trips of inspection, etc., are held when necessary, 
in addition to the regular meetings. 

All personnel matters for the Department, with the exception of that of the 
institutions, are handled through this Division. 

The accounting office handles all financial matters of the Department from the 
time a request to purchase originates in a Division until the appropriation accounts 
are closed at the end of the fiscal year. All institution accounting is routed through 



22 
this office also. The multicopy work of the Department is handled through this 
office and approximately 1,055,000 letters, circulars and leaflets were mimeo- 
graphed or multigraphed during the past year. 

Another centralization feature of the work of the Division is that of the filing 
office. Mail for the divisions of the Department located in the State House is 
received, opened and routed from tins office. All material from the divisions 
located within sufficiently close proximity to the Division of Administration to 
make central filing practicable is filed here. 

The work of the Cancer Section is under the immediate direction of the Com- 
missioner and is included in the Division of Administration. The program, 
however, is sufficiently distinct from the other work of the Division to warrant a 
separate statement of its activities. 

The Cancer Section 

In accordance with the direction of the Legislature the Departments of Public 
Welfare and Public Health made a study, in 1925, of cancer in Massachusetts. 
One of the most striking findings of this studjr is that Massachusetts has the 
highest death rate from this cause of any State in the Union. Upon receipt of this 
report the Legislature, in 1926, directed this Department to continue the study, 
and appropriated money for the re-conditioning of the Norfolk State Hospital for 
the care of cancer cases, and also for aid in the establishment of cancer clinics 
throughout the State. 

The Department is now devoting much time and attention to broadcasting all 
available knowledge relative to this disease so that the people of the State may 
know the "danger signs" of cancer and seek early advice. It is encouraging and 
aiding the establishment of clinics where competent advice may be available for 
those who have heeded the "danger signs". Several clinics are already estab- 
lished and others are under consideration. Each clinic is under a local medical 
committee and has the support of a committee of lay people to aid in the educa- 
tional work locally and also to help in the solution of the many economic problems 
which will appear among the patients of the clinic. 

The Department is going ahead as rapidly as possible in the preparation of a 
hospital at Norfolk for the care of patients who would be unable to receive suitable 
care elsewhere. This hospital when ready will have facilities for ninety patients 
and will have on its visiting staff men of the highest abilities in the care of cancer 
cases. 

By continuing its studies along the many lines of interest brought out in the 
previous study, the Department hopes to add something to the present knowledge 
of the cause of this disease. 

DIVISION OF COMMUNICABLE DISEASES 

The Division of Communicable Diseases, as its name implies, is concerned with 
the investigation and supervision of all communicable diseases occurring in the 
State, as well as the study of the causes of disease, the sources of infection, any 
unusual prevalence or outbreak, the affect of localities, employment and other 
conditions, on the public health. 

The Division has a personnel of thirty-one. Its staff is made up of a Director, 
an Epidemiologist, a Lecturer on Social Hygiene, four Bacteriologists, and a field 
force of seven District Health Officers. The District Health Officers, who are the 
general field representatives of the Department and the direct representatives of 
the Commissioner in their respective districts, are, for administrative purposes, 
placed under the Division of Communicable Diseases. Obviously, their work 
involves close co-operation with the work of all of the other divisions of the Depart- 
ment. This, of necessity, requires that their energies be directed at times toward 
other problems than those concerned strictly with communicable disease. Corre- 
spondence relating to communicable diseases and the necessary statistical records 
of the thirty-eight diseases made reportable to this Department under the statutes, 
through the local boards of health, are carried on by an office force of six. In 
addition to the physician who lectures on social hygiene, a social worker and special 
investigator concern themselves with the following activities in the field of venereal 
disease: investigation of sources of infection, lapsed and delinquent cases, visits 



23 

to local boards, communities, social agencies, courts, probation officers and police 
officials. 

The Bacteriological Laboratory is engaged in the examination of specimens for 
the diagnosis of disease. Without this valuable service, the Division would function 
poorly indeed. Supplementing the staff of four Bacteriologists, there is a force of 
two clerks, three laboratory assistants and four laborers. There is in the Bacterio- 
logical Laboratory, a distributing station for biologic products and diagnostic out- 
fits used for the collection of specimens mailed to the Bacteriological Laboratory. 

Under the present laws, notification of all cases of disease declared dangerous 
to the public health is made by physicians and householders to the local boards of 
health. The local officials in turn report their cases of communicable disease to 
the Department. This system of notification has had the intelligent and cheerful 
co-operation, not only of the medical profession, but of the local health officials and 
the Massachusetts Association of Boards of Health. 

DIVISION OF FOOD AND DRUGS 

The Food and Drug Division collects and examines annually approximately 
8,000 samples of milk; 2,000 samples of foods other than milk; and 200 samples of 
drugs for suspected violation of the food and drug laws. These samples are 
collected from manufacturers, producers, wholesalers, and retailers. The Division 
also annually examines approximately 8,600 samples of liquor and 100 samples of 
narcotics submitted by Police Departments throughout the State and furnishes 
expert witnesses to testify as to the results of these analyses when such testimony 
may be required. The Division also examines about 100 samples of coal per annum, 
submitted by other State Departments and by City and Town Departments, 
provided the analyses are to be used in the enforcement of the Law. 

The Division prosecutes about three hundred cases per annum for violation of 
the milk, food and drug laws. It enforces the cold storage law of the State, which 
includes the licensing of seventy cold storage warehouses located in various parts 
of the State. One inspector spends his entire time on this work, looking over the 
sanitary conditions of the warehouses ; determining the quality of the goods stored 
or submitted for storage; confiscating such food as may be decomposed; and looking 
over the character of the food upon which requests for extension of time in storage 
have been made. Each warehouse submits a monthly report of articles placed in 
storage and articles on hand. These reports are summarized each month and the 
summary is submitted to the press for publication. 

The Division also enforces the slaughtering laws of the State. Each city and 
town, except Boston, must annually nominate one or more Inspectors of Slaughter- 
ing. These Inspectors cannot be appointed until approved by this Department. 
About five hundred names are thus submitted to the Department each year, and 
their qualifications for the position are considered, and if satisfactory, the men are 
approved. Were it not for the fact that most of these names are those of persons 
who have held the position for some time, it would be necessary for the Department 
to have a great many more Inspectors. This work as it is takes the full time of 
two men and part time of some of the other men for a period of about six weeks. 
The Inspectors of this Department engaged in this line of work also look over the 
character of inspections made by these men, and in general see that the slaughtering 
laws are obeyed. 

The Division employs one Division Director, who is also the Chief Analyst; 
five Assistant Analysts; one Laboratory Helper; eight Inspectors; and a clerical 
force of six. 

As a side issue the Division operates a factory for the manufacture of certain 
arsenicals and the ophthalmia prophylactic. 

Other work of the Division consists in the enforcement of the mattress law, the 
bakery law, portions of the soft drink law. the sanitary food law, and the false 
advertising law as applied to the sale of food and drug products. 

DIVISION OF BIOLOGIC LABORATORIES 

The Division of Biologic Laboratories includes the Wassermann Laboratory and 
the Antitoxin and Vaccine Laboratory. 



24 

The Wassermann Laboratory perforins, without charge, blood tests for the diag- 
nosis and treatment control of syphilis and gonorrhea, and it also makes examina- 
tions of dogs in cases of suspected hydrophobia or rabies and carries out other 
pathologic and bacteriologic examinations for the Division of Animal Industry. 

The Antitoxin and Vaccine Laboratory manufactures and distributes to boards 
of health, institutions and physicians the following serums and vaccines: diphtheria 
antitoxin for the prevention and treatment of diphtheria, scarlet fever antitoxin 
for the treatment of scarlet fever, antipneumococcic serum, and serum for the 
treatment of epidemic cerebrospinal meningitis, outfits for the Schick test, diph- 
theria toxin-antitoxin mixture for active immunization against diphtheria, bacterial 
vaccine for the prevention of typhoid and paratyphoid fevers and vaccine virus 
for the prevention of smallpox. All these products are distributed free of charge. 

Both laboratories serve as places of instruction to health officers, public health 
and medical students, and nurses. 

DIVISION OF TUBERCULOSIS 

The tuberculosis problem of the Department of Public Health is handled by the 
Division of Tuberculosis. It has a three-fold purpose: it provides hospitalization 
for the tuberculous sick; it is engaged in a tuberculosis survey among the school 
children; it supervises the tuberculosis dispensaries and tuberculosis nurses through- 
out the State. 

To care for the tuberculous sick 1,060 sanatoria beds are provided; 500 are for 
children. The Paitland Sanatorium receives all patients from Middlesex and 
Worcester Counties and the Hospital District of Chelsea, Revere and Winthrop; 
100 beds, however, are reserved for early cases from the entire State. At West- 
field and North Reading only children are received, and schools are provided for 
their education. The Sanatorium at Lakeville is for tuberculous disease of bones 
and joints. Preference is given, under the law, to citizens of the Commonwealth. 

The medical staff in addition to their institutional duties examined 1,291 pa- 
tients in their consultation and out-patient clinics. 

In 1926 these institutions admitted 1,259 new cases, giving 332,619 days of 
treatment at a cost of $828,242. 

The Tuberculosis Survey of the school children began in Springfield in October, 
1924. 50,000 children have been examined once in three-fourths of the cities and 
towns in the State; some twice; and some three times. Only children who are 10% 
or more underweight or who have been exposed to a case of consumption in the 
home or family are examined. To obtain this Clinic the school and health authori- 
ties must make a formal request, and before a child is examined the parent or guard- 
ian must sign a request. At the Clinic the mother who accompanies the child 
receives instruction concerning her nutrition problems by nutritionists from the 
Division of Hygiene. 28 out of every 100 children examined are infected with the 
tuberculous germ. Out of these 28, one already shows signs of beginning disease 
that requires extra supervision, by the local school nurse. Open-air schoolrooms, 
summer health camps and county and state preventoria are provided for their 
benefit. It is hoped by these means to prevent the development of tuberculosis 
of the lungs later in life. 

• As comparatively few of the tuberculous patients are hospitalized, and in most 
cases the period of hospitalization is a short one, many patients are "curing" at 
home. These require instruction as to the care of sputum, rest, exercise and some 
need bedside care. This nursing supervision is given by the dispensaries and local 
public health nurses. These local nurses, however, need constant encouragement; 
new nurses need instruction and they all need stimulation to greater effort. This 
is accomplished by a force of State supervising nurses who make a check-up on 
all reported cases once a year. This enables a yearly revision of the records. The 
system of records in use since 1915 is being revised and simplified so that it will be 
more readily available for study. 

DIVISION OF WATER AND SEWAGE LABORATORIES 

This Division which has two units, an Experiment Station at Lawrence and 
laboratories in the State House, Boston, has been carrying on analytical and 
research work for the past forty years. 



25 

The Station is equipped with chemical, bacterial and experimental laboratories 
containing tanks, filters and other apparatus for use in investigations upon the 
treatment or purification of water, sewage, industrial wastes and allied subjects. 
Many new methods of water and sewage treatment have been developed there and 
investigations are carried on to enable the Department to give advice to cities, 
towns, corporations and individuals asking questions on sanitary problems. All 
the bacterial work of the Department upon water, sewage, ice and shellfish is done 
in its laboratories. Examinations are made of soils, sands and other filtering 
materials, and much other analytical work is carried on. 

In the State House are chemical and microscopical laboratories where analyses 
are made of water supplies, rivers, wells, of sewage applied to and the effluents 
from municipal sewage and industrial filters; much research is also done and other 
work bearing on health problems not at all related to the general subject of water 
supply and sewage disposal. Many of the chemists in the Division must have 
special research ability to successfully initiate and carry through required investiga- 
tions, and much of the work is of such a nature that the analytical results must be 
accurate to one hundred thousandth of one per cent to be of value. 

Every engineering investigation by the Department called for under the general 
laws or by special acts of the legislature requires much work by this Division. 
From 15,000 to 18,000 analyses are made each year and much field work is also 
done. The research work of the Division has added much to the knowledge of 
the world on sanitary subjects and is described in the annual reports of the Depart- 
ment and up to date in more than one hundred papers published in engineering 
and technical journals. Both the Station and the State House laboratories are 
visited each year by engineers, chemists, bacteriologists and students of sanitary 
science in this country and from abroad. 

ENGINEERING DIVISION 

Since the year 1886 the Engineering Division, in accordance with the General 
Laws, has had general oversight and care of inland waters, being directed to consult 
with and advise officials of cities, towns and persons having or about to have 
systems of water supply, drainage or sewerage, and also persons engaged or intend- 
ing to engage in any manufacturing or other business, drainage or sewage from 
which may tend to pollute any inland water. The General Laws provide also that 
all plans for proposed systems of water supply, sewage disposal or drainage, shall 
be submitted to the Department for its advice, and most of the enabling acts 
authorizing installation of water supply or sewerage and sewage disposal systems 
provide that plans for such shall be approved by the Department. 

In addition to these duties, the Engineering Division carries out investigations 
and studies in accordance with special legislation, among which have been those 
relative to the North and South Metropolitan Sewerage systems, the Metropolitan 
water supply, Charles River Basin, Improvement of the Neponset River, Sewage 
Disposal in the Merrimack River Valley, etc. These investigations are in some 
cases of great magnitude and represent public investments involving millions of 
dollars. 

During the year 1926 the Division investigated and reported on over 325 appli- 
cations for advice relative to water supply, sewerage, drainage, ice supply, and other 
kindred subjects, and caused the collection of some 7,200 samples for water and 
sewage analysis. 

The work of the Division is in charge of a Chief Engineer, and is carried out under 
his supervision by some fourteen engineers. 

The amount of money appropriated during the year 1926 was $63,500, of which 
152,000 was for engineering services and $11,500 for expenses. 

DIVISION OF HYGIENE 

The Division of Hygiene handles for the Department problems of child hygiene 
and adult hygiene. 

The work of the Division may be set forth under the following subdivisions: 
1. Maternal and Infant Hygiene. This is handled largely through a full time 
physician and four full time public health nurses. Their work includes advis- 



26 

ing with nurses doing such work as this in local communities and in conducting 
well child demonstration conferences throughout the State. 

2. School Hygiene. Carried on by a full time physician and a full time nurse, 
assisted by the four child hygiene nurses referred to in the previous paragraph. 
The lines followed by this group have to do with raising the standard of medical 
and nursing service to school children through regular visiting in the local 
communities and through surveys of the medical and nursing service of local 
communities. This group works in close co-operation with the Department of 
Education. 

3. Nutrition. Tins work is carried on through a Consultant in Nutrition and 
three assistants, the latter working in connection with the underweight clinics 
carried on by the Division of Tuberculosis of this Department. 

4. Dental Hygiene. In charge of a Consultant in Dental Hygiene whose func- 
tion it is to consult with local communities wishing to improve their dental 
hygiene work or to start new work. 

5. Health Education. There are two workers in this group who assist local 
agencies to extend their health education work and who prepare pictorial and 
other material for the use of local communities. 

6. Informational Service. This consists of the use of all kinds of pictorial 
material including posters, delineascope films, motion picture films, newspaper 
publicity, and the sending out of prenatal and postnatal letters to prospective 
mothers and mothers of young babies under two years of age. Many leaflets 
have been prepared and are in constant circulation dealing with various aspects 
of child care. The Division is also responsible for the editing of the Depart- 
ment's quarterly bulletin, The Commonhealth, and for a multigraphed bulle- 
tin called "Tidings" which goes to school hygiene workers and others. In 
addition to these activities a good-sized lecture service is carried on. 

All the educational material of the Department is free to residents of Massa- 
chusetts. 

BARNSTABLE COUNTY HEALTH DEPARTMENT 



By A. P. Coff, M.D., County Health Officer 



IN 1921 an organization known as the Cape Cod Health Bureau, consisting of 
the Boards of Health and School Committees of the majority of towns in 
Barnstable County (Cape Cod), was formed. It was organized with a Presi- 
dent, Vice-President, Secretary- Treasurer, and Executive Committee. Dr. Russell 
B. Sprague was appointed as Health Officer, and George T. McCarta as Sanitary 
Inspector. Mr. G. W. Hallett, Mr. Edward Chase, and Mr. Charles R. Bassett 
have served as President, Vice-President, and Secretary-Treasurer for the Associa- 
tion for many years. This Health Service functioned effectively for more than 
five years in from ten to twelve towns of the fifteen towns of the county. Appro- 
priations were made in each town at the annual town meeting and were paid in to 
a common fund for the operation of the service. The United States Public Health 
Service contributed liberally for all of this period, and the State Health Department 
has co-operated in every way. 

In 1926 the State Legislature at the request of the County Commissioners and 
the citizens in general of Cape Cod, passed an enabling act which allows the County 
Commissioners to appropriate a sufficient sum to operate a whole time County 
Health Service. This became effective on January 1, 1927, and is now in opera- 
tion. The County Health Department consists of a Health Officer, a Secretary, 
a Sanitary Inspector and an Assistant Sanitary Inspector. All nurses on the Cape 
are employed by the towns and by various nursing associations. 

The work of the Health Service on Cape Cod seems to come naturally under 
about four heads : — 

1. Work in connection with communicable and other diseases. 

2. School work. 

3. Sanitary inspection and control, including sewage and garbage disposal, etc., 
and shellfish sanitation. 

4. Inspection of dairies and general milk inspection. 



27 

For the future the objectives will be, among other things, as a part of the first 
division, the immunization of young children against diphtheria, vaccination of all 
school children and others, and continued effective control by isolation and other- 
wise of communicable disease. Under number two, the effective correction of 
defects foimd in school children. Under number three regular inspections of food 
handling places, installation of proper dumping grounds and gradual introduction of 
sewer systems where necessary. Lastly, we hope to test all cows on the Cape for 
tuberculosis: the majority have already been tested. 

The above is a general statement of some of the things which we hope to accom- 
plish in the comparatively near future, and it is not doubted that the health work 
in Barnstable County will go forward with renewed vigor under the whole time 
County Service. The United States Public Health Service continues to share in 
the work, and there is, of course, complete co-operation with the State Health 
Department. 

On January 18, a meeting was held in Hyannis to celebrate the installation of 
the County Health Department. This meeting was addressed by Dr. George H. 
Bigelow, Commissioner of Public Health, who also represented the Governor; 
Assistant Surgeon General W. F. Draper, U. S. Public Health Service; Surgeon 
L. L. Lumsden, U. S. Public Health Service; Dr. Richard P. MacKnight, State 
District Health Officer; Mr. Hallett, Mr. Bassett, and Mr. John D. W. Bodfish, 
County Commissioner. This meeting was attended by nearly two hundred people 
representing the Cape in general, and all are greatly interested in the matters 
discussed. 

The Cape Cod Health Bureau Association will continue to hold its regular meet- 
ings at least twice a year, and will form a valuable adjunct or auxiliary to the County 
Health Department, especially on the social side. The officers of this Association 
deserve and should receive the utmost credit for their work during the past five 
years, and no mention of health work on Cape Cod is complete without naming the 
late Dr. Russell B. Sprague, who was the first Health Officer. 

Perhaps the most encouraging part of health work in Barnstable County is the 
fact that the local Boards of Health, School Committees and citizens in general 
are really interested in the work and in the County Health Service. Many citizens 
in every town could be named who have always taken a great and personal interest 
in all matters pertaining to the health of their towns, and by this is not meant a 
perfunctory or official interest only but a genuine one. 

The following is from the last report of the United States Public Health Service 
on Co-operative Rural Health Work for 1925-26: — 

"The Massachusetts Legislature in its 1926 session adopted an act enabling the 
board of commissioners of Barnstable County to establish a county health depart- 
ment. The Barnstable County health department, under the direction of a whole- 
time county health officer, is to begin operation in January, 1927. Thereafter 
the health service for Cape Cod will be supported with appropriations from the 
county treasury instead of pooled appropriations from the town treasuries. The 
advantages of having the county as the unit for the local health administration are 
obvious. 

"The Barnstable County health department will be the first county health depart- 
ment established in New England. The precedent is of historic interest and is 
expected to prove of far-reaching practical importance." 



28 

Editorial Comment 

Current Health Legislation. The Legislature is still in session as 

this is written, so this resume" may seem 
a little premature. But optimism is often dependent on prema- 
turity. First, as to some of the bills that are still living and may be 
passed. The most important are, perhaps, those that have to do 
with milk. Tuberculosis free milk will be encouraged by the so- 
called "Area Testing Bill" which would require tuberculin testing 
of all cattle in a town or county when a large majority of the farm- 
ers so request. The Director of the Division of Animal Industry 
has sponsored this since it will develop "clean" areas in Massa- 
chusetts from which replacements of "clean" cattle can be made. 
Also the licensing of pasteurizing plants by local boards of health 
under regulations promulgated by this Department may be author- 
ized. If the enormous protection which pasteurization offers is to 
be realized, the process must be adequate. 

Radium will probably be purchased by the State for use in cancer 
cases at the Pondville Hospital in Norfolk which will open early in June. 

The Department will probably be directed to study the smoke 
nuisance in the State, the purification of shellfish, and certain water 
supply problems. 

And now as to the failures. Even with the support of health 
officers, physicians and many farmers' organizations we were unable 
to convince the Committees on Public Health and Agriculture that 
eventually only pasteurized or tuberculosis free milk should be 
sold within the Commonwealth. Apparently to convince them of 
the menace, we must again go through the slow process of demon- 
strating that much of our raw milk contains living tubercle bacilli 
capable of killing guinea pigs. This we shall proceed to do. 

Authority was denied to coerce the typhoid carrier when co-opera- 
tion failed, and this in spite of the recent disasters in Lincoln and 
Wakefield, and the present one in Billerica to which the answer is 
not yet. It was felt that to fine or confine a milker or other food 
handler who after careful instruction insisted on returning to food 
handling, and thereby on continuing to spread typhoid, was unwar- 
ranted interference with personal liberty. It is still the inalienable 
right of all typhoid carriers to infect others if they happen to prefer 
food handling to other methods of livelihood. Also to extend 
compulsory vaccination to the private schools is unduly coercive 
in the eyes of the Senate though such compulsion in public schools 
is tolerated. This bill passed the House. Must our State be 
visited by pestilence even as Florida, California, Michigan, Minne- 
sota and other states in order to appreciate the protection of 
vaccination, and this 131 years after Jenner? 

One member of the Public Health Committee said that in all 
the legislation which the Department sponsored there was merit. 
Yet the impression was that he opposed practically all. Is this 
ratiocination? It is true that in our over-enthusiasm we must 
not lose a sense of proportion. But, although Rome was not built 
in a day, still it never would have been built at all if each day all 
the marble had been rejected. 



29 

The Summer Round-Up. The campaign to get our girls and boys 
into school physically fit emphasizes 
anew what a job of training the health educator has on Ms hands. 
First the parents have to be informed and convinced; then the 
child has to be examined and his physical defects corrected; and 
then one is just ready to begin on the task of health habit promotion. 

That this is no easy task, especially from the mental aspect, is 
evidenced every day by a glance at the newspapers. To a greater 
degree than ever before people seem to be maladjusted to their 
environment. Too, the environment is likely to become more 
rather than less complex as time goes on. Automobiles and sky- 
scrapers, apartment nouses and movies, jazz bands and the rest of 
the long category seldom make for phj^sical or mental poise. 

During the war the call was sent forth to conserve the health of 
the child in the name of patriotism. Should not the call be just 
as clear now to prepare the child to hold his own amidst the com- 
plicated mechanisms of fife which the older generation, through 
necessity or stupidity, is passing on to him. 

Barnstable County Health Department. For many years one of the 

serious problems facing 
the State of Massachusetts has been this: How can the smaller 
towns of the Commonwealth obtain adequate health service at a 
cost which they can afford? Under the statutes each municipal 
board of health has very broad powers, far broader than they have 
often been able to make adequate use of. The small town has never 
felt that it could afford a whole-time health officer, especially a trained 
one, and yet its problems are such as should receive the attention 
of such a trained official. 

In view of this condition the answer has seemed to be fairly 
obvious, namely, some sort of combination of towns. This is 
entirely feasible under the statutes, although hitherto in health 
matters there has not been a tendency towards a county unit which 
is seen in most other states. Most counties are made up both of 
cities and towns, the cities being more or less able to look out for 
themselves, the smaller towns not having adequate facilities. 

Five years ago on Cape Cod a Health Bureau was established, 
with a full-time health officer. The money to carry on this work 
came_ partly from the contributions of the towns which made up 
the Health Bureau, and partly from the Federal Government. The 
ultimate aim of all connected with this work was some time to make 
it a County Bureau in the strict sense of the word. That has now 
been accomplished and on January 18, 1927, in Hyannis, a meeting- 
was held to celebrate the beginning of the new Barnstable County 
Health Department. About one hundred and fifty persons repre- 
senting all parts of the Cape were in attendance at these meetings. 
This is indicative of the widespread interest in the new department. 

Dr. A. P. Goff, the County Health Officer, will serve boards of 
health and school committees of the fifteen towns of the Cape. An 
excellent opportunity will be presented to the new County Health 
Department to show the rest of the State the proper way to handle 
the health problem of the smaller town. 



30 

The State Cancer Program. The legislature last May, it will be 

recalled, passed a bill authorizing an 
intensive educational program for the control of cancer together 
with a plan for the establishment of a state cancer hospital. Activi- 
ties directed towards the accomplishment of both of these phases 
of the cancer program have been steadily progressing since then. 

On the informational side authoritative statements have been 
presented through lectures by well-known physicians before pro- 
fessional and non-professional groups. Information has been 
offered to the public through pamphlets and motion pictures. 
Special groups such as nurses and dentists have also been reached 
through pamphlets. 

Intensive studies have been carried on by Dr. Lombard of the 
State Department of Public Health in order to bring together all 
available material that relates to cancer in Massachusetts and also 
to the subject at large, so that Massachusetts may have the benefit 
of facts as well as the experience of others in laying a foundation. 
The State Department has been generously assisted in these studies 
by the Department of Vital Statistics of the Harvard School of 
Public Health, by the Collis Huntington Memorial Hospital for 
Cancer, and by other Boston hospitals. The fundamental fact 
which stares us in the face with regard to cancer is that this dis- 
ease is responsible for one in every seven deaths of all persons over 
forty years of age in Massachusetts, about one in nine among men, 
and one in six among women. Furthermore, our death rate from 
cancer is steadily increasing. 

Cancer is not a reportable disease in Massachusetts and it does 
not seem wise to make it such at the present time. The City of 
Newton, however, through its physicians, has volunteered to 
collect the information which can be obtained only through the 
reporting of all cases of cancer. 

One of the statutory requirements laid upon the State Depart- 
ment of Public Health by the legislature was the establishment of 
clinics for the detection of cancer. Such clinics have already been 
opened in Newton, Springfield and Worcester; in addition, Lynn, 
Lawrence, Lowell, Fall River, and New Bedford are preparing to 
open clinics in the near future, which with Boston will bring up 
the total number to nine in Massachusetts. In every clinic city 
there is a committee of interested citizens who are organized to 
work under the medical committee and help with the task of bring- 
ing to the public the knowledge of the opportunities offered. 

Turning now to the hospital facilities, the State Hospital is soon 
to be opened in Norfolk, which will accommodate 95 patients. 
It will be equipped with operating facilities, X-ray and radium 
for the treatment of the resident patients, and also for out-patient 
use. It is hoped that the out-patient department of the State 
Cancer Hospital will be of great value to the country districts 
about the hospital where there are no special clinics for diagnosing 
cancer nearer than Boston. 

Testimonial Exercises to Dr. Charles V. Chapin. Every great 

movement has 
its outstanding figure and to this rule the cause of public health is 



31 

no exception. All public health workers recognize gladly what has 
been contributed to public health in this country by Dr. Charles V. 
Chapin, Superintendent of Health of Providence, R. I., and at the 
present time President of the American Public Health Association. 
In January of this year the Rhode Island Medical Society held 
testimonial exercises in honor of Dr. Chapin and on this occasion a 
portrait of the doctor was unveiled. The address of the evening 
was given by Dr. George E. Vincent, President of the Rockefeller 
Foundation, who in his own extremely effective way set forth the 
accomplishments of Dr. Chapin and their meaning to the health of 
the people. 

The Commonhealth joins with Dr. Chapin's many other admirers 
in hoping for a long continuance of his service to the community. 

Health Bulletin Service. A real live monthly health bulletin 
with simple, popular articles on general 
health topics and clever cartoons is now available to any town or 
city board of health in the country. 

The American Public Health Association has developed an eight- 
page bulletin that can be adopted just as it is or parts can be pur- 
chased to be used with a city bulletin already in circulation. 

The "Healthometer" includes: 

An illustrated cover page 
Two or three illustrated articles 
Nutrition news 
Bill Jones cartoon 
Children's page 

The entire issue can be purchased for twenty-five dollars plus cost 
of paper and printing, the plates being sent direct to the printer. 
This is a splendid piece of health publicity and we urge boards of 
health throughout the State to write the American Public Health 
Association, 370 Seventh Avenue, New York City, for further 
details. 

Summer Course at Hyannis. It seems timely to call attention 

again to the Summer Course for 
School Nurses which has been given for a number of years at the 
State Normal School at Hyannis during July and August, under the 
auspices of the State Department of Public Health and State Depart- 
ment of Education. The course this year will be similar to that 
given in the past. Those interested may apply for further infor- 
mation to the Division of Hygiene, Massachusetts Department of 
Public Health, 546 State House, Boston, Mass. 



32 
REPORT OF DIVISION OF FOOD AND DRUGS 

DURING the months of October, November and December, 1926, samples 
were collected in 151 cities and towns. There were 1,934 samples of milk 
examined, of which 423 were below standard, 36 samples had the cream 
removed, 57 samples contained added water, and 2 samples contained dirt. 

There were 693 samples of food examined, of which 280 were adulterated. These 
consisted of 10 samples of butter, 2 samples of which were low in fat, 7 samples 
sold as butter which proved to be oleomargarine, were submitted for analysis by 
the Department of Agriculture, and 1 sample sold as fresh but was cold storage; 
169 samples of eggs, 137 samples of which were cold storage not so marked, and 32 
samples were sold as fresh eggs but were not fresh; 2 samples of frozen custard 
which were falsely advertised; 2 samples of soft drinks which contained coloring 
matter and were not properly labeled; 9 samples of cream which were below the 
legal standard in fat; 30 samples of maple syrup which contained cane sugar; 15 
samples of sausage, 1 sample of which contained coloring matter, 6 samples con- 
tained starch in excess of 2 per cent, and 8 samples which contained a compound 
of sulphur dioxide not properly labeled, 1 of which also contained starch in excess of 
2 per cent; 18 samples of hamburg, 16 of which contained a compound of sulphur 
dioxide not properly labeled, and 2 samples were decomposed; 2 samples of mince 
meat which contained benzoic acid; 7 samples of canned cranberries which were 
decomposed; 1 sample of vinegar, sold as pure cider vinegar, but upon examination 
was not found to be such; 1 sample of clams which contained added water; 3 samples 
of dried fruits which contained sulphur dioxide not properly labeled; and 11 samples 
of nuts which were decomposed. 

There were 3 samples of drugs examined, of which 1 sample was adulterated. 
This was a sample of spirit of nitrous ether which was deficient in the active ingre- 
dient. 

The police departments submitted 2,097 samples of liquor for examination, 
2,073 of which were above 0.5 % in alcohol. The police departments also sub- 
mitted 26 samples of poisons for examination, 5 of which were morphine, 1 corro- 
sive sublimate, 1 tincture of iodine, 6 opium, 4 cocaine, 1 caustic potash, 1 ethyl 
acetate, and 7 samples examined for poison with negative results. 

There were 11 samples of coal examined, 3 samples conforming to the law, and 
8 samples contained an unreasonable amount of impurities. 

There were 63 hearings held pertaining to violations of the Food and Drug Laws. 

There were 96 convictions for violations of the law, $2,034 in fines being imposed. 

The Waldorf System Incorporated, Albert Muswlowski, and William H. Marshall, 
all of Chelsea; and Kam A. Wong, 2 cases, of Lawrence, were convicted for selling 
cream below the legal standard. Kam A. Wong, 2 cases, of Lawrence, and Albert 
Muswolowski of. Chelsea, appealed their cases. 

The Boulevard Restaurant and Coffee Pot Incorporated, Kyrikos Tareises, 
Charles Demos, 2 cases, and James Stanhope, all of Pittsfield; Edward F. Dempsey, 
2 cases, of Williamstown; William H. Marshall, 2 cases, of Chelsea; Noel W. Hart 
and James Strike of Great Barrington; Raymond E. Purnelle of Bridgewater; 
Peter Coussoule of Adams; George Dionne of Pelham, New Hampshire; Wilson 
Goyette of Plain ville; Melvin H. Jenkins of Bradford; Joseph Sylvia of South 
Dartmouth; Delos C. Keeney, Samuel Tuvman, and James Van Dyk Company, 
all of Springfield; Hector J. Pelotte of Dracut; John Sexton of Maynard; Fred 
Bauer of Buckland; Joseph Kairis and Jong Logshel of Worcester; Chin Quon and 
Charles P. Whelton of Greenfield; and Stanley Saukalowitz of Millville, were all 
convicted for violations of the milk laws. Noel W. Hart of Great Barrington, and 
Hector J. Pelotte of Dracut, appealed their cases. 

Franklin Creameries Incorporated of Springfield; Edmund Cesati of Haverhill; 
Arthur Manley of Methuen; Manuel Silva of Lowell; and United Butchers Incor- 
porated of Attleboro, were all convicted for violations of the food laws. United 
Butchers Incorporated of Attleboro appealed their case. 

Bernard Kaizer and William J. Thayer of Worcester; and John H. Libby and 
William W. Whitfield of Providence, R. I., were all convicted for misbranding food. 
Bernard Kaizer and William J. Thayer of Worcester appealed their cases. 

Lee Dip, John E. Georgian, and Wong Ing, all of Lawrence; Nicholas Pappas of 
Lowell; Abraham A. Rudman, John Stritas, and University Cafeteria Incorpo- 



33 

rated, all of Cambridge; Samuel Alpert of Attleboro; H. L. Dakin Company Incor- 
porated, 2 cases, and Bernard Kaizer of Worcester; and Lester Kohr of New York, 
were all convicted for false advertising. H. L. Dakin Company Incorporated, 2 
cases, and Bernard Kaizer, both of Worcester, appealed their cases. 

Morris Foihb, Abraham Berkson, Arthur Gilbert, Morris Shapiro, and Ralph 
Smith, all of Charlestown; Frank Angelo, Manuel Espanilo, Michael Neketuk, 
Bolis Yuromskas, Aleck Zournas, Nicholas Brox, Samuel Patrick, and Albert 
Samia, all of Lawrence; Joseph Bigos, Max Broady, Augustine Rounine, Frank 
Bistowski, Sarkis Boyajian, and Jacob Pasciak, all of Lowell; Armond Berthiame, 
Arthur Daignault, Gottlieb Koch, George L. Mathieu, Albert Precuch, Martin 
Schuhle, and David Solomon, all of Turners Falls; Romeo Bisson, Stanley Malinski, 
and Victorian Talbot, all of Fall River; Julian Golaszewski and Andrei Popko of 
Millers Falls; Hyman Karp, John Uksanish, Moses Whitman, all of Worcester; 
John Koulouris and Elias Peribolas of Springfield; Samuel Palmer of Haverhill; 
Joseph Schein of Taunton; and Frank Simpson of Methuen, were all convicted for 
violations of the cold storage laws. Samuel Palmer of Haverhill appealed his case. 

Atlantic Bottling Company of Hull; and George W. Lowell of Brighton, were 
convicted for violations of the soft drink law. Atlantic Bottling Company of Hull 
appealed their case. 

Atlantic Bottling Company of Hull was convicted for violation of the sanitary 
food law. They appealed the case. 

In accordance with Section 25, Chapter 111 of the General Laws, the following is 
the list of articles of adulterated food collected in original packages from manufac- 
turers, wholesalers, or producers: 

Milk which contained added water was produced as follows; 11 samples, by Joseph 
Sylvia of South Dartmouth; 7 samples, by Melvin H. Jenkins of Bradford; 6 
samples, by Hector J. Pelotte of Dracut; 5 samples, by Perley Wells of Exeter, 
New Hampshire; and 3 samples, by Samuel Rain of Salem, New Hampshire. 

Cream which was below the legal standard in fat was obtained as follows: 

1 sample each, from The Canton Restaurant of Springfield; from The Royal 
Chinese and American Restaurant of Northampton; from Fairburn's Restaurant 
of Lowell; from Boulevard Restaurant of Pittsfield; from Orient Restaurant of 
Holyoke; and from Nicholas Dascale of Newburyport. 

Maple syrup which contained cane sugar was obtained as follows: 

3 samples, from Cole's Inn of Lowell; 2 samples each, from Chin Lee Restaurant 
of Lowell; Du Pont's Sea Grill of Haverhill; and The Star Lunch of Lawrence; 
and 1 sample each, from The Traymore, W. J. Bond, Charlesbank Cafeteria, Crim- 
son Lunch, Mayflower Lunch, and The Imperial Restaurant, all of Cambridge; 
from Plaza Lunch and Fairburn's Restaurant, both of Lowell; from Canton Low 
Company, New China Restaurant, Royal Restaurant, and Jarvis Cafeteria, all 
of Lawrence; from Chinese Restaurant of Maiden; Mansion House, A. Wedge, 
Maniatty's, and Mohawk Restaurant, all of Greenfield; from Parker's Restaurant 
and Alpha Lunch, both of Worcester; from Hub Lunch, Boulevard Restaurant, 
and Majestic Lunch, all of Pittsfield; from Mayflower Lunch of Salem; and from 
New Park Square Hotel of Westfield. 

Two samples of frozen custard which were falsely advertised were obtained from 
Kohir Brothers, concessionaires from New York. 

Two samples of soft drinks which contained color and were not so labeled were 
obtained from Superior Bottling Company Incorporated of Salem. 

One sample of butter which was low in fat was obtained from Tait Brothers of 
Springfield. 

One sample of butter which was sold as fresh but was cold storage was obtained 
from The Mohican Market of Holyoke. 

Hamburg steak which contained a compound of sulphur dioxide not properly 
labeled was obtained as follows: 

5 samples from Sawyer's Market of Taunton; 2 samples, from Ovila Beauchamp 
of Holyoke; and 1 sample each, from Porter Brothers and Louis Ward of Brookline; 
from David Waks of Boston; from Bertha Lebow of Cambridge; from Jacob B. 
Pearlswig of Maiden; from Atlantic and Pacific Store Incorporated of Framingham; 
from Hager & Houghton Company of Gardner; from Colonial Market and John 
Parent of Haverhill; and from United Butchers Company of Attleboro. 



34 

One sample of hamburg steak which was decomposed was obtained from Herman 
Zass and Louis Zass, both of Fall River. 

Two samples of sausage which contained starch in excess of 2 per cent were 
obtained from Arthur Manley of Methueu; and 1 sample, from A. C. Hunt of 
Springfield. 

One sample of sausage which contained a compound of sulphur dioxide not prop- 
erly labeled and also contained starch in excess of 2 per cent was obtained from 
Eugene Barthol of Gardner. 

There were fourteen confiscations, consisting of 136 pounds of decomposed 
chickens; 203 pounds of decomposed fowls; 145 pounds of decomposed geese; 21% 
pounds of decomposed turkeys; 11 pounds of decomposed lamb; 7 pounds of decom- 
posed fresh shoulder; 40 pounds of decomposed veal; 101 cans of decomposed orange 
marmalade; and 5 cans of decomposed cranberries. 

The licensed cold storage warehouses reported the following amounts of food 
placed in storage during the month of September, 1926: — 866,520 dozens of case 
eggs, 317,315 pounds of broken out eggs, 2,248,455 pounds of butter, 1,066,174 
pounds of poultry, 2,720,564 pounds of fresh meat and fresh meat products, and 
2,841,598 pounds of fresh food fish. 

There was on hand October 1, 1926: — 9,363,270 dozens of case eggs, 1,967,256 
pounds of broken out eggs, 15,932,970 pounds of butter, 3,244,779 pounds of 
poultry, 9,598,425 pounds of fresh meat and fresh meat products, and 21,890,121 
pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of food 
placed in storage during the month of October, 1926: — 481,260 dozens of case 
eggs, 355,955 pounds of broken out eggs, 768,316 pounds of butter, 1,501,248 
pounds of poultry, 1,949,775 pounds of fresh meat and fresh meat products, and 
3,093,463 pounds of fresh food fish. 

There was on hand November 1, 1926: — 7,091,520 dozens of case eggs, 1,779,091 
pounds of broken out eggs, 13,442,388 pounds of butter, 4,017,969 pounds of 
poultry, 7,275,800 pounds of fresh meat and fresh meat products, and 21,334,936 
pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of food 
placed in storage during the month of November, 1926: — 488,220 dozens of case 
eggs, 281,656 pounds of broken out eggs, 429,498 pounds of butter, 1,692,636 
pounds of poultry, 2,355,617 pounds of fresh meat and fresh meat products, and 
1,558,956 pounds of fresh food fish. 

There was on hand December 1, 1926: — 4,429,470 dozens of case eggs, 1,537,870 
pounds of broken out eggs, 9,362,843 pounds of butter, 6,059,507 pounds of poultry, 
6,683,283 pounds of fresh meat and fresh meat products, and 17,292,582 pounds of 
fresh food fish. 



35 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH. 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council. 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration . 
Division of Sanitary Engineering 

Division of Communicable Diseases 
Division of Water and Sewage Lab 

oratories 

Division of Biologic Laboratories 

Division of Food and Drugs 

Division of Hygiene 
Division of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark. 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, Merrill E. Champion, M.D. 
Acting-Director, 

Henry D. Chadwick, M.D. 



State District Health Officers, 



The Southeastern District . 

The Eastern District . 
The Northeastern District . 
The North Midland District 
The Worcester County District 
The Connecticut Valley District 
The Berkshire District 



Richard P. MacKnight, M.D., New 

Bedford. 
George T. O'Donnell, M.D., Boston. 
Lyman A. Jones, M.D., Swampscott. 



Oscar A. Dudley, M.D., Worcester. 
Harold E. Miner, M.D., Springfield. 
Leland M. French, M.D., Pittsfield. 



Publication of this Document approved by the Commission on Administration and Finance. 
5,000, 4-*27. Order 8641. 



THE 
COMMONHEALTH 



Volume 14 

No. 2 



>L APRIL-MAY-JUNE 
&^ 1927 




CANCER 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 

GEORGE H. BIGELOW, M.D., COMMISSIONER 



i> 



THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of 
Public Health. 

Sent Free to any Citizen of the State. 

Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 



PAGE 

The Cancer Program of Massachusetts, by George H. Bigelow, M. D. 39 

Cancer Studies by the State, by Herbert L. Lombard, M.D. 41 

National Aspects of Cancer, by Franklin G. Balch, M.D. . .42 

How Private Organizations are Helping, by Edith R. Avery 44 

Social Service and the Cancer Campaign, by Ida M. Cannon 45 

The Part the Nurse Can Play in Cancer Control, by Elizabeth Ross, 

R. N 47 

Cancer Education in Massachusetts, by Mary R. Lakeman, M.D. 48 

Service at the Pondville Hospital, by Robert B. Greenough, M.D. 51 

The Cancer Clinic, by Kendall Emerson, M.D. .52 

Editorial Comment: 

The Summer Round-Up ....... 55 

May Day 55 

Immunization ......... 56 

Winchester Health Survey ....... 57 

Advisory Committee on Dental Hygiene . .57 

The Control of Communicable Diseases . . .58 

A Public Health Institute 58 

The Control of Ophthalmia Neonatorum . . . .58 

Report of Division of Food and Drugs, January, February and 

March, 1927 61 



39 
THE CANCER PROGRAM OF MASSACHUSETTS 



By George H. Bigelow, M.D. 
State Commissioner of Public Health 



Massachusetts has the highest death rate from cancer of any state 
in the Union. In spite of such factors as the increasing length of life, 
improved diagnostic acumen, different racial distribution and density 
of population, some of which can be allowed for and all of which we 
are studying, it still remains true in all probability that we have rela- 
tively the largest cancer problem of any of the states. We have about 
5,000 deaths each year, which means nearly 10,000 cases. There is an 
average delay of eight months from the first symptom to the first visit 
to a doctor. When you consider that a group of uterine cancer cases 
recently studied at the Huntington Memorial Hospital showed that 
each month of delay in instituting rational therapy decreased the 
chances of cure sixteen per cent, it is no wonder that the figures on 
the end results of the "average" case are rather disheartening. Also 
it brings into very sharp relief the enormous importance of the time 
element. The conquest of cancer, in view of our present knowledge, is 
a fight against time. 

The cases that are beyond hope of cure offer a different problem. 
The death rate of this group cannot be affected but through them the 
humanities can be served. Through recourse to modern resources 
anguish and offense can be reduced, and the period of usefulness and 
at least partial contentment can be prolonged. For this group of cases 
and resources, with any approaching adequate medical care, are much 
more limited than are those for the cases with some hope of cure, since 
the general hospital will handle the latter group. Perhaps two hundred 
and fifty more of such beds are needed for the entire state. Hospital 
expansion, which is sound medically, socially and economically, is a 
very considerable problem and in meeting it we must remember that 
we are forming a precedent which may well be used for the cardiacs, 
arthritics and the whole grist of degenerative diseases which form the 
great no-man's-land of preventive medicine. 

Under the spur of legislation passed in 1926 we have developed a 
tripartite program composed of a cancer hospital, cancer clinics, and 
further cancer studies. The hospital will open in June for ninety 
patients, a third of whom must be ambulatory because of the nature 
of the renovated buildings. It is some twenty-five miles from Boston 
on the Providence Turnpike and will be known as the Pondville Hospital 
at Norfolk. The quality of service will be high as to consultative, vis- 
iting, resident and nursing staff. Thoroughly adequate operating, X-ray 
and radium facilities will be available. In addition to the terminal 
cases a certain proportion of curable or at least alleviatory cases must 
be served in order that they may return benefited into the community 
and thus protect the name of the hospital. Otherwise the place will 
be no more than a gilt-edged almshouse, and the gilding will soon 
begin to chip. But such service is expensive, enormously expensive. 

The cancer death rate can be cut at present only by early recognition 
and the institution of adequate therapy. This means extending diag- 
nostic and therapeutic resources and their full utilization. This in 
turn means local clinics and education of the public. The Department 
is co-operating with cancer committees appointed by the medical so- 
cieties in various of the larger communities. These local medical com- 
mittees are responsible for the policies and the quality of service ren- 



40 
dered. A subcommittee of lay men and women are furthering the dis- 
semination of information as to the proper utilization of these clinics. 
Such clinics are operating at Lynn, Newton, Springfield and Worcester, 
and others will be developed as resources warrant. At one of the 
clinic sessions six of the ten patients were cancerous. Three were 
operable, had never been to a doctor before, and read of the clinic in 
the papers. One patient had lived under the fear of cancer for two 
years following an injury, without daring to see a doctor, and was found 
to be non-cancerous. That session was reward enough for a year's 
work. But the results cannot be judged by clinic figures. Following 
the opening of clinics in one city two competent physicians told of ten 
patients in six days coming to their private offices as a result of the 
general cancer publicity. 

In our education we must be careful not to overshoot the mark. 
Should we develop in ten persons a groundless cancerphobia for every 
one we get to the clinic sufficiently early, we should probably do more 
harm than good. Cancer is a favorite subject to be whispered in old 
wives tales by knitters in the sun. In a generation tuberculosis has 
been lifted out of the bog of vague mouthings regarding "scrofulous 
taint" and "King's Evil" to a position where it can be faced squarely 
and this through community organization, both medical and lay groups. 
Even with our less precise knowledge of cancer, the same can be done 
though it will take more time so we should be less tolerant of delay. 
In addition to the all-important local cancer education committees, the 
Department has seven physicians who have given of their time to speak 
on request, also much printed material for professional and lay groups, 
a film put out by the American Society for the Control of Cancer, mul- 
tiple news articles, and a physician of experience in organizing com- 
munity resources. 

Further cancer studies are imperative, first as a guide to future 
sound expansion of service in this and other degenerative diseases; 
second because of possible leads into the vast unknown of cancer; and 
third because of a considerable obligation to fully utilize the unusually 
rich data available. The co-operation of physicians, hospitals and 
visiting nurses has been magnificent and this is an era plagued with 
questionnaires. But what lines will we study? Is it true that per- 
haps the peak of the cancer death rate is in sight? Does density of 
population, race or occupation play a part? The size of the problem 
for the next generation will depend on the proportion of old people in 
the population. With extension of life, restriction of immigration, 
etc., this is going up. How rapidly? Can resources be taken to the 
home more economically and with a greater quotient of contentment 
rather than eternally taking patients to hospitals which it will break our 
backs to build? Should new beds be centrally located in a few insti- 
tutions far from most of the homes or should they be allocated some- 
how in small units to existing institutions? If there is one time when 
a human being needs all the solace possible from friends and familiar 
surroundings it is when facing the Great Adventure. We found this 
in tuberculosis. Must we go through the same fumbling in hospital- 
izing cancer? What percentage of cancer deaths need terminal hos- 
pitalization and for how long on the average? One month or one year? 
Can we develop from our cases reported in Newton, from our uniform 
clinic records, our district nursing case histories with the control 
histories on non-cancerous, from our hospital records and our death 
returns any new lead as to how these people have lived that they should 
incur this cancerous mystery? Can we develop standards of service, 
however rough, that approach both the adequate and the practical? 
One's head whirls at this vast perspective as contrasted with the near- 



41 

ness of the horizon of the "known." One's head also whirls at the 
enormity of interpreting it all in words of intelligible legislative syl- 
lables. Yes, it is the studies that give promise of the dawn and in 
guiding these studies we can call on high talent to advise us as in all 
the other branches of this work. 

CANCER STUDIES BY THE STATE 



By Herbert L. Lombard, M.D. 
Epidemiologist, Massachusetts Department of Public Health 



Epidemiology is of inestimable value in cancer research. This dis- 
ease requires exhaustive study to separate the facts from the theories. 
In all probability, more diverse theories have been propounded for 
cancer than for any other disease; therefore, sound epidemiology is 
needed to clarify many of the contested points as well as to furnish new 
light on the subject. 

Now epidemiology is based fundamentally on the laws of cause and 
effect. The epidemiologist must continually be searching for the 
causes of disease in order that he may decrease its prevalence. From 
time immemorial it has been the custom of people to reason that be- 
cause an event followed some other event the preceding one was the 
cause. Sumner in his "Folkways" relates that in Molamba, Africa, 
pestilence broke out shortly after the death of a Portuguese there. So 
certain were the natives that this death caused the pestilence they 
took every precaution to prevent any other white man from dying in 
their country. Again he tells of another instance on the Nicobar 
Islands when some natives who had just begun to make pottery died. 
From that time on the art of pottery making was given up and never 
again attempted. 

But one does not need to revert to ancient times and primitive people 
for examples of the "post hoc ergo propter hoc" form of reasoning. We 
are constantly finding specimens of it in all walks of life, and particu- 
larly in cancer theorizing. For instance, a little child had cancer. Her 
grandmother cared for her and later developed cancer. This caused 
the statement that the grandmother contracted the disease from the 
child. On another occasion, a mother had cancer and later her daugh- 
ter developed one, which resulted in the claim that heredity was the 
cause. Three brothers, also, had cancer, and the fourth, who did not, 
attributed his freedom from the disease to the fact that he drank 
alcohol while his brothers did not. These and similar theories must be 
either established or disproved by epidemiological methods. 

We have not had adequate statistics for a sufficiently long time to 
study epidemiology from a biological standpoint. Plague disappeared 
after persecuting us for two or three centuries. Leprosy was once 
very prevalent in Europe. Diphtheria is on the decrease. How much 
of the decrease in these diseases is due to public health measures and 
how much to natural causes we do not know. Will cancer follow 
plague, leprosy and diphtheria? 

Statistics are used to shed additional light on past events and not for 
the purpose of demonstrating anything. To help in this most difficult 
field of separating the truth from the untruth, the State Department 
of Public Health is making several intensive studies into cancer epi- 
demiology. These studies are varied and cover many phases of the 
cancer problem. 

The death records of all cancer patients are being tabulated in a va- 



42 

riety of ways. From them we have learned factors concerning the preva- 
lence of cancer, the ages at which it is most common, the natural dura- 
tion of unoperated and operated cancer, the geographical distribution 
of cancer, the relation between cancer and density, and the relation 
between cancer and nationality. 

While we know that the foreign born have a higher cancer rate than 
the native born in Massachusetts, we are lacking in sufficient data 
concerning the age distribution of the various races and cannot, there- 
fore, compute reliable rates regarding the specific races. This de- 
ficiency is even more marked when we wish to study cancer among the 
Jews, as Judaism is a religion rather than a race, and even crude pop- 
ulation figures are not available. The Massachusetts General Hospital 
is, therefore, making a study of nationality and religion in its relation 
to cancer. The total admissions at the Massachusetts General Hospi- 
tal will make a miniature world in which the cancer rate for the va- 
rious races can be computed. 

Although mortality figures and hospital records for this disease are 
available and have been freely studied, little is known regarding can- 
cer morbidity in the community at large. The physicians of Newton 
are, therefore, conducting a morbidity study. The number of those 
who die of cancer can be ascertained, but as the individuals who had 
cancer and have been cured are usually reticent regarding their con- 
dition, the exact number of cures is unknown. The Newton Morbidity 
Reporting Area should do much to meet the existing need. 

The visiting nurses throughout Massachusetts are filling out ques- 
tionnaires which give, in detail, information regarding the habits of the 
cancer patient. Each nurse will obtain similar information from a non- 
cancerous patient as a control. When a sufficient number of ques- 
tionnaires are obtained any difference which may exist between the 
habits of the cancer patient and the non-cancerous individual can be 
noted, and studies can be made to determine whether these differences 
are instrumental in causing the disease. 

The cancer clinics throughout Massachusetts will furnish neces- 
sary information of a special character. When a patient presents him- 
self to one of the State-aided cancer clinics a few questions are asked 
of him regarding the symptoms and what reason induced him to come 
to the clinic. It is felt that the average patient presenting himself to 
a clinic should be questioned as little as possible owing to his emo- 
tional excitement; and extensive questioning of patients might tend 
to decrease the attendance at the clinics. The few facts obtained, 
however, will furnish valuable data on the social aspects of the disease, 
and the value of the various forms of educational pubicity. 

Studies will be conducted at the Pondville Hospital at Norfolk and 
analysis will be made of data obtained in a house-to-house survey in a 
selected community. 

It is highly improbable that the etiology of cancer will be discovered 
by statistical methods alone, but studies similar to those which we 
are now conducting give promise of furnishing leads which may enable 
men working in the laboratories to arrive at sound conclusions regard- 
ing the cause of this disease. 

NATIONAL ASPECTS OF CANCER 



By Franklin G. Balch, M.D. 

Chairman for Massachusetts 

American Society for the Control of Cancer 

Cancer is one of the big national health problems of the present 



moment, but the fight against it is being taken up all over the country 
by the American Society for the Control of Cancer and in a few out- 
standing instances, as in the case of Massachusetts, by other agencies. A 
vigorous effort is being made towards education: education of the 
laity and education of the doctors. The national Society has through 
its representatives in the various states staged many successful drives 
towards this end and figures begin to show that the effort has not 
been in vain. Statistics prove that cancer is increasing apparently 
more rapidly in the densely populated than in the sparsely inhabited 
portions of the country. This increase seems to be definitely estab- 
lished though, of course, a portion of it may be due to more accurate 
methods of diagnosis and a portion to the fact that people are gradu- 
ally being educated to the fact that cancer is curable in its early 
stages but incurable if allowed to go, and so are reporting cases that 
formerly were allowed to run until some kindly disposed doctor signed 
the death certificate as dropsy or enlargement of the liver or some 
such obscure term concealing a fatal case of cancer. 

The American Society for the Control of Cancer publishes campaign 
notes bringing out all the recent points of progress, reports of what 
the society is doing in the various states in the matter of publicity, 
and so on. It also publishes and distributes large numbers of leaf- 
lets of an educational nature. These are distributed freely to those 
people who apply for them and who will make good use of them. 

Others have written about the work which Massachusetts is doing in 
this connection. It has the honor of being the pioneer state in making 
war against cancer a state obligation. It is to be hoped that ultimately 
other states in the Union will follow her example, but until such time 
the American Society for the Control of Cancer must assume the bur- 
den of the fight over the whole country. The conduct of these cam- 
paigns has been left largely to the individual state chairman with help 
and suggestions from the parent society. They have all combined 
newspaper publicity, with talks to the various men's clubs, women's 
clubs, and even in the churches. 

In educating the doctors more has been done in Massachusetts than 
elsewhere and constant reiteration in the medical journals, the lay 
press, and elsewhere has brought most medical men to see that their's 
is the great opportunity to bring the cases in for early attention. In 
connection with these campaigns free clinics have been conducted, as 
a rule, and it is surprising how many cases, supposed to be unimpor- 
tant, have turned out to be early forms of cancer. Some of these pa- 
tients have gone to the clinics unknown to their doctors and the report 
which they have brought home has in some cases helped to make the 
"backward ten per cent" of medical men awake to the necessity of 
doing something if they would keep their patients. Not the least ad- 
vantage of these clinics is perhaps the peace of mind which they bring 
to patients who had themselves supposed they had cancer and learn on 
the highest authority that they have not. When we consider that 
cancer is a disease not of infancy or early years, but takes patients who 
are in their fullest activities, it is readily seen what an enormous 
economic loss it causes. Recent opinion seems to show that nearly 
seventy per cent of these patients having cancer in easily recognized 
positions could be cured if the disease were discovered early enough 
and promptly operated upon. It is not alone that the patient is slow 
to report to his doctor but a surprisingly large number of doctors are 
negligent-in letting these cases go until the golden opportunity when 
they were curable has passed. This neglect seems to be about as com- 
mon in one part of the country as another, but an improvement is evi- 
dent in localities where an educational campaign has been carried on. 



44 
We have no accurate figures on this for the country as a whole but 
the recent experience in Pennsylvania as shown in the latest report of 
the Pennsylvania State Cancer Commission is probably typical. They 
compared the results of 1910 with those of 1923. People are seeking 
aid earlier and doctors are for the most part paying attention to com- 
plaints much earlier. There is still a small proportion of physicians 
whose methods are dilatory and whose treatment is inefficient. The 
full report can be found in the Atlantic Medical Journal for September, 
1924 and is well worth reading. It certainly shows that cancer educa- 
tion pays and has reduced the interval between the time of the discov- 
ery of the disease and the application of the proper remedy to an ex- 
tent which greatly increases the patient's chance of recovery. Thir- 
teen years of education has reduced the average time between the dis- 
covery of the first symptoms in superficial cancer and this first call on 
the doctor 20%. It is still 14.6 months. In cases of deep seated can- 
cer it has been reduced nearly 50%. The doctors have improved even 
more and have reduced the time from first seeing the patient to the 
starting of treatment 65% in superficial cancer and 70% in the deep 
seated varieties. The American Society for the Control of Cancer has 
brought these figures to the attention of the whole country and it is 
fair to predict that another ten years will see as great or even greater 
improvement as the delay is still in excess of what it should be. The 
backward 10% of doctors, as the Commission calls them, were ac- 
countable in 1923 with 77% of the delay on the part of the doctors. 
The 90% of doctors can be held responsible for only 0.9 of a month 
delay. 66% of the doctors first consulted allowed no delay at all. 

The conclusions and recommendations made by the Commission are 
as follows: 

"The Commission believes that this report proves conclusively that 
cancer education pays, and should be continued by all proper means, 
and with increased vigor under the stimulating influence of success. 

It is urged, with the greatest possible conviction, that a cancer 
division be added to the state health department clinics. This would, 
to a very large extent, eliminate the pernicious influence of the "back- 
ward ten per cent," but its greatest usefulness would be in giving poor 
people a chance for thorough examination early. 

The Commission urges, therefore, the establishment of a cancer 
division in the state clinics as the most important work for the future, 
and hopes that the Commission's successors, backed up by the weight 
of the entire state medical society, will make this their major activity 
for the coming year, taking it before the legislature, if necessary. The 
expense of carrying on additional service recommended would be rela- 
tively small." 

As stated before, Massachusetts has taken the initiative in starting 
a campaign of education by establishing cancer clinics in widely sep- 
arated parts of the state and is about to open the Pondville Hospital 
for the diagnosis, study, and care of cancer. It is a step in the right 
direction and as the problem is a national one, it is greatly to be hoped 
that her lead will rapidly be followed by other states of the Union. 

HOW PRIVATE ORGANIZATIONS ARE HELPING 



By Edith R. Avery 
Member of Advisory Committee on Cancer Education 



From my experience as a club woman I appreciate the difficulty of 
presenting subjects of this nature to the average club woman. 



45 

She does not care to hear a lecture which she anticipates may be 
gruesome and must be persuaded that the subject will be treated in 
such a way that it will not be unpleasant to the hearers. 

In spite of this rather discouraging statement it is evident that the 
attitude of club women is changing, although rather slowly. 

We are now receiving requests for speakers on cancer, and in at 
least one instance a return engagement was asked for as the talk 
proved interesting and instructive. 

Mothers are usually ready to listen to lectures on health if such lec- 
tures help them to care for their children more intelligently but when 
the health of the mother herself is under consideration her attitude is 
rather indifferent. 

The first step must be to convince her that periodic health examina- 
tions are not a luxury but a necessity and that danger cannot be over- 
come nor disease checked by her refusal to hear and learn more about 
it. 

The advisability of periodic health examinations has been brought to 
our club members through means of lectures and at conferences. We 
find that women expect their fathers, husbands, sons and brothers to 
have such examinations as most men carry life insurance policies. 

Women policy holders are comparatively few and they have not 
yet acquired the habit of periodic health examinations. 

We must help them form this habit. 

We have asked the assistance of the medical fraternity in presenting 
this subject more clearly to our members as it is at present one of our 
real problems and co-operation will be helpful. 

To sum it up briefly, the best way for organizations to help in the 
cancer campaign is to create an interest among their members, em- 
phasizing the early importance of early diagnosis. 

Such slogans as "Cancer, Be Quick", and "Time, Tide and Cancer 
Wait for No Man", are volumes in themselves. 

They must present lecturers whose words are convincing and in 
whom the audience has the greatest confidence. 

If the public were only as willing to receive information as physicians 
are to give it, much more could be accomplished for physicians have 
been most generous with time and knowledge, but we are not yet in a 
sufficiently receptive mood. 

If people are slow to respond to the efforts being made in their 
behalf we must continue with more publicity and lectures and suggest- 
ing helpful books not too technical for the layman to understand. 

In addition to giving information to members all organizations can 
help by contributing to cancer research funds. 

Men and women are giving their lives to this cause but money is a 
necessity for further research and study. 

SOCIAL SERVICE AND THE CANCER CAMPAIGN 



By Ida M. Cannon 
Chief of Social Service, Massachusetts General Hospital 



Social workers experienced in problems arising out of physical 
ills would probably agree that cancer has through many years, pre- 
sented the greatest of difficulties. They are familiar with the ruthless 
statistics made vivid through knowledge of many individual trage- 
dies, of death at ages when life is most full of interest and capacity, 
normally at its best. They are familiar with the dread and fear not 
only of patients themselves, but of those near to them; fears of death 



46 
and dread of prolonged pain. 

What can the social worker say? What message can she have for 
the public at this time when a campaign of education is being pro- 
moted by the Department of Public Health of our Commonwealth and 
the most progressive of our local Boajds of Health? 

There is surely no use in underestimating the unhappy facts about 
this scourge. We gain nothing by blinding ourselves to them and 
playing the ostrich in the sands. If there is one striking characteristic 
of our American people these days, it is that of our increasing readiness 
to face facts; possibly more characteristic of the young than of the 
old. But I see no other way either of meeting the troubles that are 
inevitable or being ready for the more hopeful aspects of the problems 
that are increasing as scientific medicine makes progress and as it will 
continue to do in its search for truth about the cause and cure of 
cancer. 

One of the facts that we must face is that at present our leading 
medical authorities have no such clear cut plan of campaign with posi- 
tive evidence of cause and cure as they have in tuberculosis for in- 
stance. They are asking the co-operation of the public while the pro- 
gram is in the making, while science is still searching for fundamental 
knowledge of the disease. 

This is the blackest side of the picture. If we face all the facts we 
can also see that there is much encouraging evidence that cancer in 
many forms can be arrested if recognized early and treated by com- 
petent physicians and surgeons. While the fear of cancer seems at first 
thought to be the special dragon we must slay, may it not truly be the 
greatest safeguard if tempered to lead people to seek advice early? 
Thus can we hope to have apprehension lead many to get assurance that 
all is well or the early treatment which, happily, we have reason to 
believe in the majority of instances will arrest the disease? 

The State is inaugurating a campaign unique in public health activ- 
ities of the country. We of the public should stand back of that pro- 
gram, help in the establishment of facilities for diagnosis and treat- 
ment of the highest order in such form and in so far as they are needed 
to supplement what is now available through our present hospital and 
clinic facilities, the services of physicians and public health nurses. 

It is the plan that the new state hospital at Pondville and the local 
cancer clinics as they are established, shall be supplied, not only with 
every modern equipment and physicians of skill, but also that medical 
social service shall 6e available for patients presenting personal prob- 
lems arising out of illness, and for accumulation of such social data 
as may be important to the study of cancer. 

There are still many unanswered questions as to the relation of can- 
cer to nationality, occupation, dietary habits and age groups. But it 
will be chiefly in personal service to the patients that the medical 
social worker will find her place in this program. If we have only the 
best of such service we should find our state hospital and our clinics 
equipped with women trained in medical social work, skilled in psy- 
chological understanding, resourceful in helping people to help them- 
selves when sickness takes them unawares or the necessity comes for 
facing the fact — which is common to us all but which curiously enough 
we never face until we must — that the span of life is definitely limited. 
The quality of the life that remains is then the dominant problem and 
every resource of the physician, nurse and medical social worker 
should be available to help those patients, whose families cannot free 
the patient's mind of haunting fears of leaving dependents unprovided 
for and to make the last days as happy and comfortable as possible. 

The physical problems of cancer, unlike many other diseases of con- 



47 
cern to the public health, are distinctly individual. A great majority 
of patients can be treated successfully with slight interruption of nor- 
mal activities and responsibilities, if we can but get over to the citi- 
zens of Massachusetts the importance of early diagnosis and treatment. 

Not alone the health officers, physicians and public health nurses, 
but the general citizenship of the State ; teachers, mothers, clergymen, 
business men, industrial workers, should have the knowledge on which 
to act intelligently. No public health campaign under our Depart- 
ment of Health has called for more general public support than this 
attack on the problem of cancer. Let us rally to this attack with cour- 
age, with faith in those whose every energy is being given to the search 
for further knowledge of cause and cure and give intelligent co-opera- 
tion with the State's educational program. 

Accurate information as to present facilities for care, cost of hospi- 
tal and nursing home care will surely be found at our State Depart- 
ment of Health and the newly established local cancer clinics. The 
public will learn to turn to them for advice as the quality of service 
justifies public confidence. Patients will tend more and more to go to 
reliable physicians who will be honest with them rather than to the 
unscrupulous charletan who glibly guarantees "cure of all cancer with- 
out the knife." 

Undoubtedly hospital facilities of the right sort must be increased 
where surgical facilities, radium and other effective treatment and good 
nursing care can be secured, not merely for those whose last days may 
have to be spent in the hospital but increasingly for those who need 
only temporary care. Home ties should, of course, never be severed 
unnecessarily and home care with physician and nurse will surely be 
the chief means for care of the bedridden patient. 

Hospitals adequately equipped are costly and should be established 
only when justified by a knowledge of the real community need. We 
are not now prepared to say what more and what kind of facilities 
should be developed. 

There is a place in this program for medical social workers in serv- 
ice to individual patients, in accumulation of information as to the 
types and extent of resources needed for care of patients, in helping 
to extend and interpret to the laity the message of scientific medicine 
on this subject', and to promote the assembling of social data signifi- 
cant to the study of cancer as a social and public health problem. 

THE PART THE NURSE CAN PLAY IN CANCER CONTROL 



By Elizabeth Ross, R.N. 
Superintendent of Nursing, Pondville Hospital at Norfolk 



All leaders in preventive medicine recognize the important part the 
nurse has to play in educational as well as curative health work. This 
does not apply alone to the public health nurse. She may have a 
special responsibility. But, the institutional and the private duty 
nurses also have a wonderful opportunity to teach positive health. The 
nurse has an approach to the individual and to the family group that is 
not given to many, and if she is awake to her opportunity she can 
bring help and hope to many that "sit in darkness." This is especially 
true in the control of cancer. All authorities agree that the hope lies 
in the early diagnosis of the disease and the discovery of the precan- 
cerous conditions before they develop into cancer. Against this is the 
fact that the average cancer patients delay about eight months be- 
tween the first symptoms noted and the first consultation with a physi- 



48 
cian. This fact alone shows the great need of teachers for the gospel 
of prevention. 

To be a good teacher the nurse must make herself familiar with the 
subject of cancer. She should know the early signs that are the first 
danger signals, she should also know what are the approved methods 
of treatment and how and where they are available. There is always 
a question of cost and no person should delay because he cannot afford 
to have the proper medical treatment and care. This means that the 
nurse needs to know what are the medical resources of her city or town 
for caring for people who cannot carry the whole or even part of the 
financial burden of sickness. She should know of such resources as 
clinics, hospitals, private, municipal or state, and what agencies to 
turn to in order to make the best arrangements for the patient and to 
secure the highest type of scientific diagnosis and care. 

It is also of great importance to know something about the fake prac- 
titioners that find the cancer patient such easy prey, for much of the 
money that could be spent in the right kind of treatment flows into the 
coffers of these vultures who are always waiting to prey upon those 
who are sick in body and mind. 

More than anything else, the nurse, if she is to be of help to others, 
must herself have faith in what she teaches or all of her efforts will end 
in failure of the worst kind. She must also have an understanding of 
the many fears, superstitions and the unaccountable feeling that it is 
a disgrace to have a cancer and that it should be hidden as long as 
possible. It will often take real courage for the nurse to free herself 
from these same influences and can only be done by building up a 
barrier of knowledge gathered from the authentic sources. This alone 
will make her sure of herself and useful to others. 

Every nurse, because of her intimate relation to her patients and the 
members of their families, receives many confidences and if she is 
wise and willing to give of herself she will find many opportunities to 
guide those who are fearful of cancer but do not know where to turn 
for advice. 

Suppose every nurse in Massachusetts should say to herself, "I am 
going to save one person from death by cancer. I will do it by watch- 
ing for the early signs that people so often neglect, and if any such 
signs come to my notice I will not rest until everything possible is done 
to eliminate or alleviate the disease if it is found to be present." Could 
anyone give a greater service to his fellowmen? 

The State Department of Public Health, in behalf of the people of 
this great Commonwealth, asks the nurses of Massachusetts to enlist 
in the army that is organized to fight cancer. It asks that they arm 
themselves with knowledge, faith and courage and stand ready to fight 
the good fight. 

CANCER EDUCATION IN MASSACHUSETTS 



By Mary R. Lakeman, M.D. 
Epidemiologist, Massachusetts Department of Public Health 



If it be true that "interest is the greatest word in education" then 
one long step in popular education looking toward the control of our 
cancer problem has already been taken. For in this vicinity there is 
scarcely a mature man or woman who does not, too often for some 
close personal reason, look forward with eagerness to the day when 
our civilization may be freed from tragedies such as have overtaken 
his own family or friends, or show immediate interest in any sugges- 



49 
tion that that day may be at hand. Our task then is not one of arous- 
ing the interest of an indifferent public. Rather it is to transform the 
feeling of fear and undefined dread which generally prevails among 
our people into one of confidence in the ability of modern medicine 
to deal with many of the problems of cancer and to create in them an 
intelligent desire to learn the conditions which lead to the development 
of cancer. 

To respond to this demand with correct information and to reward 
this willingness to face the facts by bringing skilled treatment within 
reach of all is the challenge that confronts us today. 

Nearly every person who develops cancer has received some warn- 
ing in time to prevent a serious outcome through the discovery of 
noticeable lesions before they have become malignant or while in an 
early stage of malignancy. 

No single fact is more obvious as we face the problem of cancer than 
that favorable results follow in a large proportion of cases in which 
the growth is discovered while it is still a local affair and before there 
has been time for the spread of diseased tissue through the lymphatic 
channels to neighboring glands. For instance, eminent surgeons as- 
sure us that at least three-fourths of the cases of cancer of the breast 
might be permanently cured if every woman who discovers a tiny lump 
in her breast were as wise as the few who go immediately to a repu- 
table physician and who take his advice. If the lump is found to be a 
malignant growth his advice will practically always be immediate 
operation, the only safe procedure. As a matter of fact, only about 
18% of such cases are now being permanently cured for the simple 
reason that most of them are seen by the surgeon only after the time 
has passed when the little lump was in reality a single growth. By 
the time it is brought to his attention it has already extended into the 
glands nearby and has become a grave menace to life and health. 
The same is true of skin growths, sores on the lip and other growths in 
accessible regions. 

It has been found that the average person discovering one of these 
symptoms or signs waits eight months before consulting a physician 
— eight precious life-giving months during which, in one form of 
cancer, the possible chances of complete cure are vanishing at the 
rate of 16% with every month of delay. 

Again there is a further average delay of two months before satis- 
factory treatment is given. Perhaps during this time the patient is 
"shopping around" from one doctor to another in the hope of finding 
one who will propose some milder form of treatment than the dreaded 
knife. That "doctor" when found is likely to be an unprincipled quack 
interested alone in securing the patient's money, and often demanding 
payment in advance. 

So far our problem is fairly clear. The facts which everyone needs 
to know are few. They may be learned by a reasonably intelligent per- 
son in a very short time. The real crux of the problem is to bring this 
information within reach of all the people so that we may be assured 
that the person most in need of knowledge of the beginnings of cancer 
may have the facts so vital to him at the time when such knowledge 
may determine the balance between life and death. 

It was upon the suggestion of its Advisory Committee on Cancer Edu- 
cation that the Department of Public Health made a definite effort to 
secure the aid of certain groups of "key" people — those coming in 
close contact with the homes and having more or less intimate rela- 
tions with people as a very practical means of carrying the message 
straight into large numbers of homes. Hence, the nurses of the State 
were approached through their alumnae associations and in the public 



50 

health field. They have responded cordially and are carrying the new 
word of cheer about cancer wherever they go. 

The social workers who know so well the suffering and sorrow that 
come through the ravages of late cancer are eager to have a hand in 
the campaign of prevention and have generously offered to serve by 
studying their own series of cases and by offering opportunities for 
study which come through the large hospital clinics. 

The agents of the life insurance companies have been willing to lis- 
ten to our message and are now carrying into the homes they visit the 
new message of hope about cancer. 

The women's clubs and other women's organizations and a few of 
the men's clubs have shown an interest beyond our fondest hopes if we 
may judge by the number of requests for speakers and the interest 
shown by members of these organizations. The lessons of cancer are 
of especial importance to club women because of the coincidence of the 
age at which cancer is most prevalent with that of the average club 
member. It is among women over the age of 30 that perhaps the 
greatest amount of good can be accomplished by extending knowledge 
about cancer for it is in this group that two of the most promising and 
at the same time the most prevalent forms occur — cancer of the breast 
and cancer of the uterus. 

Perhaps the most valuable of all the proposed means for reaching 
the public will be found in the groups of interested citizens who are 
acting as educational committees in the cities in which cancer clinics 
have been and are being established. These committees are assuming 
full responsibility for public education in plain facts about cancer 
which everybody should know and for the spread of information about 
the clinic facilities in each community. 

These committees are in several instances also facing the social 
problems, and questions of hospitalization which are opened up as 
existing cases of cancer in a community are brought to light. 

To judge the effectiveness of our campaign of education we must 
consider it in two aspects : 

1. The long time educational program by means of which, if it suc- 
ceeds, we shall have an enlightened public opinion in the essential fac- 
tors in cancer prevention. 

2. Immediate information designed to bring persons possibly need- 
ing it under treatment. 

The results of the first type of teaching we may not hope to know 
for months or years to come, although from time to time opportunity 
may be found to test the effectiveness of methods used by comparing 
the time with relation to their condition at which patients apply for 
treatment at a given time, such as the opening of a clinic, and again 
after educational measures have been carried on for an extended period. 
If we should find that people on the whole are applying to their physi- 
cians or at a clinic within a period materially less than eight months, 
which is now the average time of delay, we may infer that a measure 
of success has been attained. 

That this time of delay may be shortened through popular education 
has been shown by a study made in Boston over a period of four years. 
During this period the time of delay was reduced from five and one-half 
months to four and one-half months. 

Results from the second type of educational method, the giving of 
immediate information, are readily seen in the attendance at clinics 
as well as in the private physician's office and in the proportion of pos- 
itive cancer cases in relation to the total attendance at the clinic. If 
in our efforts to inform, we may have created undue fear, we shall 
naturally see an unequalled percentage of people who have become un- 



51 
duly frightened. 

Perhaps after all has been said the most fundamental principle h. 
all our cancer education is that of extending the growing custom of 
periodic examinations. When it becomes a universal custom among in- 
telligent people to visit a physician annually or oftener while still in 
apparent health, many a case of cancer will be discovered by the 
physician before the individual in his inexperience can hope to recog- 
nize the danger signals. Through this practice the patient is further- 
more given the advantage of the physician's professional judgment in 
the detection of slight deviation from the normal, while the physician 
is by the same means given an opportunity to make prompt use of the 
newer knowledge of cancer prevention which is now coming at a rapid 
rate from both field and laboratory. 

The aim therefore of cancer education is very direct. It is : 

1. To shorten the time between the discovery of one or another of 
the signs mentioned above or others which might be mentioned and the 
first visit to a physician in good standing. 

2. To minimize the time of delay between the visit to the physician 
and the carrying out of effective treatment. 

3. To encourage the custom of periodic examination by means of 
which a person is given the advantage of a physician's knowledge in 
detecting pre-cancerous conditions or the earliest traces of malig- 
nancy. 

SERVICE AT THE PONDVILLE HOSPITAL 



By Robert B. Greenough, M.D. 
Director of Cancer Commission, Harvard University 



The act of the Legislature which authorized the reconstruction of the 
State Hospital at Norfolk for use as a Cancer Hospital, under the State 
Health Commissioner, was evidently intended to supply, in part at 
least, the lack of hospital beds for advanced cases of cancer, which 
had been demonstrated by the survey made by the Department of Health 
in the previous year. The reconstruction of the buildings and the 
equipment which has been provided, are designed to provide for ad- 
vanced cases of cancer every resource which is known to medical sci- 
ence for the effective treatment of this disease, and for the alleviation 
of symptoms of those cases which may be too far advanced for cure. 
It has been the policy of the Health Department, to provide an institu- 
tion which should be a model for other similar institutions which may 
be established in other portions of the State of Massachusetts, and in 
other states as well. 

To this end, full equipment for the application of radium, and X-ray 
treatment of the most up-to-date type, together with surgical appli- 
ances for standard operative measures and for the newer surgical 
methods such as electro-cauterization and coagulation have been pro- 
vided, together with a medical and surgical staff, experienced in this 
very special line of treatment, and qualified to make use of these 
methods to the best advantage of the individual patient, and to the 
advance of knowledge of this extraordinary and little understood 
disease. 

In these respects the difference between the Pondville Hospital and 
many other institutions for advanced cancer cases will be conspicuous ; 
and by the judicious use of one or more of the many different methods 



52 
hf treatment available, no case will be permitted to feel that something 
-co relieve his condition cannot be done. 

The care of advanced cases of cancer is indeed a very necessary and 
desirable object. Until a better knowledge of the early symptoms of 
cancer is acquired by the public, and by the medical profession as well, 
the need for institutions and resources for the care of advanced and 
incurable cases will be a pressing one, and this need the Pondville 
Hospital will supply to the extent of its capacity. The State's cancer 
program, however, contemplates a far more constructive effort than 
this; for closely linked with the Pondville Hospital there will be a 
series of cancer clinics throughout the state co-ordinated under the 
general supervision of the State Health Department, but organized 
and administered in those existing general hospitals which are suffi- 
ciently supplied with material equipment and professional talent to 
maintain them on the high professional level which is demanded. It is 
these organized free cancer clinics which will be the chief feeders of 
advanced cases to the Pondville Hospital; and it is upon these cancer 
clinics that will rest the chief burden of providing instruction to the 
public as well as to the profession in the diagnosis and treatment of 
the early and curable cases of cancer, which now so frequently have 
progressed to the incurable stage before the nature of their disease 
is recognized. 

It is proposed that a uniform method of recording cases shall be em- 
ployed in these diagnostic clinics, and in the Pondville Hospital as 
well, and material help can be given to those clinics which may wish to 
avail themselves of it by the provision of consultation service, and of 
radium and X-ray therapy also, for those clinics which are not at first 
supplied with these resources. Furthermore, for that part of the com- 
munity which is accessible to Norfolk, a diagnostic clinic for ambula- 
tory cases will be available, second to none in New England in profes- 
sional talent or in resources. With all of these diagnostic and treat- 
ment clinics available, it will be surprising if the high mortality rate 
for cancer in Massachusetts cannot be diminished; and the citizens of 
this State can look with pride upon their legislature and their public 
health officers for the progressive position they have taken in making 
of cancer a problem of State Medicine. 

THE CANCER CLINIC 



By Kendall Emerson, M.D. 
Chairman, Worcester Medical Cancer Committee 



All clinics have two essential objectives: the cure of disease and its 
prevention by education. A cancer clinic differs from others in its 
greater emphasis on the latter function. We are still groping for 
effective methods of treating cancer, but our knowledge of its onset and 
early characteristics has advanced to a point which justifies the exist- 
ence of an educational campaign for its prevention. The clinic is an 
important element in such a campaign. 

There are certain minimum requirements for the physical equip- 
ment of a cancer clinic. Unless there is by fortunate chance a large 
endowment at hand, economy dictates that it be attached to a well 
established hospital, preferably with out-patient facilities. Such a 
hospital should be able to provide necessary housing space, light, heat 
and power. It would have at least the nucleus of essential X-ray appar- 



53 

atus which can be expanded to meet the needs of the cancer clinic. 

Furthermore, a pathological laboratory is a fundamental requirement 
and is available in all grade A hospitals. Scientific and accurate work 
would be impossible without the constant services of a trained patholo- 
gist. 

A clinic should have access to an adequate supply of radium. This is 
among the major difficulties in establishing a proper clinic. Many hos- 
pitals either cannot afford to own radium themselves or do not care to 
assume the responsibility. Emanations can be obtained but often with 
delay and always at considerable expense. For Massachusetts clinics it 
is the writer's opinion that the State Department of Public Health should 
make some provision for supplying necessary radium or emanations at 
a minimum cost. 

Most important of all a clinic should have trained and varied personnel. 
A general surgeon may well be in charge but all the specialties should 
be represented among the physicians on the staff of the clinic, by no 
means omitting the internist. If the patient is to receive adequate treat- 
ment and advice every case should be looked on as requiring a consulta- 
tion and the specialist most immediately interested should contribute the 
value of his advice. 

Lastly a clinic will not serve its full purpose without a comprehensive 
record system. A clerk is necessary for this work and the duties may 
well be assumed by a nurse who has had social service training and who 
is also equipped to do the visiting and follow-up work which such a clinic 
requires. Patients with a presumably hopeless disease are very prone 
to become floaters, trying many physicians, clinics and advertised cures. 
It is self-evident that supervision of the patient outside the actual clinic 
is indispensable. Furthermore, referring physicians should receive let- 
ters from the staff giving the result of findings and recommending treat- 
ment, which latter he may prefer to carry out himself or, if he so desires, 
may be undertaken at the clinic. The staff cannot carry out these details 
and without a tactful and efficient social service worker the enterprise 
will have but a partial success. 

It is not within the province of this paper to discuss methods of treat- 
ment. But it is well to remember that a cancer clinic sponsored by the 
State Department of Public Health is not an experimental laboratory. 
Accepted methods of procedure should be followed and treatment should 
be consonant with that approved by the well equipped cancer centers in 
the country. To this end the director of the clinic and the consultants 
should be men ready to take time for visiting such centers and willing 
to maintain an open mind toward the slow but steady progress being 
made in many parts of the world in the study of this great enemy of 
mankind. 

From the educational standpoint the cancer clinic has two distinct 
duties to perform, one toward the medical profession, the other toward 
the public. Its value to the physician would appear to be self-evident. 
Here the cancer morbidity of the community is at least partially epito- 
mized, and the busy practitioner may come himself for study and obser- 
vation. It is the task of the clinic to make immediately available for 
the profession advances in cancer research or changes in medical opinion 
and practice as they occur. Physicians are encouraged to bring their 
patients personally and follow through the examination, and perhaps 
biopsy, as the case progresses. To every physician who refers a case 
a full statement of the findings is forwarded as soon as the diagnosis is 
complete, and recommendations for the future handling of the patient 
are included. 

The occasional cancer clinics held in the past by District Medical So- 



54 
cieties have always been largely attended and as material accumulates 
at the clinics it is hoped to hold stated demonstrations for the profession 
to further intensive instruction in diagnosis and treatment. It is as yet 
by no means true that the average doctor is sufficiently impressed with 
the importance of the early recognition of suspicious signs and symp- 
toms. We can hardly expect lay co-operation until we are ourselves better 
equipped to meet the requirements of accurate diagnosis and prompt 
treatment while the disease is still in a hopeful period of its development. 

Lay education is carried on through several channels. The staff of the 
clinic should be always alert for the talking points in each individual 
case of tumor which appears at the clinic. Some of the tumors are be- 
nign. A patient should be commended for wisdom in seeking advice, 
never laughed at no matter how insignificant the lesion he may present. 
He should be pointed out as an excellent example of forethought to his 
neighbors and friends. In case the lesion is malignant he should be led 
to see the unwisdom of any delay which he may have shown in appearing 
for diagnosis and his family's attention should be called particularly to 
this criticism. 

The social worker plays a still more important part in this form of 
lay education as she visits at the home of the afflicted and seizes every 
opportunity to instruct the members of the circle in which the patient 
lives in the importance of early diagnosis. 

A lay committee is a most valuable adjunct of the clinic. Such a com- 
mittee calls the attention of clubs, churches and societies to the need of 
early consultation on doubtful bodily conditions. It also handles all 
matters of publicity and secures the co-operation of the Press. Its func- 
tion is to popularize known facts about Cancer in such a way as to arouse 
no hysteria yet still to inspire in the public a wholesome fear of abnor- 
mal physical manifestations and to encourage immediate investigation. 

The distribution of the excellent printed matter issued by the National 
Society for the Control of Cancer is a function of the clinic itself and to 
be carried out as well through all these other channels. It is put out in 
such form as not to be unduly alarming and most of it is in simple terms 
for lay consumption. 

This in very brief form is an outline of the plans and purposes of a 
cancer clinic. The object in view includes a clearer knowledge of the 
incidence of cancer in the community. With this determined the coming 
years must decide by statistical analysis whether our educational meth- 
ods are productive of results in lowering the present high cancer mor- 
bidity in Massachusetts. 



55 

Editorial Comment 



The Summer Round Up. Two years ago the National Congress 

of Parents and Teachers invented a 
most felicitous phrase, not new in itself but new in its applica- 
tion to a phase of public health. This term — the Summer Round 
Up — has to do with a nation-wide endeavor to bring about the 
annual physical examination in the spring of all children who 
are about to enter school for the first time in the fall. This early 
examination allows for the correction of the physical defects 
found, during the summer months preceding the opening of 
school. 

The Summer Round Up offers great possibilities to those pro- 
moting child health. In the first place it is a permanent activity 
since we shall always have children entering school for the first 
time in the fall. Again it is a most definite enterprise whereas 
to many certain important phases of public health work seem 
indefinite and to promise results only in the distant future. 

In Massachusetts this idea of an annual examination seems 
to be meeting with considerable favor this year. Work is being 
carried out in various ways depending upon the facilities of the 
given community. In some, the school department is advancing 
the date of its annual physical examination required by law to 
June so far as the new entrants are concerned. Another com- 
munity will offer this diagnostic service through the board of 
health. Still another one will concentrate its efforts on getting 
the parents of these children to take them to the family physi- 
cian for a careful looking over with subsequent correction of 
defects found. In every instance it is expected that the state 
school record form which is prescribed by law will be used so 
that the examination will not only be of value to the child himself 
but will also aid the school department in that the latter will 
have a record of the health of the child at the very date of his 
entrance into school. 

This movement ought to be of considerable interest to the 
taxpayer. If public health officials are correct in taking it for 
granted that the value of the educational opportunities offered 
the child by the taxpayer will be enhanced by virtue of the fact 
that the child is entering school free from physical defects, then 
we may safely appeal to the average hard-headed citizen to sup- 
port this movement. In order, however, that it may not be left 
entirely to this often nebulous individual called the hard-headed 
citizen the Massachusetts Department of Public Health is en- 
couraging the formation in every town of a child hygiene com- 
mittee whose interest it will be to foster this and other meas- 
ures directed towards the promotion of child health. 

May Day. The celebration of May Day as Child Health Day in 

Massachusetts this year surpassed all expectations. 

Although it is still too early to give definite reports, letters from 



56 

local chairmen and the many press reports tell an interesting 
story and show that a big percentage of the towns throughout 
the State joined in this National Movement. The Department 
has received hearty co-operation from the local chairmen, boards 
of health, school committees, and from private organizations, 
and it is chiefly owing to their efforts that May Day proved 
such a success. 

Displays in stores, book shops and libraries were new features 
this year. Whole communities celebrated Child Health Day this 
year where before it had been left to the schools. 

In some schools the May Day celebration took the form of a 
real recognition day. Children were given badges for the cor- 
rection of physical defects. This is the type of program that is 
most constructive and most permanent. May Day is no longer 
an isolated day of joyful celebration; it is the climax of the 
year's work and a beginning for a bigger health program for 
Massachusetts boys and girls. 

Immunization. As we go to press everyone is planning his or 
her summer vacation and is, of course, antici- 
pating not only a pleasant time but happy results in health and 
pep to last through the winter. In planning a vacation, how- 
ever, it is not enough merely to pick an attractive place to stay 
with plenty of bathing and boating facilities. The swimming 
may be good and the drinking water or milk deadly. 

There are many evils in this world which cannot be warded 
off by the exercise of human care and ingenuity. This is not 
true, however, of certain diseases which so often have their 
origin in the summer vacation. Chief amongst these is typhoid 
fever. The temptation to drink from the roadside stream which 
looks clear and sparkling is very great during a tramp on a hot 
day. The temptation to drop into a small roadside refreshment 
stand and eat ice cream of unknown origin is to many people 
equally strong. Either temptation if yielded to injudiciously 
may turn the happy remembrance of a pleasant vacation into an 
unhappy recollection of typhoid fever. 

The methods for avoiding this anti-climax to a vacation are 
several. Obviously one is to refrain from drinking water or 
milk which is not above reproach. One should avoid eating in 
dirty restaurants. But even with these precautions there is the 
ever present danger of the typhoid carrier who, it will be re- 
membered, has no distinguishing physical characteristics to 
enable us to detect him at a glance. This typhoid carrier may 
infect a perfectly good food supply at any time. We know that 
there must be thousands of typhoid carriers of whom health de- 
partments have no records whatsoever. In order to protect our- 
selves against this danger we have only one recourse and that is 
immunization. Immunization against typhoid can be given by 
any physician with material obtained free from the State Health 
Department . It involves three doses of the immunizing vaccine 



5? 

given at intervals of about ten days. With this immunization 
and with the use of the other precautions already outlined the 
vacationist, full of pleasant anticipations, may go on his trip 
with the consciousness that whatever happens he has at least 
done all that science and common sense dictate. 

Winchester Health Survey. Surprisingly little definite infor- 
mation seems to be available with 
regard to certain most important facts upon which a health pro- 
gram ought to be based. We know relatively little for example 
concerning the relationship of physical defects and retardation in 
school. Again, how much do we know regarding the proportion 
of reported cases of communicable disease especially amongst 
children of pre-school age as compared with cases which never 
get reported. It is important also to know how much non-com- 
municable disease there is existing at any given time in a com- 
munity, diseases which in part at any rate, may be prevented. 
In order to make a study of this sort a community has to be 
chosen whose school and health officials are co-operative; whose 
population is intelligent; and furthermore, which is sufficiently 
near the headquarters of the organization making the study to 
render administrative difficulties as few as possible. The Massa- 
chusetts Department of Public Health has undertaken such a 
study as that outlined above in the town of Winchester. The 
study of certain school records which have been specially kept 
during the past year will throw some light upon the relationship 
between preventable disease and absenteeism from school. The 

house-to-house canvass now being carried on will throw light on 
the incidence of communicable disease and the ages at which it 
is most prevalent and will also tell us something about the pres- 
ent incidence of chronic diseases of one kind or another. A 
summary of the results of this study will appear in a later issue 
of The Commonhealth. 

Advisory Committee on Dental Hygiene. For some time past, 

the department has 
had a dental advisory committee to assist it with advice on the 
fundamental phases of dental hygiene with which the Division 
of Hygiene of the Department is constantly coming in contact. 
It is a pleasure to record that the leaders of the dental profes- 
sion have been willing to serve on this committee. 

The present membership of the committee is as follows: 
Dr. Harold DeWitt Cross, Director, Forsyth Dental Infirmary 

(ex officio) 
Dr. Richard Norton, President, Massachusetts Dental Society 

(ex officio) 
Dr. Frank Delabarre, Chairman, Public Health Committee, 

Massachusetts Dental Society (ex officio) r 

Dr. William Rice, Dean of Tufts Dental College (ex officio) 
Dr. Leroy M. S. Miner, Dean of Harvard Dental School (ex 

officio) 



58 
Dr. Edwin N. Kent, formerly Supervisor of Mouth Hygiene, De- 
partment of Public Health. 
The president of the Massachusetts Dental Hygiene Council 
also is a member ex officio of this committee. This year, Dr. 
Cross occupies this position. 

The Control of Communicable Diseases. The American Public 

Health Association has 
had for some time a committee studying the question of Stand- 
ard Regulations for the Control of Communicable Diseases. The 
first report of this committee was published in the Public Health 
Reports of the United States Public Health Service on October 
12, 1917. A revised report of this committee has been officially 
approved by the United States Public Health Service and was 
published in the Public Health Reports for December 1926. The 
American Public Health Association has also brought out this 
report in a very attractive vest pocket style which can be ob- 
tained at the headquarters of the American Public Health Asso- 
ciation, 370 Seventh Ave., New York City. 

A Public Health Institute. There will be held this summer at 

the Massachusetts Institute of 
Technology a public health institute for health officers and other 
public health workers. The course will run morning and after- 
noon for twenty-seven days beginning Tuesday, July 5 and end- 
ing Thursday, August 4. Mornings will be devoted to lectures 
and round table discussions and in the afternoons there will be 
a laboratory exercise, clinical demonstration or field trip dealing 
with the given subject. 

The fee for the course is $40. Further information may be 
obtained by addressing Prof. S. C. Prescott, Department of Bi- 
ology and Public Health, Massachusetts Institute of Technology, 
Cambridge, Massachusetts. 

The Control of Ophthalmia Neonatorum. Opthalmia neona- 
torum, or inflam- 
mation of the eyes of the new-born, includes all the inflamma- 
tory conditions of the conjunctiva that occur shortly after birth, 
usually before the end of the first month. Although in the ma- 
jority of instances severe conjunctivitis of the new-born is of 
gonorrheal origin, such is not necessarily the case. The in- 
flammation may be due to any of a number of different micro- 
organisms, and even when not of gonorrheal origin may have 
serious results. 

Infection of the eyes, in the vast majority of instances, occurs 
during the process of birth and is due to previous infection of 
the parturient canal of the mother. Infection subsequent to 
birth, however, is possible. 

The prevention of the disastrous sequelae often resulting from 
ophthalmia neonatorum begins, necessarily, with the considera- 
tion of the health of the parents. Disease in parents is, how- 
ever, oftentimes concealed or difficult of diagnosis, so that physi- 



59 
cians must consider whether an adequate system of prophylaxis 
shall require that all children, irrespective of family history, are 
to be regarded as possibly exposed to the infection. Experience 
in lying-in hospitals has shown that the universal use of prophy- 
lactics has, in these institutions, practically stamped out this 
disease. 

The physician should use a prophylactic at the birth of the 
child. The Department of Public Health, through local boards 
of health, distributes free of charge a one per cent solution of 
nitrate of silver for prophylaxis. 

Before leaving a confinement case the physician should in- 
struct the nurse or some member of the family, to notify him at 
once if the baby's eyes become sore, inflamed or discharge mat- 
ter. 1 During the entire period of attending the mother the phy- 
sician should, at every visit, examine the eyes of the child. 

The physician attending the mother, or one called to a case of 
inflammation in the eyes of the new-born, must notify the local 
board of health immediately. 2 

Some physicians still make a distinction between conjunctivitis 
and ophthalmia neonatorum, assuming that the latter only is of 
gonorrheal origin. Reports are often delayed until the condition 
becomes severe, or pending bacteriological examination. Such 
delays have frequently been disastrous. It is impossible, in the 
early stages of the disease, to distinguish those cases which are 
of little consequence from those which will, within a short time, 
be so severe as to make it impossible to save the child's eyesight. 
Physicians should, therefore, report all inflammations of the 
eyes of the new-born, no matter how mild in character. 

On being notified of the existence of a case of ophthalmia 
neonatorum, the local board of health must notify the. Depart- 
ment of Public Health of such a case within twenty-four hours. 3 



1 The law requiring householders to report to local boards of health cases of in- 
flammation of the. eyes of the new-born infants reads in part as follows : "If either 
eye of an infant becomes inflamed, swollen and red, or shows an unnatural discharge 
within two weeks after birth, the nurse, relative or other attendant having charge 
of such infant shall report in writing, within six hours thereafter, to the board 
of health of the town where the infant is, the fact that such inflammation, swelling 
and redness of the eyes or unnatural discharge exists. On receipt of such report, 
or of notice of the same symptoms given by a physician as provided by the following 
section, the board of health shall take such immediate action as it may deem nec- 
essary, including, so far as may be possible, consultation with an oculist and the 
employment of a trained nurse, in order that blindness may be prevented. Who- 
ever violates this section shall be punished by a fine of not more than one hundred 
dollars." (G.L. Ill, Section 110) 

2 Following are the provisions of G.L. Ill, Section 111 : "If a physician knows that 
a person whom he visits is infected with smallpox, diphtheria, scarlet fever or 
any other disease declared by the department dangerous to the public health, or if 
either eye of an infant whom or whose mother a physician, or a hospital medical 
officer registered under section nine of chapter one hundred and twelve, visits be- 
comes inflamed, swollen and red, or shows an unnatural discharge within two weeks 
after birth, he shall immediately give written notice thereof, over his own signa- 
ture, to the board of health of the town: and if he refuses or neglects to give such 
notice he shall forfeit not less than fifty nor more than two hundred dollars." 

3 Following are the provisions of G.L. Ill, Sec. 112 : "If the board of health of a 
town has had notice of a case of any disease declared by the department dangerous 
to the public health therein, it shall within twenty-four hours thereafter give notice 
thereof to the department, stating the name and the location of the patient so 
afflicted, and upon request the department shall forthwith certify any such reports 
to the department of public welfare." 



60 

When a case of inflammation of the eyes of the new-born is 
reported to a local board of health, an immediate investigation 
of the case should be made by an agent of the board. 

If on investigation it is found that the case cannot be given 
proper treatment at home, every effort should be made to have 
it admitted to the Massachusetts Eye and Ear Infirmary in Bos- 
ton, or some other similar institution or specially equipped hos- 
pital. If, for any reason, the case cannot be so removed, it should 
be kept under constant observation by the attending physician 
in consultation with an oculist assisted by a trained nurse, in 
order that no measures may be omitted looking to the prevention 
of permanent damage to the eyes. 

Information for mothers concerning the dangers of this in- 
fantile affection, as well as others, can be accomplished through 
a booklet "Your Baby — How He May be Kept Well", which may 
be obtained from the State Department of Public Health. 



61 
REPORT OF DIVISION OF FOOD AND DRUGS. 

During the months of January, February and March, 1927, samples 
were collected in 149 cities and towns. 

There were 1,721 samples of milk examined, of which 332 were be- 
low standard, 46 samples had the cream removed, and 33 samples con- 
tained added water. 

There were 886 samples of food examined, of which 159 were adul- 
terated. These consisted of 4 samples of butter which were low in 
fat; 9 samples sold as butter which proved to be oleomargarine, 3 
samples of which contained coloring matter; 7 samples of cream which 
were below the legal standard in fat; 1 sample of clams which con- 
tained added water; 3 samples of dried fruits which contained sul- 
phur dioxide not properly labeled; 38 samples of eggs, 28 samples of 
which were cold storage not so marked, 9 samples were sold as fresh 
eggs but were not fresh, and 1 sample was decomposed ; 21 samples of 
maple syrup which contained cane sugar; 20 samples of hamburg steak, 
18 of which contained a compound of sulphur dioxide not properly 
labeled, and 2 samples contained added starch, 1 of which also con- 
tained a compound of sulphur dioxide and was not properly labeled; 
2 samples of kiszki which did not contain sufficient cereal; 47 samples 
of sausage, 32 of which contained starch in excess of 2 per cent, and 
15 samples contained a compound of sulphur dioxide not properly 
labeled; 1 sample of vinegar which was low in acid; 3 samples of soft 
drinks which contained benzoic acid ; 1 sample of maple sugar adulter- 
ated with cane sugar other than maple; and 2 samples of oranges which 
were decomposed. The samples of oleomargarine were submitted by 
the Department of Agriculture. 

There were 95 samples of drugs examined, of which 22 samples were 
adulterated. These consisted of 3 samples of lime water, 12 samples 
of spirit of nitre, all of which were deficient in the active ingredient; 
4 samples of diluted acetic acid not conforming to the U. S. P. stand- 
ard; and 3 samples of syrup of squill which contained an excessive 
amount of acetic acid. 

The police departments submitted 2,261 samples of liquor for ex- 
amination, 2,241 of which were above 0.5% in alcohol. The police de- 
partments also submitted 31 samples of poisons for examination, 6 of 
which were opium, 11 morphine, 2 phosphorus, 4 iodine, 1 cocaine, 1 
mercuric chloride, 1 codein, and 5 samples which were examined for 
poison with negative results. 

There were 13 samples of coal examined, 7 samples conforming to 
the law, and 6 samples containing an unreasonable amount of impuri- 
ties. There were 78 hearings held pertaining to violation of the Food 
and Drug Laws. 

There were 146 convictions for violations of the law, $2,364 in fines 
being imposed. 

Harry S. Chong, Harold Fisher, and Fred 0. Bean, all of Springfield; 
F. W. Woolworth Company of Fall River; George Chouchos, Harold 
McKenna, and Joseph Nardine, all of Cambridge; Nicholas Dascale of 
Newburyport; Michael Gilhooly of Gardner; John Kielbasa of West- 
field; Ovide Proulx of Southbridge; Nicholas Scomvas and John Toohey 
of Marlboro; and Alex Steve of Holyoke, were all convicted for viola- 
tions of the milk laws. 

William A. Dakis and Joe Fun of Holyoke; Nicholas Dascale of New- 
buryport; Peter Lampropoulous and Brockelman Brothers Company, In- 
corporated, of Lowell; Boulevard Restaurant & Coffee Pot, Incorpor- 
ated, of Pittsfield ; Ung Lang of Springfield ; P. Howe Wong of North- 
ampton; Charlie Jim of Lynn; and James Kokaras of Amesbury, were 
all convicted for selling cream below the legal standard. 



62 

William Lebow of Cambridge; Louis Jacobson of Fitchburg; Ruben 
Porter and Jacob Ward of Brookline ; Morris Sawyer, 2 cases, of Taun- 
ton; Alpha Lunch Company of Worcester; David Waks and Frank 
Bartz of Boston; Louis Zass of Fall River; Woburn Provision Com- 
pany, Incorporated, of Woburn; Ovila Beauchamp, Michael Lenarcen, 
Frank Matusek, Peter Kusnierz, and Honore LaLiberte, all of Holy- 
oke; Boleslaw Kocot, Stanley A. Popielarczyk, and Michael Naznayko, 
all of Northampton; Benjamin L. Barron, Phillip Miller, and William 
B. Meyer, all of Somerville; Great Atlantic & Pacific Company of 
Framingham; Antoine LaLiberte of Lowell; William Kline and Hubert 
J. Feilteau, of Lynn; Bernard J. Arntz of Jamaica Plain; A. C. Hunt 
Company, Samuel Solomon, Edgar Beargeon, and Max Lipovsk, all of 
Springfield; Abraham Goodstine and Thomas M. Kilduff of Roxbury; 
and William Dunphy of Salem, were all convicted for violations of the 
food laws. Alpha Lunch Company of Worcester, and Louis Zass of 
Fall River, appealed their cases. 

John B. Walsh of Brookline; and Manuel Finn, 2 cases, of Maiden, 
were convicted for violations of the drug laws. 

Boulevard Restaurant & Coffee Pot, Incorporated, and Edward Dondi 
of Pittsfield; Brockelman Brothers Company, Incorporated, Lewis G. 
Fisher, Thomas J. Healey, and Max Bogdornoff, all of Lowell; J. J. 
Newberry Company of Worcester; Theodore Buyukles of Northamp- 
ton; Alexander Papouleas of Salem; Princess Cafeteria Incorporated, 
of Medford; Jackson's Confectionery Company, and Douglas Peterson 
of Holyoke ; Harry Kalenus and Harry V. Morgan of Lawrence ; Robert 
Ladabouche of Fitchburg; Patrick A. Sullivan of Chelsea; and Peter 
Varros of Brockton, were all convicted for false advertising. J. J. 
Newberry Company of Worcester appealed their case. 

David Gold, 2 counts, of Springfield; and Jacob Dold Packing Com- 
pany of Buffalo, New York, were convicted for misbranding food. 

Rocco Pandiscio of Fitchburg; Wilfred Pothier and Charles Wy- 
socki of Northampton; Vansilis Poulos and Peter Varros of Brockton; 
David Gold; 4 counts, of Springfield; Morris Risner, Morris Russell, 
Mallie Singer, and H. Winer' Company, all of Boston ; Bernard Sushel 
of Salem; Henry Abraham, Abel S. Price, and Leo Rind, all of South 
Boston; George Christopher, Leo Hiller, and M. Winer Company, all of 
Cambridge; Felix Cincotta, Andrew Fitzgerald, and George Smith, all 
of Marlboro; Abe Morse, Harry Scepasisky, Harry Tobin, Thomas Kil- 
duff, and H. Winer & Company, all of Roxbury; William Duggan of 
Taunton ; James Hume of Arlington ; Max Jacobson, Michael Lenarcen, 
and Robert Persky, all of Holyoke; Antonio Ancelmo, Aldige Chausse, 
Robert Gouveia, John Moura, George Venetias, Michael Blaszezak, Er- 
nest L. Larievere, and Puritan Grocery Stores, Incorporated, all of New 
Bedford; Louis Angelakis, Peter Chipouras, and Albert Lombara, all 
of Lynn; William Corey of Lawrence; Hannibal Ferraris and Gastino 
Zaia of Everett; Joseph M. Aleknas of Milford; Louis Ash, Oscar Con- 
lomb, Arthur J. Levesque, and Manuel F. Rapnsode, all of Fall River; 
Nicholas Bulavko, Frank S. Hollis, Hormespas Moses, Abraham J. 
Panitch, Robert Peach, Jacob Pollen, Louis Promisell, H. Winer Com- 
pany, and Morris Cohen, all of Chelsea; and Paul Baranow of Lowell, 
were all convicted for violations of the cold storage laws. H. Winer & 
Company of Roxbury; and William Corey of Lawrence appealed their 
cases. 

Arthur King, 3 cases, of Sutton; Charles H. Taylor and William 
Walker of Harwich ; and W. Ptak of Housatonic, were all convicted for 
violations of the slaughtering laws. 

Eastern Mattress & Bed Spring Company of Lowell was convicted 
for violation of the mattress law. They appealed their case. 

In accordance with Section 25, Chapter 111 of the General Laws, the 






63 

following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers: 

Milk which contained added water was produced as follows : 5 sam- 
ples, by Robert Talent of Millis; 3 samples each, by Harry Terzian of 
Whitman, Garabed Kahayian, and Anthony Staniunas, both of Bolton; 
and 2 samples, by Einar Mortensen of Holliston. 

Milk which had the cream removed was produced as follows: 3 sam- 
ples, by Marshall Barrier of Franklin; and 1 sample, by Mary Dineen 
of Millis. 

Sausage which contained starch in excess of 2 per cent was obtained 
as follows: 

6 samples from Albany Packing Company of West Albany, New 
York; 3 samples from Honore LaLiberte of Holyoke; 2 samples each, 
from Uphams Corner Market of Dorchester, and Antoine LaLiberte of 
Lowell; and 1 sample each, from Chicopee Sausage Company of Chico- 
pee; from George Legare of Haverhill from Henry Furneaux of Law- 
rence ; and from H. J. Feilteau of Lynn. 

Sausage which contained a compound of sulphur dioxide not properly 
labeled was obtained as follows: 

3 samples from Bernard J. Arntz of Jamaica Plain; and 1 sample 
each from William P. Meyer of Somerville; Cooley Store of Pittsfield; 
Masonic Street Cash Market of Northampton; and Joseph Patnaude of 
South Hadley Falls. 

Hamburg steak which contained a compound of sulphur dioxide not 
properly labeled was obtained as follows: 

2 samples from Peoples Market of Holyoke; 1 sample each, from 
Village Market, and Joseph Glen of Brookline; from Wasye Macina & 
Michael Nezayka of Northampton; from Frank Matusek & Stanley 
Sigda of Holyoke; from Peoples Market of Fitchburg; from Philip 
Miller and Benjamin L. Barron, of Somerville ; from Philip Kamisck of 
Chelsea; from William Kline of Lynn; from Woburn Provision Com- 
pany of Woburn; from Abraham Goodstein, and Blair's Food Land Mar- 
ket, of Roxbury; and from North End Market of Boston. 

One sample of hamburg steak which contained starch was obtained 
from Fitts Brothers of Framingham. 

One sample of hamburg steak which contained starch and also con- 
tained a compound of sulphur dioxide not properly labeled was ob- 
tained from Fitts Brothers of Framingham. 

One sample of kiszki sausage which did not contain sufficient cereal 
was obtained from Joseph Kilimonis of Lynn. 

Soft drinks which contained benzoate were obtained as follows: 1 
sample each, from Victory Market, Star Bottling Company, and Hampton 
Soda Company, all of Springfield. 

Dried fruits which contained sulphur dioxide not properly labeled 
were obtained as follows : 

1 sample each, from First National Stores Incorporated of Arling- 
ton; Octave Benjamin of New Bedford and M. Winer Company of 
Roxbury. 

One sample of maple syrup which contained cane sugar was obtained 
from Jackson's Confectionery Company of Holyoke. 

There were eight confiscations, consisting of 1,325 pounds of tuber- 
culous beef; 425 pounds of beef affected with hydremia; 300 pounds 
of beef affected with septicaemia ; 180 pounds of unstamped veal ; 125 
pounds of decomposed hog kidneys, 10 pounds of decomposed chickens ; 
and 40 gallons of decomposed oysters. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of December, 1926: — 
602,430 dozens of case eggs, 193,507 pounds of broken out eggs, 752,130 
pounds of butter, 4,612,494 pounds of poultry, 4,045,913 pounds of 



64 
fresh meat and fresh meat products, and 2,394,143 pounds of frtesh food 
fish. 

There was on hand January 1, 1927, 1,926,270 dozens of case eggs, 
1,251,603 pounds of broken out eggs, 5,326,940 pounds of butter, 9,546,- 
575 pounds of poultry, 8,849,242 pounds of fresh meat and fresh meat 
products, and 13,123,290 pounds of fresh food fish. 

. The licensed cold storge warehouses reported the following amounts 
of food placed in storage during the month of January, 1927: — 411,000 
dozens of case eggs, 414,334 pounds of broken out eggs, 486,997 pounds 
of butter, 1,967,812 pounds of poultry, 4,258,552 pounds of fresh meat 
and fresh meat products, and 2,536,747 pounds of fresh food fish. 

There was on hand February 1, 1927, 624,420 dozens of case eggs, 1,- 
160,898 pounds of broken out eggs, 2,312,417 pounds of butter, 10,358,409 
pounds of poultry, 11,054,421 pounds of fresh meat and fresh meat prod- 
ucts, and 10,072,908 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of February, 1927: — 166,440 
dozens of case eggs, 186,774 pounds of broken out eggs, 647,341 pounds 
of butter, 804,070 pounds of poultry, 3,754,787 pounds of fresh meat and 
fresh meat products, and 2,309,148 pounds of fresh food fish. 

There was on hand March 1, 1927, 162,780 dozens of case eggs, 954,018 
pounds of broken out eggs, 907,459 pounds of butter, 9,668,171% pounds 
of poultry, 12,483,438 pounds of fresh meat and fresh meat products, 
and 6,649,633 pounds of fresh food fish. 



65 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH. 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council. 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration . 
Division of Sanitary Engineering 

Division of Communicable Diseases 

Division of Water and Sewage 

Laboratories 
Divison of Biologic Laboratories 

Division of Food and Drugs 

Division of Hygiene . 

Divison of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scam man, M.D. 

Director and Chemist, H. W. Clark. 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers. 

The Southeastern District . 



The Metropolitan District 
The Northeastern District 

The Worcester County District 
The Connecticut Valley District 
The Berkshire District 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George T. O'Donnell, M.D., New- 
ton 

Oscar A. Dudley, M.D., Woreester. 

Harold E. Miner, M.D., Springfield. 

Leland M. French, M.D., Pittsfield. 



Publication op this Document approved by the Commission on Administration and Finance 
12M, 6-'27. Order 9338. 



THE 
COMMONHEALTH 



VOLUME 14 
NO. 3 




JULY-AUG.-SEPT. 
1927 



DEPARTMENTAL NUMBER 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 






THE COMMONHEALTH 

Quarterly Bulletin op the Massachusetts Department op 
Public Health 

Sent Free to any Citizen of the State 

Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 



PAGE 

Pasteurization, by George H. Bigelow, M.D. ..... 69 

Outbreaks of Contagious Disease and School Closure, by Clarence L. 

Scamman, M.D., and Merrill Champion, M.D. . . . .70 

Hospitalization of the Tuberculous State Case, by Sumner H. Eemick, 

M.D 72 

Some Unsolved Problems in Child Hygiene, by Merrill Champion, M.D. 74 

The Present Status of Some Biologic Products, by Benjamin White, Ph.D. 76 

A Brief Summary of Bacterial Methods and Standards in Water Analysis, 

by H. W. Clark 78 

Editorial Comment: 

Food on the Farm . . . . . . . . .81 

! Training for Schoel Nurses . . . . . . .81 

Reporting Progress ........ 82 

Report of Division of Food and Drugs, April, May and June, 1927 . 83 



69 
PASTEURIZATION 



By George H. Bigelow, M.D., 

Commissioner of Public Health, Massachusetts Department of Public Health. 



Probably the greatest single factor in limiting the spread of disease through 
our food supply is the application of heat. As the remoteness of these food 
supplies and also the numbers of persons handling each article increase, this 
protection becomes more and more important. This is peculiarly true of milk, 
which is particularly susceptible to contamination since it is an animal food, 
is fluid, and in this country is so largely consumed outside of cooking. In Eng- 
land, for instance, where the "milk drinking habit" has not been extensively 
developed, a much less adequately protected supply may cause less disease 
since most of it is cooked. This makes us particularly dependent in this coun- 
try on the protection furnished by pasteurization. In Massachusetts this 
method of applying heat to milk should be even more effective than in the past 
since Chapter 259 of the Acts of 1927 gives health authorities power to license 
all pasteurizing establishments. 

Pasteur showed that heat will attenuate or kill many disease producing 
organisms even though not applied for sufficient time or at a sufficient degree 
to sterilize. Theobald Smith, Park and others showed that 140° F. applied for 
twenty minutes killed tubercle bacilli. We know that the organisms of the 
other diseases commonly spread by milk are killed at lower temperatures or in 
less time. Since pasteurization in this State is defined by statute as a tem- 
perature of 140° to 145° F. applied for thirty minutes, milk so treated is safe, 
provided, no infection occurs after the process. The new law then allows us 
to see that the old law is adequately enforced. What a clumsy thing the law is! 

We have recently brought up to date the studies of milk-borne disease in 
Massachusetts, previously made by Dr. Kelley. From 1910 to 1923 there had 
been a decrease of some 90 per cent in the amount of sickness annually traced 
to milk. By 1926 there was a still further reduction in the total number of 
cases, but there was nothing like as great a reduction in total outbreaks. In 
other words, although in the last three years each outbreak of scarlet fever, 
diphtheria, septic sore throat, or typhoid fever traced to milk showed fewer 
cases per outbreak, the total number of such outbreaks showed no such en- 
couraging reduction. This is important since a milk supply showing five dis- 
tinct outbreaks totaling fifty cases of disease traced to it in a given time 
is in all probability much more vulnerable than one showing one outbreak of 
fifty cases in the same time. We can control whether or not infection is pres- 
ent, but given the presence of infection we cannot control the number of cases 
produced. Thus the safety of our milk supply has probably not increased as 
much as the decrease in total milk-borne disease would indicate. 

Further improvement will depend, as in the past, on three factors: healthy 
animals, cleanly handling, and adequate pasteurization. Extension of the 
tuberculin testing of animals, particularly those that will furnish milk to be 
consumed raw, has to do with the first point. The cleanly methods of handling 
is a matter which local health authorities must supervise. It means constant 
vigil and an adequate budget, although the standards set by certified milk have 
done much to educate the producer to the market value of cleanliness. 

The third factor is the one dealt with in the new legislation. Apparatus 
giving uniform temperature must be assured, the operator who pasteurizes 
by "instinct" without a thermometer must be done away with, the infecting of 
the finished product while cooling, storing in dirty containers, or capping must 
be prevented. Under the law the State Department of Public Health is re- 
quired to draw up rules and regulations to this end. Under these the local 
boards of health are to issue licenses to all plants that would pasteurize. The 
license may be revoked by either local or state health authorities for violation. 



70 
Some timorous souls fear that by airing the dangers of raw or inadequately 
pasteurized milk the public may be frightened away to some more dangerous 
beverage. They feel that every effort should be made to produce a safe product 
but that these efforts should be made quietly and under a thick screen of 
silence, lest the great nutritive value of this product be lost through appre- 
hension. But the public is getting too sophisticated to feel that just because 
milk is white and can still be poured it is therefore safe. As they hear of this 
legislation and its enforcement they will gain confidence in the safety effected 
by pasteurization. Confidence is the greatest asset any producer can have. 
One community has shown a 25 per cent increase in the consumption of milk 
in the two years since a strict milk ordinance was enforced. Our recent study 
showed that a general increase in milk consumption of 25 per cent would be of 
advantage to the general health of the people of the entire State, but only if 
that milk were safe. Now some 60 per cent of our people have heat protected 
milk. But what of the other million and a half ? The opponents of pasteuriza- 
tion will point to the recent typhoid scandal in Montreal and say that was pas- 
teurized milk. Do not be deluded. There is reason to suppose that the cause 
was raw milk that was passed out from a pasteurizing plant. Even should 
it prove to be pasteurized milk (and proof may be difficult to get because of 
conflicting commercial and political interests) it was inadequately pasteurized 
since typhoid bacilli cannot live in milk treated for thirty minutes to 140° F. 
or more. The public, the producers, the dealers, will all profit by adequate 
enforcement of this new legislation since it will mean greater confidence in, 
and greater consumption of, our most valuable single food product, milk. 



OUTBREAKS OF CONTAGIOUS DISEASE AND SCHOOL CLOSURE 



By Clarence L. Scamman, M.D., 

Director, Division of Communicable Diseases 

and 

Merrill Champion, M.D., 

Director, Division of Hygiene, Massachusetts Department of Public Health 



Boards of Health and School Committees, especially in communities of 10,000 
or under, are often at loss whether to close schools or to keep them open in the 
presence of an outbreak of communicable disease. The problem is not so diffi- 
cult with the less fatal of the so-called diseases of childhood, namely, chicken 
pox, german measles and mumps. Public panic in the presence of these three 
diseases, even though they may be epidemic, is seldom great enough to force 
school closure. With the continued high prevalence of diphtheria, scarlet fever, 
measles and whooping cough in a community the health authorities are often 
obliged to consider whether or not schools shall be closed. One may well ask 
here what forces the hand of the health authorities to close the schools in such 
circumstances. In general the answer is the pressure of public opinion. What 
are the factors which ordinarily crystallize public opinion? The people them- 
selves with their neighborhood gossip; the school authorities, including the 
superintendent and every teacher; the health authorities and the community 
physicians; and last but by no means least the attitude of the press — all 
these go far toward the solidifying of public opinion. 

The public can scarcely be blamed for wanting the schools closed. They have 
been led for years to believe that closing the schools would "stop" an outbreak 
of contagious disease. Although most school superintendents and some teach- 
ers are beginning to be divorced from the idea of the magic of school closure 
in the prevention of an epidemic, most school committees and many teachers 
are convinced of its efficacy. Lay members of boards of health and some 
physicians still believe that there is no other way to control outbreaks of con- 



71 
tagious disease. Under such circumstances, with public opinion clamoring for 
"something to be done," one can hardly blame the press for following what 
would seem sound, namely, public opinion. This press support for school closure 
is often clinched by the fact that the school committee wants to close the 
schools and the board of health doesn't know what it wants to do. In any 
event an outbreak of diphtheria or scarlet fever in a town is useful if for no 
other reason than that it brings the school and health authorities together 
so that when the affair is over they are at least acquainted with each other. 
One can scarcely imagine a more unfortunate situation than that in a grave 
emergency of this type the school authorities and the health authorities are 
found going their own way with complete disregard not only for each other's 
authority but with expressed contempt by individuals of one board for indi- 
viduals of another. Fortunate indeed is that community which has school and 
health authorities working together for the common good, and doubly fortu- 
nate is that community with a superintendent of schools and a health officer 
who are given to discussing problems of this nature together. In such a com- 
munity you will find, even in time of public panic over an outbreak of con- 
tagious disease, that the thinking people, including the physicians and the 
press, will support the opinon and action of its school and health authorities. 
Why? Because they repose confidence in their opinions and will back up their 
acts. 

But what can be done in an outbreak of diphtheria or other infection to con- 
trol the situation if not to close the schools ? 

Seek out the sources of infection in the community. These sources can be 
discovered with the aid of medical and nursing personnel plus the cooperation 
of the practising physicians and the householders. 

With the schools open this task is much easier from every possible point of 
view than with them closed. All absentees are readily noted and their physical 
condition can be determined almost immediately. In visiting households to 
check up on the condition of this group the physician and nurse can inquire 
into the history of illness in other members of the family, and make such ex- 
aminations or take such specimens for laboratory examination as may be indi- 
cated with the cooperation of the family physician. 

While this type of investigation is going on the community physicians can 
be interviewed by telephone in regard to any cases under their care which may 
be of the type of contagion under consideration. If necessary a house to house 
canvass can be made to determine whether or not any mild or unrecognized 
cases exist in the community. 

In the meantime, every child entering school morning and afternoon with the 
slightest suspicious symptoms has been segregated until seen by the school 
physician. If the usual staff of school physicians is unable to see the group 
of children excluded, the staff should be increased during the emergency. 

All the information gathered by the groups, whether working under the 
direction of the school authorities or health authorities, should be made avail- 
able for the executive officers of both board of health and school committee. 
These two individuals and their staffs of physicians and nurses can control any 
situation of this sort much more effectively by pooling their resources. 

Such an emergency almost always means the expenditure of money for an 
increase in the number of physicians and nurses, for without these two groups 
working immediately to locate "missed" or unrecognized cases or in the case 
of diphtheria and scarlet fever "carriers" there is no hope of controlling an 
outbreak. 

Health authorities are beginning to realize that it is not enough to isolate, 
quarantine and placard in our attempts to control contagion. Active effort at 
least must be made to locate if possible the sources of infection. This is by no 
means simple. Keenest efforts in this direction are often unsuccessful. Never- 
theless there is a source, and the source ordinarily is either an unrecognized 
case of the disease or a "carrier." 



72 

"Transmission," as Hill says, "is accomplished with few exceptions by the 
route that infected body discharges take from the patient or carrier to the 
uninfected individual." This cannot be repeated too often. 

The public must learn that "people, not things, spread disease." They must 
understand that if the recognized cases of the disease are properly isolated, 
their importance, in so far as the spread of infection is concerned, is rela- 
tively small in comparison with the importance of the unrecognized cases and 
"carriers" in the community. In this connection it is not too much to say that 
almost never are all the cases of a particular disease reported to the health 
officials, the reason being that physicians are never called to many mild cases. 

We may summarize, then, in conclusion: 

(1) The closing of schools in time of epidemic or threatened epidemic is 
usually the result of well-intentioned but poorly informed public opinion. 

(2) There is too often a lack of cooperation between school committee and 
board of health with respect to procedure to be followed. 

(3) With schools open and school and health departments cooperating, a 
daily watch may be kept on communicable disease suspects both in the school 
and at home. 

HOSPITALIZATION OF THE TUBERCULOUS STATE CASE 



By Sumner H. Remick, M.D., 

'Director, Division of Tuberculosis, Massachusetts Department of Public Health 



The hospitalization of the so-called "State case" presents one of the most 
serious problems in our progress toward eradicating tuberculosis, as we rec- 
ognize the advanced case, with positive sputum, must be institutionalized if 
we are to protect the home and the community from the spread of infection. 

Let us first define the exact meaning of "State case" in Massachusetts. The 
term is used to describe a resident of the Commonwealth, who, owing to our 
complicated and antiquated settlement laws, has not been able to acquire a 
so-called legal settlement in any city or town. To acquire a legal settlement 
a person must have lived at least five continuous years in a given community, 
without aid. "State cases" may have been born in other states or other coun- 
tries, or within the boundaries of our own state. Hundreds of these cases have 
contributed their share to society and the Commonwealth all their lives, but 
are unable to weather the storm when illness overtakes them and are forced 
to seek the aid of the Commonwealth and its facilities for hospitalization. The 
only hospital which provides care for the "State case" is the unit at Tewks- 
bury, which is under the management of the State Department of Public Wel- 
fare. Unfortunately the tuberculosis unit at Tewksbury is unpopular and the 
task of persuading patients to go there is most difficult, The tuberculosis unit 
of this institution consists of two buildings, one for men and one for women, 
well equipped and excellently located at a considerable distance from the main 
group. Dr. John Nichols, the superintendent, has done everything possible for 
the comfort of his patients with the funds available, but in spite of the effi- 
cient management the hospital is so greatly handicapped by inadequate ap- 
propriations it cannot equal the service rendered at the State Sanatoria. At 
the State Infirmary at Tewksbury the weekly per capita cost is approximately 
$8.00, while we find a $15.00 per capita cost prevails in the Sanatoria. This 
spells the difference between success and failure of the two services. It is 
acknowledged by all health agencies that few patients willingly go to Tewks- 
bury for the above reasons, together with the unfortunate publicity which 
this institution suffered years ago and has been unable to live down. 

To illustrate the present situation let us put ourselves in the place of Mrs. B., 
a cultured lady of 40 years of age, who has developed tuberculosis; married, 
and the mother of five children, whose husband, owing to the character of his 



73 
work, has been unable to live five consecutive years in any one place, thus 
having no legal settlement. _ Due to his moderate salary and large family he 
has been unable to save enough money to send his wife to a private hospital. 
Thus they are forced to appeal to the State for help in their great need. The 
only place the State can care for Mrs. B. is at the tuberculosis unit at Tewks- 
bury. So great is Mrs. B.'s aversion for the "almshouse," as she calls it, she 
will not accept what the State offers. She thus remains at home, where she 
may or may not recover, and probably will infect her entire family. This is 
not a pretty picture but a perfectly true one. Many similar cases could be 
cited. The Division of Tuberculosis is constantly facing these situations but 
the jurisdiction does not lie with the Department of Public Health, where it 
might appear to belong. The Division of Tuberculosis could not care for these 
cases because there are not enough available beds in the State Sanatoria, while 
at the State Infirmary there are nearly always vacancies. 

To show another side of the situation let me cite this example: A certain 
city in a county having a contract with the State Department of Public Health 
to hospitalize its cases at the State Sanatorium at Rutland, recently had sev- 
eral "State cases" which it tried to send to Tewksbury. Only two could be 
persuaded to go. In a very short time they absconded and returned home. 
The city, feeling that this burden properly belonged to the State, would not be 
financially responsible for their care at Rutland, where the patients could be 
persuaded to take treatment. Again you find the patient staying at home, a 
danger to its members and to the community. I contend that these unfortunate 
people should have the same privileges as other citizens in the Commonwealth 
ill with tuberculosis, namely, the care and treatment equal to that provided in 
the State Sanatoria. How much longer is this illogical and unjust situation to 
continue? If it does continue it is because it is known only to the official 
health agencies and to a very small number of citizens interested in our pro- 
i gram for the control of tuberculosis. I believe it can be remedied, with or 
without legislation, but in both instances by an increased cost to the State. 
I offer the following possible solutions for consideration: 

First: To change the present settlement laws. 

This probably is not possible as tuberculosis constitutes a minor problem as 
compared to the whole settlement problem, which is too complicated to be 
discussed. 

Second: No change in laws or present policy but an increase in the appro- 
priation for the tuberculosis unit at Tewksbury so that service may equal that 
of State Sanatoria, thus making Tewksbury more acceptable and attractive to 
the patient. 

Third: That the management of the tuberculosis unit at Tewksbury be 
transferred from the State Department of Public Welfare to the Division of 
Tuberculosis under the State Department of Public Health. This would imme- 
diately place this unit on a par with the State Sanatoria, provided adequate 
appropriations were made. It would undoubtedly help local health authorities 
to persuade their patients to enter this institution. 

Fourth: To abandon the entire unit at Tewksbury and hospitalize all "State 
cases" locally in the State, County and Municipal sanatoria. Under this plan 
the Department of Public Welfare or the Department of Public Health would 
reimburse these hospitals at a reasonable rate per week. This proposal, with- 
out doubt, would be the most satisfactory to the patients and their friends and 
thereby accomplish the most good. It would, nevertheless, be the hardest to 
put into effect because it would necessitate adding beds to some local insti- 
tutions. 

Fifth: State ownership and management of all tuberculosis hospitals, as is 
the case with the Mental Disease hospitals for the care of the insane. The 
initial investment under this policy would be heavy, but under State manage- 
ment the present per capita cost would be reduced and the total yearly burden 
of the taxpayer would be lightened. 



74 

Again, under this plan, it would not be necessary to increase our total bed 
capacity, since the State as a whole has approximately 3,600 beds available, 
with less than 3,000 deaths per year. These could be more efficiently utilized 
under centralized management. 

In this limited space I have tried to sketch the outlines of this serious situa- 
tion, and one which must be met in the near future. These suggestions which 
I have pointed out are the only feasible ones which present themselves to me 
at present. The adoption of any one of these I feel would be a distinct im- 
provement. 

SOME UNSOLVED PROBLEMS IN CHILD HYGIENE 



By Merrill Champion, M.D., 

Director, Division of Hygiene, Massachusetts Department of Public Health. 



One test of intelligence is the ability to face facts, whether favorable or not 
to our own pet projects. It is good for our enthusiasm to dwell on our suc- 
cesses; it is good for our souls to take account of our failures. The following 
discussion will, it is hoped, set forth fairly and without flinching some of the 
baffling phases of child hygiene in the hope that facing facts may stimulate 
to greater efforts at solution of problems still unsolved. 

In order not to scatter our attention over too large a field, let us, for the 
purpose of this paper, consider a few of the difficulties inherent in six phases 
of the child hygiene problem: 

(1) The maternal mortality. 

(2) Early infant mortality. 

(3) Reaching the pre-school child. 

(4) What constitutes adequate school health supervision. 

(5) The child about to go to work. 

(6) The problem of the clinic. 
The Maternal Mortality 

At the first glance, the problem of the mortality due to puerperal causes 
ought to be in a fair way of solution. We have better trained physicians than 
we ever had. We have far more and better trained nurses. We have more and 
better equipped hospitals. But, speaking broadly, the maternal mortality is 
going up, not down. Public health workers have been concerned about the 
maternal mortality for some time. Studies have been made from time to time 
to see if the cause might be found. Such a study was that made by the Mas- 
sachusetts Department of Public Health of 984 deaths due to puerperal causes. 
Many facts are brought out by such investigations. It is found that the deaths 
are not limited to families financially unable to pay doctors' bills. They do 
not occur disproportionately in remote districts far from available medical 
service. Undoubtedly they occur largely amongst those ignorant of hygiene. 
But why are these people too careless of hygiene to avail themselves of ade- 
quate prenatal and obstetric care when information is to be had for the ask- 
ing ? What are the hidden factors — for such there must be — which inhibit the 
activating effect of all our propaganda? We can guess at some, but we don't 
know. We must find out. 

Early Infant Mortality 

The usual infant mortality rates tell only part of the story. They seem to 
be coming down more or less rapidly due to a multiplicity of causes, many of 
which are uncontrollable or at any rate not easily directed. They are lowest 
in many communities which carry on little or no educational work directed 
against the mortality among infants. We know or think we know some of the 
causes of the diminishing rate. Some we cannot explain at all. 

The total infant mortality, however, is not the whole story. The early infant 



75 

mortality — under one month or even under one week — forms, in a large pro- 
portion of cases, 60 or more per cent of the total infant mortality. And this 
early mortality shows small sign of being reduced. New Zealand has done 
wonders with her total infant mortality. As regards her early infant mortality 
and her maternal mortality she is in the same boat with the rest of us. Why 
has not her apparently highly effective work against the total infant mortality 
carried over to a greater degree to prevent early infant and maternal mor- 
tality? Nobody seems to have a convincing answer. Public health workers 
cannot feel certain of their present methods until they can answer this 
question. 

Reaching the Preschool Child 

During the last few years a unanimous cry has been raised that the run- 
about or pre-school child has been neglected. He certainly has been. The 
reason for this, however, is not so often discussed. It is not due entirely to 
carelessness or ignorance that this has come about. The simple fact of the 
matter is that we have no good method for reaching him. The school authori- 
ties cannot do it legally or effectively. The board of health ought to make the 
attempt, but usually does not through lack of funds or interest. Well child 
conferences, whether conducted under public or private auspices, are usually 
not particularly well attended when one considers the number to be reached. 
Besides there are vital questions of family responsibility involved in them, 
touched on more fully later. Parents will not as a rule take their children to 
the family physician for a health examination and even if they did, only a 
superficial examination would as a rule be given except in the case of sickness. 

The so-called Summer Round-Up is the most promising thing developed thus 
far in the field of pre-school hygiene, but this applies only to children about 
to enter school in the fall. 

Must we pin our faith largely to "education" — of parents, of physicians, of 
health workers? This is slow — the slowest thing there is. But is it not the 
only effective measure at our disposal at the present time ? Who will discover 
a more rapid if not a more effective one ? 

What Constitutes Adequate School Health Super-vision? 

Many persons think they can answer this question. But no two persons will 
agree on the answer. How often should the school child be examined ? Taking 
all the difficulties into consideration, administrative and financial as well as 
others, we do not know. It ought to be possible to develop a standard, how- 
ever. How thorough an examination is the school under obligation to give? 
Some would say that a "screening" is enough; others stand out for a complete 
examination and diagnosis. Who should administer the school health pro- 
gram? Many have preferences, but who has irrefutable arguments? What 
should be our attitude towards treatment clinics for school children? Some 
of us are willing to grapple with all comers on this subject and we find plenty 
of persons to grapple with. 

Is it not true that opinion has not yet completely crystallized on the subject 
of school hygiene and rightly enough considering the lacunae which exists still 
in our knowledge of what may constitute basic standards of child health ? The 
study now in progress conducted by the American Child Health Association 
may help us here. 

The Child About to Go to Work 

Here is a child who is sadly in need of a wise attention which he is not get- 
ting now. Some children go to work because they must. More go to work 
because they want to for one reason or another. A few, perhaps, are hanging 
around a school when they would be better off at work. Many more are wast- 
ing their time in school when a more flexible school system might correct this 
condition. 

It may well be asked, what experimental evidence have we from the health 
field upon which to base a categoric answer to the question, How soon may a 



76 
child go to work ? What are the physical results of going to work as compared 
with those of school attendance ? We can hardly feel secure in answering this 
question at present. Several years ago Rowell in New Bedford did some good 
work along this line using the child's nutrition as a criterion. We need more 
investigation of this sort before we can speak as one with authority. 

The Problem of the Clinic 

This is one of the hardest of the puzzles. Theoretically there is an answer 
to it, but, practically, to be consistent in the answer requires that quality of 
being "hard-boiled" which has never been a characteristic of a race of public 
health workers whose traditions are those of sentimentality rather than the 
opposite. It seems to be a fact that a large proportion of the population can- 
not afford first grade medical supervision at prevailing cost. Yet how can such 
a medical need be met without creating a race of dependents who are always 
looking for a "hand-out" at public expense? The tendency seems to be to 
give people, for nothing, that which they are not willing to pay for. This is 
especially true of the child health field. 

The nub of this unsolved problem seems to be: How can the official and 
private community agencies do their duty by the child without weakening or 
destroying the sense of independence of the family? Some quick and accurate 
thinking along this line is needed. 

Summary 

(1) It is good for our souls to think about some of our unsolved problems — 
some of our failures. 

(2) There are many such in the child health field. 

(3) Enough to keep us busy for a long time may be found in the maternal 
and early infant problem; in efforts to reach, adequately, the pre-school child; 
in clarifying our ideas about school health supervision; in studying the child 
about to go to work; and, finally, in helping the average citizen care for his 
child's health without at the same time taking away said citizen's backbone. 



THE PRESENT STATUS OF SOME BIOLOGIC PRODUCTS 



By Benjamin White, Ph.D., 
Director, Division of Biologic Laboratories, Massachusetts Department of 
' Public Health 



In view of the many inquiries which come to this laboratory for information 
concerning the latest developments in the preparation and use of serums and 
vaccines, it seems desirable to summarize some of this information for the 
readers of The Commonhealth. The information most frequently requested 
is as follows: 

1. The Schick Test. 

It now seems advisable to omit the Schick test on all individuals under ten 
years of age because the majority of children of this age group give positive 
reactions and, therefore, the test is unnecessary as a preliminary to active 
immunization. The Schick test, however, should always be done six months 
after the third injection of toxin-antitoxin mixture in order to determine 
whether or not the person has become immunized by the toxin-antitoxin in- 
jections. Great care should always be observed in performing this test. Fresh 
outfits only should be used. They should be kept continuously in the coldest 
part of the refrigerator until they are needed. Only fresh toxin dilutions 
should be employed for injections and the injections should always be made 
into the skin as superficially as possible. 



77 

2. Toxin- Antitoxin Mixture. 

The l/10th L+ mixture as distributed by the Commonwealth still seems to 
be the most satisfactory agent for producing active immunity to diphtheria. 
Three injections of this mixture given a week apart will produce immunity 
within six months in from 85 to 95 per cent of persons so treated. While 
diphtheria toxoid or anatoxin is being used in France, Canada and in certain 
places in this country, it has certain limitations. It appears to have good 
immunizing properties, but its use has to be restricted to children under six 
years of age because in persons of the older age groups it frequently causes 
both local and systemic reactions which, while not dangerous, cause consid- 
erable discomfort. 

3. Diphtheria Antitoxin. 

Diphtheria antitoxin in concentrated solution is now being distributed by this 
Department in 1,000, 5,000 and 10,000 uuit doses. This product has been im- 
proved both in appearance and quality, and these improvements have been 
responsible for a marked diminution in both the number and severity of cases 
of serum sickness following the use of such a product. It should, of course, 
be given at the first suspicion of a case being one of diphtheria and it should 
be given in the manner and in the amounts specified in the leaflet of directions 
accompanying each vial. 

4- Scarlet Fever Products. 

This laboratory does not yet prepare scarlet fever streptococcus toxin either 
for the Dick test or for active immunization. While both these procedures 
undoubtedly are of value, they are not yet sufficiently reliable for general dis- 
tribution. They should, however, be applied to the personnel of hospitals or 
other institutions where scarlet fever patients are treated; but their applica- 
tion should be accompanied by a realization of their inaccuracies. The use of 
scarlet fever antitoxin, however, for the treatment of scarlet fever is now on 
a sound basis. At the first indication that a person is suffering from scarlet 
fever, the antitoxin should be administered according to the directions accom- 
panying the vials. When this antitoxin is used early enough and in sufficient 
quantity, its therapeutic effect is even more rapid and sure than that of diph- 
theria antitoxin in diphtheria. The use of this antitoxin, however, for prophy- 
lactic immunization of contacts or persons exposed to scarlet fever is not rec- 
ommended, except in those instances where these contacts are not to be seen 
daily by a physician. 

5. Typhoid-paratyphoid Vaccine. 

The outbreaks of typhoid fever not only in this State but also in other parts 
of this country and Canada have shown the increasing menace of typhoid 
carriers and the necessity of active immunization against a possible infection 
from contaminated milk or other food or water supplies. This vaccine is sup- 
plied by the State with a recommendation that three injections be given — the 
first y 2 c.c. and the other two injections of 1 c.c. each given one week apart. 
It is not desirable to shorten this period between injections, although in an 
emergency it might be shortened to five day. intervals. A complete course 
of immunization should be repeated every two or three years. 

6. Smallpox Vaccine Virus. 

The amount of smallpox vaccine virus distributed by this Department is 
steadily increasing and it is only through widespread and general vaccination 
that the remarkable freedom of this State from smallpox can be maintained. 
Not only should all children be vaccinated before entering school, but a still 
greater protection can be obtained if children are vaccinated in infancy, pref- 
erably before the end of the first year. It should be borne in mind that a per- 
son vaccinated in infancy and again at school age runs small risk of ever hay- 
ing smallpox in any except the lightest form. All persons traveling in this 
or foreign countries, all public health workers and the personnel of all hospitals 



78 
and institutions should be vaccinated every five years. The new method of 
vaccination constitutes a great advance in this practice. The method used 
should always be that recommended by this Department, which is known as 
the Kinyoun method or the parallel pressure method. When vaccinations are 
done in this way, no dressings are necessary unless the vaccination "take" is 
injured. It causes no pain, gives a circumscribed "take," leaves practically 
no scar and yet affords adequate protection against smallpox infection. On 
revaccinations, the vaccination site should always be observed on the second 
or third day to note the possible presence of one of the vaccinoid or immune 
reactions. 

Detailed information concerning this method and the various reactions can 
be obtained on application to this Department. All these products can be 
obtained without cost by applying to your nearest local board of health or to 
the Department of Public'Health, State House, Boston. 

7. Erysipelas. 

An antitoxin has been developed which apparently has great curative value 
in cases of erysipelas. In some respects this antitoxin is comparable to scarlet 
fever streptococcus antitoxin, and while it is not yet made by this laboratory, 
it can be purchased from dealers and is recommended in all eases of erysipelas. 

8. Measles. 

While as yet the various serums which have been tried for the prevention 
of measles have not yet been sufficiently developed for general distribution, it 
is possible to prevent measles by the injection of the serum of persons either 
recently convalescent from this disease or of persons who have some time ago 
recovered from it. The method of obtaining convalescent serum and a report 
of its use have been published by Richardson and Jordan in the June number 
of the American Journal of Public Health. They advise a dose of serum, pref- 
erably from 6 to 10 c.c. given intramuscularly and it should be given as soon 
after exposure as possible. In the hands of Richardson and Jordan this method 
of immunization has led to the protection of the majority of children who had 
been exposed and were so treated. 



A BRIEF SUMMARY OF BACTERIAL METHODS AND STANDARDS IN 

WATER ANALYSIS 



By H. W. Clark, 

Director, Division of Water and Sewage Laboratories, Massachusetts Depart- 
partment of Public Health 



Bacteriology and bacterial methods have been a slow growth of the last 
forty years. When the Lawrence Experiment Station was started, in the lab- 
oratories of which all the bacterial work upon water, sewage, industrial wastes, 
shellfish, etc., of the Department is carried on, bacteriological methods were in 
their infancy. Only six years before that date Koch had proposed the use of 
solid media by means of which quantitative determinations of the numbers of 
bacteria and the isolation or study of species of bacteria became possible. The 
use of the Petri dish which extended the scope of the Koch methods and made 
possible the rapid and accurate determinations of the number of bacteria in 
water, etc., now so common, was proposed in the same year that the Lawrence 
experiments were inaugurated (1887) but was not generally adopted until sev- 
eral years later. Soon after the establishment of the Station, or in the early 
90's of the last century, a committee of the American Public Health Associa- 
tion was formed to standardize chemical, bacterial and microscopical methods 
for the examination of water. From the beginning, members of the force of 
this Division were on this committee and through many years different mem- 



79 
bers of this force served as chairman as well as being connected with similar 
committees of the American Chemical Society, the American Water Works As- 
sociation and the United States Public Health Service, and for many years de- 
terminations of bacteria in the water supplies of the State have been carried 
on at Lawrence, largely by the standard methods partly developed there. Fur- 
ther, during recent years the quality of water supplies has been judged quite 
largely by standards of purity established by these various committees. In 
1925 the Advisory Committee on Official Water Standards of the United States 
Public Health Service in its report made the following statement: 

"The bacteriological examinations which have come to be generally recog- 
nized as of most value in the sanitary examination of water supplies, are — 

(1) The count of total colonies developing from measured portions planted 
on gelatin plates and incubated for 48 hours at 20° C. 

(2) A similar count of total colonies developing on agar plates incubated 
for 24 hours at 37° C. 

(3) The quantitative estimation of organisms of the B. coli group by ap- 
plying specific tests to multiple portions of measured volume. 

Of these three determinations the test for organisms of the B. coli group 
is almost universally conceded to be the most significant, because it affords 
the most nearly specific test for the presence of fecal contamination." 

Taking everything into consideration the committee agreed to include this 
latter test only in the bacteriological standard recommended, stating, however, 
that the omission of plate counts, etc., was not to be construed as denying or 
minimizing the importance of such routine examinations made in the control 
of purification processes and they also stated that the B. coli group should 
be defined as in the publication known as the "Standard Methods of Water 
Analysis," issued by the American Public Health Association, namely, "as 
including all non-spore-forming bacilli which ferment lactose with gas forma- 
tion and grow aerobically on standard solid media." 

While as stated above this Division has quite generally followed the stand- 
ard methods, we have had to vary them to some extent owing to the great 
variety of the samples examined by us. For example, we discontinued many 
years ago the use of gelatin and incubation for 48 hours and use instead agar 
and count after four days' incubation. This is necessary owing to the great 
number of examinations of sewage and badly polluted water lost by the lique- 
faction of gelatin. We differ from the standard methods in partial confirma- 
tion, so called, of the coli-aerogenes group in that we use litmus lactose agar 
instead of endo or eosin methylene blue as recommended. The procedure used 
by us has always given satisfactory results. The statement in the "Standard 
Methods of Water Analysis" that "our knowledge is not sufficiently complete to 
warrant the adoption of any single test or group of tests" in differentiation 
of fecal from non-fecal members of the coli-aerogenes group is in accordance 
with the experience of these laboratories and we believe that until further 
information is gained any member of this group when found should be re- 
ported as B. coli and in addition that streptococci when found on confirmation 
plates have the same significance as B. coli. The carrying out of the entire 
series of B. coli confirmation tests adopted by the various committees and 
given in "Standard Methods," is impossible for this laboratory, generally 
speaking, with the force employed and when samples are coming in with 
great rapidity and, in fact, few laboratories carry all these tests to completion. 
Each year several hundred samples and cultures are carried by us through 
the complete series of confirmatory tests, however, and the results year after 
year have shown that 98 per cent of our coli results as reported are not 
changed or eliminated when the complete tests are used. For example, in 1926, 
161 cultures reported as B. coli according to our usual methods were further 
examined according to the procedure outlined under steps E and F on page 108 
of "Standard Methods," 1925 edition, and of these 158 were completely con- 



80 

firmed. In addition the 158 completely confirmed cultures were further ex- 
amined by the Gram test and were found to be Gram negative. This is typical 
of all our work on confirmation. 

In regard to the significance of red colonies developing in twenty-four hours 
on litmus lactose agar plates the following statement can be made: All such 
colonies are counted by us without regard to their resemblance to typical B. 
coli. These plates are made from 1 cubic centimeter of water on a solid medium 
while B. coli tests are made in .1 of a cubic centimeter, 1 cubic centimeter and 
in five 10 cubic centimeter portions in a liquid medium and this liquid medium is 
much more favorable to the development of attenuated bacteria. Consequently 
B. coli are often found in the 10 cubic centimeter portions and even occasion- 
ally in the 1 cubic centimeter portions, although no red colonies develop on 
the 24-hour plates. It has been our experience that a very small number of 
the red colonies on these plates are confirmed as B. coli when found in what 
may be classed as good waters while in waters of poorer quality the number 
is much higher. 

The standard of quality decided upon by the Advisory Committee of the 
United States Public Health Service is as follows: 

"Jl) Of all the standard (10 c.c.) portions examined in accordance with 
the procedure specified below, not more than 10 per cent shall show the pres- 
ence of organisms of the B. coli group. 

(2) Occasionally three or more of the five equal (10 c.c.) portions consti- 
tuting a single standard sample may show the presence of B. coli. This shall 
not be allowable if it occurs in more than — 

(a) Five per cent of the standard samples when twenty (20) or 
more samples have been examined; 

(b) One standard sample when less than twenty (20) samples 
have been examined." 

This standard is very rigid and only waters of the greatest bacterial purity 
can conform to it. It has been of interest, however, during the past year or 
two, to compare certain of the water supplies of this State with this standard, 
and it is apparent, as would be expected, that the greater the number of 
samples collected and examined the more definite is the amount of information 
obtained in regard to these waters and that none should be judged from the 
results of the examination of a few samples. Enough have been taken, how- 
ever, from the Metropolitan supply of the State as delivered to its consumers 
to show that 90 per cent of the samples are of the required quality and that 
most of the good surface water supplies which are stored in lakes and reser- 
voirs will also meet the requirements of the standard in a large percentage of 
the samples examined. The most polluted source of water supply in the State, 
the Merrimack River, is used by the city of Lawrence after slow sand filtration 
and chlorination. Seven hundred and two examinations of this supply as de- 
livered to the consumers were made during 1926 and 91 per cent of these sam- 
ples passed this rigid standard. The typhoid fever death rate of Lawrence 
during the year was at the exceedingly low point of 1.1 per 100,000. It is un- 
necessary to say that practically all the good ground waters of the State, as 
drawn from driven wells 25 to 50 feet deep, also pass the standard, and, in 
conclusion, it can be stated that of the total number of samples of public sup- 
plies examined during 1926, 88 per cent were satisfactory according to this 
United States Public Health Service standard of quality. 



81 



Editorial Comment 

Food on the Farm. "Yes, he is very thin, but he sure gets good food 

'cause we live on a farm," might have been the 

response of any of the five hundred rural mothers recently attending 

the Well Child Pre-school Conferences in the western part of the State. 

The general trend of the conversation dealing with nutritional his- 
tory is about as follows: "Milk — oh, yes — we have fifteen cows and 
we keep a quart out every day for cooking and for the three children 
to drink. Well, the canned vegetables are all gone and, of course, the 
gardens aren't ready — that's right — I suppose we could use the 
greens! Oh, no — we can't get fresh fruit — the apples lasted up to 
about a month ago. Yes, I could use prunes and the canned fruits 
would be better than not any!" 

Further discussion usually adds more astonishing facts to the sum 
total. For instance, the nutritionist finds that fried potatoes, dough- 
nuts, and coffee constitute a first rate farm breakfast, meat is abso- 
lutely necessary at least twice a day, home made bread must always 
be made with white flour and a late bedtime is essential as there is 
no one with whom the children can stay while father and mother go 
away. 

With these facts before her the nutritionist attempts tactfully to 
enlighten the mother, who, in the majority of cases, is intensely in- 
terested and most eager to learn. Soon she is quite willing to see the 
relation of poor quality food to undernourishment, the significance of 
eating for teeth and the importance of regular habits and systematic 
routine in running the body machine. 

"Farm food" is hardly synonymous with "good food," but continual 
education along nutritional lines will, in time, make it so. 

Training for School Nurses. School nursing, a relatively new branch 

of an old profession, seems to be grow- 
ing rapidly in importance. Many states are getting school nursing on 
a State, county, or municipal basis. Our own State of Massachusetts 
requires that every municipality have this service with certain pos- 
sible exceptions which have not as yet materialized. 

After some years of experience with this type of service it is be- 
coming evident that the first step only has been taken when school 
nursing service is secured either through legislation or otherwise. 
Quantity is not the only consideration; quality is even more impor- 
tant and quality at present cannot easily be obtained. School nursing 
is quite popular but not so often efficient. The school nurse's hours 
and vacations are attractive to many whose only qualifications are a 
strong wish for the job and a stout heart — both good things but in- 
adequate by themselves. There is a further consideration to be taken 
into account. The school nurse has to work in the atmosphere of 
the school. If her preliminary, general education is insufficient she 
does not show up well as compared with the school teachers. 

We may safely say, then, that there is at present an insufficient 
number of properly trained school nurses. To be properly trained, 
they should have had, in addition to their general nursing background, 
a course in general public health nursing and courses in methods of 
teaching psychology. A normal school training and experience in 
.school teaching add immensely to the school nurse's usefulness. 

Failing this highly desirable background, provision should be made 



82 

for summer courses where concentrated instruction may remedy in 
part previous shortcomings. 

The school nurse with the ample background of education ought to 
be able to take her rightful position in the educational field and render 
a maximum of service. 

Reporting Progress. During the first six months of 1927 Well Child 
Conferences were held in 38 towns. In 11 of 
these towns only those children who will enter school in September 
were admitted. At all the other conferences children from six months 
to six years were admitted as usual; 1,437 children were examined, of 
whom 268 showed defects needing attention. There was an average 
of 37 children per conference. At a few of the large conferences a 
second physician assisted. We had a nutritionist at our conferences 
this year and she has been a very great help; having her has meant 
a good deal to both the mothers and the doctors examining. 

If each child could receive a well balanced diet, have the right 
amount of rest and sleep and be given a sound foundation of habit 
training, we feel that our "number of children with defects" would 
decrease as by magic. Undernourishment and dental and nose and 
throat defects still loom largest in our summaries. With the ma- 
jority, these troubles are the result of poor food for mother and child, 
neglect of early defects and poor or complete lack of training. We 
are emphasizing especially three points in teaching our mothers child 
care; "the three R's" we call them: "Right food," "Sufficient Rest" 
and "Regularity." 

The mothers are almost invariably eager to learn but they can't 
take in all we would like to tell them at once. Sometimes we see so 
much that needs to be done that we feel a bit staggered and sympathize 
heartily with the young mother who seemed a trifle dazed by all she 
had heard and seen at the clinic. She was overheard to remark, "My, 
ain't it awful what a job it is to bring up a young one and do it right!'" 



83 
REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of April, May and June, 1927, samples were collected in 
175 cities and towns. 

There were 2,381 samples of milk examined, of which 420 were below stand- 
ard, from 44 samples the cream had been in part removed, 1 of which also 
contained added water; and 26 samples contained added water. 

There were 244 samples of food examined, of which 55 were adulterated. 
These consisted of 4 samples of butter which were low in fat; 4 samples ex- 
amined for the Department of Agriculture sold as butter which proved to be 
oleomargarine and contained coloring matter; 2 samples of cream which were 
below the legal standard in fat; 37 samples of maple syrup which contained 
cane sugar; 3 samples of maple sugar adulterated with cane sugar other than 
maple; 1 sample of sausage, and 1 sample of hamburg steak, both of which 
contained a compound of sulphur dioxide not properly labeled; 1 sample of 
soft drink which contained saccharine; 1 sample of olive oil which contained 
cottonseed oil; and 1 sample of scallops which contained added water. 

There were 41 samples of drugs examined, of which 7 samples were adul- 
terated. These consisted of 6 samples of spirit of nitre which were deficient in 
the active ingredient; and 1 sample of diluted acetic acid not conforming to 
the U. S. P. standard. 

The police depai*tments submitted 2,277 samples of liquor for examination, 
2,242 of which were above 0.5% in alcohol. The police departments also sub- 
mitted 31 samples of narcotics, etc., for examination, 7 of which were morphine, 
9 iodine, 5 mercury bichloride, 3 cocaine, 4 medicines, and 3 samples which 
were examined for poison with negative results. 

There was 1 sample of coal examined which conformed to the law. 

There were 48 hearings held pertaining to violation of the Food and Drug 
Laws. 

There were 60 convictions for violations of the law, $1,417.70 in fines being 
imposed. 

Marshall Barrier of Franklin; Charles F. Benz of East New Lenox; George 
E. Kohlrausch of Westford; Albert M. Brown of Harvard; Joseph Denaro 
of Concord; Garabed Kahayian of Stow; Joseph W. Kirchner of Pittsfield; 
Giacomo Maffei of Clinton; Erner H. Mortensen of Holliston; John Log Shee, 
Waldorf System, Incorporated, 2 cases, and John Alexander, all of Worcester; 
Anthony Staniunas of Bolton; John Manolidas of Whitman^ Robert Talent 
of Millis; George Economy of Rockland; Anthony Fachini of North Adams; 
H. P. Hood & Sons, Incorporated, of Sudbury; Paul Alexander of South Sud- 
bury; Edward D. Leonard of Athol; John W. Buderick of Waltham; Roy W. 
Busby and John Casey of Great Barrington; Floyd Milk Company of Winthrop; 
Quality Cafeteria, Incorporated, and Anthony Stathis of Somerville; John 
Papanicou of Boston; and Joseph Nogneira of Plymouth, were all convicted 
for violations of the milk laws. Joseph W. Kirchner of Pittsfield appealed his 
case. 

Floyd Milk Company of Winthrop was convicted for selling milk as pas- 
teurized, which was not pasteurized. 

William L. Johnson of Winthrop was convicted for false advertising in re- 
gard to pasteurization. 

Charles W. Parker of Worcester; Fitts Brothers, Incorporated, of Framing- 
ham; Guy Munafo, Albiani Lunch Company, Charles Maliotis, John Papanicou, 
and Phillip Vincensini, all of Boston; Honore LaLiberte and John Dobosz of 
Holyoke; Anthony Stathis of Somerville; Ephrine Ducharme and Stanislaw 
Sitarz of Chicopee; and Frank A. Kuczarski of Springfield, were all convicted 
for violations of the food laws. Charles Maliotis of Boston appealed his case. 

John Demetros of Springfield; John Tries of Middleboro; Astoria Cafeteria, 
Boylston Cafeteria, Incorporated, Chimes Spa, Incorporated, George Mataliotis, 
Puritan Lunch, Incorporated, Alfred J. Shea, Sterling Cafeteria, Incorporated 



84 
and Whiting- Cafeteria, Incorporated, all of Boston; George Chouchos and 
Anthony E. Durakis of Cambridge; and James Georgens of Roxbury, were all 
convicted for false advertising. Puritan Lunch, Incorporated, of Boston ap- 
pealed their case. 

Benjamin Barnoff and Howard Spring of Sandisfield; and Joseph Katz of 
North Adams, were all convicted for violations of the slaughtering laws. 

In accordance with Section 25, Chapter III, of the General Laws, the fol- 
lowing is the list of articles of adulterated food collected in original packages 
from manufacturers, wholesalers, or producers: 

Milk which contained added water was produced as folloAvs: 7 samples, by 
Albert M. Brown of Harvard; 4 samples, by Walter S. Parker of Spencer; and 
2 samples each, from Giacoma Maffei of Clinton, and George E. Kohlrausch 
of Westford. 

Milk which had part of the cream removed was produced as follows: 1 
sample each, by Michael Ferejohn and Arthur Easland, both of Pittsfield. 

One sample of cream which contained added water was obtained from Unity 
Lunch of Brookline. 

Butter which was low in fat was obtained as follows: 1 sample each, from 
Lyndonville Creamery Association of Lowell; and H. P. Hood & Sons of 
Charlestown. 

One sample of scallops which contained added water was obtained from 
First National Stores of Brookline. 

One sample of soft drink which contained saccharine and was not properly 
labeled was obtained from Queen Bottling Company of Worcester. 

There was one confiscation, consisting of 224 pounds of decomposed sea 
scallops. 

The licensed cold storage warehouses reported the following amounts of 
food placed in storage during the month of March, 1927: 2,301,160 dozens of 
case eggs, 570,247 pounds of broken out eggs, 337,011 pounds of butter, 660,789 
pounds of poultry, 2,616,519 pounds of fresh meat and fresh meat products, 
and 1,410,844 pounds of fresh food fish. 

There was on hand April 1, 1927: 2,143,620 dozens of case eggs, 1,188,606 
pounds of broken out eggs, 370,865 pounds of butter, 7,937,011 pounds of poul- 
try, 12,553,037 pounds of fresh meat and fresh meat products, and 3,567,525 
pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of food 
placed in storage during the month of April, 1927: 6,713,040 dozens of case 
eggs, 1,356,348 pounds of broken out eggs, 209,032 pounds of butter, 953,466 
pounds of poultry, 3,122,531 pounds of fresh meat and fresh meat products, 
and 2,347,326 pounds of fresh food fish. 

There was on hand May 1, 1927: 8,165,610 dozens of case eggs, 2,200,589 
pounds of broken out eggs, 130,495 pounds of butter, 6,140,177 pounds of poul- 
try, 12,012,637 pounds of fresh meat and fresh meat products, and 4,514,467 
pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of food 
placed in storage during the month of May, 1927: 4,953,570 dozens of case 
eggs, 858,724 pounds of broken out eggs, 2,058,038 pounds of butter, 1,150,164 
pounds of poultry, 2,510,137 pounds of fresh meat and fresh meat products, and 
3,726,725 pounds of fresh food fish. 

There was on hand June 1, 1927: 12,405,960 dozens of case eggs, 2,682,123 
pounds of broken out eggs, 1,891,707 pounds of butter, 5,385,893 % pounds~of 
poultry, 12,024,348 pounds of fresh meat and fresh meat products, and 7,226,400 
pounds of fresh food fish. 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration 
Division of Sanitary Engineering 

Division of Communicable Diseases 

Division of Water and Sewage Lab- 
oratories 

Division of Biologic Laboratories 

Division of Food and Drugs 

Division of Hygiene . 

Division of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 

The Southeastern District . . 



The Metropolitan District . 
The Northeastern District . 
The Worcester County District . 
The Connecticut Valley District . 
The Berkshire District 



Richard P. MacKnight, M.D., New 

Bedford. 
Edward A. Lane, M.D., Boston. 
George M. Sullivan, M.D., Lowell. 
Oscar A. Dudley, M.D., Worcester 
Harold E. Miner, M.D., Springfield 
Leland M. French, M.D., Pittsfield 



Publication of this Document approved by the Commission on Administration and Finance 
5M. 7-'27. Order 9748. 



11 

COMMONHEALTH 



Volume 14 
No. 4 




Oct.- Nov.- Dec. 
1927 



PREVENTION OF 
BLINDNESS 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 



THE COMMONHEALTH 

quaetekly bulletin of the massachusetts department of 
Public Health 

Se *■ Free to any Citizen of the State 



Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
R*- ""'. 546, State House, Boston, Mass. 



CONTENTS 



PAGE 

Hygiene of the Normal Eye, by Ralph A. Hatch, M.D. ... 89 

One Teacher's Experience in Eye Testing, by Stella A. Chiasson . 91 

Vision and Illumination, by H. W. Stevens, M.D. .... 92 

Ophthalmia Neonatorum in Massachusetts, by Robert I. Bramhall . 95 

The Prevention of Blindness from the Point of View of the Board of 

Health, by Margaret E. Gaffney, R.N 97 

Glaucoma — Blindness, by George S. Derby, M.D. .... 98 

The Sight Saving Class, by Ida E. Ridgeway 99 

The Work of the Division of the Blind, by Robert I. Bramhall . . 102 

Editorial Comment: 

May Day and the Summer Round-Up 104 

Town Meeting 104 

Legislation 104 

FormM 105 

Reportability of Suppurative Conjunctivitis 105 

Report of Meeting of Dental Advisory Committee . . . 106 

Summary of Well Child Conferences — November 30, 1926, to Decem- 
ber 1, 1927 107 

Summary of Nutritional Service of Well Child Conferences, 1927 . 108 

Study of 217 Deaths from Puerperal Toxemia, by Susan M. Coffin, 

M.D 108 

Report of Division of Food and Drugs — July, August, September, 

1927 Ill 

October, November, December, 1927 113 

Index 117 



89 

HYGIENE OF THE NORMAL EYE 

By Ralph A. Hatch, M.D. 
Associate Ophthalmic Surgeon, Massachusetts Eye and Ear Infirmary 

The care of the infant's eye consists chiefly of simple cleansing and 
the avoidance of injury. 

Routine irrigation is not necessary. If there is a pendency to slight 
secretion, the ordinary boric acid solution, squeezed irom a small bunch 
of cotton, or from a dropper, two or three times a day is sufficient. The 
lids may be cleansed with the same solution. The boric solution may be 
obtained in standard strength from the druggist .or^may be mixed at 
home. There is no danger of having it too strori > If it is at room 
temperature the water will not absorb more than tLd proper amount of 
the boric acid. 

Do not let the baby stay long with its eyes in the full glare of bright 
sunlight. A baby's bonnet has no brim or visor and he will be irritated, 
as any of us would, and may even suffer real injury to the eyes. 

Be careful not to leave sharp implements or strong chemicals where 
the baby might get hold of them and injure his eyes with them. And 
look out for older children playing around the baby with such things. 
The number of eye injuries caused each year by sticks, stones, knives, 
scissors, needles, arrows, BB shot, fireworks, the bursting of whirling 
buttons on strings, and so on, can be realized only by one who is in con- 
tact with a large hospital clinic. 

When the school age arrives, new problems present themselves. 

The routine vision tests, such as are now made in all schools, are most 
valuable and discover many defective eyes which would otherwise have 
gone unrecognized. You cannot, however, be sure, simply because a 
child passes this test, that his eyes are normal. There is a type of eye, 
a common one too, which is not discovered at all by such a test and I am 
going to diverge for a moment beyond the strict limitations of my sub- 
ject to say a word about it. 

It is the hypermetropic or "far-sighted" eye. Such eyes have normal 
vision by ordinary tests (they do not see farther than normal eyes) but, 
in order to see well, they must constantly overwork their focusing mus- 
cles. This may produce severe symptoms of eye strain, such as headache, 
eye fatigue, nervous digestive symptoms and malnutrition. The moral 
is this: if a child has such symptoms, do not assume, simply because the 
school test was reported as good, that the eyes cannot be to blame. Nor- 
mal vision does not necessarily mean perfect eyes. 

Take such a case to the oculist for a thorough examination. Do not 
be afraid of "drops" used in testing. A young child cannot be examined 
properly, if at all, without them and they will not do harm. 

When real hard study, with much home work, begins it would be a 
wise thing for each child to have a thorough examination by a competent 
person. Future trouble might be avoided in many cases. 

Do not encourage extensive reading outside of necessary school work. 
Some children are natural "book worms" and, if allowed to, will spend 
every spare moment with a book. Most eyes will stand a lot of punish- 
ment, but that is no reason why they should be subjected to it unneces- 
sarily. It is not uncommon to see myopia (near-sightedness) develop 
in children who formerly had normal eyes. These cases are usually in 
the "book worm" type. The condition may increase to such an extent 
that all reading has to be given up for a time and may cause damage to 
the eyes other than the permanent myopia. 

Train the child not to hold reading matter too near the eyes. The 
nearer it is held the more effort is required of the muscles. The fact 
that a child holds a book near the eyes does not, on the other hand, neces- 
sarily mean that the eyes are defective. 



90 

Daylight is best, where possible. The modern electric bulb is an excel- 
lent source when artificial light is necessary. For desk or table light 
the standard 50 watt bulb is good. There will rarely be too much light 
from this. The position of the light should be such that it does not shine 
directly in the eyes and does not reflect the glaze Of the paper. There is 
a widespread idea that the light should come over the left shoulder. This 
is so only in writing by a right handed person, in which case the shadow 
of the hand does not fall on the work. 

When doing continuous near work, make it a habit to look up across 
the room or out of the window for a brief period every few minutes. This 
gives the muscles a bit of relaxation and tends to avoid cramp. To get 
up and walk about is still better. 

Much that has been said of the school age applies to the later years. 

If you are using your eyes on close work in an office for eight or ten 
hours a day, do not expect them to read for three or four hours more in 
the evening. They, may stand it, but if they protest don't blame them, 
blame yourself. Eyes were provided originally for the purpose of ob- 
serving our surroundings, searching food and avoiding enemies. When 
we think of the work that they are called upon to do in modern life we 
cannot help marvelling at the way they stand up under it. 

The amount of work which normal eyes will do varies greatly with dif- 
ferent individuals. It is largely a matter of general body tone. Many 
eyes which are normal by all usual tests will not work comfortably for 
any length of time, simply because there is not the necessary amount of 
general stamina behind them. It is like trying to run a perfect engine 
without sufficient steam. They cannot be forced. 

It is very widely believed that reading in bed is a serious offence 
against eyes. If the light is good and the person is propped up on pil- 
lows to a semi-sitting position, this is no worse than reading anywhere 
else. 

Reading on trains and street cars is tiring because of both the motion 
and the poor quality of the light which is usually present. 

The modern moving pictures are probably not harmful to most eyes. 
The best rule is, if you find they are fatiguing in your individual case, 
avoid them. 

A few toilet preparations, such as powders, creams and hair dyes are 
apt to produce swollen and inflamed lids. Some of them affect only cer- 
tain persons who are "sensitive" to such things. 

Eyes which are used almost constantly in indoor occupations do not 
have the normal amount of resistance to bright sunlight and may need 
some protection against it. The best guide is your individual experience. 
If you have much discomfort from bright light, get some tinted glasses 
of good quality from a reliable optician or on the prescription of an ocu- 
list. Such glasses are made in different degrees of tint and are not con- 
spicuous. Do not pick up cheap blue smoked or amber glasses anywhere. 
The glass may be so irregular that it will make you dizzy and the pro- 
tection is not of the best. 

After exposure to wind and dust, irrigation of the eyes with common 
salt solution (a teaspoonful to the pint) or the usual boric acid solution 
is advisable. Plain water in the eyes is somewhat irritating. 

As a rule, hot bathing, or hot followed by a dash of cold, is preferable. 
Prolonged cold applications should not be made to normal eyes, especially 
in older people. 

Smoking, or smoking plus alcohol, causes, in rare cases, a serious affec- 
tion of the optic nerve. Usually, however, it is only a question of the 
effect on the general health. 

Around the age of forty-five, it may be two or three years on either 
side, there comes to everybody with normal eyes a time when the num- 
bers in the telephone book begin to be hard to read and all reading matter 
has to be held farther away from the eyes than formerly. 






91 

To many this causes a fright and the feeling that something serious to 
vision is going on. 

It is really a perfectly natural event and is due to the normal diminu- 
tion in the focusing power of the eye at this age. 

The remedy is to have proper glasses for near work. They need not 
be strong to start with. 

Do not delay because of pride or unwillingness to bother with glasses. 
You may suffer for it later. Remember that the trouble comes to every- 
body. If you see persons much beyond this age reading without glasses, 
it is because they are nearsighted. 

This change goes on rather rapidly for some five years after it starts 
and then more slowly. 

After middle age comes the time when a number of physical ailments, 
such as arteriosclerosis, high blood pressure, kidney disease and diabetes 
may arise. Any of these may cause serious eye affections. The timely 
discovery of these ailments, through routine physical examination (say 
once a year) may result in saving vision. 

A chapter on "The Hygiene of the Normal Eye" should not fail to in- 
clude a word on "Focal Infections." 

Thousands of cases of more or less serious eye troubles are caused each 
year by diseased teeth, tonsils, sinuses and other foci. These eye affec- 
tions could all have been prevented by the timely discovery and treatment 
of the infected places. 

Diseased tonsils should be removed. Every "devitalized" tooth is a 
possible source of eye trouble. Such teeth should be X-rayed at least 
every two years. The trouble arises around the roots and can be found 
out in no other way. 

To summarize: 

1. Make sure that your eyes are normal, by a proper examination. 

2. There is a limit to the amount of work which normal eyes will 
stand. This limit varies with different individuals and with the general 
bodily health and vigor. 

3. Give your eyes the best possible working conditions. 

4. Keep in the best possible general condition and be forewarned of 
bodily ailments which may affect eyes, by proper routine examinations. 



ONE TEACHER'S EXPERIENCE IN EYE TESTING 

By Stella A. Chiasson, 
Fourth Grade Teacher, Horace Mann School, Newtonville, Massachusetts 

Among the children who entered my room last fall was a little girl who 
blinked her eyes and made queer faces much of the time. I immediately 
looked over Mary's medical inspection card to see what the doctors and 
her teachers of previous years had reported. I found she had passed a 
normal eye test during these years of her school life. The doctors re- 
ported malnutrition and poor posture. I had worked with her in a special 
health class for corrective work in posture but still found that she held 
her head forward. To give her immediate help, Mary was seated as near 
the blackboard as possible. It always took her a little longer than other 
children to work from the board, but as Mary is exceedingly slow in all 
her actions, that wasn't surprising. 

The day for eye testing arrived! Our children are accustomed to all 
sorts of tests, but fearing that someone might be anxious, I explained 
that we wanted to know whether our eyes helped us in every way they 
should to do our very best work. Then we practiced placing a piece of 
paper first over one eye, then over the other. The papers were large and 
firm and the children were cautioned not to press the paper against the 
eye. The members of the class were provided with necessary materials 



92 

for a free drawing lesson. This is a special treat always, as each child is 
allowed to draw or construct anything he chooses and it is no strain on 
the eyes just preceding the test. The testing went on at the back of the 
room, where the correct distance had been measured and the light was 
good. The children came up one at a time, row by row. As one child 
took his seat the child in front of him came up and if he was too deeply 
engrossed in his work a child's tap on the shoulder was a gentle re- 
minder. The class of thirty-eight children was tested in forty-five min- 
utes. 

I was interested in what Mary would do. She couldn't tell the direc- 
tion in which even the largest letters were pointing. The next day Mary 
was retested with the card of the alphabet letters. Here again she failed. 

That night I telephoned Mary's mother and told her what the eye test 
revealed. She said she had noticed that Mary's eyes were often red and 
itchy, but as Mary had never complained she had done nothing about it. 
Maybe, as Mary seemed to have almost an obsession about wearing glasses, 
she never complained. 

The day Mary was out of school having her eyes tested by the oculist 
I prepared the class for what might happen to her. Consequently, the 
children told her, on her return, that they liked her glasses. Her mother 
says the attitude her classmates took helped a great deal. 

Since she has worn glasses Mary's work has improved steadily in 
speed and accuracy; her eyes apparently do not itch, there is no redness 
of the lids and she does not distort her face. She is very happy and not 
the least self-conscious, as we feared. She has forgotten her former fear 
in her new comfort. 

We don't always get the necessary home co-operation. Such cases are 
reported to the school nurse and all our efforts are united. If the school 
nurse finds the family cannot pay for the examination and glasses, she 
reports the case, and the Junior Red Cross Fund helps in securing them. 
In some cases the parents pay back a little each week but where this is im- 
possible the glasses are provided. 

A great deal of stress is laid on proper posture at all times and the 
correct position of books at the proper distance from the eyes. Good 
health and the knowledge of how to keep it are among our greatest assets 
in accomplishing good work. Good health habits, the correction of all de- 
fects, success in our school work, all increase the mental health and so 
secure greater happiness for our children. 

1 

VISION AND ILLUMINATION 

By H. W. Stevens, M.D. 
Director, Health Department, Jordan Marsh Company, Boston, Mass. 

"Doth God exact day-labor, light denied?" Perhaps not. At least if 
we accept the sentiment of poetry and philosophy, the handicapped of 
vision may find courage in the assurance, "They also serve who only 
stand and wait." 

The Social Responsibility to be Productive 

Our industrial code, however, seems not to provide any such com- 
forting exemption. Industry may accept the dictum that service some- 
times^ consists in standing and waiting, but it eventually asks "for 
what" and "how long." For concrete achievement is the chief, if not 
the only, virtue known to business. The standard of performance as a 
test of individual worth is not to be disparaged — uncompromising as 
it may seem. It has brought to light and to correction concrete defects 
which otherwise would have remained undiscovered handicaps, and 
many dependents have thereby become producers, and producers have 
become more productive. 



93 
I recall a healthy young delivery driver, whose employer complained 
that the man was slow and that he couldn't "make his route." The 
young man admitted occasional dizziness and blurring of sight. Exam- 
ination discovered that his vision was about one-tenth of normal in one 
eye and one-twentieth in the other. The right glasses worked a trans- 
formation in this man and his work. His story is typical of many 
handicapped workers. 

Civilization and Illumination 

It is said that the use a people make of the methods of illumination 
at their disposal is a measure of their state of civilization. Certain it 
is that the development of the coal and petroleum industry brought 
the oil lamp and gas to supersede pine knot and candle, and almost im- 
mediately came Edison's invention to flood our communities with un- 
imagined artificial light. Most of this, however, together with the gen- 
eral application of optical knowledge to lenses as an aid to vision has 
come within the last hundred years. 

Recall that perhaps. 60 to 80% of individuals have eye defects severe 
enough to constitute a handicap, and that these are in urgent need of 
special care — add to this the fact that the artificial conditions created by 
modern lighting impose a severe tax upon even the normal eye and we 
begin to realize the scope of the responsibility created by this recent 
evolution of the problem of light and vision. 

The Prevalence of Impaired Vision 

The application of standards of vision indicate that about one-quarter 
of our 24,000,000 school children have defects hampering them in school 
activities. Among 42,000,000 persons industrially employed, nearly 
two-thirds have defects sufficient to handicap at work. These defects 
uncorrected represent untold personal annoyance and enormous social 
and economic waste. 

Impaired vision is, unfortunately, not always recognized as lack of 
ability to see. "Eyestrain" manifested as headache, indigestion, ner- 
vousness, general fatigue, irritability, mental slowness and bodily 
clumsiness resulting in accidents is a common result of the unconscious 
effort to see under difficulties. Eyestrain when present is usually a 
consequence of defective eyes, but not always. Normal eyes will stand 
much abuse but even normal eyes under the conditions created by artifi- 
cial light and hours of concentrated use may suffer all the difficulties 
to which defective eyes are subject. 

Extreme Demands Made Upon the Eye 

A rather startling realization of the enormous range of demand made 
upon eyes comes with the appreciation that the normal use of the eye 
is for distant vision by daylight, the intensity of which is often several 
thousand times that of the indoor illumination under which eyes are 
sometimes required to do close work. 

From the fact that sunlight is about 500 times as intense as the 
brightest indoor illumination practicable, it is quite natural that too 
little light should be a common fault of indoor illumination. Legal 
standards of illumination which define the minimum amount of light 
for various kinds of work have succeeded fairly well in maintaining 
the required minimum which, however, is often far from the best for 
satisfactory vision. 

Faults of Illumination 

Glare is probably the most common and most injurious of the faults 
in lighting. It is not a matter of absolute intensity but of relative 
brightness of different parts of the field of vision. Glare may be ex- 



94 

perienced as the contrast of sun against a brilliant sky; as sky con- 
trasted with the lighting of indoor walls and fixtures; as the motor 
headlight of a few candle-power against the darkness of the night; as 
the direct light from any unshaded indoor lighting fixture. Contrary 
to common supposition, however, the sensation of dazzling light is not 
the test of glare. Even the single and relatively dim oil lamp still in 
use where electricity is not available for more general and diffuse 
illumination may be a source of troublesome glare. Glare may be 
present in the contrast between a brightly lighted page or piece of 
work and the surrounding shadow. In all moderate cases, regardless 
of absolute intensity of light, or sensation of dazzling brightness, glare 
puts an undue burden upon the accommodation of the eye as it is 
obliged to adjust for widely different grades of light and causes strain. 
A practical example of the avoidance of glare interfering with the best 
vision is found in the practice of the surgeon who covers his operating 
field with gray material instead of white. 

The Hygiene of Vision 

The chief problem in the hygiene of the eye, aside from prevention and 
care of disease and injury, seems to be the avoidance of "eyestrain." 
Most of the existing eye defects underlying poor vision are for practical 
purposes permanent and not subject to remedy as such. Excepting 
acute eye diseases and injuries and cases where general hygiene is at 
fault, remedial as well as preventive measures for impaired vision are 
largely restricted to modification of the light factor of environment 
which is primarily concerned in vision. 

Special Hygienic Measures 

Lenses are an aid not only to the abnormal eye but to the normal as 
well, under exacting conditions. The provision of appropriate lenses 
is, of course, a very special matter requiring a thorough knowledge of 
the structure and physiology of the eye. Control of source and distribu- 
tion of illumination involves also very special problems for the illumin- 
ating engineer, and those special problems appear as questions of the 
best light for home, church, school, factory, theaters and motion pic- 
ture houses; as a question of the best light for all grades of work 
from porter to watchmaker and engraver, for motorist and engineer, 
for sales person and customer; as questions of color and surface of 
paper, shape and size, color and spacing of type for the printed page. 
These special problems may well — indeed must — be left to the physician 
and the engineer. 

Everyday Hygiene of Vision 

The general principle of the eye and light is knowledge — quite ap- 
propriate to be inculcated through schools, public health and social 
agencies. Such knowledge made a part of common education would 
bring industrial and social advantage beyond estimate. 

Common household knowledge that two or three out of every four 
people have vision that is at fault and that for most of these help is at 
hand, would be a long step in the right direction. The knowledge that 
for indoor lighting with ordinary methods it is practically impossible 
to get too much light; an understanding of the real nature of "glare," 
and an appreciation of the fact that the most common and worst faults 
are too little light and glare, may be mastered and made valuable use 
of by householder, teacher, executive — in fact by anyone having com- 
mon sense in everyday matters of darkness and light. 

The Vision Not Dependent Upon Light 

An exposition of the social good resulting from the application of in- 
dustrial standards of performance would be unjust if it failed to con- 



95 

sider the relative few to whom vision in the ordinary sense is impos- 
sible; for even the most practical industrialist will allow that vision 
of a kind is possible even without eyes. But blindness, as other forms 
of total disability, although generously compensated, seems unaccount- 
able — even a matter of awe and superstition to the practical man of 
business. 

A satisfying philosophy of total and permanent disability has not yet 
been stated. Poets have essayed and have put the case courageously 
and hopefully but partially and none too exactly — for example, as the 
prayer of the blind plowman, "God who took away mine eyes that my 
soul might see." The genuinely practical engineer in "spiritual-illum- 
ination" is not common. He would be an invaluable aid in the social 
problems of visual and other disability. 

OPHTHALMIA NEONATORUM IN MASSACHUSETTS 

By Robert I. Bramhall, 
Director, Division of the Blind, State Department of Education 

The work for the prevention of blindness in Massachusetts was initiated 
by the Massachusetts Association for Promoting the Interests of the 
Blind which became sponsor in February, 1903, for the petition to the 
legislature for a commission to investigate the condition and needs of 
the blind in the Commonwealth. 

While this special commission was investigating the whole problem of 
the blind, the Association appointed an agent to experiment along in- 
dustrial lines with blind adults. In June, 1905, the Association secured 
the services of an expert woman physician, who kept in daily communica- 
tion with the Massachusetts Eye and Ear Infirmary, visiting the patients 
at the hospital and in their own homes. Her investigations of the prev- 
alence, distribution, and results of treatment of ophthalmia neonatorum 
created great interest in the problem, and later led to the establishment 
in October, 1907, of the social service department at the Infirmary. The 
studies of the social service department gave the first substantial founda- 
tion for an active movement in Massachusetts for the prevention of blind- 
ness. 

Upon the petition of the Association, the legislature in March, 1905, 
made ophthalmia neonatorum a reportable infectious disease. 

With the establishment of the Commission for the Blind, July 6, 1906, 
a large part of the work of the Association was taken over by the State. 
The Association continued to further the movement for the prevention of 
blindness through the publication of information in the Outlook for the 
Blind, and by providing funds in 1910, for the employment by the Com- 
mission of a trained field agent to investigate cases of preventable blind- 
ness. 

One of the early activities of the newly organized Commission for the 
Blind was to collect and disseminate information on the prevention of 
blindness, through the publication and wide distribution of such pamph- 
lets as "Ophthalmia Neonatorum," "Stop Blindness," "Needlessly Blind 
for Life," and "A Campaign for Good Eyesight." An advisory commit- 
tee was organized, with representatives of medicine, philanthropy, and 
social work. The research department of the School for Social Workers, 
aided by the Russell Sage Foundation, made an important study of the 
records of hospitals and infirmaries to determine the major causes of 
blindness. 

It was discovered that in 1908 and in 1909 fourteen babies, or about 
5% of all the persons becoming blind in Massachusetts, lost their sight 
from ophthalmia neonatorum. To prevent this needless blindness, a lay 
campaign, backed by an advisory board of public health officers, physi- 
cians, educators, was begun by the Commission for the Blind, in co-opera- 



96 
tion with the State Board of Health, the Massachusetts Eye and Ear In- 
firmary, the Society for the Prevention of Cruelty to Children, and 
others. 

In 1909 the State Board of Health first required the reporting of all 
cases of ophthalmia neonatorum by the local boards to the State. The 
State Board of Health sent a circular letter to every physician in Massa- 
chusetts calling attention to the fact that any inflammation of the eyes of 
a baby in the first two weeks should be reported within six hours to the 
nearest health officer, under the penalty of a fine of $100.00. 

Finally, in April, 1910, the legislature passed a law providing for the 
free distribution by the State Board of Health of a prophylactic to all 
registered physicians. Under this law, the State Board of Health, in 
1910, distributed droppers containing a one per cent solution of silver 
nitrate, accompanied by an important circular letter. 

The State Board of Charity adopted a rule requiring the use of a 
prophylactic at every birth in a lying-in hospital, and made the license 
conditional upon obedience to the reporting law. 

The Boston Board of Health prosecuted 7 physicians and 2 nurses for 
failure to report cases. The Massachusetts Society for the Prevention 
of Cruelty to Children prosecuted 3 physicians. The health committee of 
the Boston Chamber of Commerce, and a special committee of "Boston- 
1915" co-operated in a study of the midwife problem, and issued leaflets 
in several languages for the instruction of midwives in the prevention of 
blindness. The Boston City Registrar printed the reporting law on the 
birth return blanks, and sent out leaflets to parents. The Massachusetts 
Medical Society sent admonitions to negligent physicians. 

But probably of greatest importance was the follow-up system adopted 
in 1910 by the State Board of Health, whose district health inspectors 
looked up all cases reported, and advised the local boards of health as to 
the necessary treatment. 

In 1911, a well attended meeting was held in Boston, addressed by 
Helen Keller, Dr. F. Park Lewis, Dr. Mark W. Richardson, Henry Copley 
Greene, and others. Similar lectures on the prevention of blindness were 
delivered before other organizations. This campaign for the prevention 
of blindness has well been called "the most concentrated and persistent 
piece of social work ever attempted on a single subject by public insti- 
tutions." Its success was due to the facts furnished by the social service 
department of the Massachusetts Eye and Ear Infirmary and the research 
department of the Boston School for Social Workers, to the rigorous en- 
forcement of the law by the State and local boards of health, especially in 
the city of Boston, and to the educational work and leadership of the 
Commission for the Blind and the Massachusetts Association for the 
Blind. 

As a result of this intensive campaign, while the number of cases of 
the disease reported rose steadily from a negligible number to some 200 a 
month, at the same time the number of babies blinded from "sore eyes" 
began to fall, until in 1915, only one new case from this cause was dis- 
covered. Though cases of total blindness from ophthalmia neonatorum 
have become relatively rare in this State, the campaign for the prevention 
of needless blindness must not be relaxed, and occasional cases of criminal 
carelessness in the medical profession must be rigorously prosecuted. 

At the present time seventeen of the 120 beds in the lower school at 
Perkins Institution are empty, and at the Blind Babies Nursery there are 
only three totally blind babies in their family of twenty-five babies of 
whom only four are there because of ophthalmia neonatorum. 

During the past two years careless medical treatment has broken the 
remarkable record of the State in the prevention of needless blindness 
from ophthalmia neonatorum. Surely the words of that leader in the 
movement, Dr. F. Park Lewis are still true, — "The right of the child to 
preserve its most important faculty — that of sight — should not be sacri- 



97 

ficed through any feeling of consideration for those who bring upon a 
human being such an irreparable misfortune. The responsibility for the 
protection of those helpless babies rests upon society." 

THE PREVENTION OF BLINDNESS FROM THE POINT OF VIEW 
OF THE BOARD OF HEALTH 

By Margaret E. Gaffney, R. N. 
Board of Health, Springfield, Massachusetts 

The practical eye work as done by the health department nurse in the 
city of Springfield is one of the most interesting and important phases 
of public health work. 

The Health Department has a very definite program mapped out for 
care in eye infections. Of course, it is required by law to report any 
redness, swelling or discharge in the eyes of the new-born infant within 
twenty-four hours after birth. Many cases are reported from the local 
hospitals where the patient is confined. The hospital assumes the respon- 
sibility of caring for these cases until the mother and baby are discharged, 
which usually covers a period of from twelve days to two weeks. When 
the patient is discharged the hospital notifies the Health Department of 
the condition of the eyes at departure. A visit is then made to the home 
and a talk with the physician in regard to the case and the carrying out 
of his orders. The mother is taught how to care for the baby's eyes and 
is instructed in the necessity of cleanliness and how to prevent further 
infection. If the case is a moderate one the nurse visits daily and cares 
for the eyes. If the condition is serious with no possibility of special 
treatment, she recommends further care at the Health Department Hos- 
pital where there is a room equipped for the care of these cases, and where 
special attention is given, and with good results. Occasionally we have a 
mother who will not allow the child to go to the hospital; then an eye 
specialist is called in and the nurse continues the care of the eyes under 
his supervision. Many times these severe cases do not clear up in less 
than from four to six weeks. In every instance there is a smear taken and 
although many of these do not show a positive reaction, the precautions 
taken are just as great as in cases of positive gonorrheal conjunctivitis. 

The particular types of eye cases coming under our attention are in- 
flamed and discharging eyes and ophthalmia in the new-born infant, phlyc- 
tenular conjunctivitis and trachoma in children and adults. 

In ophthalmia neonatorum the majority of cases, particularly almost 
all of the severe cases, owe their origin to gonococcus. The infection as 
a rule occurs during parturition and usually breaks out on the second or 
third day after birth. The symptoms are redness and swelling of the lids 
and profuse purulent discharge. The treatment consists of frequent and 
complete cleansing of the eyes with a saturated boracic acid solution and 
the use of twenty per cent solution of argyrol or whatever the physician 
prescribes. The application is continued until the cure is complete, other- 
wise the process might recur to a moderate degree. Frequent cleansing 
is more important than medication. Conjunctivitis in the new-born may 
also be produced by other germs than gonococcus. In these cases too, 
infection occurs at birth but the inflammation usually breaks out later 
and runs a milder course. The treatment in any event is the same, 
namely keeping the eyes clean and the use of twenty per cent argyrol 
solution or whatever the physician prescribes. In these cases prophylaxis 
plays a great part. Since the adoption by law of the Crede Method the 
number of ophthalmia neonatorum cases has become almost negligible. 
The system adopted in our Health Department Hospital for the past sev- 
enteen years has been frequent irrigation of the eyes with a saturated 
boracic acid solution and use of a solution of twenty per cent argyrol. By 
frequent irrigation is meant as often as every 15 or 20 minutes. The con- 



98 
trol of the disease depends more on cleanliness than on the effect of the 
medicine. Under this system of treatment the sight of an eye has not been 
lost in seventeen years. 

Occasionally the second eye becomes infected in gonorrheal conjunc- 
tivitis due to secondary infection from the eye originally infected. Very 
few of these cases, however, are reported to the Health Department. 
When they happen every effort is made to get them to our hospital for 
treatment. 

Phlyctenular conjunctivitis is frequently found in children from one to 
twelve years of age, more commonly in the case of children amongst the 
poorer classes receiving insufficient and unsuitable nourishment and living 
in damp and poorly-ventilated houses. These cases are referred to an 
eye specialist. 

Trachoma is occasionally found. This is an inflammation of the con- 
junctiva and extends over a period of years, rendering many of those 
who are attacked by it half or wholly blind. In a particular case I have 
in mind the mother of five children, who had irritation of the eyes for 
some ten years, the intensity varying from time to time, who found it 
necessary to seek advice from a physician who prescribed for her and 
reported the case to our department, as required by law. After visiting her 
and advising prophylactic measures it was realized the condition was very 
serious and arrangements were made with an eye specialist for regular 
visits. Later, however, on his advice she was taken to the Massachusetts 
Eye and Ear Infirmary, where she remained under observation until an 
operation was performed by which she was improved. We have kept 
this family under observation and none of them have developed any 
symptoms of trachoma. 

GLAUCOMA— BLINDNESS 

By George S. Derby, M.D. 

Ophthalmic Chief of Service, Massachusetts Eye and Ear Infirmary 

The disease known as glaucoma causes probably one-quarter of all 
blindness occurring in the latter half of life. A very large part of this 
loss of sight is preventable if the disease is recognized early and proper 
measures taken. 

If you will place your fingers on your own eyeball you will find it is 
firmly elastic to the touch (like an inflated footfall). In other words, to 
maintain its shape and fulfill its functions the eye must be maintained at 
a certain degree of pressure. In glaucoma the pressure in the eye is 
greater than it can bear without damage. In many cases of glaucoma we 
do not know what causes this increase in pressure, but we do know what 
happens to the eye, and in very many instances it can be relieved if the 
condition is recognized early enough. 

There are two principal forms of glaucoma. The first, known as acute 
glaucoma, is characterized by a sudden rise in pressure (the football 
over-distended), which causes intense pain, inflammation of the eye and 
sudden blindness. The symptoms are so acute that the patient almost 
always seeks medical relief. This condition can usually be cured by oper- 
ation if there is not too much delay. 

By far more common and dangerous to sight is the chronic or simple 
glaucoma, because it causes no pain and because dimness of sight often 
does not come until the late stages of the disease. This form of glaucoma 
may exist for a long time before it is recognized. It does not cause the 
individual anxiety because there is no pain and the symptoms of its 
presence are not alarming, and yet it is one of the most dangerous of eye 
conditions that exist. 

Fluid is constantly flowing in and out of the eye during life. In acute 
glaucoma there is a sudden clogging of the little pipes by which the 



99 
fluid escapes. The result is a sudden rise in pressure. In chronic simple 
glaucoma the clogging is only partial and the pressure rises only to a 
slight degree. However, this increase in pressure is sufficient after a 
time to damage the delicate nerve fibres in the back of the eye, just as a 
constant dripping will eventually wear away even solid rock. The deli- 
cate nerve fibres which form the seeing membrane of the eye, the retina, 
are gradually damaged and finally cease to function. Some of these nerve 
fibres are designed to give us keen sight, to enable us to do fine work. 
This function is known as central or acute vision, and, in most cases, these 
fibres escape serious damage until late in the disease. There are many 
other fibres, however, which suffer, and these are the fibres which main- 
tain what we call the field of vision. If we look straight forward at an 
object we see it distinctly, but we also see, if both eyes are open, upward, 
downward and ninety degrees to each side. We only see distinctly the 
objects directly in front of us, but the ability to see over a wide area, 
even if indistinctly, is of great importance to us. The ability to see dis- 
tinctly directly in front of us is known as central vision. The ability to 
see indistinctly over a wide area is known as peripheral vision. For the 
highly organized human being, central vision is a necessity. It is, how- 
ever, not necessary to, and is not possessed by, lower animals. The rab- 
bit, for instance, cannot see distinctly in any direction, but as his eyes are 
set in the side of his head he has the ability to see almost around the 
whole circle of 360 degrees. This is a great asset in avoiding danger 
which may come from any direction. Fewer people would be killed by 
automobiles if they had eyes like the rabbit. 

In most cases of chronic simple glaucoma, peripheral vision, otherwise 
known as the field of vision, is narrowed until in the late stages the sight 
of such a person may often be limited as though looking through a long 
narrow tube such as a gun barrel. Central vision is affected usually late 
in the disease, and then reading is no longer possible and fine objects 
cannot be seen. 

In addition to the narrowing of peripheral vision there may be a blur- 
ring of sight at times and colored rings are seen around artificial lights 
at night. These are known as haloes. In the final stages of the disease 
blindness ensues and sight cannot be restored. The loss of the field of 
vision usually begins on the nasal side and here the field is normally nar- 
rower in all people as the bridge of the nose is in the way. If you will 
shut one eye, look straight forward and test your field of vision with 
your fingers you will find that they are visible at right angles on the tem- 
poral, or outer side, while on the nasal side you can see only about two- 
thirds as far. It is this nasal side which becomes increasingly narrowed 
in glaucoma until the fingers must be brought almost in front of the eye 
before they can be seen. Therefore, if over forty-five years of age, be 
on the lookout for a narrowed field of vision. Be suspicious of blurred 
eyesight, which is not improved by glasses. If you see rainbows around 
lights at night something may be wrong and you should get expert advice. 

Chronic simple glaucoma can be controlled by treatment or by opera- 
tion if recognized in time. A competent medical eye specialist can recog- 
nize the disease in its early stages and can in all probability save your 
eyesight. If you do not know whom to consult ask your doctor to refer 
you to a medical eye specialist. If you have no family doctor seek advice 
at a reputable hospital. 

THE SIGHT SAVING CLASS 

By Ida E. Ridge way 

Supervisor of Work for Children, Division of the Blind, 

State Department of Education 

All about us we find evidence that the child is truly looked upon as "the 
chief asset of his country." Much stress is placed upon his efficiency. To 



100 
meet life's responsibilities there is prepared for him a compulsory, elab- 
orate and expensive educational program and all possible physical, mental 
and moral barriers are removed so that he may progress in his schooling. 

His teachers attend to his mental and moral instruction and his school 
physician and nurse to his physical well-being. Progressive cities have 
established special classes for the training of those who are mentally 
unable to compete with the average child, there are Open Air Classes for 
the pretubercular and undernourished, classes for the delinquent, the 
foreign born and a few for the deaf. However, the type of class we will 
consider is for children whose handicap is seriously defective eyesight. 
These are the Conservation of Eyesight, popularly called the Sight Saving 
Classes. 

We are told that fully 90% of all human activity involves more or less 
eyesight and we know that the chief avenue to education is through the 
eyes. In elderly people we expect to find impaired eyesight, but children 
suggest joy and sunshine and are generally looked upon as being normally 
sighted unless they are definitely blind. Only the few who have the fact 
forcibly brought to their attention realize that there is a third group — 
the children who live in the twilight. These little ones whose visual 
acuity may be anywhere from one third down to one tenth of the normal 
are with the same classroom equipment expected to meet the standards 
reasonably demanded of the normally sighted. 

It is less than one hundred years ago that education for blind children 
was available in this country- In 1832 The New England Asylum for 
the Blind, one of the first American schools of the kind was opened in 
Boston. This is now The Perkins Institution and Massachusetts School 
for the Blind, in Watertown, which within its ample and beautiful plant 
cares yearly for about two hundred Massachusetts children and one 
hundred from other States. Its doors are open to the occasional child 
who is barred from the ordinary school on account of low vision, but 
usually tactile methods are not advisable for him. The child with suffi- 
cient eyesight to read the little raised dots of the braille will not learn to 
read with his fingers and he will be under far greater eyestrain than 
with the ordinary ink-print text book. 

Many children have been sent out" along the highway to delinquency 
through the drudgery of the home or the evil influence of the street be- 
cause there was no provision for them in school. Mr. E. E. Allen, director 
of Perkins Institution visited the Classes for Myopes in London and 
brought the good message home to us. So the Boston School Department 
in co-operation with Perkins Institution and the Massachusetts Commis- 
sion for the Blind opened the first Sight Saving Class in this country in 
April, 1913. 

The first two teachers were experienced in instructing the blind and, in 
preparation for their new venture, gathered information from Germany 
and England, where similar work had been done for several years, and 
adapted the classroom work to meet the needs of children with very poor 
eyesight. Our first class was housed in the upper room of the Abby May 
School Annex out in Roxbury. The room was poor, the lighting bad and 
not all the children were suitable candidates. However, Perkins Institu- 
tion came to the rescue with considerable schoolroom equipment, our 
pupils were more carefully "weeded out" and the Sight Saving Class be- 
gan to make its benefits felt. Today we have twenty-eight good classes 
in fourteen Massachusetts cities with four more about ready to open. 

Boston, 11 classes; Cambridge, New Bedford, Worcester and Fall 
River, 2 each; 1 each in Lowell, Salem, Lynn, Chelsea, Somerville, New- 
ton, Brockton, Holyoke and Springfield. Before February, classes are 
expected to open in Revere and Roslindale and the school boards of Law- 
rence and Haverhill have voted to have classes, but have not yet made 
definite provision on account of lack of room. 

There are approximately 350 children attending these classes. We esti- 



101 
mate that there are about 500 children in Massachusetts who should be 
provided for by special sighted methods. There are some 290 Sight Sav- 
ing Classes in the United States. 

The housing of the Sight Saving Class is quite an important factor. 
As children come from a wide area the class should be centrally located 
and, if possible, in a modern building where lighting and blackboard 
facilities are usually good. A good neighborhood is always an asset, for 
parents feel justified in refusing to take their children out of desirable 
residential districts and send them to what they term "the slums." The 
classroom must be well lighted from the north or northeast with window 
space equal to at least one-fifth of the floor space. Suitable artificial 
illumination should be worked out by a lighting engineer for there are 
dull days when natural light is inadequate to the needs of the semisighted 
child. Ceilings should be white or cream and walls done in a soft light 
tint with a mat finish. The furniture should be in dull finish to avoid re- 
flected lights. 

The classroom is equipped with movable and adjustable desks which 
have extra long side uprights enabling the work to be brought up to 
nearly level with the eyes, when the head is held in an upright position 
and at a distance of 12 or 13 inches. The special text books of clear 
black characters in 24 point type are printed on unglazed buff paper. 
Outline maps are generally used. These are done in extra heavy white 
or yellow outlines on blackboard cloth. Soft, very black lead pencils are 
used on double sized arithmetic paper for much of the written work. 
Children in upper grades find the touch system on the typewriter to 
their advantage. 

With the teacher lies the success or failure of the Sight Saving Class. 
Our custom in Massachusetts has been to have the local superintendent 
choose from his own staff a teacher who knows the school methods of her 
city, who has had successful grade experience and possesses that most de- 
sirable qualification — personal initiative. These- teachers are granted 
time to visit and observe Sight Saving Classes in operation and have 
open to them summer courses on Sight Saving Classes. Instructions on 
eye conditions are given from time to time. 

Many of our teachers have entered the work without enthusiasm but 
the satisfaction of a real service has held them and little other than matri- 
mony or death has disturbed the faithful group. The class unit is from 
ten to fifteen children, ungraded. Each child receives practically individ- 
ual instruction in ways modified to meet his particular need. While the 
hours of the Sight Saving Class are less than the session of the ordinary 
grade, the teacher is obliged to spend a great deal of time in preparation 
for each day's work. The salary of the Sight Saving Class teacher runs 
from sixty to one hundred and eighty dollars in excess of that of the 
ordinary grade teacher. 

Children recommended for the Sight Saving Class have, after all has 
been done to help their eyesight, visual acuity of from 20/70 to 20/200. 
In cases of progressive nearsightedness where powerful glasses are worn, 
a child with considerably better eyesight might be admitted to the class. 
Roughly the causes of low vision in our classes are from myopia or near- 
sight about 50%, from opacities of the cornea 25% and the others are due c 
to albinism, congenital cataracts, atrophy of the optic nerve, dislocated 
crystalline lenses and conditions found in the choroid and retina. 

These children are reported to the Division of the Blind either directly 
by the oculist or the clinic, through the school or friends. One of the 
children's workers gets the eye report and recommendation from the 
oculist, visits at the home, carefully explaining the eye condition and 
arranging for the child's transfer to the Sight Saving Class when that is 
indicated. Less than half the children suggested as candidates prove 
suitable for the class. In the minds of quite a number of rather intelligent 
people a child is semi-sighted when he has a blind eye and a normal eye. 



102 

After being assured that all possible care has been given the applicant's 
eyes and that he is of sufficiently good mentality, his recommendation is 
forwarded to the local superintendent for transfer. Through the Division 
of the Blind the State subsidizes every sight saving class to the extent 
of $500 yearly and in addition supplies every new class with $250 worth 
of equipment. 

One of our problems is the child from the rural district who cannot see 
enough to progress in the ordinary grade and yet sees too muqh to learn 
with his fingers at the school for the blind. Many of these are being sup- 
plied with large typed textbooks and a few are in Perkins Institution. 
We realize that there should be a small residential center for these scat- 
tered children who are now getting very little benefit from their schooling. 

The Sight Saving Class can help the child by : 

1. Conserving his eyesight through eliminating all possible eyestrain 
and teaching habits of eye hygiene. 

2. Benefiting his general health through saving him from the nerve 
strain attending competition with the normally sighted. 

3. Making possible that which was unattainable. 

This type of class provides for repeaters who pull down classroom 
standards. It gives the community intelligent citizens instead of illiter- 
ates. In every city with an elementary school enrollment of 7000 chil- 
dren there is the nucleus for a sight saving class which will stand as a 
monument to its progress and humanity. 

THE WORK OF THE DIVISION OF THE BLIND 

By Robert I. Bramhall, 
Director, Division of the Blind, State Department of Education 

Massachusetts has an honorable place in the history of work for the 
blind in this country, for it was in Massachusetts that Perkins Institu- 
tion, the first school for the blind in America was incorporated in 1829, 
and it was in Massachusetts in 1906, that the first state commission for 
the blind was organized. The progress in the education of blind chil- 
dren at Perkins Institution has had a world wide influence, and the 
pioneer work of the Commission for the Blind in the prevention of blind- 
ness and in ameliorating the conditions of the adult blind has had wide 
influence in the development of similar work in many other states and 
in some foreign countries. 

All cases of seriously defective vision in children should be promptly 
reported to the Division of the Blind in order that the parents may be 
visited by its representatives and advised to secure proper medical atten- 
tion for the child, that the proper glasses may be secured when necessary 
or that the child may be relieved of unnecessary eye strain through the 
use of clear-type books or by attendance at the local sight saving classes. 
For those blind children who need schooling, the Division is ready to 
assist in making arrangements for their education at public expense at 
Perkins Institution. 

The Division of the Blind urges all to report promptly all new cases of 
blind adults in order that the Division may make available its facilities 
for rehabilitation and placement. 

The first approach to a newly blinded person is usually made through 
the blind home teacher of whom the Division employs seven. The home 
teacher helps the newly blinded person to believe in himself, teaches him 
"how to be blind," and gives him finger training. 

For those who have no other handicap, such as the infirmities of age, 
or low mentality, the Division endeavors to find employment, either in 
factories, offices and shops in competition with the seeing, or in sub- 
sidized workshops for the blind, or in home industries. The placement 



103 
agents are constantly seeking out new opportunities for the employment 
of young blind men and women in bench assembly work in factories, 
tuning pianos in piano warehouses, tagging merchandise in stores, type- 
writing in offices, as salesmen or as proprietors of small food stands in 
factories. Where necessary the Division provides for the preliminary 
training, or gives a weekly allowance for a guide, or helps arrange for a 
proper boarding place. 

The Division maintains six subsidized workshops for the blind in 
which some 110 blind men and 15 blind women are employed. The 
workshops are located in Cambridge, Fall River, Lowell, Pittsfield and 
Worcester. The men manufacture corn brooms, wet and dry mops, cot- 
ton rag rugs, and they reseat chairs. The women either weave art fab- 
rics on hand looms or reseat chairs. 

In 1926, the aggregate sales of the Division amounted to $147,770 and 
the gross expenditures for the maintenance of these workshops amounted 
to $222,830. 

There is also a small workshop conducted by Perkins Institution in 
South Boston, in which 20 blind men are employed in making and reno- 
vating hair mattresses, in feather pillow work and in reseating chairs. 

Home industries such as poultry raising, reseating chairs, stringing 
tennis rackets, weaving baskets, knitting, tatting, sewing and wood work 
are developed by providing training in the particular handwork through 
the home teachers or by an apprenticeship with a seeing craftsman. In 
some cases the Division or co-operating private associations assist 
through the loan of the necessary equipment for starting the home in- 
dustry. 

The Division maintains two salesrooms, one in Boston, and one in 
Pittsfield, and conducts many sales in private homes, in stores, or in pub- 
lic halls with the co-operation of local organizations, in order to assist the 
blind home workers to find a wider market for their products. The Di- 
vision also assists the home workers by purchasing raw materials for 
them at wholesale, by cutting out patterns, and arranging for volunteers 
to help in the finishing. 

In very many cases, however, blindness comes in old age or with other 
infirmities, making gainful employment impossible. For this group the 
Division brings greater happiness through busy work taught by the 
home teachers, and through financial relief when necessary. In 1926, the 
Division expended $125,000 in giving financial assistance to needy blind 
persons. Most of this aid was given to those who also suffered from the 
infirmities of age. 

During the year 1926 the Division provided training for 288 blind 
adults, secured employment in factories, stores and offices for 37, fur- 
nished employment on its staff or in its workshops for 132, gave direct 
financial assistance to 722, aided 173 in home industries, and gave advice 
or information to 1479. Visits were made to 942 persons to whom no 
special service was rendered. The gross expenditures for all the activ- 
ities of the Division amounted to $425,380, of which amount $147,770 
was derived from receipts from sale of products. 

Systematic work for the amelioration of the condition of blind adults 
is as yet so new that much remains to be done. Just as the cost of edu- 
cating a blind child is approximately 10 times as expensive as that of a 
seeing child, so too the work of re-educating blind adults is expensive to 
society. A very great deal has been accomplished in helping blind people 
to help themselves. 

The greatest curse of blindness is idleness; so too the only solution of 
blindness is prevention. 



104 

Editorial Comment 

May Day and the Summer % Round-Up. — "In time of peace prepare for 
war" is a maxim which comes in for heavy criticism in certain quarters 
these days. But no one can take exception to the idea that all times and 
seasons are suitable for preparations to improve the health of children. 
Consequently in January one may well begin to plan for the celebration 
of May Day as Child Health Day and to get ready for the Summer Round- 
Up, which is the physical examination of all children about to enter school 
for the first time in the Fall. Local Child Hygiene Committees are urged 
to start work at once. Communities not yet having such committees are 
urged to consult the State Department of Public Health about forming 
one. 

Town Meeting. — Town Meeting time will soon be here. Why not plan 
to remedy the illegal situation which still exists in some towns regarding 
the anti-aid provisions of the State Constitution? Towns cannot legally 
subsidize private organizations however worthy they may be. Again, 
how about the statutory provision regarding dental and other clinics ? If 
municipal funds are to be expended on these, it must be done through the 
board of health. 

These laws need not hamper in the least the promotion of public health 
in the municipalities of the State. They are wise laws as a matter of 
fact. The Department of Public Health will be glad to explain to any 
community how it may carry on the desirable health activities legally 
and at the same time effectively. 

Legislation. — The Legislature will have before it in 1928 several meas- 
ures of importance to the public health. The Department is introducing 
two bills of this sort: one has to do with the licensing of food handlers 
and the other with the pasteurization of milk. 

The bill regarding food handlers requires any food handler, without 
cost to himself on suspicion of the state or local health officer, to submit 
to an examination to determine whether he is suffering from a com- 
municable disease or is a carrier of such disease. Employers are for- 
bidden to allow such infected persons or carriers to handle food. Sus- 
pected persons refusing to submit to examination are subject to fine. 

The bill relative to the sale of milk provides that by 1931 all milk sold 
shall either be pasteurized or be from non-tuberculous cattle except in 
towns of less than 5,000 population where this is optional. 

A third bill, introduced by the Department of Education, is of im- 
portance to health officers. It would allow municipal officials to travel 
outside the municipality for inspectional or other business purposes con- 
nected with municipal duties, and for attendance upon professional meet- 
ings. 

There are valid reasons for the introduction of all three of these bills. 
The carrier who handles food to be used by others is a permanent menace 
especially in the case of the typhoid carrier on a milk farm. This is too 
obvious for further comment. The problem of raw milk from untested 
cows is of the utmost importance to all interested in the health of chil- 
dren, especially, or adults. The milk bill is a very modest one indeed. 
Many strong arguments might be adduced for a much more stringent one. 
As for the bill giving permission to travel at municipal expense, the wis- 
dom of this is apparent, even if one refers only to the provision for travel 
in connection with attendance on meetings. No health officer can keep 
up to date if he does not attend such meetings. The return to the town 
is increased and better service easily justifies this expenditure of mu- 
nicipal funds. 



105 

Form M. — Attention is called to "Form M," to be used in recording the 
physical examination of school children applying for employment certifi- 
cates. This form, in accordance with statutory requirement, is furnished 
to local school committees by the Department of Labor and Industries, by 
whom it has been prepared after conference with the Department of Edu- 
cation. 

The use of this form puts on a sounder basis this most necessary pro- 
tection to the health of the child about to enter industry. Without ade- 
quate records, the health examination tends to become perfunctory as has 
been proved by years of experience in this State. 

Reportability of Suppurative Conjunctivitis. — It has become so much 
a matter of habit now to stress ophthalmia neonatorum and its report- 
ability that it seems necessary to call attention again to suppurative con- 
junctivitis. 

On the list of diseases declared by the Department of Public Health to 
be dangerous to the public health and so reportable we find that both 
ophthalmia neonatorum and suppurative conjunctivitis. It is necessary 
then to report all cases of sore eyes occurring at any age whether of gon- 
orrheal origin or not. 



106 

REPORT OF MEETING OF DENTAL ADVISORY COMMITTEE 

December 21, 1927 

State House 

Annual Report 

Doctor Champion opened the meeting by reading the Annual Report of 
the Dental Consultant, Miss Eleanor Gallinger. The report covered a 
brief summary of the dental hygiene work of the State Department of 
Public Health since its beginning in 1919, as well as a report of progress 
under the new Policy adopted in May, 1926. 

Analysis of field conditions in December, 1927, show that 180 towns 
and cities in Massachusetts are carrying on dental hygiene programs. 
These 180 communities represent 92% of the total school population of 
the state. 

Preschool Work 

It has been necessary to discontinue the services of the dental hygienist 
at the State Well Child Conferences. A new nutrition worker has been 
added, however, and a new scheme of dental follow-up devised. It is 
hoped that this scheme of follow-up will furnish the Department with in- 
formation concerning the number of children who go to the dentist at the 
recommendation of the pediatrician, and the number that the dentists 
refuse to work on. 

An analysis of the 1,763 children from two to six examined last year 
at the State Well Child Conferences shows that 48.2% were in need of im- 
mediate dental attention. 

Need of Traveling Dental Clinics 

Miss Gallinger stated that there were many towns in Franklin and 
Berkshire Counties and in the Cape district in need of a Traveling Dental 
Clinic. Doctor Norton, President of the Massachusetts Dental Society, 
assured the Committee that his organization would be willing to co-oper- 
ate in seeing that these children were no longer neglected. A detailed 
summary of the situation will be sent to Doctor Norton to discuss at his 
next Executive Board meeting. 

PLANS FOR 1928 

Miss Gallinger proposed the following plans for discussion and endorse- 
ment: 

Association of School Dental Workers. — That all school dental workers 
(dentists, hygienists, assistants and school nurses, when in direct charge 
of the program) form an association; that the dental health workers 
throughout the State be called together in January, 1928, to form an 
Association and to elect a President (that this President be made a mem- 
ber of the Dental Advisory Committee of the State Department of Public 
Health) ; that the Dental Consultant of the State Department be Secretary 
ex-officio and be responsible for the mailing list of members and the 
editing of a monthly bulletin to keep the workers in touch with the dental 
work in other states; that this Association have a part in the regular 
program of the Annual Convention of the Massachusetts Dental Society 
in May. 

This plan was discussed and endorsed by the Committee. 

Regional Consultants. — That this State Dental Consultant have dentists 
interested in public health work appointed as Regional Consultants to the 
State Department of Public Health in the different districts of the State. 
That these consultants be on call to advance the interest of preventive den-, 
tal hygiene work in the communities in their districts. 



107 

This plan was endorsed by the Committee and it was agreed that the 
State Department would ask the President of the Massachusetts Dental 
Society to appoint six regional consultants to the Department. 

Endorsement of Bulletin. — A bulletin on the Toothbrush Drill pre- 
pared for school dental workers in the interests of stimulating better 
methods of teaching toothbrushing was discussed. 

Changes recommended : 

1. That children be sold or given new brushes at the time that 
they are being taught in small groups to brush their teeth, rather 
than bring their own brushes from home. 

2. When teaching the value of toothbrushing in the schoolroom 
that it be recommended as a good health habit and an important part 
of general cleanliness rather than a means of preventing toothache. 

With these changes the bulletin was endorsed. 

Revision of Dental Policy. — As a result of nearly two years practical 
application of the new policy in the field several changes have been made 
in the recommendations to communities. The only change in operating 
policy was as follows : 

"Concentrate the dental hygiene program on children from five to 
seven years of age and follow-up through the grades." (The old Policy 
reads: "Concentrate on pre-school children and follow-up through the 
grades") . 

This change was accepted by the Committee and the meeting was ad- 
journed. 

SUMMARY OF WELL CHILD CONFERENCES 
November 30, 1926— December 1, 1927 

Number of conferences — 60. 

Held in — 58 towns. 

2,309 children under six years from 1,709 families were examined. 

Ten of the conferences were for school entrants only, or what we term 
"Summer Round-Up" clinics. Interest in this type of conference is par- 
ticularly good and many towns will do their own in 1928 as they did in 
1927. 

Of the 2,309 children examined, no defects were noted in 415 instances 
or 18%. 

Dental defects were extremely common, occurring in 746 of the chil- 
dren, or 32%. This is a large number because so many children were 
under two years (415 or 29%). 

"Follow-up" of the children showing defects is variable because the 
nursing service of our towns is still so widely varying. It is very good 
where there are both a general and a school nurse, or a competent inter- 
ested nurse doing both types of work, or where there is an up-to-date 
nursing center. Occasionally there is no way of getting any follow-up 
service and in such circumstances we write an individual letter to each 
mother, whose children had defects, about a month after the conference 
was held. 

Twenty-six of the towns in which conferences were held in the past 
three years have started local conferences of their own with physician or 
physicians examining the children. Fifteen more have established a 
weighing and measuring conference with the local nurse in charge. 

Reports are coming in pretty steadily now of defects corrected or im- 
provement following the adoption of advice given at our demonstration 
conference. 

To get good attendance at a conference publicity suitable to the in- 
dividual community is essential. With this we have little trouble. 

To get satisfactory results from the conference itself follow-up work 



108 
by a competent nurse is vital and this is not always possible, but is im- 
proving steadily, we feel. 

We still adhere strictly to our rule of "no treatment suggested: no 
formulas given," confining our advice to dental, nutritional and habit 
training problems, and we find these quite sufficient for our limited time 
and small staff of three — nurse, doctor and nutritionist, with the local 
nurses helping always when possible. 

All children with defects are referred to the family physicians and 
the children's records are sent to them. A detailed summary of defects 
will be printed later. 

SUMMARY OF NUTRITIONAL SERVICE 

OF WELL CHILD CONFERENCES 

1927 

A Nutritional Conference with each mother has been an established 
part of the Well Child Conference during the past year. The mothers 
have received detailed nutritional advice (relating specifically to their in- 
dividual cases according to recommendations made by the physician on 
the Physical Record Card) involving in some cases menu planning, bud- 
geting and habit training. 

A Nutritional Record Card has been devised during the year and in its 
final state gives the child's name, age, weight, height, and normal weight 
for height. The nutritional guide posts are printed in the center with a 
space on one side for history and on the other for recommendations. The 
card definitely indicates the difference between what is done and what 
should be done. The mother is given a copy to take home. The local 
nurse receives a copy with the Nutritional Report which summarizes the 
nutritional conditions found. The names of all children found to be 10% 
or more underweight are listed and the nurse is urged to give special at- 
tention in her follow-up work to those specific cases. 

The food fallacies discovered are astonishing. Lack of discipline, poor 
habit training and actual lack of knowledge concerning food composition, 
food preparation and menu planning are the big difficulties. The common 
fallacies in the rural community are' faulty breakfasts (fried potatoes, 
doughnuts and coffee), too much meat and too many eggs, surprising 
lack of vegetables (especially during the winter), and infrequent use of 
dark bread. The outstanding urban problem seems to be lack of rest and 
an abundance of candy. Definitely poor care of teeth with few exceptions 
is an outstanding difficulty in the condition of the pre-school child. 

The disinterested mother is exceptional. The response is, on the whole, 
one of sincere, earnest interest. The mother realizes that her problem of 
proper feeding and sensible buying — the job of feeding her family — is 
vital. The nutritional service given at the Well Child Conference is of 
benefit to the whole family. 

STUDY OF 217 DEATHS FROM PUERPERAL TOXEMIA 

By Susan M. Coffin, M.D. 
State Department of Public Health 

In the study of 984 maternal deaths undertaken by the Massachusetts 
Department of Public Health in 1922-1923, the primary cause of death 
was given as some form of puerperal toxemia in 217 cases, or 22% of 
the whole number studied. 

We studied, in this whole series, only those mothers six months or 
more pregnant, and dying within one month of delivery, if delivery took 
place. (53 undelivered). 

We have included the following diagnoses appearing on the death certifi- 



109 
cates and verified so far as possible by personal consultation with the 
physician concerned: eclampsia, acute yellow atrophy of the liver in 
pregnancy, uremia and convulsive toxemia of pregnancy. 

Prenatal Care 

Fortunately, prevention is not beyond our reach because of the vague- 
ness of our present knowledge of exact causes of puerperal toxemia. 
Adequate prenatal care is now fully proven to be the best preventive. For 
the purpose of this study we have accepted the standard given by Wood- 
bury of the Children's Bureau, and termed "Grade A" prenatal care:* 

1. Supervision by a private physician from the fifth through the ninth 
month or monthly visits to a maternity clinic during that period. 

2. Monthly urinalysis for the above period. 

3. At least one abdominal examination. 

4. Pelvic measurements if a primipara. 

We found no records of weight being taken, but many careful physicians 
now recommend taking it regularly throughout pregnancy as undue gain 
in weight may indicate an oncoming pre-eclamptic condition before local 
edema or other symptoms are observed. 

Only 28 mothers in this group had approximate "Grade A" prenatal 
care. The lack of prenatal care appeared to be due in each case to one 
or more of the following reasons: 

1. Ignorance of the mother as to the importance of having medical care 
throughout pregnancy and neglect on her part to see her family physician 
or go to a prenatal clinic. 

2. Neglect on part of the mother to carry out directions given by her 
physician or at the clinic, sometimes wilful, sometimes due to ignorance, 
often because of difficulties in the home. 

3. Lack of opportunity to get prenatal care because of distance, pov- 
erty, or lack of interest on the part of the physician to whom the mother 
first went. 

4. Neglect on part of physicians and nurses in teaching mothers the 
importance of prenatal care. 

The opportunity of and the need for a well trained public health nurse 
in this work are enormous. She can keep the mother from drifting away 
from medical care, help her to adjust, and allay her many doubts and 
fears to an extent impossible for the busy practitioner. Next to the 
physician she is the most valuable ally in combating maternal and infant 
death and morbidity rates, in any community. Every community should 
provide such service for its mothers at a reasonable price. 

Delivery 

Of the 193 mothers delivered (24 were undelivered) 48 were spon- 
taneous deliveries, 44 forceps deliveries, 37 versions, 54 Cesarean sections, 
other operative procedures, 6,f and 4 where method of delivery was not 
stated. Doubtless the number of "emergency" Cesarean Sections (37) 
would be much less today, as this operation is no longer looked upon 
as the best procedure in most cases of this type. 113 were nine months 
pregnant at the time of delivery, so there was not the excuse of early 
pregnancy as in some other causes of death. 

Types of Toxemia 

1. Eclampsia was the most common diagnosis met with. Theoretically 
eclampsia is a toxic condition distinct from uremia or nephritic toxemia 

* Woodbury's Grade A Prenatal dare — See "Maternal Mortality in Massachusetts" : Journal 
American Medical Association for February 6, 1926. Had this study been made at a later time 
the standards of prenatal care as outlined by the Maternity Welfare Committee working in con- 
junction with the Children's Bureau, Washington, would have been used. They are Bet forth 
in Publication No. 153 of the Children's Bureau, 1926. 

t 2 deliveries by bagging, 1 a manual delivery, 1 induced, 1 footling and 1 breech. 



110 
but practically this is a distinction hard to maintain as the clinical picture 
may be identical. According to good authority (Williams and others) the 
only absolutely 'characteristic feature of eclampsia is the presence of 
hepatic lesions, but as autopsy was performed in only five cases in this 
group, this feature was of little use as a criterion. 

Eclampsia has been defined as an "acute toxemia occurring in preg- 
nant, parturient and puerperal women, usually accompanied by clonic and 
tonic convulsions, during which there is a loss of consciousness followed 
by more or less prolonged coma and which frequently results in death." 
(Williams). 

Causes 

As to the causes of eclampsia, we will not attempt any list of the theor- 
ies as put forth at present : a comprehensive survey of them is offered in 
a standard text book on obstetrics to the extent of eleven closely printed 
pages, which clearly indicates our lack of accurate information along 
this line. 

2. Hepatic Toxemia. Six patients in our series were diagnosed finally 
as having the hepatic type of Toxemia but as only one had had autopsy, 
evidence was incomplete. 

Late vomiting occurred in all but one of these cases, jaundice in three, 
and in one other case the baby was severely jaundiced at birth though the 
mother was not. 

The physicians with whom we talked considered this type of Toxemia 
the most serious and the least amenable to both preventive measures and 
remedial treatment, in their experience. 

3. Nephritic Toxemia. Thirty mothers had nephritis. Nine of the 
thirty had had no prenatal care. 

In this group convulsions occurred in 16, and 12 died in coma. 
At no time perhaps is prenatal care more important than in the follow- 
ing groups : 

(a) The primipara with a past history of nephritis. 

(b) The multipara who gives a history of nephritis in preceding preg- 
nancies. 

(c) The primipara or multipara who develops symptoms of toxemia 
during her pregnancy. 

Frequent blood pressure and urinalysis are tremendously important 
here, as well as the prompt reporting of edema, scanty urine, headache or 
eye symptoms. Many a young mother pays no attention to these symp- 
toms, having been told by neighbors that these things all go with preg- 
nancy. Such a case came to our notice accidentally at a Well Child Con- 
ference in the country where the inexperienced young mother was suf- 
fering from headache, blurring of the eyes and swelling of the ankles. 
She said, "Why, my nearest neighbor says she had all these troubles with 
all her five children and that it was silly for me to worry about them." 
Prompt treatment on the part of her family physician, to whom we 
hastened this lady, fortunately resulted in a living mother and child fol- 
lowing delivery, but the physician got more than one gray hair over this 
case. (We might note, a matter of reflection, that the "nearest neighbor" 
had lost all her five babies but one, at or shortly after birth) . 

Convulsions and Coma 

159 of these toxemic mothers had convulsions — 96 before delivery, 42 
after delivery; and 21 who were undelivered. Coma also occurred in 89 
instances all told (following convulsions 68; without convulsions 21). 

Summary 

1. 217 women, 6 months or more pregnant, between the ages of 16 and 
45 lost their lives because of puerperal toxemia in some form, eclampsia 
predominating (176). 



Ill 

2. Only 28 of the 217 mothers had had what could be considered even 
approximately adequate prenatal care. 99 were primiparae. 

3. 98 of these 217 mothers were delivered in hospitals as emergencies 
arriving at the hospital moribund or nearly so in many instances, too late 
to benefit from hospital facilities, however great. 40 had no prenatal 
care. Convulsions occurred in 159 instances. 

4. Many of these mothers died at the age they were most needed by 
their families. 117* were multiparae. They left, all told, 384 living 
children. 

5. Of the 197 babies born to these mothers, 72 were stillbirths and 34 
died in early infancy, leaving 81 infants living when last heard from. 24 
mothers were undelivered. In a large number of instances we learned 
that the home was broken up by the mother's death and the children 
scattered among relatives, or boarded out. In a considerable number of 
instances the "new" baby, apparently healthy at birth, died one or two 
months after the mother's death. 

Conclusions 

All recent investigations of Toxemia of pregnancy as one cause of ma- 
ternal death points unerringly to the importance of prenatal care as a 
preventive measure. Large hospitals in Massachusetts and elsewhere re- 
port no toxic deaths among those mothers attending their prenatal clinics 
for a reasonable period. This being the case, we feel sure that we now 
have at least one weapon at hand by means of which we can effect a ma- 
terial reduction in maternal death rates. 

The problem is to develop a feeling of responsibility for making pre- 
natal care universal. Many, even among doctors, do not yet see the enor- 
mous importance of it. We who do must work incessantly to make clear 
the importance to all concerned. We must convince women, both Ameri- 
can and foreign born, of its value — by means of "information, authentic 
and reliable, in ways and in a language easily understood." For, on 
women themselves depends to a large extent the future of mothers and 
babies. What mothers steadily demand, physicians, nurses and com- 
munities will ultimately see that they get. We pride ourselves on being 
a country where demand never goes unanswered. 



REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of July, August and September, 1927, samples were 
collected in 155 cities and towns. 

There were 2,017 samples of milk examined, of which 578 were below 
standard, from 57 samples the cream had been in part removed, one of 
which also contained added water; and 51 samples contained added water. 

There were 94 samples of food examined, of which 22 were adulterated. 
These consisted of 8 samples of eggs which were sold as fresh eggs but 
were not fresh; 5 samples of ice cream which were below the legal 
standard in fat; 4 samples of maple syrup which contained cane sugar; 
and 5 samples of smoked salmon which were decomposed. 

There were 20 samples of drugs examined, of which 10 samples were 
adulterated. These consisted of 8 samples of spirit of nitrous ether, and 
2 samples of lime water, all of which were deficient in the active ingredi- 
ent. 

The police departments submitted 2,167 samples of liquor for examina- 
tion, 2,124 of which were above 0.5% in alcohol. The police departments 
also submitted 19 samples of narcotics, etc. for examination, 10 of 
which were morphine, 2 magnesium sulphate, 1 sample each of calomel, 
strychnine, a mixture of gasolene and kerosene, opium, heroin, tobacco 



* Number of pregnancies unknown. 



112 
examined for morphine but found to contain none, and 1 sample which 
was examined for poison with negative results. 

There were 31 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 43 convictions for violations of the law, $670 in fines being 
imposed. 

Louis Atnes and George Pappas of Nantasket; Michael Anagnos of 
Nantucket; Angelo Bamvakas, Albert Bonazoli, and James A. Cutulis, all 
of Newton; Jesse Costa of Tiverton, R. I.; Manuel S. Soares, Louis Z. 
Gaisson, Chrisloplias Johnson, and Jordan Pappas, all of New Bedford; 
Alan C. Moceup and Frank Rego of Fall River ; Peter Theodore of Chico- 
pee ; Ernest C. Papadoycanis of Attleboro ; Michael Roumacker of Turners 
Falls ; Roy W. Busby, 2 cases, of Great Barrington ; Charlie King of Ply- 
mouth; Nicholas Pappas of Bridgewater; James Vincent of Waltham; 
Chris Christopulas of Buzzards Bay; Nick Oestrides of Onset; and John 
Zahos of Salisbury Beach, were all convicted for violations of the milk 
laws. Manuel S. Soares of New Bedford; Michael Roumacker of Turners 
Falls; Charlie King of Plymouth; and John Zahos of Salisbury Beach, all 
appealed their cases. 

Bernard Collins of Boston; and First National Stores, Incorporated, 
of Brookline, were convicted for violations of the food laws. Bernard 
Collins of Boston appealed his case. 

Edward 0. Earls and Eugene J. Murphy Company, Incorporated, both 
of Fitchburg, were convicted for violations of the drug laws. 

John J. Papp, Puritan Lunch Incorporated, Sterling Cafeteria Incor- 
porated, and Worthy Lunch Company Incorporated, all of Boston; Well- 
worth Service Stores Incorporated of Framingham; Louis Demeo of 
Waltham; Chrisloplias Johnson of New Bedford; Charlie King of Ply- 
mouth; Charles Conaries of Milford; Thomas J. Biggins of Peabody; 
Owen W. Doonan of North Saugus; Edward E. Watson of Lynnfield; and 
Louise Hannaford of Lexington, were all convicted for false advertising. 

Puritan Lunch Incorporated of Boston, and Charlie King of Plymouth, 
appealed their cases. 

Karl Konkol of Auburn; and Reinhold Ullrich of Pittsfield, were con- 
victed for violations of the slaughtering laws. 

In accordance with Section 25, Chapter 111 of the General Laws, the fol- 
lowing is the list of articles of adulterated food collected in original pack- 
ages from manufacturers, wholesalers, or producers: 

Milk which contained added water was produced as follows : 7 samples, 
by John Smith of Newburyport; and 6 samples, by Jesse Costa of Tiver- 
ton, Rhode Island. 

Four samples of milk which had the cream removed were produced by 
John Rezendes of Somerset. 

One sample of maple syrup which contained cane sugar was obtained 
from Quality Lunch of Milford, and Royal Restaurant of Gloucester. 

There were seven confiscations, consisting of 147 pounds of rancid 
chicken fat; 15 pounds of decomposed wild goose; 24 pounds of decom- 
posed venison; 165 pounds of tainted ox tails; 400 pounds of diseased 
beef; 110 pounds of tainted chitterlings; and 1350 pounds of decomposed 
salmon. 

The licensed cold storage warehouses reported the following amounts of 
food placed in storage during the month of June, 1927 : — 3,415,260 dozens 
of case eggs; 677,752 pounds of broken out eggs; 7,643,882 pounds of but- 
ter; 1,396,288 pounds of poultry; 4,644,580% pounds of fresh meat and 
fresh meat products ; and 2,944,370 pounds of fresh food fish. 

There was on hand July 1, 1927:— 15,038,130 dozens of case eggs; 
2,842,610 pounds of broken out eggs; 8,891,440 pounds of butter; 5,016,- 
800y 2 pounds of poultry; 13,879,988y 2 pounds of fresh meat and fresh 
meat products ; and 9,207,650 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 



113 
of food placed in storage during the month of July, 1927: — 1,109,370 
dozens of case eggs ; 223,234 pounds of broken out eggs ; 6,767,521 pounds 
of butter; 1,122,026 pounds of poultry; 3,592,590 pounds of fresh meat 
and fresh meat products; and 5,393,139 pounds of fresh food fish. 

There was on hand August 1, 1927: — 14,900,580 dozens of case eggs; 
2,697,193 pounds of broken out eggs; 14,665,427 pounds of butter; 4,624,- 
371% pounds of poultry; 14,676,010 1 /2 pounds of fresh meat and fresh 
meat products ; and 13,644,982 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of 
food placed in storage during the month of August, 1927: — 996,720 
dozens of case eggs; 312,141 pounds of broken out eggs; 4,289,786 pounds 
of butter; 877,064^ pounds of poultry; 2,501,604 pounds of fresh meat 
and fresh meat products; and 4,321,704 pounds of fresh food fish. 

There was on hand September 1, 1927: — 13,143,030 dozens of case 
eggs; 2,495,421 pounds of broken out eggs; 16,894,269 pounds of butter; 
3,735,326% pounds of poultry; 13,041, 804^ pounds of fresh meat and 
fresh meat products; and 15,678,176 pounds of fresh food fish. 



REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of October, November and December, 1927, sam- 
ples were collected in 152 cities and towns. 

There were 1,696 samples of milk examined, of which 293 were below 
standard, from 36 samples the cream had been in part removed, and 50 
samples contained added water. 

There were 450 samples of food examined, of which 148 were adulter- 
ated. These consisted of 4 samples of clams, 1 of which was decom- 
posed, and 3 samples were watered; 118 samples of eggs, 70 samples of 
which were cold storage not so marked, 47 samples were sold as fresh 
eggs but were not fresh, and 1 sample was decomposed; 7 samples of 
maple syrup which contained cane sugar; 11 samples of sausage, 4 of 
which contained starch in excess of 2 per cent, and 7 samples contained 
a compound of sulphur dioxide not properly labeled; 2 samples of ham- 
burg steak which contained a compound of sulphur dioxide not properly 
labeled; 2 samples of oysters, and 1 sample of scallops, which con- 
tained added water; 1 sample of cider which contained benzoate and 
was not properly labeled ; and 2 samples of dried fruits which contained 
sulphur dioxide not properly labeled. 

There were 17 samples of drugs examined, of which 5 samples were 
adulterated. These consisted of 5 samples of spirit of nitre which 
were deficient in the active ingredient. 

The police departments submitted 2,007 samples of liquor for exam- 
ination, 1,977 of which were above 0.5% in alcohol. The police depart- 
ments also submitted 19 samples of narcotics, etc. for examination, 12 
of which were morphine, 1 bichloride of mercury, 2 opium, 1 ergot, 2 
zinc chloride solution, and 1 sample which was examined for poison 
with negative results. 

There were 60 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 2 samples of coal examined which conformed to the law. 

There were 59 convictions for violations of the law, $1,150 in fines 
being imposed. 

Peter Bega of Milford; Benjamin M. Harrison of Acton; Seraphin 
G. Steele of Provincetown ; Mary H. Wolski of Cambridge; Eugene 
Gandini, and Jackson Confectionery Company, Incorporated, of Spring- 
field; John Smith of Newburyport; Robert Tallent of Millis, Floyd 
Milk Company of Winthrop ; Camila Anthier, Henry Christian, Liggetts 
Drug Company, Augustas Mazzolini, Andrew Orsini, and Fred Rigali, 
all of Holyoke; Mary Janakonis of Bridgewater; Seid F. Woo of Pitts- 



114 
field; George W. Cox of West Bridgewater; Peter Liapes of Lynn; and 
Frank Mitchell of Attleboro, were all convicted for violations of the milk 
laws. 

George Queior of Chicopee; Frank Bartz, 2 cases, and Alpha Lunch 
Company, both of Boston; The Great Atlantic & Pacific Tea Company 
of North Attleboro; Joseph Duffy and William F. Duffy, both of Re- 
vere; Fitts Brothers, Incorporated, of Framingham; Damon W. Free- 
man and Victor R. Wells, both of Winthrop; and Albert A. Smart of 
Lynn, were all convicted for violations of the food laws. Joseph Duffy 
and William F. Duffy, both of Revere; Damon W. Freeman and Victor 
R. Wells, both of Winthrop ; and Albert A. Smart of Lynn, all appealed 
their cases. 

Albert P. Quimby of Essex ; Ernest Strecker of Lawrence ; The Massa- 
chusetts Mohican Company, Morris Abrahams, 2 cases, and The Great 
Atlantic & Pacific Tea Company, all of Pittsfield; Thomas R. McEwen 
of Springfield ; The Mayflower Stores of Attleboro ; Theodore H. Loukas, 
Anastos K. Dennis, and Georgian Cafeteria Company, all of Cambridge ; 
Frank Wong of Gloucester; Harry Burns of Fall River; and Nicholas 
Ptsakeres, Alpha Lunch Company, George D. Kacavas, and James Pupu- 
lias, all of Boston, were all convicted for false advertising. Ernest 
Strecker of Lawrence ; and Georgian Cafeteria Company of Cambridge, 
both appealed their cases. 

Israel Gilbroord, George Yazbeck, and Alexander Roguski, all of 
Lawrence; Hyman Persky of Holyoke; Abraham Amazon, Stanley 
Moleska, and Gregory Mosca, all of Pittsfield; Richard Connolly and 
Michael Diorio, both of Salem; and William G. Gauthier of Attleboro, 
were all convicted for violations of the cold storage laws. Michael 
Diorio of Salem appealed his case. 

Abraham Garbatsky of New Bedford was convicted for violation of 
the slaughtering laws. He appealed his case. 

In accordance with Section 25, Chapter 111 of the General Laws, the 
following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers : 

Milk which contained added water was produced as follows : 4 sam- 
ples, by Morris Charney of Chelsea; 3 samples, by Frank Mitchell of 
South Attleboro; and 1 sample each, by Michael and Mary Janukonis 
of Bridgewater. 

One sample of clams which was decomposed was obtained from Fitts 
Brothers of Framingham. 

Sausage which contained a compound of sulphur dioxide not properly 
labeled was obtained as follows: 

1 sample each, from Frank Bartz, and Mohawk Sausage & Provision 
Company, both of Boston; and Frank Borron of Holyoke. 

One sample of sausage which contained starch in excess of 2 per 
cent was obtained from Carl Weitz of Boston. 

Hamburg steak which contained a compound of sulphur dioxide not 
properly labeled was obtained as follows: 

1 sample each, from Harry Gillis, and Idel Goldenberg, both of Boston. 

One sample of scallops which contained added water was obtained 
from the Atlantic & Pacific Tea Company of North Attleboro. 

One sample of cider which contained benzoate and was not properly 
labeled was obtained from the Blue Ribbon Bottling Company of Rox- 
bury. 

There were nineteen confiscations, consisting of 252% pounds of de- 
composed chickens; 46 pounds of decomposed fowls; 345% pounds of 
decomposed turkeys; 50 pounds of decomposed geese; 200 pounds of 
decomposed beef; 40 pounds of decomposed lamb and pork; 20 pounds 
of decomposed smoked shoulders; 10 pounds of decomposed frankforts; 
5 pounds of decomposed veal; 16 pounds of decomposed lobsters; 25 



115 
pounds of decomposed mackerel ; 5 pounds of decomposed ground fish ; 
and 35 gallons of decomposed opened clams. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of September, 1927: — 
610,950 dozens of case eggs; 132,017 pounds of broken out eggs; 1,901,- 
341 pounds of butter; 988,576 pounds of poultry; 2,942,292 pounds of 
fresh meat and fresh meat products ; and 3,908,407 pounds of fresh food 
fish. 

There was on hand October 1, 1927: — 10,985,880 dozens of case eggs, 
2,084,450 pounds of broken out eggs, 15,502,093 pounds of butter; 3,- 
624,864% pounds of poultry; 11,088,535 pounds of fresh meat and fresh 
meat products; and 16,273,606 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of October, 1927: — 385,380 
dozens of case eggs; 282,506 pounds of broken out eggs; 1,078,752 
pounds of butter; 1,080,329 pounds of poultry; 2,506,465 pounds of fresh 
meat and fresh meat products ; and 3,430,541 pounds of fresh food fish. 

There was on hand November 1, 1927: — 7,944,270 dozens of case 
eggs; 1,797,656% pounds of broken out eggs; 12,772,503 pounds of but- 
ter; 3,847,800% pounds of poultry; 8,170,584 pounds of fresh meat and 
fresh meat products; and 14,103,665 pounds of* fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of November, 1927 : — 403,950 
dozens of case eggs; 333,913 pounds of broken out eggs; 804,193 pounds 
of butter; 2,543,061 pounds of poultry; 3,114,838 pounds of fresh meat 
and fresh meat products; and 2,545,752 pounds of fresh food fish. 

There was on hand December 1, 1927 : — 4,346,770 dozens of case eggs ; 
1,550,776% pounds of broken out eggs; 8,994,307 pounds of butter; 
5,526,009 pounds of poultry; 8,256,864 pounds of fresh meat and fresh 
meat products; and 12,086,331 pounds of fresh food fish. 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, ALICE M. ETHIER. 



Division of Administration 
Division of Sanitary Engineering . 

Division of Communicable Diseases 

Division of Water and Sewage Lab- 
oratories 

Division of Biologic Laboratories 

Division of Food and Drugs . 

Division of Hygiene . 

Division of Tuberculosis . 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 

The Southeastern District 



The Metropolitan District 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District . 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., Lowell. 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



117 

INDEX 

PAGE 

Activities of the Massachusetts Department of Public Health . . 21 

Advisory Committee on Dental Hygiene 57 

Avery, Edith R., How Private Organizations are Helping (Cancer) . 44 
Bacterial Methods, A Brief Summary of, and Standards in Water 

Analysis, by H. W. Clark 78 

Balch, Franklin G., M.D., National Aspects of Cancer .... 42 

Barnstable County Health Department 29 

Barnstable County Health Department, by A. P. Goff, M.D. . . 26 

Bigelow, George H., M.D., Pasteurization 69 

Bigelow, George H., M.D., Cancer Program of Massachusetts . . 39 

Biologic Products, Present Status of Some, by Benjamin White, Ph.D. 76 
Blind, Work of the Division of the, by Robert I. Bramhall . . .102 

Blindness — Glaucoma, by George S. Derby, M.D. .... 98 
Blindness, Prevention of, from the Point of View of the Board of 

Health, by Margaret E. Gaffney, R.N 97 

Bramhall, Robert I., Ophthalmia Neonatorum in Massachusetts . 95 

Bramhall, Robert I., The Work of the Division of the Blind . . 102 
Breast Feeding Demonstration, Report of First Six Months of a, by 

Lela M. Cheney, R.N 18 

Brief Summary of Bacterial Methods and Standards in Water Analy- 
sis, by H. W. Clark 78 

Cancer Campaign, Social Service and the, by Ida M. Cannon . . 45 

Cancer Clinic, The, by Kendall Emerson, M.D 52 

Cancer Education in Massachusetts, by Mary R. Lakeman, M.D. . 48 

Cancer — How Private Organizations are Helping, by Edith R. Avery. 44 

Cancer, National Aspects of, by Franklin G. Balch, M.D. ... 42 

Cancer Program of Massachusetts, by George H. Bigelow ... 39 

Cancer Program, The State 30 

Cancer Studies by the State, by Herbert L. Lombard, M.D. . . 41 
Certain Aspects of the Psychology of the Pre-school Child, by Rose S. 

Hardwick, Ph.D. . 5 

Chiasson, Stella A., One Teacher's Experience in Eye Testing . . 91 
Champion, Merrill, M.D., May Day and the Summer Round-Up . 7 
Champion, Merrill, M.D., Some Unsolved Problems in Child Hygiene. 74 
Champion, Merrill, M.D., and Clarence L. Scamman, M.D., Out- 
breaks of Contagious Disease and School Closure ... 70 

Chapin, Dr. Charles V., Testimonial Exercises to 30 

Cheney, Lela M., Report of the First Six Months of a Breast Feeding 

Demonstration 18 

Child Hygiene, Some Unsolved Problems in, by Merrill Champion, M.D. 74 
Clark, H. W., A Brief Summary of Bacterial Methods and Standards 

in Water Analysis 78 

Coffin, Susan M., M.D., The Maternal and Child Hygiene Activities of 

the Massachusetts Department of Public Health . . . 15 
Coffin, Susan M., M.D., Study of 217 Deaths from Puerperal Toxemia 108 
Common Communicable Diseases — Protection for the Infant and Pre- 
school Child, by Clarence L. Scamman, M.D 9 

Communicable Diseases, Control of 58 

Conjunctivitis, Suppurative, Reportability of 105 

Contagious Disease, Outbreaks of, and School Closure, by Clarence L. 

Scamman, M.D., and Merrill Champion, M.D. ... 70 

Current Health Legislation 28 

DeNormandie, Robert L., M.D., Maternal Mortality .... 1 

Dental Advisory Committee, Report of Meeting of .... 106 

Dental Hygiene, Advisory Committee on 57 

Derby, George S., M.D., Glaucoma — Blindness 98 

Division of the Blind, Work of the, by Robert I. Bramhall . . .102 



118 
Editorial Comment: page 

Advisory Committee on Dental Hygiene 57 

Barnstable County Health Department . . . . .29 

Control of Communicable Diseases 58 

Control of Ophthalmia Neonatorum 58 

Current Health Legislation 28 

Food on the Farm 81 

Form M . . m 105 

Health Bulletin Service 31 

Immunization ... . . A 56 

Legislation 104 

May Day 55 

May Day and the Summer Round-Up 104 

Public Health Institute, A .58 

Reportability of Suppurative Conjunctivitis 105 

Reporting Progress 82 

School Nurses, Training for . . . . . . . .81 

State Cancer Program 30 

Summer Course at Hyannis 31 

Summer Round-Up 29, 55 

Testimonial Exercises to Dr. C. V. Chapin 30 

Town Meeting 104 

Winchester Health Survey 57 

Emerson, Kendall, M.D., The Cancer Clinic 52 

Essentials of Physical Examination of the Pre-School Child, Two to Six 

Years Old, by Fritz B. Talbot, M.D 3 

Eye, Hygiene of the Normal, by Ralph A. Hatch, M.D. ... 89 

Eye Testing, One Teacher's Experience in, by Stella A. Chiasson . 91 
Food and Drugs, Report of Division of: 

October, November, December, 1926 32 

January, February, March, 1927 61 

April, May, June, 1927 83 

July, August, September, 1927 Ill 

October, November, December, 1927 113 

Food on the Farm 81 

Form M 105 

Gaffney, Margaret E., R.N., Prevention of Blindness from the Point of 

View of the Board of Health 97 

Gallinger, Eleanor B., S.B., Importance of First Teeth ... 10 

Glaucoma — Blindness, by George S. Derby, M.D. .... 98 

Goff, A. P., M.D., Barnstable County Health Department ... 26 
Hard wick, Rose S., Ph.D., Certain Aspects of the Psychology of the 

Pre-School Child 5 

Hatch, Ralph A., M.D., Hygiene of the Normal Eye .... 89 

Health Bulletin Service 31 

Hospitalization of the Tuberculous State Case, by Sumner H. Remick, 

M.D 72 

How Private Organizations are Helping (Cancer), by Edith R. Avery 44 

Hygiene of the Normal Eye, by Ralph A. Hatch, M.D 89 

Immunization 56 

Importance of First Teeth, by Eleanor B. Gallinger, S.B. ... 10 

Lakeman, Mary R., M.D., Cancer Education in Massachusetts . . 48 

Legislation 104 

Lombard, Herbert L., M.D., Cancer Studies by the State ... 41 
Lombard, Lou, S.B., Nurtition of Mother and Baby .... 1 
Massachusetts Department of Public Health, Activities of . .21 
Maternal and Child Hygiene Activities of the Massachusetts Depart- 
ment of Public Health, by Susan M. Coffin, M.D. . . 15 
Maternal Mortality, by Robert L. DeNormandie, M.D. ... 1 

May Day 55 

May Day and the Summer Round-Up 104 



119 

PAGE 

May Day and the Summer Round-Up, by Merrill Champion, M.D. , 7 

Mother and Baby, Nutrition of, by Lou Lombard, S.B. . . . 1 

National Aspects of Cancer, by Franklin G-. Balch, M.D. ... 42 

Nurse — Part She Can Play in Cancer Control, by Elizabeth Ross, R.N. 47 

Nutrition of the Mother and Baby, by Lou Lombard, S.B. ... 1 

Nutritional Service of Well Child Conferences, 1927, Summary of . 108 

One Teacher's Experience in Eye Testing, by Stella A. Chiasson . 91 

Ophthalmia Neonatorum, Control of 58 

Ophthalmia Neonatorum in Massachusetts, by Robert I. Bramhall . 95 
Outbreaks of Contagious Diseases and School Closure, by Clarence L. 

Scamman, M.D., and Merrill Champion, M.D. ... 70 

Part the Nurse Can Play in Cancer Control, by Elizabeth Ross, R.N. 47 

Pasteurization, by George H. Bigelow, M.D. 69 

Physical Examination of the Pre-school Child, Two to Six Years Old, 

Essentials of, by Fritz B. Talbot, M.D 3 

Pondville Hospital, Service at the, by Robert B. Greenough, M.D. 51 
Pre-school CMd, Certain Aspects of the Psychology of the, by Rose S. 

Hardwick, Ph.D 5 

Pre-School Child, Two to Six Years Old, Essentials of Physical Exam- 
ination of the, by Fritz B. Talbot, M.D 3 

Present Status of Some Biologic Products, by Benjamin White, Ph.D. 76 
Prevention of Blindness from the Point of View of the Board of Health, 

by Margaret E. Gaffney, R.N 97 

Psychology of the Pre-school Child, Certain Aspects of the, by Rose S. 

Hardwick, Ph.D 5 

Public Health Institute, A 58 

Remick, Sumner H., M.D., Hospitalization of the Tuberculous State 

Case 72 

Report of First Six Months of a Breast Feeding Demonstration, by 

Lela M. Cheney, R.N 18 

Reportability of Suppurative Conjunctivitis 105 

Ridgeway, Ida E., The Sight Saving Class . . . . . .99 

Ross, Elizabeth, R.N., The Part the Nurse Can Play in Cancer Control 47 
Scamman, Clarence L., M.D., Common Communicable Diseases — 

Protection for the Infant and Pre-School Child 
Scamman, Clarence L., M.D., and Merrill Champion, M.D., Out- 
breaks of Contagious Disease and School Closure . . 70 
School Closure, Outbreaks of Contagious Disease and, by Clarence L. 

Scamman, M.D., and Merrill Champion, M.D. ... 70 

School Nurses, Training for 80 

Service at the Pondville Hospital, by Robert B. Greenough, M.D. . 51 

Sight Saving Class, The, by Ida E. Ridgeway 99 

Social Service and the Cancer Campaign, by Ida M. Cannon . . 45 
Some Unsolved Problems in Child Hygiene, by Merrill Champion, 

M.D 74 

State Cancer Program 30 

Stevens, H. W., M.D., Vision and Illumination 92 

Study of 217 Deaths from Puerperal Toxemia, by Susan M. Coffin, 

M.D 108 

Summer Course at Hyannis 31 

Summer Round-Up 29, 55 

Summer Round-Up, May Day and the 104 

Summer Round-Up, May Day and the, by Merrill Champion, M.D. . 7 

Sunlight for Babies 12 

Talbot, Fritz B., M.D., Essentials of Physical Examination of the Pre- 
School Child, Two to Six Years Old 3 

Teeth, The Importance of First, by Eleanor B. Gallinger, S.B. . . 10 
Testimonial Exercises to Dr. Charles V. Chapin . . . . .30 
Toxemia, Puerperal, Study of 217 Deaths from, by Susan M. Coffin, 

M.D. . 108 



120 

PAGE 

Town Meeting 104 

Tuberculous State Case, Hospitalization of the, by Sumner H. Rem- 

iek, M.D 72 

Vision and Illumination, by H. W. Stevens, M.D. . . . . 92 
Water Analysis, A Brief Summary of Bacterial Methods and Stand- 
ards in, by H. W. Clark 78 

Well Child Conferences (Reporting Progress) 82 

Well Child Conferences, Summary of, from November 30, 1926, to 

December 1, 1927 107 

Well Child Conferences, 1927, Summary of Nutritional Service . 108 

White, Benjamin, Ph.D., Present Status of Some Biologic Products . 76 

Winchester Health Survey ... ..... 57 

Work of the Division of the Blind, by Robert I. Bramhall . . . 102 



Publication op this Document approved by the Commission on Administration and Finance 
6 M. l-'28. Order 919. 



THE 
COMMONHEALTH 



Volume 15 
No. 1 




Jan.- Feb.- Mar. 
1928 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 



% 



THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of 
Public Health 

Sent Free to any Citizen of the State 



Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 



Rural Sanitation with Special Reference to Water Supply, by X. H 
Goodnough ........ 

The Control of Nuisances, by Harold E. Miner, M.D. 

The District Health Officer, by Edward A. Lane, M.D. . 

The Law Says, by Merrill Champion, M.D 

Again, May Day —Child Health Day, by Albertine C. Parker, S.B 

Massachusetts: Association of School Dental Workers 



Developing the Prenatal and Pre-School Aspects of a Community 
Dental. Program, .by F. M. Erlenbach, M.D. 

The Teacher's Own Health Score Card . 

Editorial. p/mment' : 

Cancer Campaigh' • < ... 

A Plea for More Follow-Up in the Homes 

Law — and Persuasion .... 

Results of the Ten Year Program . 

Regional Consultants in Dental Hygiene 

Help Fight Cancer ..... 

Announcement of Summer School Courses 

Summary of Well Child Demonstration Conferences, November 30, 
1926— December 1, 1927 



PAGE 

3 
7 
10 
13 
14 
16 



17 
18 

22 
22 
22 

23 
23 
24 

24 

25 



> 7? V 



3 

RURAL SANITATION WITH SPECIAL REFERENCE TO WATER 

SUPPLY 

By X. H. Goodnough, 
Chief Engineer, Massachusetts Department of Public Health 

In the State of Massachusetts nearly 97% of the inhabitants live in 
cities and towns which are supplied with water from public works. The 
total number of cities and towns so supplied is about 220, and that num- 
ber contains a population of 4,006,421. The aggregate population of 
the remaining towns is 137,784, but in many of this latter group of 
towns there are small villages or groups of houses which are supplied 
from a common source. On the other hand there are in some cases 
thinly inhabited areas in towns which are provided with public water 
supplies to which the public supply has not been extended. In the hilly 
regions, especially in the central parts of the State and in the moun- 
tains west of the Connecticut River, the farm water supply is obtained 
in many cases from springs located on a hillside from which water is 
supplied by gravity to the buildings, giving running water in the house 
and barn. In the sandy regions of Cape Cod and in the southeastern 
parts of the State, water supplies are commonly obtained from tubular 
wells driven in the porous soil. Such wells are usually iron pipes hav- 
ing a diameter from 1 inch sometimes to as great as 8 inches, but usu- 
ally 2 or 2 1 /2 inches, and are sunk to comparatively shallow depths, usu- 
ally not more than 20 to 30 feet. 

By far the greater number of water supplies in Massachusetts out- 
side the limits of town or village water works systems are obtained 
from ordinary wells dug in the ground to depths of 10 to 30 feet, curbed 
commonly with field stone and having usually a diameter of 3 to 4 feet. 
Such wells are generally located as near as practicable to the farm 
buildings, especially to the dwelling house, for convenience in obtain- 
ing water for household use, and at many farm and village dwellings 
the household well is located for convenience in the cellar of the house 
or even in a corner of the barn. In earlier years water was usually 
drawn by means of a bucket and sweep and later with a hand pump. 
In more recent years, water is supplied in many houses by means of a 
power pump connected with a pressure tank so that water is supplied 
under pressure to faucets in the buildings. 

While improvements have been effected in the methods of supplying 
water in rural districts, comparatively little attention has been paid 
until recent years to the location of the well or to circumstances which 
might affect the quality of the water. Many of the wells now in use 
were constructed at a time when little or nothing was thought of the 
danger of the pollution of the water and a well water that was clear 
and colorless and free from taste and odor was regarded as wholly sat- 
isfactory. 

The question is often asked why old wells which apparently yielded, 
and probably did yield, good water many years ago do not furnish water 
of the same quality today. The answer in many cases is that when the 
well was first dug the buildings which it was designed to supply had 
only just been constructed, and little or no sewage had ever been de- 
posited upon the ground in the region about the well. As soon as the 
premises were occupied the seepage from the privy, sink drain or cess- 
pool, which were commonly located at no great distance from the well, 
began percolating into the ground in its neighborhood. The drawing 
of water from a well naturally draws the ground water at that point to 
a lower level than elsewhere in the neighborhood and induces a flow of 
water through the ground in its direction, and where sewage is dis- 
charged upon or into the ground in the region influenced by the draft 
of water from the well, seepage from sewage receptacles would nat- 
urally have a tendency to percolate toward the well. 



It is probable that in the beginning, and perhaps for many years, pol- 
luting matter from privies, cesspools, etc., thus percolating through 
the ground was thoroughly purified by oxidation and nitrification in its 
passage through the soil before reaching the well, but after a long pe- 
riod of continuous passage of water containing organic matter through 
the ground with air excluded, the efficiency of the purification becomes 
less and the effect of the pollution upon the ground water more serious. 
It is also possible that some of the finer matters in the soil may be grad- 
ually washed out, and the passage of the water through the ground thus 
allowed to become more rapid. 

The natural surface waters of Massachusetts are for the most part 
very soft except in the limestone regions of western Berkshire and in 
a few other isolated localities, and the same is true of the ground wat- 
ers collected in unpolluted territory. If a well water is noticeably hard 
except in the limestone regions referred to, it is usually an indication 
that the ground water has at some time been polluted before entering 
the well. Such water may not be unsafe for drinking if the pollution 
occurs at a point sufficiently remote from the well to allow for the thor- 
ough purification of the water in its passage through the soil, but in 
general if a water is hard outside the limestone regions referred to it 
is often a reason for suspicion of its quality and safety for drinking. 

The indications are that polluting matter from a privy or cesspool 
percolating toward a well does not spread out over a very large section 
of soil in passing through the ground to a lower level. Where the soil 
is fairly homogeneous the area affected is confined to a section not 
much greater in area than that of the privy or cesspool from which it 
comes. It is sometimes practicable to determine quite definitely the 
area affected by seepage from a privy or cesspool when excavations are 
made across the line of seepage from such a receptacle. An example 
of this was once seen by the writer, where a reservoir, upon one shore 
of which were located several privies and cesspools, was drawn down, 
exposing a steep slope from which the surface had been removed when 
the reservoir was built. In this case the areas through which the liquid 
percolating from the privies and cesspools to the reservoir was passing 
were clearly marked by the iron rust which settled out of the water on 
its coming to the air at the bank of the reservoir. In these cases it was 
evident that the path of the polluted water was quite direct, and that 
the area of cross section through which it passed was but little greater 
in any of these cases than the area of the privy or cesspool itself. The 
path of the waste had evidently remained the same for many years, in- 
dicating that the passage of the polluted liquid did not have a tendency 
to clog up the ground, but that rather the ground offered less resistance 
to the passage of the polluted water as time went on. The soil in this 
case was but slightly porous, being what is sometimes called a gravelly 
hardpan. 

The rate of percolation of water through the soil varies greatly with 
the character and porosity of the material, and liquid percolating from 
a cesspool toward a well may require a long time in its passage through 
the ground before it materially affects the character of the water of 
the well, but, where the soil is porous sand or gravel and much water 
is drawn from the well, percolation is more rapid. 

Under the general geological conditions in Massachusetts, the water 
which enters a well is derived from the rain which falls upon the 
ground immediately about it and percolates through the ground to the 
well. The area from which ground water is influenced to flow toward 
a well depends upon the porosity of the soil, the quantity of water 
drawn, and the general trend of the ground water of the locality in 
which the well is situated. The area from which a well derives its sup- 
ply cannot always be determined very definitely, but it can usually be 
determined with sufficient accuracy for practical purposes. 



An average family of six persons would rarely use — with the water 
required for animals, etc., and allowing a small amount for irrigation 
of gardens about the house in the summer season — as many as 600 gal- 
lons of water per day, and in most cases the quantity used is probably 
much less than that amount. 

A collection of one-third of the rainfall on the drainage area of the 
well would be a very large yield, and the quantity obtainable is usually 
much less. Assuming that one-fifth of the rainfall on adjacent ground 
is collectible in a well, the area of ground required for securing a sup- 
ply of 600 gallons daily would include a space 230 feet in diameter; 
that is, a privy or cesspool located within 115 feet of a well which de- 
rives its water equally from all directions would be likely to drain 
toward the well, even if the rainfall were distributed in equal daily 
quantities throughout the year. 

Of course, the yield from the rainfall varies, the amount being large 
in the winter and spring and small in the summer and autumn, so that 
in the drier portion of the year water might be influenced to flow toward 
the well if the soil were favorable from a considerably greater distance 
than 115 feet. 

The foregoing figures refer only to average conditions where the soil 
is of the same porosity and character over a considerable area. As the 
character of the soil usually varies considerably, even in short dis- 
tances, the flow of ground water is probably not usually the same from 
all directions about a well. There is also likely to be a variation in the 
flow of water toward a well due to the slope of the ground water, so 
that pollutions discharged into the ground may be carried to the well 
from a much greater distance on the side of the well from which the 
ground water flows most freely than pollutions deposited in other direc- 
tions about the well. 

It is important in order to secure water that is safe for drinking from 
a well dug near a dwelling house to locate the well at a point sufficiently 
remote from the places of sewage disposal, such as the sink drain, cess- 
pool, privy, etc., to insure that drainage from any of these will not affect 
the well. The best plan is, of course, to locate the sink drain, cesspool, 
privy, and also the barn, at a lower level than the well, but obviously this 
may not always be possible when it is desired to locate the well in the 
immediate neighborhood of the house. Where it is impracticable to dis- 
pose of the household sewage at a lower level than the water in the well 
it is important to locate the places of sewage disposal as far as practicable 
from the source of water supply. If the soil is sand or gravel and fairly 
homogeneous a distance of 250 feet will probably be adequate, provided, 
of course, that the sewage disposal receptacles are not placed in a locality 
from which the ground water drains most readily toward the well. 

It is usually not very difficult to determine the probable trend of the 
ground water and to take advantage of it in locating a well in such a 
way that, under the conditions mentioned, drainage from the receptacles 
for sewage is unlikely to affect it. 

Where the buildings are located on sloping ground, draining toward 
a stream or pond, and the well is on the upper side of the buildings and 
the sewage receptacles on the lower side, the latter may be located at a 
lesser distance from the well without affecting the quality of the water 
than where the ground is more nearly level; but it is not advisable, un- 
less expert examination shall show otherwise, to locate a receptacle for 
sewage nearer than 250 feet from a well unless, of course, the sewage is 
discharged at a lower level than the water in the well. 

It sometimes happens that in order to dispose of sewage effectively and 
satisfactorily it is necessary to convey it in a pipe for a considerable dis- 
tance from a dwelling, and the pipe line may perhaps have to pass near the 
well or through soil draining toward the well. In such cases it is always 
best to construct the pipe of iron with tight lead joints throughout the 



R 

section likely to be affected by drawing water from the well. In order to 
make sure that the pipe is tight it should be carefully laid and the joints 
tested by filling the pipe with water under considerable pressure before 
the trench is filled in. 

Beside the danger from sewage disposal receptacles it is important to 
avoid the heavy manuring or fertilizing of the land in the immediate 
neighborhood of a well. This practice has been known to affect the water 
of wells otherwise good and should be carefully avoided for a space of 
250 feet or more from the well, especially on the side from which it derives 
its chief supply. 

While the most important requirement in maintaining a good well 
water supply is to so dispose of the sewage that it will not affect the water, 
it is also important that the well be carefully covered so as to prevent the 
entrance of surface water and prevent animals or objectionable matter 
from falling into it. 

The best protection — and usually a sufficient one — for a well is to lay 
the upper 5 feet of the stone curbing in cement mortar, carrying the curb- 
ing to a few inches above the level of the ground, so that surface water 
will be diverted from the well and cannot enter it at the top. A cover 
should be placed over the well or upon sills set in cement on top of the 
curb, and such covering should be water tight. 

If water is drawn from the well by a pump passing up through the 
platform it is highly important that the platform be made absolutely 
tight and so sloped that water falling upon it will be carried away from 
the well. 

Although the water of a well may be unpolluted and apparently of good 
quality for domestic use, certain tests may show that the water will cor- 
rode pipes through which it is supplied or tanks in which it is stored. Be- 
fore accepting a new well as a source of water supply, tests should be 
made to determine the amount of certain dissolved gases present in the 
water, especially carbon dioxide, as the presence of this gas in consider- 
able quantities may cause the water to act upon lead pipe and cause lead 
poisoning or may act upon brass or copper pipe, causing this pipe to de- 
teriorate rapidly and result in green deposits on cooking utensils and 
plumbing fixtures, or the water may attack iron pipe in such a manner as 
to cause a rusty condition of the water. A pipe of block tin or of lead 
lined with tin, provided the pipe is so made that tin or some other suit- 
able material is in contact with the water, would be safe to use. Pipes 
lined with tin or with cement are also satisfactory for conveying drink- 
ing water when the water is found to be corrosive. When the water is 
not corrosive galvanized wrought-iron pipe is usually satisfactory. 

It is not practicable within the limits of this article to go into the ques- 
tion of well-water analysis except in the most general way. Ordinarily 
it is impossible to tell from the appearance, taste and odor of a well water 
whether it is safe for drinking or not. A clarified sewage in an ordinary 
glass may be clear and colorless and may have no very marked odor and 
is often not to be distinguished in appearance from spring water. The 
senses are unreliable when it comes to deciding whether a water of good 
appearance and free from taste and odor is safe for drinking or not. On 
the other hand, if a well water which has usually been satisfactory be- 
comes suddenly objectionable to taste and smell its use should be dis- 
continued until an examination has been made. 

Unpolluted waters are not usually affected by objectionable tastes 
and odors, though even to this rule there are exceptions, since waters 
derived from hardpan soils have at times a noticeable taste and odor, 
even though analysis shows that the water is not polluted or otherwise 
objectionable for domestic use. 

The sudden appearance of turbidity or color in a water which has 
always apparently been clear and colorless, is also good cause for sus- 
picion of the quality of the water even though it is free from taste and 



odor, and a water which becomes suddenly turbid or colored should not 
be used until its safety has been ascertained. 

As to the best method of obtaining a new supply, it is impracticable 
to lay down any definite rules, since circumstances vary so widely from 
place to place that a rule by which a good well might be secured in one 
place might not produce satisfactory results in another. 

In the sandy and gravelly regions, — found mostly in the southeastern 
parts of the State, but to a considerable extent in the river valleys of 
the central and western portions — it is usually not difficult to secure 
ground water of good quality and in large quantity by sinking a well in 
low ground at almost any point, provided it is sufficiently distant from 
possible sources of pollution; but wells sunk in the immediate neigh- 
borhood of swamps will ordinarily not supply good water, and it is gen- 
erally best in swampy regions to locate the well on the upland 50 to 
100 feet from the swamp, if practicable. 

In many cases water supplies are obtained by sinking tubular wells 
usually from 4 to 8 inches in diameter into the underlying ledge, some- 
times to depths of several hundred feet. It is a frequent experience 
that such wells do not furnish water of satisfactory quality as the 
water is commonly affected by more or less mineral matter, chiefly iron, 
which makes it objectionable for many domestic uses. Furthermore, 
such wells usually yield a comparatively small quantity of water. In 
the case of such wells it is rarely possible to determine accurately the 
sources from which the water is derived, since it may percolate for 
long distances through seams in the rock. Cases have occurred where 
such wells have been badly polluted by sewage or other organic matter 
seeping for long distances and from areas which apparently were not 
draining toward the well. It is desirable in all cases where a new well 
is to be located for domestic supply to secure the advice of an engineer 
of experience in water supply matters before investing any consider- 
able amount in such sources of water supply. 

THE CONTROL OF NUISANCES 

By Harold E. Miner, M. D., 

District Health Officer, Massachusetts Department of Public Health 

One of the most annoying and, at times, difficult problems to solve by 
boards of health has to do with the abatement of nuisances. This is 
especially true with the health officials of the smaller towns where this 
type of "health work" takes considerable of their time and patience 
involving them in what often prove to be neighborhood quarrels sprin- 
kled with a pinch of spite. City health departments usually have their 
sanitary inspectors investigate and report on such cases and where ac- 
tion is necessary handle the matter without fear or favor according to 
legal procedure. 

Along with the disposal of ashes and garbage the control of nuisances 
was placed by our forefathers with boards of health, feeling at that 
time that the source and spread of practically all disease lay in filth 
and was closely associated with the environment of the individual. 
This was during the period when sanitation was everything. These be- 
liefs have been modified to a great extent through the advent of bac- 
teriology and later studies have shown that we must look to the indi- 
vidual or his discharges for most of the spread of communicable dis- 
ease. 

Health officials in general feel that nuisances are very distantly re- 
lated to public health, if at all. Chapin, of Providence, facetiously re- 
marks that an uncovered cesspool is the cause of death only by drown- 
ing and adds that the police department could manage the nuisances 
better than any other department. On the other hand the late Pro- 



8 
fessor Whipple felt that environmental factors, such as bad smells and 
tastes are injurious to health although very indirectly. 

It must be remembered, however, that the Supreme Court has ruled 
that in order to amount to a nuisance it is not necessary that the cor- 
ruption of the atmosphere should be such as to be dangerous to health; 
it is sufficient that the effluvia are offensive to the senses and render 
habitation uncomfortable. It should also be borne in mind that what- 
ever the feeling on this subject among health workers may be, the Gen- 
eral Laws of Massachusetts very definitely place the problem of ordi- 
nary nuisances on the shoulders of the local boards of health. Author- 
ity over what we shall refer to as special nuisances or "Noisome 
Trades" has been placed jointly with local and state health depart- 
ments. This will be discussed more in detail later. 

As stated above, authority relating to the abatement of ordinary 
nuisances is definitely given by law in Massachusetts to local boards of 
health. By ordinary nuisances we mean complaints relating to over- 
flowing cesspools, privy vaults, sink drains, filthy dumps, yards, pig 
pens, poultry yards, stables, dead animals and the like. It is not within 
the province of this paper to quote verbatim the sections dealing with 
this subject, as the local health officer may readily orient himself by 
study of Sections 122 to 158, Chapter 111 of the General Laws. Ap- 
pended to these sections are numerous rulings by the courts which 
clear up questions which often arise. 

The special object of this article is to briefly review the subject from 
the standpoint of the complainant, the local board of health, and the 
State Department of Public Health, as seen by a somewhat neutral ob- 
server — the District Health Officer. 

A great many complaints by individuals are trivial matters and if 
personally taken up in the right spirit with a neighbor involved could 
be easily adjusted. But even this is not tried. Immediately they rush 
to the telephone and in a none too amiable frame of mind, besides mak- 
ing the complaint, express their opinion of the local board in no un- 
certain terms, threatening dire consequences if the matter is not at- 
tended to at once. They even threaten to take the matter up with the 
State Department of Public Health, which brings a smile to the local 
officials. This method of approach gains very little. Oral complaints 
are unsatisfactory and often forgotten, the proper method being to sub- 
mit a written petition to the board of health. The remarks directed to 
the local board during mental stress have taken away some of the 
board's ardor to help them out of their difficulty. 

Many times the individual has good cause for complaint on matters 
which are extremely annoying to himself and family. When this oc- 
curs, after assuring himself that the nuisance is real and not imagi- 
nary, and after unsuccessful attempts to settle the trouble personally 
in an amiable manner (if an immediate neighbor), he should put in 
writing his complaint and submit it to the local board of health. Should 
the local board fail to act the complainant has recourse to the county 
commissioners or the superior court (G. L. Chapter 111, Sections 140- 
141). This action is very seldom taken when it is learned that costs 
of such shall be advanced by the applicant — the commissioners later 
awarding the costs as they judge best. 

Local boards of health are given definite and ample authority 
to handle nuisances. Indeed the law is mandatory upon them. "The 
Board of Health shall examine into all nuisances, source of filth and 
causes of sickness within its town — shall destroy, remove or prevent the 
same as the case may be required, etc." (Section 122, Chapter 111, G. L.) 
The sections immediately following explain very carefully legal methods 
which are to be followed in carrying out the provisions of this act. 

Although it is not necessary for the board of health to wait until a com- 



plaint is filed this is the usual procedure, especially in small towns. Upon 
receipt of complaint members of the board preferably, or its agent, should 
investigate the alleged nuisance. It may be well at times to visit the 
complainant and obtain a more complete story from this source. Oppor- 
tunity is also afforded at this time to judge if previous ill feeling is at the 
bottom of the case. Considerable tact and judgment are necessary in the 
actual investigation. Officiousness on the part of the agent complicates 
the situation and makes the owner feel that he is being persecuted. It 
should be made plain that he is in duty bound to look into the matter and 
in case he is satisfied a nuisance exists, to have it abated in a manner 
most agreeable to all parties concerned. It is not for the board to state the 
specific manner in which it is to be abated. In a great many cases an 
understanding is reached and the owner agrees to abate the nuisance at 
once. When this is not the case a letter is sent the owner calling his at- 
tention to the nuisance and requesting that it be abated within a speci- 
fied time. If, however, after the specified time has elapsed the nuisance 
still exists and the owner or occupant has manifested no intention of com- 
plying with the request of the board of health, the latter may send to him 
the legal order set forth in Section 124, Chapter 111, G. L. It is well to 
point out at this time that the members of the board should thoroughly 
understand its powers and limitations and that the order be served in a 
legal manner by a constable or deputy sheriff. The officer serves one 
copy and returns the other copy to the board with a statement that he has 
served the notice properly. When any question of procedure arises which 
is not thoroughly familiar to members of the board it is well that the 
town counsel be appealed to. 

In case that the board finds that after the time specified in the order 
nothing toward its abatement has been done it may proceed in two differ- 
ent ways. It may abate the nuisance at the owner's expense or it may 
enter complaint in the district court against the person named in the 
order for violation of said order. Although necessary at times, the first 
procedure of abatement by the board at the owner's expense is often un- 
satisfactory as litigation may be necessary to collect the costs. Com- 
plaint to the court is a much better procedure. A summons usually 
brings the party to his senses and when the owner shows a disposition to 
correct the condition the board may recommend to the judge that the 
case be continued for a week on condition that the defendant agrees to 
abate the nuisance before the expiration of that time. Appeal to the 
superior court, however, is open to the defendant if he is finally found 
guilty. 

A study of the nuisance laws will clearly show that the Massachusetts 
State Department of Public Health is given no authority in the abatement 
of ordinary nuisances. The local board of health, county commissioners 
and superior court are supreme, yet in spite of this the State Department 
receives numerous complaints annually requesting the abatement of nui- 
sances. These letters are usually answered by the Department explain- 
ing their lack of authority and referring them to the local board of health 
and the other courts of appeal. The district health officers often lend 
advice to the local boards and at times have been able to act as "go-be- 
tweens" and aid in the settlement of numerous complaints. 

Under "Noisome Trades" which is a special type of nuisance, the 
State Department of Public Health is, under Section 152, Chapter 111, 
G. L., given the same powers already given local boards of health under 
Section 143 of the same chapter. The only difference is that the State De- 
partment is bound to give notice to the party and allow him a hearing 
before it can pass an order of prohibition. The order is subject to appeal 
and trial by jury. This section has to do with the assignment of certain 
places for the exercise of any trade or employment which is a nuisance or 
hurtful to the inhabitants, injurious to their estates, dangerous to the 
public health, or is attended by noisome and injurious odors, etc. 



10 

Among the more common nuisances of this type may be mentioned 
odors from sewage, garbage disposal and rendering works, gas and chemi- 
cal works, oil refineries, asphalt and varnish works and tanneries. 

Local boards of health are authorized to, and do, to a large extent, 
handle this type of nuisance. Due to the fact that the sanitary engineer 
is often needed to conduct the investigation and give technical advice, 
the State Department of Public Health is often appealed to. On receipt 
of such requests hearings are conducted and decisions rendered. It often 
happens that the objectionable trade is located in one town and the com- 
plaint comes from a neighboring locality. In this instance the State De- 
partment usually investigates and holds a hearing. As stated before, the 
aggrieved party may appeal from the orders of both boards to the superior 
court. 

Nuisances, like taxes, are always with us. It would seem to be the 
wisest course on the part of the local boards of health for them to adopt 
measures to prevent nuisances arising. The control of nuisances would 
then cease to take up so much valuable time of the health officer, enabling 
him to concentrate more on modern health procedures. 

THE DISTRICT HEALTH OFFICER 

By Edward A. Lane, M. D. 

State District Health Officer, Metropolitan District, Massachusetts 
Department of Public Health 

Provision is made in the public health laws for dividing the State 
into "not more than eight health districts." For each district there is 
appointed by the Commissioner, with the approval of the Public Health 
Council, a District Health Officer. There are at present six such dis- 
tricts and District Health Officers. The districts are known as the South- 
eastern, Metropolitan, Northeastern, Worcester County, Connecticut Val- 
ley and Berkshire Districts. 

Representative of the Commissioner 

The law further provides that "each District Health Officer shall act as 
the representative of the Commissioner, and under his direction shall se- 
cure the enforcement within his district of the laws and regulations re- 
lating to public health. He shall have the powers and perform the duties 
set forth in this chapter, and, under the direction of the Commissioner, 
shall perform such other duties as he may prescribe." For administra- 
tive purposes the District Health Officers are attached to the Division of 
Communicable Diseases. 

Powers and Duties 

The powers and duties referred to in the foregoing paragraph are of a 
broad, general nature. It is stated that "every District Health Officer 
shall inform himself respecting the sanitary condition of his district and 
concerning all influences dangerous to the public health or threatening to 
affect the same; he shall gather all information possible concerning the 
prevalence of tuberculosis and other diseases dangerous to the public 
health within his district, shall disseminate knowledge as to the best 
methods of preventing the spread of such diseases, and shall take such 
steps as, after consultation with the Department and the local authorities, 
shall be deemed advisable for their eradication." Another section of the 
law provides that the District Health Officer shall inspect police stations, 
lock-ups, jails, prisons and reformatories, and the inspection of contagious 
disease hospitals and of dispensaries, for which the State Health Depart- 
ment is made responsible, is likewise performed by the District Health 
Officer. His activities have largely, however, to do with communicable 
disease control. 



11 

An Advisory Health Officer 

The protection of the public health in Massachusetts is by law primar- 
ily a local responsibility. Local city and town boards of health or other 
official public health agencies have been given quite complete control over 
health matters within their jurisdictions. This is possibly the result in 
part of the insistence of the people upon local self government and partly 
because in Massachusetts, with its old health traditions, local health 
activities antedated state health work. The State Board of Health, the 
oldest in this country, was not organized until 1869. At any rate, it is 
necessary to keep the scheme of health organization in mind in order to 
understand the position and activities of the District Health Officer. 
While his powers and duties are quite broad and general, he acts of ne- 
cessity largely in an advisory capacity in his district. He might very 
aptly be considered as a liaison officer between the State Health Depart- 
ment and the various local health authorities. As the immediate repre- 
sentative of the State Commissioner of Health, he is in charge of the De- 
partment program in his district and it is through him that most of the 
district contacts are made with the Department. This arrangement serves 
in part to relieve the central office of much unnecessary detail and saves 
both time and travel. 

Relationship with Local Boards of Health 

The very definite limitation of the direct responsibility of the District 
Health Officer under the arrangement in vogue in this State should in- 
crease very greatly the need for and field of usefulness of such a health 
officer. Local health affairs are in all cities and many towns in the hands 
of a separate board of health. In cities, one member of the board must 
be a physician; in the case of towns, there is no such requirement. In 
the smaller towns the board of selectmen functions as the board of health. 
It is probably seldom that the board of selectmen includes a physician. 
Five cities only have a full-time medical health officer. Aside from these 
five cities, the local agents functioning under the various boards of health 
and in direct charge of local health activities are all laymen with varying 
degrees of training and experience in the field of public health. When 
one considers how highly refined and technical public health work has be- 
come, the value of a specially trained and experienced advisor can be ap- 
preciated. Obviously, however, the benefits accruing from such a service 
will depend in part upon the qualifications of the advisory health officer 
and in part upon the willingness of local health authorities to seek and 
profit by his advice. Such an arrangement calls for active and progressive 
local health service. 

In the past public health was a much simpler matter, dealing largely 
with questions of environmental sanitation, nuisances and routine quar- 
antine measures. Laboratory practice in communicable disease control 
has now become highly developed and often calls for some difficult inter- 
pretation. Emphasis has shifted from environment to the infectious in- 
dividual as the primary and most important cause of communicable 
disease, and this in turn calls for some very careful and critical epidem- 
iological investigation. There is a growing demand for health education, 
which subject is becoming increasingly technical. Industrial processes 
dealing with food supply which call for public regulation are becoming 
more complicated. The application of the principles of child hygiene calls 
for special training, while public health administration is paying greater 
attention to efficient organization and special office procedure. It is in 
this increasingly specialized field that the District Health Officer seeks 
to be of service to the local health authorities, and with an organization 
such as exists in Massachusetts it is in so doing that his greatest field of 
usefulness should lie. 



12 
Specific Communicable Disease Control Activities 

While his communicable disease interests and activities are limited 
only by the character and extent of occurrence of such diseases in his 
district, the District Health Officer pays special attention to those diseases 
which, because of our more complete knowledge of their cause and pre- 
vention are more readily controlled. 

As a part of his general duties he receives reports and keeps records of 
cases of communicable disease occurring within his jurisdiction. This 
enables him to note any unusual increase in the incidence of a disease 
which would call for special investigation or intensive control measures. 

One of the major activities in the present Department program is the 
promotion over the State of active diphtheria immunization. In this con- 
nection the District Health Officer lends his advice and, if need be, tem- 
porary personal assistance. He also makes a personal investigation of 
all diphtheria deaths. With toxin-antitoxin to prevent diphtheria, and 
antitoxin to effectively treat it, there would .appear seldom, if ever, to be 
any justification for deaths from this cause. These investigations furnish 
the data for an annual study by the Department of diphtheria mortality 
in the State. 

Information is secured concerning all cases and localized outbreaks of 
typhoid fever, in an attempt to uncover possible typhoid carriers. With 
the great reduction which has occurred in the incidence of this disease, 
the carrier has come to play an increasingly important role in its dissem- 
ination. Emphasis has gradually shifted from the mode to the source of 
infection. In addition, a semi-annual check-up is made of all known ty- 
phoid carriers, now numbering over one hundred. 

Other interests of late have been the adoption by local health authori- 
ties of a set of minimum quarantine regulations recommended jointly by 
the Massachusetts Association of Boards of Health and the State Health 
Department, in an attempt to secure a more uniform practice over the 
State; the approval and acceptance by cities and towns of the ten-year 
juvenile tuberculosis control demonstration offered by the Department; 
and the improvement, through tuberculin testing of cows or by pasteur- 
ization or both, of the local milk supply. 

In addition to the advice and assistance tendered local boards of health, 
the District Health Officer, because of his frequent contact with the in- 
fectious diseases, is often called in consultation by private practitioners 
in cases of questionable diagnosis. 

Relationship to Other Groups in the Community 

With various official and non-official health agencies at work in a com- 
munity, it may become necessary to correlate their activities if the great- 
est benefit is to be derived. This may call for a community health survey, 
which may be conducted by the District Health Officer, or to which he 
may contribute his assistance if conducted by some outside agency. 

The school health service is so directly linked up with the health of the 
community as a whole that it is of the greatest interest to the District 
Health Officer. Other groups with which he is apt to make contact are 
visiting nursing associations, health centers, anti-tuberculosis societies, 
and various civic and social clubs interested in the public welfare. 

As may be inferred from this brief description of his responsibilities 
and duties, the work of a District Health Officer is extremely varied and 
furnishes much of the spice of life. Like all promotion work, there are 
ups and downs. There is seldom a day, however, when some satisfaction 
may not be derived from the feeling of having actually contributed some^ 
thing to the smoother and more effective operation of the health machinery 
and for a more healthful and happy Commonwealth. 



13 
THE LAW SAYS 

By Merrill Champion, M. D., 

Director, Division of Hygiene, Massachusetts Department of Public Health 

It is commonly said that the government of the United States and of 
the several states is one of laws and not of men. Observation would 
hardly convince an unbiased stranger that this is so. For example, 
few persons are familiar with the laws concerning the public health, 
while many of those who are somewhat familiar with them pay little 
attention to them if it seems more convenient to do otherwise. It is the 
purpose of this article to call attention to a few of the more important 
of these laws concerning which questions most frequently arise and 
to offer a word of interpretation. 

Forty-sixth Amendment 

Since the constitution of Massachusetts is to us second in importance 
only to the constitution of the United States, let us begin with that. In 
1917 there was adopted an amendment to our State Constitution which 
has had a far-reaching influence upon the promotion of the public 
health. This amendment, usually referred to as the anti-aid amend- 
ment, forbids a municipality to subsidize a private charitable organiza- 
tion. As a result, municipalities can no longer make contributions to 
visiting nurse associations or similar organizations as formerly was 
the custom. 

While the results of this requirement have been temporarily embar- 
rassing to certain organizations, none the less the ultimate result is 
good. It tends to prevent towns from dodging responsibility for the ex- 
penditure of the taxpayer's money. The service obtained under the old 
plan can easily be obtained under the new. All that is necessary is for 
the town — through its board of health, let us say — to employ the visit- 
ing nurse for part of her time to do public health educational work. 
During this fraction of her time she is a regular town employee, paid 
and supervised as are other town employees. The private organization 
employs her for the rest of her time to give bedside care of the sick. 
The cost of this service should be charged to the recipients — except, 
of course, in the case of those too poor to pay for it. Even these can 
often pay part of the cost. 

Under this plan the law is obeyed, service is given, business princi- 
ples observed and the devoted sponsors of private organizations do not 
find it necessary to do so much begging from house to house. 

Clinics 

Wherever two or more public health nurses are gathered together, 
there, sooner or later, arises a discussion of clinics. Clinics at private 
expense, though a very interesting topic, are outside the scope of this 
article. Public clinics, on the other hand, are very much to the point. 
The law with respect to public clinics is to be found in General Laws, 
Chapter 111, Section 50, which authorizes towns to appropriate money 
for various kinds of health clinics with the proviso that the board of 
health shall have charge of them. 

This statute troubles the minds of some school committees, as it re- 
strains them from carrying on certain kinds of service which they 
would like to offer — dental clinics, for example. Other school commit- 
tees are not sufficiently troubled by it and carry on clinics in defiance 
of the law. 

It would seem a wise provision of law that municipal expenditures 
for clinics should be carried out under the board which is responsible 
for other similar expenditures. It might be still wiser, however, to 
place the responsibility for clinic service upon private agencies such as 



14 
hospitals, restricting municipal funds to educational measures for the 
promotion of healthful living. 

School Committeeman as School Physician 

Not so long ago it was rather common to find towns with a medical 
member of the school committee serving as school physician. A su- 
preme court ruling holds this to be improper in that a committeeman 
serving as school physician is employer and employee at the same time, 
a condition contrary to public policy. There are still towns tolerating 
this illegal and unbusinesslike state of affairs. 

Employment of School Physicians and Nurses 

In towns, according to statute, the school physician and school nurse 
(both being required) must be in the employ of the school committee. 
In cities, on the other hand, boards of health if they so desire and can 
get the appropriation for it, may employ the school physician and nurse. 
If the board of health does not so act, the school committee must. 
There is no provision in the case of either town or city for a division 
of authority: the one board employs both physician and nurse. (G. L. 
Chapter 71, Section 53). 

Medical Supervision of Schools 

The law requires (G. L. Chapter 76, Section 57) a careful physical 
examination every year of every child in the public schools. The ex- 
amination must be recorded upon a form prescribed by the state. The 
tests of sight and hearing must be made by the teachers. 

Quite contrary to the frequently expressed belief, there is no law 
forbidding the stripping a child to the waist for the purposes of this 
required examination. In fact, the law cannot be met without a careful 
chest examination, and this cannot be done through the clothing. 

Closing School 

In the exercise of its general health powers the board of health may 
close the schools because of the incidence of communicable disease 
(though it is rarely good public health practice to do so). The school 
committee of course may do likewise. The board of health, on the 
other hand, does not order the opening of the schools — it merely with- 
draws its restrictions to the opening of the schools. 

Vaccination and the Schools 

No child may enter the public schools without having been vacci- 
nated unless he presents a certificate of exemption from vaccination. 
(G. L. Chapter 76, Section 15). This certificate is not a permanent one 
— the school committee may demand its renewal as often as every two 
months. (Supreme court decision, Spofford v. Carlton, 238 Mass. 528). 

The law regarding vaccination is still too often poorly obeyed. 
School authorities opposed or lukewarm to vaccination sometimes feel 
themselves above the law and free to break it. One can only comment 
that law-breaking in the case of school authorities is peculiarly un- 
fortunate. 

AGAIN, MAY DAY— CHILD HEALTH DAY 

By Albertine C. Parker, S. B. 

Vice-Chairman for Child Health Day, Massachusetts Department of 

Public Health 

The celebration of May Day as Child Health Day has aroused the 
interest of the nation in the fundamental necessities making for physi- 



15 

cal and mental health of our children. It has caught the imagination 
and spurred the efforts of all persons working for the promotion of 
child health — in the community, the church, the school and the home. 

The Child Health Committee 

The Massachusetts plan is one of local organization — each com- 
munity with a child health committee composed of representatives of 
all the local organizations (the schools, board of health, nursing asso- 
ciation, parent-teacher association, etc.) interested in community wel- 
fare. Such a committee prevents overlapping of efforts and enables 
concentrated, unified child health work on a community basis with a 
community point of view. In one hundred and twenty-five communi- 
ties there is now a local chairman functioning at the head of a child 
health committee. Here is a permanent all-year-round force standing 
for the protection and advancement of Child Health in which the back- 
ing of the representatives of private agencies supports and strengthens 
the policies of the official representatives of the public. Child Health 
Day comes along as an opportune occasion for a check-up: — does the 
community provide facilities for a well-rounded health program; is 
there prenatal supervision, baby and pre-school conferences; adequate 
conditions making for a healthy school child; healthful educational and 
recreational facilities for the adults? Are the sanitary and safety 
regulations the best that it can offer? In short, is the community a 
better place for the children than it was last year and are the children 
better for the community? 

Child Health Day in the Schools 

Here is the day of celebration — a day of recognition for the correc- 
tion of physical defects — a day of rewards. Again this year there will 
be suggestions contributed by the State Department of Education for 
games and outdoor sports stressing the importance of healthful play. 
The new note for the 1928 Child Health Day celebration is the Health 
Tag (a scheme used last year in the Newton schools) which will be 
furnished by the State Department of Public Health. These rewards 
will be given for good posture, standard weight and sound, clean teeth. 
The weight tag indicates that the child is up to standard weight (a 
range of not more than 10% below or 20% above is allowed). The pos- 
ture tag indicates good posture and the teeth tag, clean teeth, healthy 
gums, and a dental certificate (a slip signed by the dentist showing that 
all the dental work has been done). The complete May Day material 
will be sent from the Department of Public Health to each superin- 
tendent of schools and local chairman of the child health committees 
and to any person requesting it. Child Health Day can exert a truly 
potent force in the school reaching to the most fundamental aspect of 
all health work when it establishes or intensifies individual responsi- 
bility for health. 

The Community and Child Health Day 

The superintendent of schools as a member of the child health com- 
mittee is able to dovetail the celebration of the school with that of the 
whole community. The men's and women's clubs take this special op- 
portunity to concentrate their meetings upon the study of child health. 
The churches give emphasis to the spiritual phase of child life. The 
libraries display books on child hygiene. The stores and the banks 
have window exhibits. The newspapers and the milk bottle caps ad- 
vertise Child Health Day. All this community stimulus is often trans- 
lated into realization of some of the following projects: facilities for 
prenatal work; well baby conferences; Summer Round-Up (physical ex- 



16 
animations of children who are to enter school for the first time in Sep- 
tember) ; correction of defects of school children ; playground and adult 
athletic fields; and the promotion of adult educational work and indus- 
trial hygiene. The whole community is awakened through the force 
of Child Health Day to the necessity for a year-round program looking 
toward the protection and development of the physical and the mental 
health of its citizens. 

MASSACHUSETTS ASSOCIATION OF SCHOOL DENTAL WORKERS 

On February 6, 1928 about one hundred school dentists, dental hy- 
gienists and assistants met in Boston under the auspices of the State 
Department of Public Health and formed an association electing the 
following officers for the first year: Dr. Francis J. Marrs of Peabody, 
President; Dr. Emily M. Luck of Cambridge, Vice-President; Miss 
Eleanor B. Gallinger, of the Massachusetts Department of Public 
Health, Secretary-Editor. Executive Committee — Dr. F. M. Erlenbach 
of Brookline, Miss Gladys White of Plymouth and President of the 
Massachusetts Dental Society (ex-officio). 
The following by-laws were drawn up: 

Name — Massachusetts Association of School Dental Workers. 
Purpose — To promote a better understanding of dental hygiene 
and a closer cooperation between those engaged in community and 
state dental hygiene activities, and to educate the public in the correct 
principles of dental hygiene. 

Membership — All dentists, dental hygienists and dental assistants 
actually engaged in community health programs. 

Associate Membership — Such other public health workers con- 
cerned in dental hygiene programs as may be elected by the Association. 

Officers — The officers shall consist of a President, Vice-Presi- 
dent, Secretary-Editor (to be the Consultant in Dental Hygiene of the 
Massachusetts Department of Public Health, ex-officio). 

Executive Committee — The Executive Committee shall consist of the 
officers of the Association and three elected members. 

District Sections of Association — The Association shall be divided 
into six sections corresponding to the districts of the state health 
authorities. 

The officers of each district shall consist of a chairman and secretary 
to be appointed by the President with the approval of the Executive 
Committee. 

Annual Meeting — There shall be an Annual Meeting of the As- 
sociation held the first day of the Annual Meeting of the Massachusetts 
Dental Society, and such other meetings as the Association may deter- 
mine from time to time. 

District Meetings — Each district section shall hold a meeting during 
the fall, the time of which shall be determined by the President and 
Secretary of the Association and the Chairman of the section. 

Elections — All elections after the first shall be held at the Annual 
Meeting. 

Quorum — A Quorum for the transaction of business at the annual 
or special meetings shall consist of fifteen members. 

Bulletin — The official organ of the Association shall be a bulletin 
issued by the Editor, with the cooperation of the officers of the Associ- 
ation, monthly during the school year. 

This is the first association of its kind in the country and its growth 
will be watched with considerable interest. The need of such an asso- 
ciation that would bring all the dental hygiene workers together has 
long been felt. We hope that it will be a means of bettering the dental 
clinics throughout the State and of stimulating this work in communi- 
ties having no dental hygiene program at the present time. 



17 

DEVELOPING THE PRENATAL AND PRESCHOOL ASPECTS OF 

A COMMUNITY DENTAL PROGRAM 

By F. M. Erlenbach, D.M.D., Brookline, Mass. 

The prenatal and pre-school aspects of clinical or public health den- 
tistry are the natural outgrowth and the latest development coming from 
constant study and progress with the work done for the child today. It has 
been a gradual and sound, scientific development, eliminating bit by bit the 
useless or futile attempts to correct defects dentally, at least, in the child 
of 14 years, by purely mechanical means and drawing nearer the source or 
origin of the trouble by gradually working the age limit of the child 
down until now we work from the other end so to speak — that is, from 
birth up to school age. Wherever possible the educational program is 
begun with the mother. 

I am going to outline briefly the program which has been developed in 
the town of Brookline in regard to prenatal and pre-school dental work. 

First, let me state what our brethren in the medical profession are doing 
in their share of this program. 

Prenatal Clinic 

We have a prenatal clinic which is functioning regularly once a week 
with an ever-increasing number of applicants. The patients for this 
clinic are referred by the surrounding hospitals, namely the Boston 
Lying In and the New England hospitals for women, and through physi- 
cians and nurses. 

In every case accepted it is thoroughly understood that the work done 
and the advice given are purely supplementary to that of the physician in 
charge of the case. 

Physical examinations, blood pressure, urine analysis, dizziness, nausea, 
indigestion, teeth, heart burn, exercise, bathing, etc., in fact every phase 
of each case which the physician many times hasn't time to go into in 
detail at his office or during his periodical examination, are touched upon 
and advice given. 

Most mothers that we, in the course of our work, come in contact with, 
are young. As a rule you have an example of what has not been attended 
to in the child upon which you are working. Using this child as an illus- 
tration and giving suggestions as to where additional and more complete 
information may be had has been found to be very helpful. This not 
only brings to the prospective mother valuable information, but the real- 
ization that she doesn't know quite all she might learn about herself in 
her critical condition. Generally it will lead her to the doors of the clinic 
itself for examination and advice. 

In accomplishing this we have done much, for the more mothers we can 
persuade to attend to these matters early in pregnancy, the fewer the 
casualties after birth. 

Well Baby Clinic 

We have a Well Baby Clinic at the Health Center for children under two 
years of age. The work of this clinic consists in weighing and measur- 
ing, working out formulas for feeding, giving instruction in personal hy- 
giene, detecting defects and referring them to other clinics or to the 
family doctor or dentist for correction. 

All babies from three months on are immunized in this clinic and 
tested eight months later. The immunizing is continued if necessary 
until a negative Schick is obtained. 

Pre-school Clinic 

The next test these children get is some three and one-half years later 
when they enter school. This clinic is held once a week and the average 



18 

attendance is fifty babies a week. We have also a pre-school medical 
clinic for children from two years up to school age. The charge for the 
welfare clinic is $3.00 a year per family. In this clinic every child is 
given a complete physical examination every three months, is weighed 
and measured and all defects, such as eyes, tonsils, teeth, posture and 
orthopedic deformities, are referred to other clinics for correction. All 
habits such as thumb-sucking, nail-biting, tantrums, bashfulness, fear, 
nutrition, etc. are referred to habit clinics. 

Dental attention is of particular benefit here. We allot one-half hour 
each school day every week and one full month, July, every school year to 
nothing but pre-school work. The appointments for the dental clinic are 
made for us by the child welfare worker who is our contact with the fam- 
ilies of the community. 

While at the clinic we have a splendid opportunity to talk to the child, 
as well as the parent, while we are working on his teeth. We tell the 
parent about the materials needed by the child in order to produce sound 
bone tissue. The attitude of the parent in regarding, the status of the 
first teeth is interesting as we have no trouble now in securing patients 
for our child welfare clinic and seldom hear that well worn phrase 
"Those are only the first teeth." Attention at this time prevents loss of 
sleep, irritableness, loss of appetite and forms the habit of visiting the 
dentist regularly. 

Vaccination and immunizing for smallpox, diphtheria and whooping 
cough is a routine treatment for the child at the pre-school clinic. 

In summarizing this program, I would say that every effort is made to 
reach the child both medically and dentally as early as possible. Educa- 
tion, immunization, vaccination and correction are begun just as early 
as possible so that the child has a reasonable prospect of enjoying its 
share of health and happiness. It also prepares the way for the routine 
treatment which must be given the child when it enters school. 

(Read before the Massachusetts Association of School Dental Workers, 
February 3, 1928.) 

THE TEACHER'S OWN HEALTH SCORE CARD 

Prepared by the Committee on Physical Education and Hygiene, 
Massachusetts Teachers' Federation 

Name 

Date 

Height 

Weight 

Average Weight 

Date 

Total Score . . . 



Explanatory Material to Accompany Health Score Card for Teachers 

This score card is planned for the purpose of enabling teachers regu- 
larly to score themselves upon their health status and upon those health 
practices which are necessary for the maintenance of "fitness for work 
. . . and for enjoyment of life." Careful consideration has been given 
to the selection of the various items and to the relative values placed upon 
them. It is recognized, however, that even the most careful selection can- 
not represent a final authority. This piece of material is offered not as a 
substitute for careful medical diagnosis, but rather as a means of helpful 
stimulation. 

Most items included in the score card need no elaboration; their 
meaning is obvious. There are a few, however, which may require some 
interpretation. 

No. 1-7 Overweight. The problem of overweight is one which is 
frequently attacked in an unhygienic way by people who do not realize 



19 

the dangers involved. A person who is only slightly overweight may lose 
weight safely by intelligent control of diet and exercise. Those who 
are extremely overweight should not attempt to reduce except under the 
care of a competent physician or hospital clinic. 

No. II-9 Protein. It has long been known that an excess of certain 
proteins is undesirable. Recent research indicates that many people are 
under-proteinized rather than over-proteinized. The minimum daily 
requirement of an adult is said to be the equivalent of one egg, one glass 
of milk, and one serving of meat. It has been found that many obscure 
conditions are due to lack of protein. 

No. 11-12 Bathing. In addition to the warm bath which should be 
taken before retiring at least twice a week for the purpose of cleanliness, 
a daily cold bath which results in a healthy stimulation or tonicity of the 
body is an excellent practice. It may seem to some too rigorous a habit to 
subject themselves to a cold tub bath each morning. These people will 
find a beneficial effect from a quick cold sponge of the body, or even of the 
face, chest and arms. It is one of the best means for hardening the skin 
against the sensitiveness to colds which accompanies the present fashion 
of wearing furs. 

No. 11-16 Exercise. Daily exercise is as important in many ways as 
daily food or sleep. The body cannot be maintained in an efficient work- 
ing condition if we lump all of our exercise into periods which occur only 
at long intervals. The "Daily Dozen" type of exercises, the morning 
radio exercises, serve a good purpose for the city dweller, who finds it 
impossible to obtain more satisfactory ways of exercising. Much better 
than this, however, would be a rapid walk of at least two miles every day; 
a good game in the open air, and there are many which are possible ; time 
spent in skating or skiing, swimming or paddling in season. After other 
health requirements are fulfilled, there is perhaps no better contribution 
toward good health and a long life than this matter of regular exercise 
carried on in the spirit of "play." 

No. 11-18 Interests outside of work. It is commonly recognized that 
people who work constantly with other people are especially subject to 
mental and nervous fatigue. In addition to the strain occasioned by 
the nature of their work, many teachers suffer because they live wholly 
outside of a normal family life. For these reasons, it is particularly im- 
portant that teachers should safeguard their mental health in every reas- 
onable way. One important factor is the possession of vital and satisfy- 
ing interests outside of work. If a teacher has naturally found these 
through outdoor sports, theatre, books, music, arts, and the like, she is 
fortunate indeed; if she has not acquired such interest naturally, she 
should seek them intelligently and persistently, knowing that vital in- 
terests which have the power to stimulate and satisfy are among the first 
requisites for a wholesome personality. 

No. 11-24 Physical limitations. Many adults have brought with 
them from childhood or have acquired in some way certain physical de- 
fects which place limitations upon their manner of living — a weak heart, 
a postural defect, or some chronic organic affliction. Such a person, in 
order to secure the highest efficiency, should have the defect cared for to 
the utmost of scientific skill, and then learn the limitations within which 
he must live to maintain his best condition. This item on the score card 
should not be interpreted as giving approval to the type of self-pampering 
which is characteristic of the neurasthenic. 



4. 

5. 

6. 
*7. 



10. 
11. 

12. 

13. 
14. 

15. 

16. 

17. 



20 
Health Score Card 

I. Signs of Health Score 

Can you work and play without 
being more than naturally tired 
mentally or physically at bedtime? I 
Are you rested when you get up in 
the morning? 40 

Is your appetite good for whole- 
some food? 30 
Are you free from persistent trivial 
worry? 

Do you enjoy mingling with other 
people? 30 

Have you confidence in yourself? 30 

Is your weight within 10% below 
or 15% above the average for your 
height and years? 40 

Does your posture indicate health 
and efficiency? 30 

Are your arches normal and are 
you free from pain in your feet and 
legs? 20 

Are your muscles resilient? 20 

Is your vision either normal or cor- 
rected by glasses? 20 
Can you hear ordinary conversa- 
tion at 16 feet? 20 
Is your skin clear; color good? 20 
Is your hair glossy, but free from 
excessive oil (not brittle and dry) ? 20 
Are your teeth either sound or 
filled? 20 
Are you free from constantly re- 
curring infections including colds? 30 
Are you free from constant or re- 
curring pain? 30 

Score 470 



Score 



21 



II. Health Habits 



13. 

14. 

15. 

*16. 

17. 

*18. 

19. 

20. 

21. 

22. 

23. 
*24. 



Are you eating some dark bread 
daily? 

Do you drink 6 glasses of water 
every day? 

Do you average at least 8 hours' 
sleep every night? 
Do you eat sweets in moderation 
and only at the end of a meal? 
Do you eat only at mealtime? 
(Fruit may be excepted) 
Do you eat 2 vegetables, exclusive 
of potato, every day? 
Is one of these an uncooked vege- 
table (celery, lettuce, cabbage, 
etc.) ? 

Do you eat fruit at least once a 
day? 

Do you eat one of the following 
every day (meat, milk, cheese, 
nuts, fish, egg) ? 

Do you take your meals regularly? 
Do you eat slowly? 
Do you take a full bath at least 
twice a week? 

Do you clean your teeth at least 
twice a day? 

Do you have a bowel movement 
each day (without a cathartic) ? 
Do you average at least an hour 
out of doors every day? 
Do you exercise vigorously at least 
x /2 hour every day (either outdoors 
or in)? 

Do you take at least ten hours each 
week for recreation, social activ- 
ity, reading, etc. (in addition to 
the daily exercise) ? 
Have you a vital and satisfying in- 
terest outside of your work? 
Do you have your bedroom window 
open at night? 

Do you endeavor to maintain your 
best standing and sitting posture? 
During business hours do you wear 
comfortable walking shoes? 
Do you have a thorough physical 
examination once a year? 
Does your dentist examine your 
teeth twice a year? 
If you have physical limitations do 
you know them and live within 
them? 

Score 
Total Score 



Score 

20 
20 
30 
30 
10 
20 

20 
20 

20 
20 
20 

10 

10 

30 

30 

20 

20 
30 
10 
20 
10 
50 
40 

20 



Score 



530 
1,000 



22 

Editorial Comment 

Cancer Campaign. Attention is called to an announcement on another 
page of an intensive campaign of cancer education 
which will be undertaken on a state-wide basis between April 23rd and 
27th. This drive is being conducted under the joint auspices of the Can- 
cer Committee of the Massachusetts Medical Society, the Massachusetts 
branch of the American Society for the Control of Cancer, and the Massa- 
chusetts Department of Public Health. 

For a number of years it has been considered unwise to^ arouse wide- 
spread interest in the subject of cancer without suitable clinical and social 
resources to meet the demand created by public education, and it is largely 
for that reason that the custom of holding an annual "cancer week" has 
been discontinued. This year, in view of the material increase in facili- 
ties through the operation of the cancer program under the Depart- 
ment of Public Health, the three groups most concerned with cancer 
control — the organized medical profession, the organized public and the 
Department of Public Health — have concluded that the time has come 
when such a campaign of education may be expected to lead to tangible 
results. 

If the citizens of any community should see an opportunity to extend 
the activities of the campaign in their own vicinity, assistance will gladly 
be given by a representative of the committee of the above-mentioned 
organizations. 

A Plea for More Follow-Up in the Homes. When the children in one of 

the schools were examined, 
weighed and measured in preparation for the coming of the clinic for the 
prevention of juvenile tuberculosis, otherwise known as the Ten- Year 
Program, a little boy eleven years of age was found to be 15% under- 
weight. His mother, because of the birth of another baby, was unable to 
attend the clinic with him later, and therefore, missed the contact with the 
nutritionist. 

Informational material was sent home with the boy giving instruc- 
tions as to change in diet, etc. About two weeks later a letter was sent 
by the mother to the Department of Public Health, and from this letter 
one would gather that the family was in need of financial aid. When the 
Nursing Consultant for the district visited the town she talked the matter 
over with the relief-giving agency in the town, and the finding of the 
visitor of the latter agency disclosed the following : 

The family consisted of father, mother and five children. The home 
was very neat and clean and the mother was very keen and anxious to 
do everything possible for her children, as far as her budget would allow. 
Had she received this information first hand she would have been better 
able to adapt her budget to the boy's needs, but without some assistance, 
she seemed at a loss to know how to comply with the instructions given 
her boy. She was not in need of financial aid ; what she most needed was 
a home visit from the public health nurse and explanation as to how to 
rearrange her budget; also instruction relative to rest, fresh air, sun- 
light, sufficient sleep, etc., for the boy. It would have helped this mother 
greatly if she had been visited shortly after the clinic and received the 
necessary instruction. 

Doubtless, similar cases occur in other districts. Can we not have more 
immediate follow-up of the school child and pre-school child in the homes ? 

Law and Persuasion. This issue of The Commonhealth is largely devoted 

to a phase of public health work which most often 

comes to mind when health work is mentioned. It is the oldest phase. It 



23 

is a necessary phase. But it should not be thought of as representing the 
best that we can look forward to. 

It is an old saying that a man convinced against his will is of the same 
opinion still. Boards of health often convince people that way. Of 
course, a man with smallpox must be restrained even if unconvinced. But 
if he is convinced he will restrain himself. 

It takes a higher type of health officer to "sell his goods" to the pub- 
lic through persuasion and common sense than it does to "overcome sales 
resistance" through the aid of the police. May we commend the velvet 
glove for most occasions rather than the mailed fist, the latter being held 
in reserve for emergencies. 

Results of the Ten-Year Program. Every once in a while some one thinks 

that he has discovered the secret of 
perpetual motion. But it has hitherto proved to be a delusion. Every 
once in a while people seem to think that health work once inaugurated 
will go on forever of its own momentum. We have never seen it work 
out that way. 

At the present moment the State Department of Public Health is much 
interested to know why so considerable a proportion of children examined 
in its tuberculosis clinics fails to show satisfactory improvement by the 
time re-examination is given at the end of a year or more. Is it because 
the children and their parents do not follow the directions given them? 
Or is it because some undiscovered factor is neutralizing the forces 
making for improvement? Or is it lack of follow-up on the part of the 
local school and health authorities? 

The latter reason, undoubtedly, must be at the back of a good deal of it. 
The program, once launched, is expected to continue of itself. The great 
opportunities offered the school for health habit promotion through the 
temporarily increased interest of the parents in the health of their chil- 
dren are allowed to lapse. 

The coming of the Ten- Year Program to a town should not be the cul- 
mination of that year's health activity but the beginning of it. 

Regional Consultants in Dental Hygiene. The appointment of six reg- 
ional consultants in dental 
hygiene is a recent development of interest to all those working for better 
teeth for the children of Massachusetts. This plan is a result of close co- 
operation between the State Dental Society and the Department of Pub- 
lic Health as the names of the consultants were submitted by the execu- 
tive committee of the Massachusetts Dental Society and the consultants 
officially appointed by the Commissioner of Health. 

These men are chosen to represent each of the six districts of the State 
Dental Society because they are interested in preventive dentistry and in 
furthering the state dental hygiene program among thousands of school 
children. The term is indefinite and the duties not yet clearly defined. 
It is hoped, however, that these consultants will be able to take charge of a 
dental campaign for 100% good mouths by May Day — Child Health Day 
each year in the communities where there are no definite dental hygiene 
programs. The dental consultants recently appointed are: Dr. Charles 
W. Hammett of Taunton ; Dr. Walter Bryans of Lee ; Dr. George Cowles 
Brown of Worcester; Dr. Walter E. Briggs of Attleboro; Dr. Arthur E. 
Guptill of Fitchburg; and Dr. Frank A. Delabarre of Boston. 



24 
HELP FIGHT CANCER 

Under the above caption an intensive state-wide campaign will be car- 
ried on during the week of April 23rd in an effort to bring to the atten- 
tion of every citizen of the Commonwealth the few easily discoverable 
signs which may — or may not — indicate cancer in its early state. At this 
time it is often entirely curable but it rapidly becomes serious if neg- 
lected. This is not a campaign to spread gloomy facts among the people 
but to show them the hope which has been found to be justified. 

It becomes increasingly apparent that the one most certain way in 
which progress is to be made is by bringing patient and doctor together 
earlier — much earlier — than they are now finding each other. 

Instead of eight months, which on an average is the length of time 
those dying of cancer have waited before seeing a doctor, the person sus- 
pecting cancer must be under a reputable doctor's care or must go to a 
clinic on the very day he discovers something which arouses his sus- 
picion. If everyone will do this we shall have at the end of this year more 
than a thousand citizens alive and presumably well who, if they neglect 
these early signs, will be on their way to their graves. 

But, we ask, how is a person without experience to know these signs 
which should be looked into? The answer to that question is the chief 
reason for this campaign — that every adult person may know and remem- 
ber that: 

Any lump, especially in the breast, 
Any irregular bleeding or discharge, 
Any sore that does not heal, 
Persistent indigestion with loss of weight 
may indicate cancer. Pain is not an early sign. 

Clinics for the early discovery of the nature of such signs are now 
available in Boston, Worcester, Lowell, Lynn, Springfield, Newton, Fitch- 
burg, Leominster, Gardner, Pittsfield, Fall River and at the Pondville 
Hospital. 

Anyone may learn through his local Board of Health where and when 
the clinics are held in these cities. 

In Boston this cancer campaign will open with a mass meeting at Sym- 
phony Hall, in which the Governor has promised to take part. There will 
be other well known and able speakers who will tell of the hopeful outlook 
upon this great disease problem. 

In each of the cities in which clinics are held there will be similar meet- 
ings and special clinics.. 

Tickets for the Symphony Hall meeting may be had after March 15th 
on application at Room 546, State House. There will be no admission 
without ticket and all seats will be reserved. The only price asked for the 
tickets is that some one of adult years shall use each one. 

ANNOUNCEMENT OF SUMMER SCHOOL COURSES 

The courses in school hygiene which have been given for several years 
past at the State Normal School at Hyannis will be repeated this sum- 
mer with certain additions. There will be as usual the course in School 
Nursing Procedures and the course in Methods of Teaching Health Edu- 
cation. There will also be repeated the course in School Hygiene for 
teachers. 

Two new subjects are offered this year, each rating as half a course. 
One will be in Nutrition and the other in Social Service for nurses. There 
is under consideration an additional course for dental hygienists. 

There is no tuition charge for these courses to residents of Massachu- 
setts. There is a nominal charge for those coming from outside the state. 
Information regarding these courses and applications for entrance may 
be had by applying to the Director of the Division of Hygiene, Massachu- 
setts Department of Public Health, 546 State House, Boston. 



25 
SUMMARY OF WELL CHILD DEMONSTRATION CONFERENCE 

November 30, 1926— December 1, 1927 

Number of conferences, 60. 

Held in 58 towns. 

2,309 children under six years from 1,709 families were examined. 

Dental defects were extremely common, occurring in 746 of the chil- 
dren or 32% of the whole number examined. This was a large number 
because many children were under two years (415 or 29%.) 

Of the 2,309 children examined 82% showed defects. 

Twenty-six of the towns in which conferences were held in the past 
three years have started local conferences of their own with physician or 
physicians examining the children. Fifteen more have established a 
weighing and measuring conference with the local nurse in charge. 

Ten of the conferences were for school entrants only, what we term 
"Summer Round-Up" clinics. Interest in this type of conference is par- 
ticularly good. Many towns will do their own Summer Round-Up in 1928 
as they did in 1927, and other towns are planning to start in 1928. 

To get satisfactory results from the conference itself follow-up work 
by a competent nurse is vital. This is not always possible but is im- 
proving steadily. Follow-up work is very good in those towns where there 
are both a school and general nurse or a competent, interested nurse do- 
ing both types of work, or where there is an up-to-date nursing center. 
Occasionally there is no way of getting any follow-up service and in such 
an instance we write individual letters to each mother whose child had 
defects, about a month after the conference was held. In some towns 
very excellent local committees have been formed which have been of 
great assistance in the arrangement and conduct of the conferences. 

Reports are coming in pretty steadily now of defects corrected or im- 
provement following the adoption of advice given at our demonstration 
conferences. 

To get good attendance at a conference, publicity suitable to the indi- 
vidual community is essential. With this we have little trouble. 

We still adhere strictly to our recommendation of "no treatment sug- 
gested: no feeding formulas given," confining our advice to the care of 
the teeth, nutrition and habit training. We find these topics quite suffi- 
cient for our limited time and small staff — doctor, nurse and nutritionist, 
with the local nurse helping. All children with defects are referred to 
their family physicians and the children's records are sent to them 
promptly. 

During the year conferences were held in 14 of the 25 towns in Franklin 
County and 655 of the children examined were in this section. 

The plan is to hold a conference in each town in Franklin County, ex- 
cepting Greenfield, which is well provided for, with the idea of offering 
to these parents more opportunity to learn something of child care. These 
particular conferences are to be repeated from year to year for the pres- 
ent. This is being done with the hope of influencing first grade mor- 
bidity as well as making an excellent opportunity to do intensive teaching 
of baby and pre-school hygiene and to offer by means of talks, printed 
matter and posters, suggestions on prenatal care. 

The interest of the mothers (and some fathers) was most encourag- 
ing everywhere. The school physician and school superintendent visited 
the conferences in several instances and assured us of their approval and 
interest in the undertaking. There is no quicker way to parental hearts 
and brains than through the child himself, and his physical handicaps as 
discovered by stripped examination, make as good a foundation for teach- 
ing hygiene as anyone could possibly wish. 



26 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration . 
Division of Sanitary Engineering . 

Division of Communicable Diseases 

Division of Water and Sewage Lab- 
oratories .... 
Division of Biologic Laboratories 

Division of Food and Drugs . 

Division of Hygiene 

Division of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 

The Southeastern District . 



The Metropolitan District 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District . 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., Lowell 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



Publication of this Document approved by the Commission on Administration and Finance 
5M. 3-'28. Order 1615. 



5 7?/ 



THE 
COMMONHEALTH 



Volume 15 

No. 2 




Apr.. May- June 
1928 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 






THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of 

Public Health 

Sent Free to any Citizen of the State 

Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 

PAGE 

Rabies. The Treatment of Wounds and Prevention of the Disease, 

by M. J. Rosenau, M.D. ....... 27 

The Laboratory Diagnosis of Rabies, by Langdon Frothingham, M.B.V. 32 

Canine Rabies, by Dr. Hugh F. Dailey . . . . . .35 

Rabies Control in Massachusetts, by George H. Bigelow, M.D., and 

Frank B. Cummings ........ 37 

Editorial Comment: 

The Role of Sentimentality in Public Health . . . .39 

Choosing the School Nurse ....... 39 

The American Child Health Association Study . . . .40 

"The Directory" 40 

Public Health Institute ........ 40 

Maternal Deaths in Massachusetts during 1927 — A Statistical Sum- 
mary . . . . . . . . . .41 

Report of Division of Food and Drugs — January, February and 

March, 1928 41 



27 



RABIES 

The Treatment of Wounds and Prevention of the Disease* 

By M. J. Rosenau, M.D., 

Professor of Preventive Medicine and Hygiene, Harvard Medical School, 

Boston, Mass. 



We know enough about the cause and mode of propagation of rabies 
to control and even to prevent the spread of the infection; in fact, the 
disease has been entirely eliminated from England, Scandinavia and 
other insular and peninsular countries. Through the enforcement of a 
strict quarantine, rabies has been kept out of Australia. Furthermore, 
the prompt and proper treatment of wounds inflicted by mad animals 
will greatly diminish the likelihood of the development of rabies. 
Finally, thanks to the genius of Pasteur, we are able to immunize and 
protect those who are bitten. 

The cauterization of the wound and the Pasteur prophylactic treat- 
ment are efficient preventive measures for the individual, but they are 
not the true and best methods of controlling and preventing the disease. 
We should not wait until persons are bitten by mad dogs, but should 
direct measures towards the dog. Rabies is primarily a disease of dogs, 
secondarily of man. It is kept alive in nature mainly by the dog and 
the dog family. The stray pariah dog causes most of the trouble in our 
communities. The control of the disease demands that laws concerning 
the compulsory impounding of all stray animals and the proper super- 
vision of all licensed dogs be strictly enforced. The problem cannot be 
settled locally, but requires nation-wide action, for one locality or state 
which might free itself of this disease would soon become reinfected 
from neighboring states. 

Rabies is remarkable in several particulars, especially the period of 
incubation and high mortality. The period of incubation is more vari- 
able and more prolonged than that of any other acute infection. Rabies 
is practically the only disease in the entire medical repertoire which is 
almost invariably fatal after symptoms once begin. The mortality is 
practically 100 per cent. Recovery either in man or animals is so rare 
as to be a scientific curiosity and a subject of much discussion. Effec- 
tive preventive measures must therefore begin as soon as practicable 
after the infliction of the wound. 

Local Treatment of Wound 

We have a satisfactory and effective method of preventing rabies, 
provided the wound produced by a rabid animal be promptly and prop- 
erly treated. Treatment consists in cauterizing the wound with "fum- 
ing" or strong nitric acid, making certain that the acid is applied to 
every part of the surface. This matter of the prompt and proper caut- 
erization of wounds produced by the bites of animals is not well under- 
stood, and therefore is emphasized on account of its prophylactic value. 
The technic follows: 

Cauterization with Nitric Acid 

Wounds produced by the bite of an animal, in which there is any pos- 
sibility of rabies, should at once be cauterized with "fuming" or strong 
nitric acid. The acid is best applied with a glass rod very thoroughly 
to all parts of the wound, care being taken that pockets and recesses 

* This article, written at the request of Dr. George H. Bigelow, Commissioner of Public Health, 
is designed to bring up to date and emphasize two of the important practical points ; namely, 
the correct treatment of the wounds and the prevention of the disease in accordance with recent 
advances. Part of this article is abstracted from the chapter on Rabies in my book "Preventive 
Medicine- and Hygiene," (fifth edition) published by D. Appleton and Company, to which the 
reader is referred for further details. 



28 
do not escape. Punctured wounds should be laid open to allow proper 
cauterization. Experiments in my laboratory indicate the importance 
also of cauterizing the edges of the skin. Thorough cauterization with 
nitric acid reduces the danger of wound complications, and experience 
demonstrates that wounds promptly and thoroughly cauterized with 
nitric acid are seldom followed by rabies. Experiments under my su- 
pervision (unpublished) indicate that practically all guinea pigs may 
be saved by prompt application of nitric acid ; that its effectiveness de- 
creases with time, but that it is still partially protective up to forty- 
eight hours. 

Experience here and elsewhere indicates that it is still the common 
practice timidly to cauterize wounds with substances that we know are 
not effective, such as nitrate of silver (lunar caustic). It has been dem- 
onstrated conclusively that nitrate of silver coagulates the surface 
albumin and does not penetrate, and therefore does not protect. We 
have demonstrated to our entire satisfaction that even such strong 
caustic and germicidal substances as pure carbolic acid, corrosive sub- 
limate, strong formaldehyd solution and permanganate of potash are 
only partially effective. Even the actual cautery thoroughly applied 
does not give as good results as nitric acid. 

Just why nitric acid has this special selective action in destroying 
the virus of rabies in wounds is not entirely clear. On account of its 
diffusibility and penetration, it may be considered almost specific for 
rabies. 

Physicians are inclined to withhold their hand when it comes to 
cauterizing wounds of the face with nitric acid because they fear scar- 
ring. A wound on the face or anywhere else will leave a scar whether 
cauterized or not, and there is little if any additional scarring due to 
cauterization with nitric acid. 

It is well known that wounds of the face and other parts of the body 
where the naked skin is exposed to bites are especially liable to be fol- 
lowed by rabies. The reason why bites of the arms, legs and body are 
less dangerous is that the virus is apt to be wiped off when the teeth of 
a mad animal bite through the clothing. Furthermore, it is well known 
that the liability to rabies increases not only with the character, sever- 
ity and number of the wounds, but with their location, the most danger- 
ous being those in regions where the nerve supply is rich. 

Susceptible Animals 

Every mammal is susceptible. Even birds may contract the disease. 
It is most common in dogs, but it also occurs frequently in wolves, jack- 
als, foxes and hyenas. Rabies in cats and skunks is comparatively rare 
and but occasionally transmitted to man. Cattle, sheep and goats are 
infected relatively in about the same degree. It is less common in 
horses. Swine contract the disease less frequently than other domestic 
animals. 

Rabies is perpetuated in civilized communities almost exclusively by 
the domestic dog and to a small extent by wild animals of the dog 

family. 

Period of Incubation 

From the standpoint of prevention it is fortunate that the period of 
incubation of this disease is prolonged. This period varies from four- 
teen days to a year or more. Such prolonged periods of incubation in- 
dicate latency. The average period is as follows: Man, forty days (apt 
to be shorter in children or following bites on the face) ; dogs, twenty- 
one to forty days ; horses, twenty-eight to fifty-six days ; cows, twenty- 
eight to fifty-six days; pigs, fourteen to twenty-one days; goats and 
sheep, twenty-one to twenty-eight days; birds, fourteen to forty days. 

The period of incubation depends upon the amount and virulence of 



29 

the virus and the nature and site of the wound, especially with refer- 
ence to the nerve supply. It requires about fifteen days, counting from 
the last injection, to induce an active immunity to the disease by means 
of the Pasteur preventive treatment. There is, therefore, usually suf- 
ficient time, if started early, to prevent the development of symptoms. 
But, there is no time to lose and delays are hazardous. 

It is probable that the prolonged and variable period of incubation is 
due in part to the fact that it takes time for the virus to travel along 
the nerves to the central nervous system, and that it may there remain 
dormant (latent) until conditions favor multiplication. 

Prophylactic Treatment 

Pasteur announced his prophylactic method on December 6, 1883, at 
the International Congress at Copenhagen, and on February 24, 1884, 
he laid before the French Academy the details of his experiments and 
results. For many years the classic Pasteur method was used, but in 
time it was modified and improved in several particulars. In 1911, 
Lieutenant-Colonel Sir D. Semple 1 published the results of his studies 
with fixed virus killed with phenol. This dead virus is injected subcu- 
taneously daily for fourteen days. The method was first tried out in 
India with good results. Its simplicity and relative safety made an ap- 
peal which caused it to grow in popularity and it is rapidly becoming 
the method of choice. In view of the fact that it has only recently been 
introduced into this country, a brief description of the method and its 
results follow. 

The Semple Method 

The material for the prophylactic injections is prepared from the 
fresh fixed virus in the brain, medulla and spinal cord of rabbits. This 
is ground in sterile salt solution containing one per cent carbolic acid, 
strained through fine muslin, and kept at 37 °C. for 24 hours. At the end 
of this period the virus is dead — at least Semple found that it is not in- 
fective when injected into susceptible animals. The material is now 
diluted with an equal volume of sterile normal saline solution. This 
final dilution contains four per cent of the dead virus in 0.5 per cent 
carbolic acid normal saline solution. The dose is 2.5 cc. injected into 
the subcutaneous tissues of the abdominal walls once a day for 14 days. 

The advantages of the Semple method consist first of all in its effi- 
ciency and the relative infrequency of paralytic complications. It is 
meeting with favor, furthermore, because it is economical and simple, 
and the virus may be preserved for shipment. Gloster and Taylor 2 stud- 
ied the keeping properties of carbolized antirabic vaccine and found 
that it retains a high degree of immunizing power for a period of two 
months from date of manufacture, no difference being found in its pro- 
tecting value whether kept in cold storage or at the shade temperatures 
of Rangoon with monthly mean temperatures varying from 86.2 °F., 
87.4°F. and a maximum day temperature of 99.7°F. 

Many thousand of persons have been treated by the Semple method 
and, so far as records are available, with satisfactory results. It is 
often stated that the Semple method is quite as efficient, safer and simp- 
ler than any other modification of the Pasteur prophylactic treatment. 
This comparative statement deserves critical analysis, for the figures 
are not statistically comparable: they are obtained in different coun- 
tries, at different times; recorded and edited in accordance with dif- 
ferent plans. In some localities and at certain times rabies is much 
more virulent than in other localities and at other times. Even when 
all these factors are considered, the results of the Semple method re- 
main favorable. 



1 The Preparation of a Safe and Efficient Antirabic Vaccine. No. 44, Scientific Memoirs, Govt, 
of India, 1911. 

2 The Keeping Qualities of Carbolized Antirabic Vaccine. Ind. Jour. Med. Res., 1925-26, 13, 835. 



30 
The Health Organization of the League of Nations recently held an 
international conference on rabies, the results of which have been pub- 
lished in a supplement to the Annales de lTnstitut Pasteur, 1928, which 
has just arrived. This report contains the details concerning the sub- 
ject of rabies brought up to date. There are recorded 5,035 cases 
treated by the Semple method, with 8 deaths, only one of which is de- 
scribed as a failure. The following table gives results of treatment. 



RESULTS 


OF 


TABLE I 
TREATMENT BY THE 


SEMPLE METHODS 
Annual Average 




Antirables 




Injections — 


Number of 


Mortality 


Stations 




days treatment 


Persons Treated 


Percentage 


Bombay (Inst. Haffkine) 




14 


2,875 


2.12 —0.11 


Calcutta 




14 


5,000 


4.7 —0.5 


Shanghai 




15 


130 


7.7 —1.2 


Columbus (Ohio) 




15 


6S1 




Coonoor (British India) 




14 


3,131 


1.075 — 0.75 


Cuba (Inst. Santa Clara) 




14 


150 





Hongkong 




12 


66 





Jerusalem 




14 


858 


2.5 —0.60 


Kasauli (British India) 




14 


4,030 


1.76 


Lisbon (Inst. Camara Pestana) 


15 (40inj.) 


1,669 


1.75 —0.11 


Lwow ( Poland ) 




20 


1.33S 


0.059 


Philadelphia 




14 


— 


0.5 


Rangoon (Dutch East Indies) 


14 


466 


0.22 


Rome 




15-25 


496 


0.16 


Schillong (British India) 




14 


1,503 


0.41 



The following table gives the incidence of paralysis following treat- 
ment by the Semple method: 



PARALYSIS 



Location of 
Institute 
Shanghai 
Kasauli 
Shillong 
Rangoon 
Calcutta 
Bombay 
Santa-Clara 



(Cuba) 





TABLE 


II 








FOLLOWING TREATMENT 


BY THE 


SEMPLE METHOD 3 


Name of 
Director 




Number of 
Cases of 
Paralysis 


Number of 
Wounds 
Treated 


Percentage 


Jordan 
Cunningham 
Hodgson 
Taylor 

Morison 
Lorenzo 







3 







465 
84,844 
13,532 
5,125 
11,083 
11,000 

584 



0.035 or 1/28,281 








Dr. G. W. McCoy, Director of the Hygienic Laboratory of the U. S. 
Public Health Service, writes me under date of April 20, 1928: "A 
couple of years ago we collected data on the Semple method and found 
it had been used at that time in perhaps twenty thousand cases in the 
United States with an exceedingly low failure rate and a complete ab- 
sence of cases showing paralysis. Since then the method has become 
even more popular and we still have to hear of an authentic case of 
paralysis although we have heard of a few failures to prevent rabies." 

It is stated in the Weekly Bulletin of the Department of Health of 
New York City, November 12, 1927, that "further tests are to be made 
on a series of guinea pigs as to the efficacy of the Semple vaccine. The 
results of immunological tests on a small series of guinea pigs show it 
to be at least as good if not better than vaccine produced by the Pasteur 
Method." A letter from Dr. Anna W. Williams, dated April 27, 1928, 
reports the following results with vaccine prepared by the Semple 
method in the laboratory of the New York City Health Department: 

2 cc. of a 4 per cent emulsion begun August 23, 1926. 
Cases treated to March 15, 1928, 4,841 — over one-half as 

many as in the 13 previous years. 
One case of paralysis reported a few weeks ago recovering. 
Deaths after 15 days — 2; mortality, 0.04. 
Patients bitten by rabid animals, 1467. 
Corrected mortality, 0.14. 



a Internat. Conf. on Rabies, Suppl. to Ann. de 1'Inst. Pasteur, 1928. 



Dr. Williams writes further: "The following is a summary of reasons 
in favor of using the Semple vaccine. 

"It retains its maximum potency and powers of immunization for a 
period of at least three months away from light and in an icebox. 

"The vaccine contains the smallest amount of nervous tissue com- 
mensurate with efficient treatment, and thereby are avoided the so- 
called post-treatment paralyses which occasionally follow certain other 
methods of treatment. 

"The dosage is more accurate than the attenuated cord method since 
the cords vary very much in size. In a large cord desiccation and at- 
tenuation proceed more slowly than in a small cord. For this reason, 
the virulence of various cords dried for the same number of days will 
vary. 

"The Semple vaccine is less costly. The average spinal cord will 
measure about eight inches, producing twenty doses at six cc. each, or 
sixty doses at two cc. each as used in the Pasteur method. The average 
rabbit brain weighs about 7 grams, producing one hundred doses of 
two cc. of a four per cent emulsion (160 doses of five cc. of one per cent 
emulsion). 

"Semple vaccine is more convenient as it may be produced in quan- 
tity and the whole treatment sent in one shipment. This will greatly 
reduce the necessary clerical work and the possibility of errors due to 
non-delivery by mail. 

"All doses of the Semple vaccine are the same regardless of age, sex, 
severity of the bite or location of the wound. The fourteen-dose treat- 
ment is regarded as sufficient for all types of cases. 

"Brain matter is said by Nitsch to be ten times more virulent than 
spinal cord. In using brain we are giving a large proportion of specific 
antibody-producing substance and a smaller one of the useless, prob- 
ably harmful, nervous tissue than is given in methods of cord immuni- 
zation." 

Dr. A. B. Wadsworth, Director of the Division of Laboratories and 
Research of the State Department of Health of New York, writes me: 
"Since the Semple method was adopted in November, 1926, we have re- 
ports of 148 persons who received treatments. In no case was paralysis 
reported or development of rabies following treatment. The same holds 
true of the records of the Division of Communicable Diseases, which 
include all persons treated in the State, exclusive of New York City." 

Lieutenant-Colonel J. W. Cornwall 4 of the Pasteur Institute of South- 
ern India, Coonoor, Madras, presented to the congress in Strasbourg the 
following statement concerning results. The Institute has been work- 
ing for 16 years and 28,898 persons have received the Semple treatment. 

Total number treated 28,898 

Died during treatment 45 or 0.15 per cent 

Died less than 15 days after 

completion of treatment 78 or 0.27 per cent 

Died more than 15 days after 

completion of treatment 200 or 1.70 per cent 

Total mortality 323 or 1.11 per cent 

Percentage of failures 0.7 

When to give the Prophylactic 

It is sometimes difficult to decide whether the prophylactic treatment 
should be given. Treatment causes sufficient personal inconvenience, 
not to speak of the danger (however slight) of paralysis, to avoid ad- 
vising it if unnecessary. In many cases it is impossible to discover 
whether the dog that inflicted the bite is mad or not. The rule in cases 
of doubtful exposure is to advise the treatment. 

* Statistics of Antirabic Inoculations in India. Brit. Med. Jour., 1923, 2, 298. 



32 

Persons who apply for treatment of dog-bites fall into one of the 
seven following categories with reference to the Pasteur prophylactic 
or one of its modifications, such as the Semple method: 

1. The dog is mad: In this case, begin treatment at once. 

2. The dog shows suggestive symptoms: Give the treatment at once. 
In communities having skilled laboratory facilities wait for diagnosis, 
provided this is done promptly. 

3. The dog is not mad : Observe it carefully for ten days* and if no 
symptoms develop there is no danger of rabies in the person bitten. The 
treatment therefore is unnecessary. (The dog may nevertheless develop 
rabies after ten days and if it has been bitten by another dog should 
be kept in quarantine for six months.) 

4. The dog is not identified: This is a common occurrence, especially 
with children. The rule in such cases is to advise the prophylactic 
treatment, except in regions known to be free of rabies. 

5. Exposure to saliva : Persons not infrequently apply for advice giv- 
ing the following history: They have not been bitten, but they have 
been licked on the hands and face by a dog that subsequently was dis- 
covered to have the disease. Persons are sometimes similarly exposed 
by washing the mouth of a rabid horse. In these cases the important 
question is whether there were fissures or abrasions in the skin at the 
time. There may be little wounds in the skin not evident to the naked 
eye. It is possible to infect animals by rubbing the virus on the shaved 
skin. The rule is therefore to advise the protection which the treat- 
ment affords in persons thus exposed. 

6. In psychoneurotic patients with a distressing phobia of rabies, it 
may afford comfort to give a mild course of treatment as much for its 
psychotherapeutic effect as for specific immunity. 

7. Fomites : The question is often asked whether the disease may not 
be contracted from contact with virus in saliva upon floors, on play- 
things and other objects. The situation arises with a rabid dog in the 
house, where children may be exposed in this indirect manner. While 
theoretically possible, the danger is small ; in fact, I have never heard 
of a case contracted in any such way. 

The virus is not infective by the mouth. 

THE LABORATORY DIAGNOSIS OF RABIES 

Langdon Frothingham, M.B.V., 
Department of Comparative Pathology, Harvard Medical School 

One of the strangest facts about this strange disease is that animals 
(including man) dead of rabies show at autopsy no conditions visible 
to the unaided eye which can be considered diagnostic. Therefore, be- 
fore 1903 the only accurate method of ascertaining whether or not an 
animal was rabid was to inoculate some susceptible animal with a bit 
of brain or spinal cord of the suspected animal or person and await re- 
sults. The experimental animals used for this purpose were the guinea 
pig and rabbit, and almost universally the latter was employed because 
symptoms of rabies in the rabbit are so typical of the disease. This 
method of diagnosis must still be used occasionally today and therefore 
I will briefly describe it. 

From the suspected animal small bits of brain taken from different 
regions, and a piece of spinal cord, when available, are ground and 
mixed with a small quantity of sterile water. A few drops of this mix- 
ture are injected beneath the outer membrane covering the brain, and 
a few drops are often also injected directly into the brain of an ether- 
ized rabbit, a small hole just large enough to admit the hypodermic 
needle having been drilled through the skull. The animal soon recovers 



* The ten-day period seems to allow for an ample margin of safety. An additional margin is pro- 
vided for in the regulations of the Division of Animal Industry which call for fourteen days. Ed. 



from the effects of the ether, begins again its normal life, and remains 
well unless the material injected contains the virus of rabies. If, how- 
ever, the virus is present, the animal shows symptoms of rabies, rarely 
as early as a week, usually in from fifteen to thirty days, often not for 
even longer periods, but seldom later than three months. In very ex- 
ceptional cases the incubation period may be even longer. These symp- 
toms vary but little from type, namely, at first an indescribable some- 
thing about the head and ears, and at practically the same time a slight 
loss of motion of the hind legs, which by the next day has become a very 
obvious paralysis. This rapidly increases and becomes general. The 
rabbit dies in three or four days if left alone, although it is usually 
chloroformed as soon as a diagnosis is made. It is exceptional for a 
rabbit with rabies to show excitability and a desire to bite, though in 
the guinea pig such symptoms are not infrequently observed and it may 
die without showing much or even any paralysis, but in the rabbit 
marked paralysis almost always occurs. In former days, therefore, if 
you had been bitten by a suspected rabid dog, there followed an anxious 
period, frequently of several weeks, before you knew whether the dog 
had rabies or not, and it was wise not to wait before beginning the Pas- 
teur preventive treatment. Of course, for many years the laboratory 
man had been working for some other and more rapid means of diag- 
nosis. It seemed to him that there certainly must be some organ or 
tissue of the body which microscopically would show definite conditions 
pointing to rabies. Several observers had noted that certain ganglia 
(small nodules consisting of nerve cells found at intervals along main 
nerve trunks in various parts of the body), especially the Gasserian 
ganglia from rabid animals, showed upon microscopic examination pe- 
culiar and characteristic changes. Some considered this condition diag- 
nostic, others were skeptical though they thought it might be looked 
upon with grave suspicion. If this method could be relied upon, it 
would take only about three days to make a diagnosis. But as there was 
still much doubt as to its accuracy animals still had to be inoculated 
for proof. 

In 1903 an Italian named Negri astonished the scientific world by 
announcing that by new methods of preparing and staining the tissues 
he had found objects in certain nerve cells of the brain not normally 
there, but almost invariably present in animals dead of rabies. These 
objects became known as Negri bodies and they were to be found most 
frequently and in greatest abundance in the large cells of the Amnion's 
horn (hippocampus major), a portion of the brain some three inches 
long and about the diameter of a pencil. The next most likely place to 
find them was in the Purkinje cells of the cerebellum. Usually bodies 
are to be found in both these situations, perhaps more plentifully in 
one than the other; sometimes present in one only and rarely com- 
pletely absent. The discovery of Negri was soon confirmed by students 
of rabies all over the world and it became the general opinion that when 
Negri bodies were found it meant rabies, and animal inoculations were 
unnecessary. 

It was now possible in most cases to make a diagnosis in about two 
days by using special "hurry up" methods, but to some of us this was 
too long a time and it seemed probable that if a number of the desired 
cells could be removed to a piece of glass, known to the laboratory as 
a slide, a quick method of staining could be devised and results ob- 
tained in a very short time. Efforts were successful and since then the 
time required for diagnosis may be considerably less than an hour, in- 
cluding the removal and dissection of the brain, after the head of a 
rabid animal reaches the laboratory. This depends of course upon a 
number of conditions, the most important of which is how soon Negri 
bodies can be demonstrated, for if very few in number many prepara- 
tions may have to be studied before even one is found. This search 



34 
should not be given up for at least an hour. On the contrary, if the 
brain is in good condition and bodies are plentiful, a few minutes mi- 
croscopic examination is all that is necessary. 

I 
What to do with a dog suspected of being Rabid 

First of all, do not kill it unless it is so ferocious that the safety of 
people and animals makes it necessary. Confine the animal in an enclosed 
space from which it can't escape ; e. g. a box stall, pen or cage, give it food 
and water, treat it kindly, call a veterinarian, and observe it carefully 
but with great caution for two weeks. If it has rabies it will show symp- 
toms probably in a few days and die shortly thereafter, but for safety 
the animal must be quarantined for at least two weeks. 

If it is necessary to kill the animal, do not shoot it in the head at 
short range, for if you do the chances are that there will be no brain 
left to examine. Call a veterinarian who knows how to kill it humanely. 
If near enough to the Animal Rescue League or the Angell Memorial 
Hospital, ask their aid. 

When there is an obvious clinical diagnosis a laboratory examination 
is unnecessary, but it should be made in all suspicious cases, especially 
if people or animals have been bitten, and the specimen should reach 
the laboratory as soon as possible. The dead animal, if a small dog or 
cat, may be placed in a box of hay, straw, excelsior, sawdust, or the 
like, and sent by express or messenger to the Division of Animal Indus- 
try, State House, Boston. In the case of larger animals, the head should 
be cut off, wrapped in a moist cloth (burlap, for example, well wet and 
then wrung out), packed in a box or tin with plenty of sawdust to ab- 
sorb blood, etc. and plenty of ice in summer. Ice and snow are easily 
obtained in winter but are not so essential if the weather is cold. If 
ice is not used in the summer, the tissues may be unfit for examination 
when the laboratory is reached. Hence the protesting jingle: 
In winter heads come packed in ice, 
In summer, Oh ! that would be nice. 

Also, never ship on a Saturday or the day before a holiday, for twenty- 
four to forty-eight hours in a warm express office may make the en- 
vironment unpleasant, if not unbearable, and laboratory examination 
out of the question. A specimen must reach the State House before 
10 A. M. on a Saturday. Otherwise it had better be kept cold and not 
shipped till Monday. 

What is done when the head reaches the Laboratory 

As soon as possible after a head arrives at the laboratory, the brain 
is removed, also the Gasserian ganglia. The brain is then cut, properly 
exposing the two Ammon's horns, which are removed. Portions of this 
tissue and of the cerebellum are laid aside for impression or smear 
preparations, the quickest diagnostic method known; other portions 
and the Gasserian ganglia are placed in proper preserving fluids for 
later study by the section method if necessary. The time required for 
the work thus far described may occupy about a half hour, but depends 
on a number of things. For example, the time of day the specimen ar- 
rives ; how many heads are waiting to be worked upon, the expertness 
of the operator, the condition of the brain (it may have been shot away 
or too putrified to be of any use, etc.). If a dog has bitten a human 
being that head is naturally given precedence. 

The next step is to make proper preparations from Ammon's horns 
and cerebellum for microscopic study, and this may take about ten 
minutes. The next step is the microscopic examination and if Negri 
bodies are plentiful they will be found within a few seconds. Thus, if 
everything is propitious a positive diagnosis may be reported within an 
hour after the specimen arrives. But such good fortune (from the lab- 



35 
oratory man's point of view) is by no means the rule. If Negri bodies 
are not found at once, careful study must follow. More preparations 
may have to be made and about an hour spent in the search, and if no 
bodies are found no report can be made for several days, or till the tis- 
sues preserved for section work can be prepared. 

That Negri bodies cannot be demonstrated by the quick method does 
not mean no rabies. Experience has taught us that often when many 
sections have been studied and still no Negri bodies found, there is still 
a grave possibility that the animal had rabies, for in a certain percent- 
age of cases the Negri bodies cannot be demonstrated and therefore the 
laboratory worker must proceed further and study the Gasserian gan- 
glia. Sections of these should be ready at the same time as the brain 
sections. Typical lesions found here are diagnostic of rabies in the 
opinion of many; atypical lesions may mean rabies. From Dr. Hinton's 
and my experience in the study of these ganglia from some 3500 rabid 
and non-rabid animals, we find that perhaps 10 per cent fall into the 
doubtful class (i.e., atypical ganglia) and of this number about half 
prove non-rabid upon animal inoculation. 

As a last resort, provided no bodies have been found and the ganglia 
show atypical or no lesions, animals must be inoculated as already de- 
scribed. As a precautionary measure, two animals are recommended, 
for one may be injured by some accident or become infected with pneu- 
monia or some other natural disease to which animals are susceptible. 

CANINE RABIES 
Dr. Hugh F. Dailey, 

Angell Memorial Hospital, Boston, Mass. 

Rabies as it affects the dog may appear in one of two forms, either 
the dumb or the furious form. Contrary to the prevailing popular idea 
of rabies in either form, the symptoms shown in the initial stages of 
the disease are far from alarming or violent. In fact they may be so 
inconspicuous that it frequently happens they are completely over- 
looked by the owners, and are only recalled when they are suggested in 
securing the history of the case. 

During the initial stages the symptoms shown in both forms are prac- 
tically the same. The dog becomes irritable, restless, and glooihy. His 
eyes take on a peculiarly bright appearance, the pupils become dilated, 
perhaps more noticeable in one eye than the other. The eyes are un- 
usually active, nothing seems to escape their notice and the dog appears 
to see imaginary objects, at times attempts to snap at imaginary flies. 
He is very sensitive and startled by sudden noises, and may slink away 
under couches or chairs. At other times he shows unusual affection 
for those he knows well and will attempt to lick their shoes and hands 
or get up into their lap and try to lick their face. During the night the 
dog wanders about the house, going into rooms he is unaccustomed to 
visit, and several times during the night he may go into the bedrooms 
and try to lick the face or hands of the sleepers. The dog will bark 
frequently for no apparent reason. This characteristic rabies bark is 
unusually high-pitched and ends in a cracked howl. In summing up 
the changes that occur in this first stage of rabies we might say that a 
noticeable change takes place in the mental attitude of the affected 
dog. This stage usually lasts from fifteen to twenty-four hours. 

During the second stage of the disease the dog affected with the 
dumb form continues to emit the peculiar howl at more frequent inter- 
vals and has great difficulty in swallowing water or food. The muscles 
controlling the throat, tongue and lower jaw gradually show evidence 
of becoming paralyzed. The lower jaw hangs open and the tongue 
seems to be in the way. The dog keeps licking his lips and a little ropy 
saliva drools from the lower lip. It is usually at this stage that the 
owner imagines there is a bone caught in the dog's throat and in at- 
tempting to search for it frequently scratches his hands on the dog's 



36 
teeth or else thoroughly impregnates any abrasions he may have on his 
hands with the saliva from the dog's mouth. This probably constitutes 
the most dangerous period of dumb rabies insofar as its transmission 
to the human is concerned. 

During the second stage of the furious form the dog becomes increas- 
ingly restless, howls continually and chews up foreign objects such as 
rags, shoes or pieces of furniture. He does not have the difficulty in 
swallowing that the dog affected with dumb rabies has. But he usually 
refuses his regular food. He may eat his own excrement. He shows 
an increasing desire to snap at members of the household as well as 
other pets kept in the house. He continually tries to escape from the 
house. If unsuccessful he becomes more and more furious and will 
chew at doors and window frames regardless of the physical damage 
that may occur to his mouth and teeth. If he is successful in getting 
out he will run aimlessly about snapping at any moving objects that 
cross his path. In this way a dog affected with furious rabies may 
travel fifty or more miles spreading the infection as he travels. His 
attack on other animals and humans during this run usually amounts 
only to a few nips directed at the head, unless he is cornered then he 
will fight furiously. I believe it is well to mention here a fact which 
may help in tracing the run of a dog affected with furious rabies. It is 
common knowledge that when two normal dogs fight both continually 
snarl, bark, and howl. When a rabid dog fights he will hardly ever 
make a sound. The dog that it attacks will do all the snarling or bark- 
ing. Sometimes after a dog affected with rabies has run for several 
hours he may return to his home, exhausted, covered with bite wounds 
and very disheveled in appearance. After he has recovered somewhat 
from this exhaustion he may start out on a second run. This stage of 
the disease generally lasts from three to four days. With the dumb 
form it is shorter than with the furious form. 

In the third stage, the paralytic stage, the two forms again show 
similar symptoms. Insensibility and dullness become more apparent. 
The eyes become dull and lusteriess, the pupils dilate, the mouth hangs 
open with the tongue protruding, dry and livid in color, saliva hangs 
in long threads from the lips. The degenerative changes taking place 
in the spinal cord cause a progressive paralysis to take place in the 
extremities, the dog staggers and stumbles as it walks. This condition 
increases until he is no longer able to stand. Marked emaciation is ap- 
parent, exhaustion increases rapidly and the dog succumbs after a brief 
period of convulsions, passing away in a state of coma. 

The period of incubation in canine rabies is usually from two to 
eight weeks. Where a complete history of the case has been obtained 
our experience at the hospital leads us to the conclusion that most cases 
develop in from twenty-one to twenty-eight days. There are however 
on record instances of incubation periods extending from six months 
to a year, but our intimate knowledge of the difficulty attending secur- 
ing the contact history in the usual run of rabies cases leads us to ques- 
tion the authenticity of such long incubation periods insofar as dogs 
are concerned. 

Short incubation periods may be expected from the bite of a rabid 
dog received about the head and neck, particularly those on the lips, 
eyelids, and ears. Bites on the legs, body, and tail seem to be conducive 
to longer incubation periods. 

As a rule gentle house dogs, extreme family pets are the dogs which 
most often develop the dumb form of the disease. Puppies under six 
months of age, vigorous out-of-door dogs and stray dogs are the types 
most commonly affected with furious rabies. 

By far the greater percent of rabies cases coming under observation 
at the hospital are of the dumb form, less than 15% being furious. 

Where rabies has become prevalent in a locality, the most essential 
steps to take in attempting to eradicate it is to round up and dispose 



37 
of all stray dogs. It is truly remarkable what large numbers of these 
come to light when a thorough job of policing the community has been 
established. Reasonable restraint of all licensed dogs in the com- 
munity should be insisted upon until in the opinion of the local health 
authorities the emergency has passed. All dogs biting persons should 
be confined in quarantine for a period of at least fourteen days, under 
the observation of a competent authority. If at the end of such a quar- 
antine the dog appears normal there is no more positive proof that he 
was not affected with rabies at the time the biting took place. 

The single dose canine rabies immunizing vaccine used so extensively 
in various parts of the country during the past five years has its merits 
if its use is properly supervised but like all other similar vaccines it 
cannot be expected to be 100 percent efficient, and will lead to no end of 
confusion if used indiscriminately. By that I mean it should be given 
only to dogs that we are reasonably certain have not been previously 
infected by contact with a rabid dog. Contact dogs should be given the 
six dose Hoegyes method vaccine which we have found very efficient 
providing the treatment is started within thirty-six hours following the 
exposure. 

Whenever we have to deal with the rabies situation we are also called 
upon to handle a number of well meaning persons who question the ex- 
istence of any such disease. In the majority of instances we find that 
these individuals have confused rabies with the ordinary cases of con- 
vulsions or hysteria commonly called fits, frequently found affecting 
dogs and due in most cases to digestive disturbances from which dogs 
usually recover. 

We believe that this confusion regarding the existence of rabies can 
only be overcome by bringing before the public in as readable form as 
possible the true symptoms shown by dogs affected with rabies. Hoping 
that this article may contribute its part to this end we have purposely 
refrained from putting it in technical form or terms. 

RABIES CONTROL IN MASSACHUSETTS 

By George H. Bigelow, M.D., 

State Commissioner of Public Health 

and 

Frank B. Cummings, 

Formerly Director, Division of Animal Industry 



That rabies exists as it does at present in the eastern part of Massa- 
chusetts indicates quite clearly that we are unable to make organized 
use of our knowledge in regard to this disease. There are tragically 
few diseases in which the most wholehearted community cooperation 
can accomplish more than fractional control. Rabies is one of the ex- 
ceptions and therefore the indifference and antagonism to control meas- 
ures which have been engendered by sentimental slop and malicious 
misinformation are particularly reprehensible. 

To the best of our knowledge, rabies has never been transmittedfrom 
one human being to another. In the West, infected coyotes and in Si- 
beria infected wolves constitute well-nigh impossible problems of con- 
trol. But here in New England the dog is the only agent of spread that 
needs serious consideration. It is the wandering, uncontrolled, un- 
licensed, stray dog that carries the disease from one section to another 
or brings its back. It is through the stray dog that our communities 
are menaced. In Mohammedan countries dogs may starve but they 
must never be killed since once a dog's bark drove a cat from the back 
of the prayerfully engrossed prophet. This seems to be the attitude of 
most of our fellow citizens toward our stray dogs. 

The dog side of the problem should be handled as follows : 

(1) All dog owners must comply with the law as regards annual 



38 
licensing. All communities should take the initiative in seeing that this 
licensing is enforced. All communities (as some have) should issue 
tags to be worn on the collars which will make identification of legally- 
owned dogs relatively easy. Local officials must be active in appre- 
hending unlicensed animals and after a reasonable period during which 
they may be claimed they should be humanely killed. The Animal Eescue 
League will give advice and assistance to the limit of their resources in 
this matter. 

(2) When the disease is prevalent all dogs should be restrained un- 
der a local order for ninety days. Muzzling has been found both in- 
human and futile. This last winter, because of the serious situation, 
the Division of Animal Industry of the Department of Conservation 
exercised its authority to recommend restraint of all dogs in the large 
Metropolitan area. Theoretically, this would allow all the licensed ani- 
mals that were infected to come down with the disease while restrained, 
(that is, while unable to infect other dogs) and would allow the police 
to easily identify and dispose of the stray dogs which would be the only 
ones at large. This was a complete fiasco through lack of public sup- 
port. 

(3) A dog, known to have bitten a person, must be kept alive under 
restraint for at least fourteen days. If at the end of that time symptoms 
have not developed the person is safe so far as developing rabies from 
that bite is concerned. 

(4) A valuable though not complete protection is given uninfected 
dogs by a single dose of canine rabies vaccine and is recommended to 
individual dog owners interested in protecting their animals, their 
children and to a certain extent the community. It should not be con- 
sidered for universal compulsory use until its effectiveness is more 
complete. Animals bitten by a known rabid dog should have a more 
extensive treatment by a competent veterinarian. 

The protection of human beings exposed to this disease depends upon 
promptly receiving the Pasteur prophylactic inoculations which consist 
of a series of daily injections into the abdominal wall. These are pain- 
ful and expensive but it can only be known definitely whether they are 
needed by waiting for the development of symptoms. By that time inoc- 
ulations are useless and death is certain. The inoculations should be 
given : 

(1) If the dog develops the disease during the fourteen days' obser- 
vation following the bite; 

(2) If the dog is killed previous to the expiration of the fourteen 
days and an examination of the animal's head shows he has the disease ; 

(3) If the dog is lost track of and the disease is prevalent in the com- 
munity, as at present; 

(4) If there has been close association and the possibility of con- 
tamination with fresh saliva even though there has been no bite, since 
the virus may enter through minute cracks and breaks in the skin. 
There are records of human and animal infection without bites. 

Do not be lulled into a false sense of security by any local treatment of 
the wound, hoivever drastic, although prompt and thorough cauterization 
of the wound with fuming nitric acid is an important protective measure. 

Death from this disease is particularly horrible. There were two hu- 
man deaths last year and two so far this year. The number has been 
kept down by the fact that hundreds have followed the advice of their 
physicians and have taken the uncomfortable inoculations. 

The experiences of the past year have only strengthened our convic- 
tion that the one hope of controlling this disease in dogs and man is 
to enforce the licensing of all dogs and the elimination of unlicensed 
dogs. Until the public can be brought to a realization of the serious- 
ness of rabies and obey the licensing law our only hope is lavish vac- 
cination for those bitten and infected, with sorrow not for the dog but 
for those who neglect or refuse this treatment. 



39 



Editorial Comment 



The Role of Sentimentality in Public Health. Emotions, it is often said, 

rather than reason are 
usually behind an individual's actions. The field of public health offers 
no exception to the general rule. Consideration for the best interests of 
the public as a whole is often made to yield to the supposed needs of the 
individual. The argumentum ad hominem is still supreme — or shall we 
say the argumentum ad canem? Towser or Rover bites Johnny Jones who 
had the effrontery to be playing in the school yard or in his own backyard. 
Poor Johnny has to take the Pasteur treatment and has the skin of his 
little tummy punctured and a welt raised daily for three weeks. By that 
time bedtime doesn't look so good to Johnny since he can't find a comfort- 
able spot to lie on. 

Johnny and his father go to remonstrate with Mr. Doglover, the owner 
of Towser. He listens to their tale with ill-concealed disgust. Then a 
noble indignation overpowers him. "What's the little fool snivelling 
about? He's still alive isn't he? Anyway, he'll get over it in time." "Re- 
strain my dog?" "How wicked!" "Man's Best Friend" (sobs here, and 
a quotation from Senator Vest). "Besides, what was the kid doing out 
alone? He knew that there were dogs on the street. You can't keep a 
dog on a leash all the time, he doesn't like it." And so forth. Exeunt 
Johnny -and his Dad, abashed but unconvinced. 

But, honestly, is a dog so much more worth while than a child that he 
should get all the consideration and the latter none ? 

Choosing the School Nurse. The question was recently asked the Editor 

why a higher standard is not maintained 
in choosing school nurses. It was a most pertinent question and deserves 
more thought than is usually given to it. 

Several factors enter into the problem. First, there is the question of 
supply and demand. Then there is the point of view of the community 
itself and the salary it is willing to pay. Lastly, but a factor of the ut- 
most importance, there is the point of view of the superintendent of 
schools. 

The supply of nurses fitted by education and training to do adequate 
school nursing is small but there is a supply. It sometimes exceeds the 
demand. And yet in Massachusetts every one of our 355 communities is 
expected to have school nursing service. Clearly, adequate service is not 
being demanded or the supply would be exhausted at once. The inevitable 
conclusion is that the community as a rule has no standard for school 
nursing and is satisfied with a more or less random choice. 

What then of the superintendent of schools? In all candor we have to 
say that he too, in many instances, might with advantage make a better 
choice. We wish that he might apply the same standards to school nurs- 
ing that he does to school teaching. It is not unreasonable to expect that 
the nurse should be fairly well educated (apart from her nursing train- 
ing) and should be a graduate of a recognized training school for nurses. 
She should also be registered. The fact that she has nursed some mem- 
ber of the family of a school committee-man acceptably is not proof that 
she is qualified for school nursing. 

Another point to be borne in mind is that a nursing training does not 
guarantee teaching knowledge or ability. Whether or not a nurse can 
teach hygiene in the schools depends on her pedagogical background and 
nothing else. 

We have to acknowledge a shortage of school nurses of the type indi- 
cated above. But we shall never have an adequate supply until there is a 
greater demand. 



. 40 
The American Child Health Association Study. There seems to be an 

epidemic of studies at 
present, some good and some — not so good. Questionnaires are as plenti- 
ful as ctenocephalus on a dog, and usually meet with the same welcome. 
Massachusetts, however, has recently had experience with one study about 
which nothing but good can be said. The Eastern Squad of the American 
Child Health Association's research group has been with us. 

The method employed by this group is entirely rational. There are, 
apparently, no preconceived ideas — no looking for things which ought to 
be there — but rather a search for things which are there. What has 
health education done for the child which can be measured by the ingeni- 
ous "y ar d sticks" which Dr. Palmer and his co-workers in the Association 
have devised? The answer to this question will mean much to all en- 
gaged in health habit promotion in children. It seems rather footless to 
waste too much time in discussions of methods of teaching until we are 
surer of what we want to teach. 

A debt of gratitude is owing the American Child Health Association 
for its courage and farsightedness in attacking this admittedly difficult 
problem. It is equally deserving of gratitude for expending the money 
and taking the time to do a real job. Whatever the conclusions finally 
drawn, they will be "front page stuff" for the health worker. 

"The Directory." There is before us the report of "The Directory, Inc." 
Concealed behind this intriguing and non-committal 
title is an organization whose object is of importance to everyone inter- 
ested in the reduction of infant mortality. Succinctly stated in the organ- 
ization's own words, the object is "to supply healthy human milk to babies 
who are ill and for some reason are deprived of their own mother's milk." 

Reading this report, one cannot help contrasting the wet nurse of 
Dicken's time with this most modern and scientific method of assuring 
mother's milk to Boston babies in need of it. Truly if any milk supply 
can be said to be safe, this is it. Study is even being given to the ques- 
tion of a satisfactory method of drying the surplus milk, for the benefit 
of patients in isolated communities or traveling. 

Modest, humanitarian enterprises such as this usually fail to get the 
credit they deserve for their efforts to protect the lives of infants. 

Public Health Institute. The Commonhealth notes with interest that the 

Massachusetts Institute of Technology is put- 
ting on this year for the second time a Public Health Institute for health 
officers and other public health workers. As before, the subjects to be 
discussed cover a wide range and the speakers are all well-known sani- 
tarians. Professor S. C. Prescott of Technology is the Director of the 
Institute. 



41 

MATERNAL DEATHS IN MASSACHUSETTS DURING 1927 

A Statistical Summary 

The death certificates for 1927 show 486 deaths due to puerperal causes. 
These deaths occurred in 160 towns. The primary causes of death are 
summarized as follows: 

Puerperal septicemia 140 

Puerperal albuminuria and convulsions 122 

Puerperal hemorrhage 58 

Accidents of pregnancy 30 

Abortion 8 

Ectopic gestation 15 

Others 7 

Other accidents of labor 72 

Cesarean section 26 

Other surgical operations and instru- 
mental delivery 9 
Others under this title 37 
Puerperal phlegmasia alba dolens, embo- 
lus and sudden death 59 
Following childbirth (not otherwise defined) 3 
Puerperal diseases of the breast 2 
The maternal death rate for 1927 was 5.9 
The infant death rate for 1927 was 64.6 



REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of January, February and March 1928, samples 
were collected in 157 cities and towns. 

There were 1,786 samples of milk examined, of which 278 were below 
standard, from 34 samples the cream had been in part removed, 57 sam- 
ples contained added water, and 1 sample contained a foreign substance. 

There were 400 samples of food examined, of which 106 were adulter- 
ated. These consisted of 1 sample of butter which was low in fat ; 48 
samples of clams, and 5 samples of scallops, all of which contained added 
water; 4 samples of cream which were below the legal standard in fat; 
7 samples of dried fruits which contained sulphur dioxide not properly 
labeled; 18 samples of eggs, 16 samples of which were cold storage not 
so marked, and 2 samples were sold as fresh eggs but were not fresh; 7 
samples of maple syrup which contained cane sugar ; 8 samples of sausage, 
4 of which contained starch in excess of 2 per cent, 3 of which contained 
a compound of sulphur dioxide not properly labeled, and 1 of which was 
colored; 3 samples of hamburg steak which contained a compound of sul- 
phur dioxide not properly labeled; 1 sample of maple sugar which con- 
tained cane sugar other than maple ; and 4 samples of olive oil, 3 samples 
of which contained cottonseed oil, and 1 contained a foreign oil which 
could not be identified. 

There were 8 samples of drugs examined, all of which conformed to the 
U. S. P. requirements. 

The police departments submitted 2,057 samples of liquor for examina- 
tion, 2,023 of which were above 0.5% in alcohol. The police departments 
also submitted 22 samples of narcotics, etc. for examination, 11 of which 
were morphine, 3 opium, 1 strychnine, 2 phosphorus, 1 tincture of iodine, 
1 ammonium sulphide, and 3 samples which were examined for poison 
with negative results. 

There were 92 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 2 samples of coal examined which conformed to the law. 

There were 170 inspections of plants, operated for the pasteurization 
of milk. " 



42 

There were 89 convictions for violations of the law, $1,385 in fines 
being imposed. 

Louis A. Bach, William Lucchesi, Adolfo Luchini, Caesar Equi, and 
Louis F. Giarmsi, all of Holyoke; Daniel W. Frye of Avon; Andrew Pow 
of Northampton; James Reid of Raynham; John Wollan of Stoughton; 
Ethmos Vasilajis and Arthur Theodoupolous of Cambridge; Winthrop 
M. Brown of Lunenburg; John Geddes of Sharon; Peter Giftos of Pitts- 
field; George Lavoulairs of Fairhaven; Peter Sardinsky of Peabody; 
Richard J. Sullivan of South Deerfield; Theodore Anagnoston and Mike 
Kectic of Chelsea; Everett E. Cummings of Woburn; Anthony Gerardi 
and George Koutrafuris of New Bedford; Edward W. Morse of Rockport; 
and Andrew Noble of Marblehead, were all convicted for violations of the 
milk laws. Theodore Anagnoston of Chelsea, and Anthony Gerardi of 
New Bedford, both appealed their cases. 

Morris Winer of Salem; Harry Gillis, Mohawk Sausage & Provision 
Company, and Irving J. Koolvson, all of Boston; Carl A. Weitz of Somer- 
ville; William F. Dennis and Owen H. Thorner of Marblehead; Lucien J. 
Fugere of Northampton; Joseph Duffy, 2 cases, of Revere; Walter R. 
Marie, 2 cases, of West Lynn ; Phillip A. Smart of Lynn ; Walter St. John 
of East Boston; Victor Wells, 2 cases, of Winthrop; Fred W. Shackleford, 
Andrew W. Lufkin, Lester F. Day, and First National Stores, Incorpor- 
ated, all of Gloucester, were all convicted for violations of the food laws. 
Joseph Duffy, 2 cases, of Revere; Walter R. Marie, 2 cases, of West Lynn; 
Phillip A. Smart of Lynn; Walter St. John of East Boston; and Victor 
Wells, 2 cases, of Winthrop, all appealed their cases. 

Simon Millman of Roxbury, and The Great Atlantic & Pacific Tea Com- 
pany of Pittsfield, were convicted for misbranding food. Simon Millman 
of Roxbury appealed his case. 

Nicholas Bakirakis of Taunton; William Papastathis of Roxbury; Man- 
uel Solovicos of Salem; Ethmos Vasilajis of Cambridge; Michael Zogra- 
fos of Waltham; Alfred Daigneau of Lynn, 2 cases; Carl Gold, Isaac Wid- 
lansky, and Samuel Tillman of Springfield; and A. H. Phillips, Incorpor- 
ated, of Chicopee, were all convicted for false advertising. Manuel Solo- 
vicos of Salem appealed his case. 

James F. Harriman of Winthrop was convicted for violation of the 
drug laws. 

Nicholas Bezereanarkis, Mederic Gaudreault, Barnard Polonsky, Sarah 
L. Provencher, and Morris Winer, all of Salem; George Bogosien of Cam- 
bridge; Nathan Castalina and George Starropoluos of Roxbury; Bessie 
Caswell of Lynn; First National Stores, Incorporated, Louis Venditti, 
and Felix Olivieri, all of Newton; First National Stores, Incorporated, 
and Samuel R. Sessine of Brighton; First National Stores, Incorporated, 
of Dorchester; E. E. Gray Company of Waltham; The Great Atlantic & 
Pacific Tea Company of Newtonville ; George Hatfield and Puritan Stores, 
Incorporated, of Fairhaven ; Myer Kaplan and Joseph La Pidas of Boston ; 
Guivanni Leone and Abdella Hyder of Lawrence; John Wollan of Stough- 
ton; Barney Beanstalk, Clement Gritsko, and Michael Mooka, all of Pea- 
body; Alex Szynaski of Pittsfield; Samuel Tillman of Springfield; and 
First National Stores, Incorporated, of Watertown, were all convicted for 
violations of the cold storage laws. Abdella Hyder of Lawrence appealed 
his case. 

John Kelso of Chester was convicted for violation of the slaughtering 
laws. 

In accordance with Section 25, Chapter 111 of the General Laws, the 
following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers: 

Milk which contained added water was produced as follows: 13 sam- 
ples, by Everett E. Cummings of Woburn; 7 samples each, by Winthrop 
M. Brown of Lunenburg, and John Geddes of Sharon; and 6 samples, by 
Levi H. Thompson of Greenfield. 



43 

Clams which contained added water were obtained as follows: 3 sam- 
ples, from Victor Wells of Winthrop; 2 samples each, from George Wells 
of Revere ; Rood & Woodbury, The Great Atlantic & Pacific Tea Company, 
and Springfield Public Market, all of Springfield ; and 1 sample each, from 
Eugene P. Beaton of North Saugus; James 0. Crowell of Saugus; Wal- 
dorf Lunch, Incorporated, of Lowell; Lawrence Fish Market, and Nunzio 
Corradino, both of Lawrence; Walter St. John of East Boston; First 
National Stores, and E. E. Gray & Company, both of Boston; Joseph 
Duffy of Revere; Walter R. Marie of West Lynn; Phillip A. Smart of 
Lynn; The Great Atlantic & Pacific Tea Company, Incorporated, of Ar- 
lington; and Schermerhorn Fish Company of Springfield. 

Scallops which contained added water were obtained as follows: 

One sample each, from The Great Atlantic & Pacific Tea Company of 
Dedham, Mansfield, and Springfield; and Schermerhorn Fish Company of 
Springfield. 

Hamburg steak which contained a compound of sulphur dioxide not 
properly labeled was obtained as follows: 

One sample each, from Irving J. Kolovson of Boston; and Beverly Pub- 
lic Market, and National Beef Company, both of Beverly. 

Sausage which contained starch in excess of 2 per cent was obtained 
as follows: 

One sample each, from A. Serani, and M. Marienberg, both of Boston. 

Sausage which contained a compound of sulphur dioxide not properly 
labeled was obtained as follows: 

One sample each, from Francis Fistori of Somerville, and from The 
Great Atlantic & Pacific Tea Company of Northampton. 

Maple syrup which contained cane sugar was obtained as follows: 

One sample each, from A 1 Restaurant, and Transfer Restaurant, both 
of Taunton; First National Store of Salem; and The Central Sea Grill 
& Restaurant of Cambridge. 

One sample of maple sugar which contained cane sugar other than 
maple was obtained from Antonio Drinkwater of Chelsea. 

One sample of cream which was below the legal standard in fat was 
obtained from Dedham Lunch of Dedham. 

There were six confiscations, consisting of 160 pounds of decomposed 
chickens; 127 pounds of decomposed fowls; 275 pounds of sour beef kid- 
neys; 184 pounds of decomposed pigs' hocks; 240 pounds of decomposed 
scallops; and 100 pounds of sour scallops. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of December, 1927: — 479,070 
dozens of case eggs; 307,379 pounds of broken out eggs; 814,892 pounds 
of butter; 2,878,839 pounds of poultry; 6,317,172 y 2 pounds of fresh meat 
and fresh meat products; and 1,520,952 pounds of fresh food fish. 

There was on hand January 1, 1928: — 1,586,790 dozens of case eggs; 
1,310,141 1 /^ pounds of broken out eggs; 5,644,912 pounds of butter; 
7,207,979 x / 2 pounds of poultry; 12,545,093 pounds of fresh meat and 
fresh meat products; 137 gallons of scallops; and 8,743,973 pounds of 
fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of January, 1928: — 194,160 
dozens of case eggs; 182,686 pounds of broken out eggs; 626,861 pounds 
of butter; 2,027,354 pounds of poultry; 5,226,018 pounds of fresh meat 
and fresh meat products ; and 1,474,333 pounds of fresh food fish. 

There was on hand February 1, 1928: — 97,260 dozens of case eggs; 
936,686 x /2 pounds of broken out eggs; 3,159,175 pounds of butter; 8,263,- 
493 V2 pounds of poultry; 14,034,351 pounds of fresh meat and fresh meat 
products ; 49 gallons of scallops ; and 5,643,462 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of February, 1928 : — 119,820 
dozens of case eggs; 499,208 pounds of broken out eggs; 424,202 pounds 



44 
of butter, 1,136,735 pounds of poultry; 5,960,716 pounds of fresh meat 
and fresh meat products; and 1,648,324 pounds of fresh food fish. 

There was on hand March 1, 1928: — 28,260 dozens of case eggs; 717,- 
963 V2 pounds of broken out eggs; 1,723,715 pounds of poultry; 7,897,- 
198% pounds of poultry; 17,613,563% pounds of fresh meat and fresh 
meat products; and 3,624,887 pounds of fresh food fish. 

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, GEORGE H. BlGELOW, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration . 
Division of Sanitary Engineering . 

Division of Communicable Diseases 

Division of Water and Sewage Lab- 
oratories .... 
Division of Biologic Laboratories 

Division of Food and Drugs . 

Division of Hygiene . 

Division of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark. 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Herman C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 



The Southeastern District . 

The Metropolitan District 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District 



Richard P. MacKnight, M.D., 
New Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., LowelL 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



Publication of this document Approved by the Commission on Administration and Finance 
5M. 6-'28. Order 2646. 



i 



THE 
COMMONHEALTH 



Volume 15 

No. 3 




July-Aug.-Sept. 

1928 



Venereal Diseases 



MASSACHUSETTS , 
DEPARTMENT OF PUBLIC HEALTH 



THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of 
Public Health 

Sent Free to any Citizen of the State 



Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 



The Massachusetts Society for Social Hygiene, by Cecil K. Drinker, 

M.D 47 

The Treatment of Gonorrhea in the Male, by J. Dellinger Barney, 

M.D., F.A.C.S 47 

Gonorrhea in the Female, by A. K. Paine, M.D. . . . .51 

Treatment of Syphilis, by Austin W. Cheever, M.D. . . .54 

Social Work and Syphilis, by Maida H. Solomon . . . .57 

The Role of the Social Worker in the Treatment of Gonorrhea, by 

Madeline C. Everett . . . . . .59 

A Study of Syphilis and Gonorrhea in Holyoke, Massachusetts, by 

Helen I. D. McGillicuddy, M.D. and N. A. Nelscn, M.D. . 62 

Editorial Comment : 

Criterion of Cure of Gonorrhea in the Female . . . .65 

The Social Worker and the Venereal Disease Clinic . . .65 

"The Strong Arm of the Local Public Health Officials" . 65 

School Hygiene in the Summer School . . . .65 

Active Immunization Against Diphtheria, by Clarence L. Scamman, 

M.D. and Benjamin White, Ph.D 67 

Report of Division of Food and Drugs, April, May, June, 1928 . 70 



47 

THE MASSACHUSETTS SOCIETY FOR SOCIAL HYGIENE 

By Cecil K. Drinker, M.D., 
President of the Society. 

The Massachusetts Society for Social Hygiene had origin in the period 
of general public effort which accompanied and immediately followed the 
war. The stimulating interest of President Eliot, Bishop Lawrence, and 
others, resulted in a period of intensive and useful work in which the 
aims of this wholly voluntary society were perhaps to a fair degree at- 
tained. 

It is often questioned whether a voluntary group, outside the possibility 
of definitely controlling action, can accomplish useful ends in a field like 
social hygiene where State and City power must so constantly take com- 
mand. But for anyone who has had experience in disease prevention, it 
has become axiomatic that the first and most indispensable prop in a 
campaign must be education, and this need increases with the general in- 
telligence of the population. 

The effectiveness of measures for the control of venereal disease de- 
pends upon the receptiveness of the group under observation. The Massa- 
chusetts Society for Social Hygiene thus takes as the first duty that con- 
fronts it, the task of providing carefully organized information upon 
venereal diseases and the great variety of factors which promote and 
maintain these diseases. 

Through the office of the Society at 41 Mt. Vernon Street, Boston, com- 
munities and individuals interested in the problems of venereal disease 
prevention may obtain literature and information. The Executive Secre- 
tary, Dr. Helen I. D. McGillicuddy has spent much of her time in giving 
addresses to organizations of women who have wanted information upon 
the general subject, and this service the Society is prepared to maintain 
through the coming year. Up to the present time funds have not been 
available to extend this work in a similar way among boys and young 
men. There are few who can look back upon their own acquisition of 
knowledge upon sexual matters and upon the mysteries of venereal disease 
without feelings of distress. At the same time we must admit that our 
own sons, as a rule, face the same casual and demoralizing experiences. 

It is a hope of the Society that friends and members will make possible 
this necessary elaboration of the educational program of the organization. 

In regard to the field of existing venereal diseases, the Society is at- 
tempting, through studies of communities where there is a reasonable 
chance for gaining information of fair completeness, to gain a true esti- 
mate of the amount of venereal disease, and to find out the most success- 
ful way of controlling and curing actual cases. The medical information 
in regard to treatment is now good enough so that if thoroughly applied, 
in many cases, the results must be splendid. One of the chief concerns 
of the Society thus becomes the task of bringing about conditions which 
result in real treatment of cases. 

The Society is neither large nor prosperous. It has but one certain 
asset — a cause for active existence which all citizens must admit. Those 
interested in the work of the organization, or solicitous for information, 
are urged to communicate with the Secretary at 41 Mt. Vernon Street, 
Boston. 

THE TREATMENT OF GONORRHEA IN THE MALE 

By J. Dellinger Barney, M.D., F.A.C.S. 

Chief of Service, Urological Dept., Massachusetts General Hospital 
Assistant Professor of Genito-Urinary Surgery, Harvard Medical School 

The first, last and most important thing to remember in the treatment 
of a case of gonorrhea in the male, is that in at least nine cases out of 
ten, the infection has either already reached the prostate and seminal 



48 
vesicles or that it will soon do so in spite of every care. In other words, 
simple, uncomplicated anterior urethritis is of only brief duration. I 
say this advisedly after an experience of nearly twenty-five years in the 
observation and treatment of this disease. It is, therefore, obvious that 
attention should be focused on the prostate and vesicles, not necessarily 
at the outset of the disease, but certainly when it comes to effecting its 
cure. With the gradual disappearance of the disease from the prostate 
it will be found that the urethral discharge, the shreds and the urinary 
disturbances incidental to prostatitis will disappear. 

Treatment of the Early Case 

As to the treatment of a case seen at the onset when probably the in- 
fection is limited only to the anterior urethra, the physician will do well 
to employ the treatment advocated and practised so successfully by Boyd 
of Atlanta (Jour. Urology, XIX, No. 1, January, 1928). His description 
of the treatment is as follows: 

"Two injections of acriflavine are made daily, one in the morning and 
one in the late afternoon; and no other medication is used during the 
first week unless the patient is given some mild urinary sedative. After 
voiding, the patient lies down and about one or two drams of 1:1000, 
aqueous solution of Boots' acriflavine are injected into the urethra. This 
is held in with pressure, exerted by the forefinger and thumb, on the 
urethra back of the glans. A piece of absorbent cotton, of a good grade 
and about 1 inch wide and 3 inches long, is then laid over the meatus and 
its ends carried back above and below the penis and the pressure on the 
urethra is released; around the penis is wrapped another similar piece 
of cotton, and the patient is kept lying on the table for ten to fifteen 
minutes with the penis held upright. By the end of that time nearly all 
of the acriflavine has oozed out of the urethra into the cotton, as can be 
demonstrated by having the patient stand up, remove the cotton and press 
upon the urethra. 

"Should the acriflavine be held in the urethra by pressure on the glans 
that part of the mucosa beneath the finger would not come in contact with 
the acriflavine except during the brief period when the solution was al- 
lowed to flow out of the urethra. By slightly sealing over the meatus 
with cotton, as I have just described, and holding the penis erect, and 
permitting the acriflavine to ooze out, this defect is avoided and that part 
of the urethra which needs the most treatment in the early cases (the 
outer part) receives the benefit of continuous contact with the antiseptic 
solution for at least ten or fifteen minutes. 

"After six or seven days I stop the acriflavine treatments and begin 
irrigations of warm, weak, potassium permanganate (2 grains to a quart) 
once or twice a day. These are given very gently at first and always at 
my office, and at home the patient employs a urethral injection of either 
a 5 per cent aqueous solution of neosilvol or a 1 per cent aqueous solution 
of protargol, with the same technique employed in my office in giving the 
acriflavine. 

"If shreds are still found in the first glass of urine after three or four 
weeks, and are evidently the result of the just treated attack of gon- 
orrhea, they readily disappear after the passage of a few sounds, dilating 
the urethra to a large size." 

Other Methods 

This is by far the best treatment I know of but, of course, other meth- 
ods may be satisfactorily employed. Permanganate of potash solution, 
1:8000 to 1:4000 is probably the most widely used drug and is certainly 
of great efficiency. It should be employed at a temperature of about 
110°F., and at least a quart of it should be used for the irrigation and 
this should be done once a day, preferably twice. The irrigation should 
involve only the anterior urethra, a statement which implies that no 



49 

force should be used while giving it. The old-fashioned glass Valentine 
nozzle attached by a rubber tube to a suspended reservoir is preferred by 
many, or the nozzle can be of the two-way metal variety which tends to 
prevent overdistension of the urethra. On the other hand, there are 
those (of whom I am one) who prefer to use a small soft rubber catheter 
(Nos. 14-16 French) inserted about half way down the urethra and at- 
tached to a large (100-200 cc.) Janet hand syringe. Still another method 
is to attach a rubber Guyon acorn tip to the hand syringe instead of the 
catheter. In any event the irrigation should be used with care and with 
but little force. The urethra should be alternately distended and emptied 
by intermittent release of the obstruction of the meatus, whether this be 
produced in the case of the catheter by the constriction of the physician's 
finger, or in the case of the acorn tip or irrigation nozzle by pressure 
against the lips of the urethra. 

In addition to receiving an irrigation once or twice a day from his 
physician, the patient should use a urethral injection at home, from 2 
to 4 times a day. This can be of 10 per cent argyrol, 1 per cent protargol 
or 5 per cent neosilvol. I prefer the latter as it is less irritating than the 
other two and has the advantage of staining the hands and clothing to a 
lesser degree. 

I do not believe that any drug is more valuable in the early stages of 
acute gonorrheal urethritis than sandalwood oil in a 10 minim capsule 
after meals. It will not cure the disease but it certainly reduces urinary 
discomforts to a minimum. With this should be given large amounts of 
water and milk and a definite restriction placed on the use of spiced or 
highly seasoned food, ginger ale and "tonics". It seems unnecessary to 
add that all sexual excitement, all alcoholic beverages and anything but 
a minimum of exercise should be absolutely avoided. 

The treatment just outlined should be continued either until the dis- 
charge has entirely disappeared which in the case of a simple anterior 
urethritis will be in from 4 to 6 weeks, or should prostatitis intervene 
(which as I have already pointed out, is generally the case and it may 
do so in a most insidious way) the cure can be effected only after from 4 
to 6 months and sometimes longer. 

Either the persistence of the discharge, the appearance of a cloudy 
second urine or the advent of a greater or less amount of frequency, 
urgency and bladder irritability, will show that in spite of a promising 
beginning and every care the infection has spread to the posterior urethra 
and the prostate (this includes also the seminal vesicles). Should these 
objective and subjective symptoms be well marked, then I find it wiser to 
continue only the treatment as for anterior urethritis until they have 
begun to subside and when the second urine has cleared almost entirely. 
At this point gentle massage of the prostate and seminal vesicles can be 
begun. 

Treatment of Prostate 

Some prefer to massage the prostate on an empty bladder. Others pre- 
fer to do the massage on a bladder filled either with urine or with anti- 
septic solution. I think it is unimportant which method is used, but I 
think it of great importance that the products of massage should be 
washed out of the patient's bladder by his voiding either his own urine 
or the injected fluid. Incidentally, this procedure will give the physician 
an idea of the amount of detritus obtaining from time to time. 

This massage should be gentle, not over a minute in duration and not 
oftener than three times a week. Just how to massage the prostate can- 
not be described in words. If is a distinct accomplishment which some 
physicians never acquire — to others it is a sort of second nature. If at 
first massage seems to aggravate the symptoms it should be abandoned 
altogether for a time, it should be given less often, or it should be done 
more gently. Do not forget that the very procedure which will bring 
about a cure of the disease may make it worse for the time being. It is, 



50 

therefore, wiser to wait until the virulence of the infection is lessened 
and until the natural resistance has increased. After a time, however, 
the physician will find that he can employ massage once, twice or thrice 
weekly without an aggravation of symptoms and with a slow but steady 
improvement. This improvement will consist of the decrease of the dis- 
charge to only a small amount of clear mucous in the morning, and of 
the change in the appearance of the urine from cloudy or hazy to clear. 
Not at first, but only after the elapse of two or three (or more) weeks will 
there be any detritus in the urine or injected fluid after massage. This 
detritus, made up of coarse and fine masses of muco-purulent material, 
some of it floating, some of it settling rapidly to the bottom of the glass, 
will eventually appear, however. As the disease approaches a cure the 
amount will decrease and finally disappear altogether. Just how long this 
may take is a variable factor in every case but it will be from 4 to 6 
months at least. It should be remembered that during this time there 
may be no urethral discharge whatever, that the urine may be perfectly 
clear or show only a few shreds, and most important of all, that the pros- 
tate and seminal vesicles as well, may show no changes whatever in size, 
consistency or sensitivity. This is a point which many do not seem to 
realize. When it is thought that the goal of complete elimination of the 
disease is approaching or has been reached, the best method to ascertain 
this point is to examine under the microscope (high-dry lens) a drop of 
prostatic secretion taken from the meatus directly after massage. The 
microscopic picture may vary from time to time but not until one has 
been able to demonstrate not more than 2 or 3 leucocytes per field can one 
say that the case is cured. An absence of leucocytes in the prostatic se- 
cretion must be found on repeated examination made at intervals of from 
2 to 4 weeks. If, meantime, the patient has indulged in alcoholic or sexual 
excitation the continued absence of leucocytes would be an even more 
favorable omen. The tendency for most laymen is to let their optimism 
run away with them, leading them to believe that they are really cured 
when they are not. Unfortunately, the tendency of many physicians is 
to take a similar attitude. On the other hand, there are those who keep 
on treating a case indefinitely just because of the presence of a few shreds 
in the urine or of the presence of a little more mucous secretion in the 
urethra than is usually the case. As in other situations it takes mature 
judgment to know just how long to treat and when to stop treatment and 
even then mistakes are made. 

In irrigating the urethra only its anterior portion should be treated in 
the early stages, so long in fact as one is sure that the posterior portion 
is uninvolved. When, however, it is demonstrated that he is dealing with 
a prostatitis, irrigation of the posterior urethra and bladder can be begun. 
While at first it is well to begin with a weak solution, permanganate of 
potash can soon be used in the strength of 1:4000 (4 grains to the quart). 
Furthermore, if the case drags on, as some cases do, the urethra may be 
stimulated to advantage either by adding silver nitrate to the perman- 
ganate solution or by using it alone in strengths of from 1:10000 to 
1:5000. 

The advisability of the use of sounds or of the Kolman dilator in the 
treatment of gonorrhea is always a subject of free and sometimes fierce 
debate. Generally speaking, I am against the use of the Kolman dilator 
except in the hands of the most expert. Even then it does but little good 
and may do harm. As to sounds they may help to clear up stubborn 
shreds or a persistent mucoid discharge from the urethra. 

To return for a moment to the matter of massage — if we remember that 
the prostate is constructed more or less on the lines of an ordinary sea- 
sponge with innumerable complicated canals of the most tortuous and 
minute caliber it will be easier for both patient and physician to under- 
stand why it is so difficult and slow an undertaking to free it from disease. 
Incidentally, no one should attempt to treat gonorrhea until he has fa- 



51 

miliarized himself with the extremely complex anatomy of the male gen- 
ital organs. He will then realize how innumerable are the possible foci 
for harboring gonococci. 

In this brief article it has been impossible to touch upon countless 
aspects of gonorrhea as it affects the male. To do so would require almost 
unlimited space. I have tried to emphasize the rarity of simple anterior 
urethritis and the frequency of prostatitis. A corollary to this is that 
massage is essential to the cure of the disease. I believe it is not ex- 
aggerating to say that massage alone would cure nine out of ten cases 
although it is also true that the irrigations and injections ordinarily em- 
ployed will shorten the time for cure. In this connection it is important 
to remember that posterior urethritis exists only in combination with 
prostatitis — with the subsidence of the prostatitis there will be a corre- 
sponding decrease of the urethritis. 

Diathermy 

A word should be said about the use of various forms of diathermic 
and high-frequency apparatus in the cure of gonorrhea. When this form 
of electrical current first appeared and especially in recent years, a good 
deal was hoped for from its use in the cure not only of anterior urethritis 
but of prostatitis. As time went on, however, it became obvious to the 
conservative and observant element in the profession that the method 
was of little value. This may be due partly to the technical difficulties 
involved and these may be overcome in the course of time. At present the 
male patient can expect diathermy to help him only to the extent of 
soothing his acutely inflamed prostate into a state of more or less com- 
fortable quiescence. Diathermic treatment of anterior urethritis is of 
no value. 

Altogether the treatment of gonorrhea in the male is a matter of diffi- 
culty. No great advances have been made except in realizing first that 
the prostate is the important organ to treat, second that the disease is 
much more tenacious than was heretofore believed. The physician must 
be prepared to encourage a discouraged and restless patient and to be 
on the watch for the many complications which are likely to arise in the 
course of the disease. 

GONORRHEA IN THE FEMALE 

By A. K. Paine, M.D., 

Surgeon-in-Chief, Gynecology Department, Boston Dispensary 

A correct understanding of the disease gonorrhea in women necessitates 
the consideration of three distinct phases or stages. 

The first stage concerns itself with the period of invasion, character- 
ized by the acute inflammatory reaction in urethra, lower vaginal glands 
and cervix. In cases in which the element of personal hygiene is lacking, 
the inflammatory reaction may be marked about the introitus generally, 
but the characteristic inflammatory reaction is that in the lower, urethra 
and urethral glands. The cervical involvement is practically simultaneous 
with that of the urethra, although the inflammatory reaction develops 
more slowly. This first stage, or stage of infection, extends over a period 
of five or six weeks, at the end of which time the acute inflammatory re- 
action has subsided, although the glands of the urethra and of the cervix 
still disclose evidences of an inflammatory process in the form of pus, 
which can be expressed from the urethral glands and which appears as 
profuse muco-purulent discharge from the cervix. The end of the first 
stage is coincident with the beginning of the second stage which clini- 
cally is the stage characterized by the inflammatory invasion of the pelvic 
organs. This invasion undoubtedly occurs in all cases but varies markedly 
in different cases in the severity of the reaction as well as its duration. 
Observation seems to disclose that the duration and severity of the pelvic 



52 

inflammatory symptoms have a definite relationship to the persistence of 
the infecting organisms. 

Aside from the cervic discharge, excessive flowing, in the form of a 
metrorrhagia usually, is the most characteristic symptom of this stage. 
To this, in certain cases, is added low abdominal discomfort, lateral quad- 
rant pain, and acute attacks which we have come to recognize as acute 
salpingitis and acute pelvic peritonitis. 

Acute pelvic inflammatory symptoms of a severity sufficient to require 
bed treatment, occur in twenty per cent of the cases. Those requiring 
operative treatment during this stage are probably something less than 
three per cent, though a much larger number is operated upon. In the 
Boston Dispensary series an appendix operation had been frequently done 
during this stage. Resection of one or both tubes was next in order of 
frequency, and suspension operations next. 

Apparently the backward excursion of the fundus is a part of the pro- 
tective mechanism in a pelvic inflammatory reaction and this backward 
position of the fundus is often assumed to be explanatory of the excessive 
flowing and other symptoms which the patients describe. 

Early miscarriages and ectopic pregnancy represent common compli- 
cations encountered in this stage. 

The third stage is essentially a stage characterized by degenerative 
changes in the pelvis, essentially sclerotic in type and subsequent to a 
more or less prolonged second stage. Partial amenorrhea, changes in the 
vaginal mucosa, pruritis, and a large group of indefinite neurological 
symptoms dependent on vaso-motor disturbances, are noted. Sterility not 
infrequently sends these patients to the physician. 

In the first stage a positive smear is not difficult to obtain although the 
first smear is negative in exactly half the cases. In the second stage posi- 
tive smears are obtained with considerable difficulty and only after re- 
peated smear examinations in many cases. 

The case which is clinically positive should receive treatment for the 
infection, irrespective of negative smear findings. 

About one-half the cases will have but one or two positive smears, with 
clinical evidence of infection rapidly disappearing, obviously cured in a 
short time. In the other half of the cases positive smears from time to 
time can be secured, often over a period of years. Clinical evidence of 
infection persists at the same time. "Reinfection" almost invariably ex- 
plains the case which has recurrent positive smears. 

Treatment 

Treatment resolves itself into three distinct parts: First, in the man- 
agement of a patient with an acute social problem ; second, in the specific 
treatment of the infection; and third, in the management of the pelvic 
inflammatory aspects of the disease. 

Any or all the three may be required in a given case and a successful 
termination of the trouble depends on an ability to successfully cope with 
each of the problems present. A large part of the social problems con- 
cerns itself with the prevention of "reinfection". Experience has clearly 
shown that the intelligent and willing co-operation of the patient can only 
be secured with her understanding of the exact situation. 

As regards the treatment of the infection itself; here the first step is 
to reduce to a minimum the possibility of "reinfection". It is obviously 
absurd to attempt to eradicate the infecting organisms in a given case if 
that case is being continually exposed to its original source of infection. 

Disregard of this very obvious fact has been largely responsible for the 
widely disseminated idea that gonorrhea in women is extremely difficult 
to cure. 

The treatment most commonly used at the dispensary following a tech- 
nic employed for six or eight years, is as follows : the patient at bed time 
takes a hot sitz bath, followed by a chlorine douche and in turn by the 



53 

insertion of a vaginal suppository containing a half grain of methylene 
blue. These patients report at the Clinic weekly, at which time smears 
from cervix and urethra are taken and the clinical condition noted with 
special reference to the development of pelvic inflammatory symptoms. 

The element of reinfection disposed of, the average number of positive 
smears in these cases will not exceed three, and the clinical evidence of 
infection usually disappears within a few weeks. 

Actual treatment must be continued as long as clinical evidences of in- 
fection exist (pus in the urethral glands and cervicitis), and this in spite 
of repeated negative smears. Cases with persistent clinical evidences of 
infection usually mean cases exposed to reinfection, and sooner or later, 
positive smears will be obtained. A single negative smear is without 
value, and further has been responsible for much ill-advised treatment 
in these cases. In an acute case there is an even chance that the first 
smear will be negative. Later there is a much greater chance that such 
will be the case. A negative smear may result in a disregard of the pos- 
sibilities in a given case and when subsequently the patient returns with 
excessive flowing as a complaint, any explanation except the correct one 
may be accepted. A retroverted uterus present, the suspension operation 
results, or if right lower quadrant pain is complained of, the appendix 
operation almost invariably follows. 

The correct appraisal of low abdominal symptoms in women is based 
very largely on the ability to determine the presence or absence of a 
gonorrheal infection. This refers not only to the cases of active infection 
but to the much larger group which has had the infection previously. 
The urethral orifice which is the site of a gonococcus infection undergoes 
permanent changes which are quite characteristic in young women. This 
change consists in prominent urethral glands from which discharge is 
usually readily expressed and a peculiar senile appearance of the mucous 
membrane such as occurs physiologically in elderly patients. One should 
be exceedingly slow in attributing to an associated laceration the cervicitis 
present in a given case. A very considerable number of repair operations 
are being done in cases in which the symptoms are produced not by the 
laceration but an active Neisser infection. These cervicitis cases should 
have repeated negative smears before any surgery for the cure of the 
cervicitis is undertaken. The importance of this point cannot be over- 
emphasized. 

Pelvic Inflammation 

Regarding the management of the pelvic inflammatory aspect of the 
disease: it is very evident that by far the great majority of these cases 
tends to spontaneous recovery or at least to a spontaneous relief from 
symptoms, with rest in bed, the ice bag and long douches. The guide to 
surgery is invariably the persistence of symptoms and not the discovery 
of a mass, or a backward displacement of the fundus. Resolution of the 
pelvic inflammatory exudates and masses can be confidently expected in 
a very considerable number of cases, and under no circumstances should 
radical surgery be resorted to during at least the first year of the trouble. 
The case which has persisting acute pelvic symptoms with accompanying 
temperature elevation for more than ten days should be drained by pos- 
terior colpotomy irrespective of the size of the mass demonstrated by 
examination. Further operative treatment in such a case is rarely nec- 
essary. ' '"' ;*!!^f^ 

If recurrent acute attacks and persistent morbidity continue for longer 
than a year, the question of radical operation must be met. The opera- 
tion, when done, is a supra-vaginal hysterectomy with the removal of both 
tubes and both ovaries. If an ovary is left, twenty-five per cent of the 
cases will have a second operation for its removal. 

Radical Operation 

The decision as to what case should have radical operation and what 



54 

case should not depends considerably on the social factors involved. The 
young married woman, for instance, is justified in putting up with long 
drawn out morbidity in the hope that ultimately her pelvic organs may 
regenerate sufficiently to permit of child birth. A widow of forty, the 
sole support of several children would find a quick return to health more 
important than an attempt to conserve her pelvic organs. The type of 
ill health produced by pelvic inflammation, especially when degenerative 
changes begin to come about, is peculiarly productive of nervous unbal- 
ance and the type of individual who is nervously unstable to start with, 
should not be permitted to suffer a long drawn out morbidity. 

Gonorrhea in Children 

A general survey of the subject of gonorrhea in women discloses two 
other aspects of considerable importance. The first of these is the disease 
in children. For a long time it has been a popular belief that gonorrheal 
vulvitis could be acquired by young girls in a manner denied adults. 
When a whole ward in a children's hospital, for instance, suddenly be- 
comes infected with gonorrhea, it necessitates a type of dissemination en- 
tirely different from what we observe in adults. Undoubtedly a number 
of the vulvitis cases are gonorrheal in origin. In these true cases we 
have almost always (excluding birth infections), a history of attempted 
assault or some irregular sex practice. This group represents approxi- 
mately ten per cent of the vulvitis cases seen. About one-half of the 
remainder, usually of an epidemic type, are undoubtedly caused by some 
organ resembling morphologically the gonococcus; the micrococcus ca- 
tarrhalis perhaps being responsible. A respiratory infection primarily it 
is easy to appreciate its epidemic nature, affecting families, wards and in- 
stitutions. The remainder of the vulvitis cases in children are caused by 
a variety of organisms in which faulty hygiene, masturbation, etc. play 
a part. 

Pseudo-Infection in Adults 

A second observation of some importance is the fact that each year is 
seen a considerable number of cases in adults presenting an acute and 
severe vaginal inflammatory reaction with a profuse pus discharge re- 
sembling an acute gonorrheal infection except that the urethra is not 
definitely involved. These cases usually occur in groups suggesting an 
epidemic and are usually associated with an epidemic of upper respiratory 
infections in the community. Such cases are almost invariably diagnosed 
clinically as gonorrhea. Occasionally an organism is discovered suffi- 
ciently resembling the gonococcus in appearance and reaction to result in 
a bacteriological diagnosis of gonorrhea. The condition clears up quickly 
under appropriate treatment. It undoubtedly represents a mucous mem- 
brane infection with some of the organisms commonly involved in upper 
respiratory infections. The clinical difference between it and a gonorrheal 
infection is indicated by the absence of a definite urethral gland involve- 
ment and by the fact that in gonorrhea a definite vaginitis as such is com- 
paratively rare. 

TREATMENT OF SYPHILIS 

By Austin W. Cheever, M.D. 
Associate Chief of the Divison of Dermatology and Somatic Syphilis 

Boston Dispensary 

In this paper I shall give only a general outline, leaving many of the 
details of dosage, length of courses, and choice of particular preparation 
to be determined by the physician after a careful study of his individual 
patient as there are great differences in susceptibility to the various 
drugs; consequently no set form of treatment can safely be applied to 
more than a minority of cases, and then only to those who are young, 



55 

vigorous, and in an early stage of the disease. Even in such, individu- 
alized treatment is advisable, but it is imperative in all others. 

The most important single principle in the treatment of syphilis is 
continuity over a period sufficiently long to eradicate the disease in pa- 
tients starting treatment very early, or to establish control in those 
coming under treatment too late for a complete cure. 

Types of Patient 

Patients may well be divided into three main groups: (1) those in 
primary and secondary stages when intensive treatment will often com- 
pletely eradicate the disease as shown by the criteria of negative blood 
and spinal fluid tests and a fair frequency of reinfections; (2) those in 
the late stage when the damage is not irreparable and when with rela- 
tively mild treatment the disease can be made to remain quiescent, doing 
little or no injury throughout the remainder of the patient's life; (3) 
those in the late stage when the damage is irreparable; when sometimes 
further damage can be prevented though scars are left; sometimes, how- 
ever, the damage continues to grow in spite of all efforts as in aortitis 
and general paresis of the insane. 

In the first group the drugs seem to be of value in the following order : 
first, the arsphenamine series; second, bismuth; third, mercury. In the 
later groups the arsphenamines lose their precedence and the order of 
the other drugs varies according to the special indications in individual 
patients. Tryparsamide, malarial therapy, and sub-arachnoid treatment 
now come to the fore. 

Early Syphilis 

In early syphilis, especially the sero-negative primary cases, treatment 
as intensive as the patient will bear should be started at once, for an 
unnecessary delay of even a day or two may make a serious difference in 
the patient's chances of recovery. The use of the dark field microscope 
or of staining methods (which though less satisfactory than the former 
require so little apparatus that they can be done by any physician in his 
own office) is urgently needed at this time as by these means a diagnosis 
can almost always be made at the first visit. To oblige a patient to wait 
for treatment until a serologic report is obtained constitutes an unpar- 
donable waste of his chances of cure. For his own sake in curing the 
disease, and for that of contacts in rendering lesions non-infectious, he 
should be started on one of the arsphenamines which have their greatest 
value at this time. This intravenous course should be followed by intra- 
muscular injections of bismuth and then of mercury, or vice versa. There 
is no set number of injections to be given in a course, the important point 
being to keep the treatment continuous throughout fully a year regardless 
of negative serology. 

Later Stages 

The same rules apply to patients first seen in the secondary stage ex- 
cept that the treatment should continue a few months longer, at least six 
months after the first negative blood test. In later syphilis through the 
latent or asymptomatic phase, when the diagnosis can be made only on 
the history and positive serology, and possibly persisting adenopathy or 
some other slight suggestive finding, such intensive treatment is unnec- 
essary and does not accomplish the desired result. Milder treatment is 
not only permissible but advantageous to the patient by helping him to 
build up his natural resistance. Such cases should be started on the less 
potent drugs as mercury or mercury and iodides for a few weeks or 
months; then a course of arsphenamine injections followed by several 
more months of mercury by any convenient route, with perhaps now and 
then a course of bismuth injections. It is frequently difficult to reverse 
the serology in such cases within two or three, sometimes more years, but 



56 

treatment should be given steadily or with short intervals in this rather 
mild form until a number of months after the establishment of negative 
tests. 

Treatment of the average case of late syphilis is approximately the 
same except that the greatest caution should be used in patients with 
aortitis lest a sudden softening of the syphilitic tissue occur allowing a 
very rapid dilation or even perforation of the aortitic wall with sudden 
death. Such cases should be started with mercury while the iodide and 
especially arsphenamine should be given with greatest care and in small 
dosage. 

Other Types of the Disease 

Central nervous system syphilis of the meningeal form is many times 
amenable to treatment such as is outlined above, but intensive and long 
courses are necessary. Tabes dorsalis can usually be checked and some 
improvement produced; however, here again treatment by all the known 
drugs is needed over very long periods, especially the use of tryparsamide 
and iodides, while treatment into the sub-arachnoid space is relatively 
less necessary since tryparsamide has come into use. General paresis 
may be temporarily controlled with difficulty even by the most extremely 
intensive treatment by every known method. 

Treatment of congenital syphilis in the infant is practically the same 
as that of primary or secondary acquired form, making necessary allow- 
ance for the difference in size. The care of these cases coming under 
observation in childhood and later is approximately the same as that of 
asymptomatic and late syphilis in the adult except that intensive treat- 
ment is needed if interstitial keratitis is present, a condition which is 
slowly but satisfactorily responsive to treatment carried out with vigor 
and over a sufficiently long period. 

Use of Drugs 

Having considered the subject from the point of view of the stages of 
the disease, let us now consider it from the point of view of the drugs. 
The arsphenamine group is most useful in early syphilis rendering the 
patient very quickly non-infectious, and most rapidly reversing the serol- 
ogy. It is extremely valuable in most forms of central nervous system 
syphilis and is widely used in all other stages in occasional courses. 

Mercury has been of great value in the treatment of syphilis since our 
earliest knowledge of the disease except for occasional periods when it 
fell into disfavor. It should probably now be used more than it is but 
the arsphenamines are more spectacular in their action and have been 
allowed to overshadow milder, well-tried methods. Along with the io- 
dides or especially following them it is valuable in preparing most latent 
and late cases for the more potent drugs. 

The iodides are most useful in healing late syphilitic lesions though 
they have relatively little effect in curing the disease. They are especially 
valuable in preparing the way for more potent drugs in late syphilis 
especially in central nervous system syphilis, in relieving the pain of 
syphilitic periostitis of any stage, and in reducing the size of even such 
early lesions as conspicuous primaries of the lip. 

Bismuth, at first used as a substitute for arsphenamine and mercury 
when* they are not well borne, is now recognized to have a value inter- 
mediate between the two. Since it is a potent and yet safe drug, it should 
be made a part of any well ordered course of treatment. 

Tryparsamide is of less value in early syphilis but is very useful in 
most forms of central nervous system syphilis though probably largely 
for its tonic effects. Malarial and other fever therapy are used especially 
in general paresis and in some other forms of central nervous system 
syphilis, but these methods call for highly specialized work and like the 
treatment given into the sub-arachnoid space require special equipment 
and training if it is to be done with safety. 



57 

The hospitals over the State which are treating the largest number of 
patients with syphilis are giving drugs in courses varying from eight to 
fifteen injections, each drug succeeding immediately after the previous 
one without intermissions. The complete combined course takes from 
three to six months and this is repeated until at least one course has been 
given after negative serology is established. 



SOCIAL WORK AND SYPHILIS 

By Maida H. Solomon, 
Social Worker Boston Psychopathic Hospital 

A most important corollary to the adequate medical care of syphilitic 
patients is efficient social service. That the medical and social approaches 
to the problem are closely allied is as true for late as for early syphilitics 
though the social effort made and the problems found vary in intensity 
and scope. Social emergencies cannot be fairly met through the medical, 
nursing or clerical staff of a clinic. 

The special value of the social worker in the handling of syphilis may 
be considered first from the standpoint of an aid to the physician in (1) 
the treatment of syphilitic patients; (2) the examination of those pos- 
sibly infected; and (3) the handling of the social situations caused by 
or coincident to the disease. 

In too many clinics today either because of lack of ready money or 
lack of interest on the part of community leaders, the social worker is 
conspicuously absent although her value as an aid to proper treatment is 
recognized by competent authorities. Statistics from the clinics with 
social workers show that through the more adequate social follow-up of 
patients, contagious patients whose treatment has lapsed can be treated 
until "cured" and thus possible new infections avoided; the sources of 
contagion can be found and brought under treatment; lost cases can be 
regained and then treated continually until discharged. The problem of 
continuous treatment is especially acute with cases of congenital syphilis 
and neurosyphilis. Here the social worker must constantly encourage 
the patient through contact in the clinic or through reiterated explana- 
tions to the family of the necessity of treatment over a period of years. 

In the case of a child the social worker can tell the parents about the 
possible alleviation of symptoms such as early skin manifestations, inter- 
stitial keratitis and early neurosyphilis. If the child is symptom free one 
can emphasize the fact that untreated he runs the risk of various in- 
capacitating diseases and that his chance to compete with others in early 
or adult life lies with the parents. 

In the late cases it is important for the social worker to keep in close 
touch with the relatives and the home. More frequent home visits in 
order to find out the patient's attitude towards the family situation, to 
increase the mate's responsibility as an active participant in restoring 
the patient to health and efficiency, to report to the family on the progress 
of treatment, all help cement the bond between patient and clinic. The 
establishment of a personal relation between clinic social worker and 
patient, obviously impossible for the busy doctor and nurse, the mere 
presence of a person in the clinic with the time to talk over industrial 
and family difficulties, may lend a friendlier atmosphere to a clinic, which 
in turn contributes to more willing and frequent reporting and the oppor- 
tunity for prolonged and more successful medical treatment. 

Importance of Familial Examinations 

In the treatment of syphilis at the clinic one necessarily deals not only 
with the patient who acquired syphilis but with the individuals who may 
have been innocently infected. One approaches the family first to pre- 
vent the further spread of syphilis. Next in importance comes the dis- 



58 
covery of existing familial syphilis where part of the damage has been 
done but where early treatment may alleviate symptoms and even bring 
about a cure. To discover the unknown syphilitic one must succeed in 
getting the family to the clinic for examination; syphilis having been 
diagnosed one must bring about continuous treatment. 

The mate and children of every syphilitic, whether seen in an early 
or late stage, deserve examination. Such endeavor cannot be spasmodic 
or only when indicated by certain facts. It must be routine and auto- 
matic in order to reach not only the immediate contacts of the contagious 
patient but the cases spread by accidental contacts, the cases of latent 
unsuspected syphilis and in order to give a clean bill of health to the 
uninfected. 

Familial examination is not always easy to bring about. Written in- 
structions handed out at the clinic, or verbal advice to bring in contacts 
is not enough. Continuous effort, which means time and ingenuity on 
the part of the social worker, including home visits and personal con- 
tacts, is often needed. Family co-operation is sometimes difficult to ob- 
tain because of lack of understanding of the connection between the pa- 
tient's disease and apparently healthy relatives, because of ignorance or 
because of a general don't care attitude. 

Adjustment of Social Problems 

The third outstanding value of the social worker in the proper handling 
of syphilis is in the attempted adjustment of the many social problems 
which occur in addition to the medical problems which caused the original 
clinic contact. The person best fitted by training and experience to handle 
family problems is the social worker. If there is no social worker, these 
maladjustments are apt to be overlooked. 

In the early contagious cases careful case work is needed so that rela- 
tives may be safeguarded from acquiring the disease. Directions must 
not only be given by the doctor on how to avoid infection but the social 
worker must see that the directions are carried out. The family morale 
must be maintained yet the family relatives, friends and co-workers must 
be protected. It must be understood that once contagious not always con- 
tagious, and that with adequate treatment the precautions may be re- 
laxed. 

The patient, if intelligent and co-operative, should be given the first 
opportunity to tell his family that he is syphilitic. If the patient has 
not said anything to his mate the responsibility then rests on the social 
worker under the direction of the doctor. The social worker, after per- 
suading the patient to be frank with his mate, should meet the family 
not only to reinforce the correct preventive information but to smooth 
over any unpleasant situations which the disclosure of syphilis may have 
raised. It is not always easy to give the patient or family the right atti- 
tude. There is often a natural tendency to feel disgraced, a desire to 
hide from the facts, a morbid syphilitic may show undue fear of infecting 
his family, a syphilitic woman who has had repeated accidents to preg- 
nancies may become neurasthenic, a syphilitic mother may dwell on all 
the horrors of syphilis which may descend on the family. While some 
persons live in terror of acquiring the disease, and are skeptical of a 
promised cure when they are syphilitic, others smile at the possibility of 
having the disease, ignore it when they have it or refuse and scoff at the 
idea of prolonged treatment. Such extremes of attitude must be handled 
by the social worker as well as the more concrete expressions of mal- 
adjustment such as threats to break up the home or secure a divorce. 

The normal routine of family life is affected by syphilis. The discovery 
of a congenital syphilitic means many regular visits to the clinic. Often 
this is difficult to arrange. It is equally difficult to transport to the clinic 
some patients in the late stages. The social worker must advise on the 
method and help provide the means to carry out suggestions. A syphilitic 



59 

baby may be such a burden that the other children suffer from improper 
care; the paretic may be deranged mentally and require watchful care; 
an accident of late syphilis may leave a person paralyzed; a tabetic in 
pain or an unreasonable paretic may demand an unusual amount of fore- 
bearance on the part of the mate. The social worker, aware of these 
possibilities, present and future, must aid in re-educating the homemaker 
to carry these burdens. 

In early cases of syphilis temporary financial aid for the family may 
have to be arranged. Hospitalization of an adolescent girl means an op- 
portunity to prepare the family for intelligent care on her return. 

In the families of late syphilitics the wage earner is usually incapaci- 
tated more or less unexpectedly in the prime of life. A gradual industrial 
decline leads to employment difficulties and inability to continue to sup- 
port the family on its former level. Failure to adjust to a competitive 
world often means an eating up of savings followed by dependence on 
relatives or charity, by the assumption of the economic burden by the 
wife, or by the breaking up of the home and the placement of children. 
The social worker should play an important part in aiding the families 
to adjust themselves both mentally and physically to the enforced re- 
organization of family life. 

Social Worker as an Interpreter 

A competent clinic social worker may be an important link between the 
sick person and the community. She should see that clinic findings are 
properly interpreted to social agencies, that such agencies may under- 
stand what a positive wasserman does or does not indicate, what the 
diagnosis means and when or when not to place out syphilitic children. 
She should be responsible for the keeping of adequate social histories and 
records so that the community may have the benefit of later research. 
She should be used in a field capacity by the doctor and interested indi- 
viduals in the locality to bring about more community interest and co- 
operative effort in the treatment of syphilis. 



THE ROLE OF THE SOCIAL WORKER IN THE TREATMENT 

OF GONORRHEA 

By Madeline C. Everett, 
Social Worker, Massachusetts Department of Public Health 

Medical social' service is an important function of any well organized 
clinic. The medical social worker has developed as an aid to the physi- 
cian in the diagnosis and treatment of disease and as a social assistant 
solving the mental, financial and moral problems of the patient under 
treatment. She is an important member of the staff of any clinic effi- 
ciently treating gonorrhea. 

Gonorrhea is a disease which has long been recognized as a serious pub- 
lic health menace, a communicable disease which is more prevalent than 
any other communicable disease, with the possible exception of the com- 
mon cold; a disease which affects primarily the youth of the nation, and 
one which if untreated may lead to very serious complications. It may 
cause sterility in either male or female, may cause blindness of the new- 
born, may result in invalidism for life, and always causes untold pain 
and heartaches. 

Choice and Duties of Worker 

The social worker in a gonorrhea clinic should be selected with especial 
care, as she has the power to "make or mar" the success of the clinic. 
She is responsible for the "atmosphere" of the clinic and for maintaining 
the morale. She is interested in each patient as an individual, and pa- 
tiently listens to his troubles and difficulties, encouraging him during the 



60 

months of treatment and observation. To be a success, she must have 
sympathy, tact and judgment. She must co-operate with the physician. 
She should understand and have an interest in the medical problem, and 
should not be prudish, moralistic, or possess a morbid sex curiosity. A 
sense of humor is an asset, and a public health viewpoint a requisite. 

The duties of the social worker are varied. In many clinics she acts 
as the clinic executive. She interviews the new patient, takes his social 
history and determines his economic status. Oftentimes a patient able 
to pay a private physician reports at a clinic because he is wary of quack 
physicians and drug store remedies. The social worker can give him the 
names of reputable physicians and advise against drug store treatment. 
She is also responsible for the "follow-up" of the delinquent patient, 
either by letter or on occasion by a friendly visit which makes a lasting 
impression. 

The social worker's first duty is to the patient under treatment. She 
explains to him the nature of the disease, the health regime to be followed 
if medical treatment is to be effective, the precautions to be taken to 
avoid cross infection, the necessity of persistent treatment and observa- 
tion over a period of time, and the public health regulations. 

When she has won the patient's confidence, she tries to determine the 
source of infection. This is a difficult, painstaking task, but most im- 
portant from the public health standpoint, since other cases of gonorrhea 
may be traced and placed under treatment. If the patient is married, it 
is most important to have the mate examined. The patient may state 
that the mate was not responsible for the infection, and was not exposed 
in any way. In this event the social worker must judge whether the pa- 
tient is telling the truth and whether the examination of the mate should 
be insisted upon. Perhaps examination can be made unwittingly through 
some other clinic. Oftentimes men are willing to escort the source of 
infection to the clinic for examination. If the girl in the issue was merely 
a "pick-up", the young man may find out her name and address, so that 
she may have the chance to receive treatment. Generally speaking, it is 
more difficult to obtain data from girls about the source of infection. 
However, if a name is given, it is apt to be correct, as the girls, unless 
promiscuous, know the man involved. In obtaining this information as 
well as in investigating cases of this type, the social worker must be ex- 
tremely careful. The clinics have various methods of handling this in- 
formation; some give the patient a card asking him to present it to the 
person named, while others refer these facts to local health departments 
for investigation. Whichever method is used, the effect is the same, — 
the examination of the suspected source in an effort to prevent further 
infection. 

A gonorrheal condition in which it is imperative to have the parents 
examined is "ophthalmia neonatorum", or blindness of the new-born. Too 
often there is a record of successive cases of ophthalmia in the same fam- 
ily due to neglect of the parents to continue treatment, or to the failure of 
the social worker or nurse to insist upon examination and treatment. The 
follow-up of the children in the family is important, since children often 
have the habit of sleeping with parents who may be diseased. A younger 
sister may be infected through sleeping in the same bed with an older 
sister who has gonorrhea and does not realize the seriousness of the 
disease. 

The social worker must also consider the possible exposures. A girl 
in the clinic who has been promiscuous may have exposed ten to fifteen 
men in the course of her wanderings. Each man should be interviewed 
to make sure that he has no disease. 

The social problems of gonorrhea are of a delicate and intimate nature. 
It must be borne in mind that it is a disease usually spread through sex 
relations. Illegitimacy, childless marriages, divorce, separation, are some 
of the problems often encountered. 



61 
Strengthening Morale 

Many patients upon the first visit to a clinic are timid, morose, and 
worried. They have strange ideas about the nature of the disease. One 
young man under treatment at a clinic told the social worker he had been 
infected with a disease which would ruin him physically, that he had been 
told by friends he could live only seven years and he decided to end it all 
by jumping into the river. The sympathetic social worker, in co-opera- 
tion with the physician, was able to correct this wrong information, to 
completely change the mental status, and alter the patient's entire out- 
look on life. The social worker must foresee emotional conflicts. A young 
girl of foreign birth, visiting a clinic at the suggestion of a girl friend 
gave a story of sex delinquency over a period of years. After several 
interviews, the social worker learned that the girl's mother had been dead 
many years. She had been boarded with one of her mother's friends, who 
did not allow her to entertain any girl friends in her home nor to speak 
to boys. Consequently, she had found her excitement and recreation in 
sex delinquency. A change in her environment, an interest in swimming, 
and a membership in a girls' club adjusted her sex life, so that she later 
was very happily married. 

During the patient's treatment at the clinic, the social worker may ob- 
tain information which is of inestimable value to the doctor in the treat- 
ment of the case. If, for example, the patient is not responding to the 
treatment, the social worker may learn the patient has thrown the medi- 
cine out of the window, as very often happens. This may explain why 
improvement is not as rapid as should be expected. If the patient has 
been incapacitated due to his infection, or has lost his job because of hos- 
pitalization, the social worker can find another position for him. If a 
girl under treatment does not properly conduct herself, continually ex- 
posing others to infection, the social worker may be instrumental in hav- 
ing her sent to an industrial school or to a correctional institution where 
she will have the proper training for a new start in life. Perhaps, a 
woman in the clinic needs to plan for an operation because of her con- 
dition. The social worker can advise the mother as to a safe boarding 
place for her young children and arrange for temporary aid during the 
period of convalescence. Inasmuch as the clinic social worker is in close 
touch with all community agencies, there are few problems which cannot 
be solved. 

Other Functions 

There still remains the obligation of the social worker to dispense in- 
formation obtained from patients to the proper agencies. She should in- 
form the community agencies, including the police departments, the 
licensing boards, the agencies for preventing delinquency, and the public 
health departments of conditions existing in the city or state. For ex- 
ample, if ten young men from the same town receive treatment withia 
a few days, the social worker should be sufficiently interested to find out 
where these ten young men were infected; and, secondly, if it is learned 
that a certain house of prostitution was visited, this information with 
full details should be given to the police officials, so that the place may 
be closed. Or again, if the social worker learns that a certain hotel in 
the city admits girls under age for immoral purposes, that information 
should be given to the board which licenses such hotels. Information of 
this type has been sufficient to cause the revocation of licenses of several 
so-called stag hotels. Or, if the social worker learns of dance halls which 
are questionable, of houses where men are going in and out constantly 
and which are questionable, she should refer this information to the police 
officials for investigation. 

Thus the social worker in the gonorrhea clinic may be of service to the 
patient under treatment, to the community and to the state. 



62 

A STUDY OF SYPHILIS AND GONORRHEA IN HOLYOKE, 

MASSACHUSETTS 

Preliminary Report 

By Helen I. D. McGillicuddy, M.D., 

Executive Secretary, Massachusetts Society for Social Hygiene 

and 

N. A. Nelson, M.D., 

Epidemiologist — In Charge of Venereal Disease Control, Massachusetts 

Department of Public Health 

A social hygiene survey including a study of the prevalence of syphilis 
and gonorrhea was made recently in Holyoke, by the Massachusetts So- 
ciety for Social Hygiene and the Massachusetts Department of Public 
Health. 

Holyoke is a mill city of about 61,000 population. There are about 
39,000 native whites and 21,000 foreign born, coming especially from 
Canada (French), Ireland, Poland, Russia, England and Germany. The 
people on the whole are industrious and of the family type. 

Much thought has been given in the schools to the development of the 
creative through music, art and good literature. The playground move- 
ment is well-developed. There are 278 acres devoted to parks and play- 
grounds, there being 11 baseball fields, 14 parks, 14 playgrounds and 4 
swimming pools. These are well supervised, during the summer season 
having well-planned programs for play. They are open until 8.30 P. M. 
In 1927, 97,000 children used the playgrounds and 123,000 the swimming 
pools. 

Much is done for the young people through the Junior Achievement 
Foundation, The Skinner Coffee House and the various agencies inter- 
ested in preventive and protective work. 

With this in mind, a study was made of the prevalence of syphilis and 
gonorrhea. Every physician, the hospital and the venereal disease clinic 
were requested to report all cases of syphilis and gonorrhea under treat- 
ment or observation on June 13, 1928. 

In all, 75 physicians and 2 osteopaths were reached by the question- 
naire. Seventy-two replied; 3 were out of town on vacations and 2 re- 
fused to report. Only 27 of the 72 who reported, treated one or both of 
the diseases. Seventeen physicians stated that they treated syphilis and 
23 reported that they treated gonorrhea. 

Syphilis Treated by Physicians, Clinic and Hospital 





No. 


Treating 
Syphilis 


Per cent 
Treating 
Syphilis 


Cases 
Treated 


Per cent of 
Total 
Cases 


Physicians 

Clinic 

Hospital 


72 
1 
1 


17 
1 

1 


23.6 
100.0 
100.0 


61 

77 
1 


43.9 

55.4 
0.7 



Total 74 19 25.7 139 100.0 

Thirty-eight, or 27.3% were non-residents. 



63 

Syphilis by Sex and Stage 





Early* 


Per cent 
Early 


Late* 


Per cent 
Late 


Total 

Sex 


Per cent 

of Grand 

Total 


Male 
Female 


19 
11 


24.7 
17.7 


58 
51 


75.3 
82.3 


77 
62 


55.4 
44.6 


Total 


30 


21.6 


109 


78.4 


139 


100.0 



* Early, duration one year or less ; late, duration more than one year. 

Gonorrhea Treated by Physicians, Clinic and Hospital 



Physicians 

Clinic 

Hospital 



Number 
72 
1 
1 



Treating 
Gonorrhea 
23 

1 





Per cent 

Treating 

Gonorrhea 

31.9 

100.0 

0.0 



Cases 

Treated 

117 

16 





Per cent 

of Total 

Cases 

88.0 

12.0 

0.0 



Total 74 24 32.4 13^ 

Eighteen, or 13.5% were non-residents. 

Gonorrhea by Sex and Stage 



100.0 













Per cent 




Per cent 




Per cent 


Total 


of Grand 


Acute* 


Acute 


Chronics* 


Chronic 


Sex 


Total 


Male 47 


49.5 


48 


50.5 


95 


71.4 


Female 19 


50.0 


19 


50.0 


38 


28.6 


Total 66 


49.6 


67 


50.4 


133 


100.0 



* Acute, duration six months or less ; chronic, duration more than six months. 

Prevalence per 100,000 Population 







Syphilis 


Gonorrhea 






Rate per 


Rate per 




Population 


100,000 


100,000 


Males 


29,320 


262.6 


324.1 


Females 


31,780 


195.2 


119.6 



Total 



61,100 



227.4 



217.6 



It must be borne in mind that the more rapid turnover of cases of 
gonorrhea will make the relation between the number of cases of gon- 
orrhea and syphilis during a year far different. It would seem from the 
above that they are about equal numerically. Actually, the calculated in- 
cidence based on the rate of turnover, is 200 per 100,000 population for 
syphilis and 422 per 100,000 for gonorrhea. 

In general, the same tendencies are shown as have been noted in the 
many other communities where similar studies have been made. Both 
gonorrhea and syphilis are more prevalent in the male; late syphilis is 
more prevalent than early, and acute and chronic gonorrhea are about 
equally prevalent. A much higher percentage of gonorrhea cases is 
treated in private practice than is the case with syphilis. 

A study of drug stores was made regarding the sale of nostrums and 
proprietary remedies for self -treatment and counter-prescribing for ve- 
nereal disease. Thirty-four were visited and the pharmacists, or in their 



64 

absence, the clerks, were interviewed. None acknowledged counter pre- 
scribing. Practically all stated that they did not carry patent medicines 
for self -treatment of venereal disease. 

In view of this fact, 100 young men between the ages of 18 and 30 years 
were interviewed in pool-rooms, "speak-easies", parks and streets, in 
various sections of the city. Conversations led up to the question of 
what they would do if infected, or what they would suggest to one who 
became infected. In the case of syphilis all suggested a physician or a 
clinic. In the case of gonorrhea 8 suggested a clinic, 51 a physician, 17 
a drug store, 7 self -treatment (Argyrol or Potassium Permanganate) and 
17 did not or could not state what they would do. 



65 

Editorial Comment 

Criterion of Cure of Gonorrhea, in the Female. — It is easy in these days 

of laboratory diagnosis 
to shift responsibility onto the slip of paper which carries the laboratory 
report. There seems to be a tendency to establish a criterion of cure of 
gonorrhea in the female, on the basis of negative smears varying from 
one to three in number. We have even been asked to revoke a report of 
gonorrhea in a female because only the first smear was positive of several 
taken while the patient was under treatment. It was assumed that a 
laboratory error had been made because no more positive smears could be 
obtained. Special attention, therefore, is called to the observations of 
Dr. A. K. Paine on "Gonorrhea in the Female" in this issue of The Com- 
monhealth. N. N. 

The Social Worker and the Venereal Disease Clinic. — The two papers on 

this subject in this 
issue of The Commonhealth reflect the attitude of the State Department 
of Public Health upon the importance of Social Service in the venereal 
disease clinic. 

Dr. John H. Stokes, Professor of Dermatology and Syphilology, Uni- 
versity of Pennsylvania School of Medicine, said recently, "Our greatest 
weakness, however, is . . . inadequate follow-up of the sick person. 
. . . Now 20 to 40 per cent is the best proportion of patients kept under 
observation of the vast numbers that annually pass through our clinics. 
The perfection of follow-up becomes therefore one of the critical prob- 
lems of the syphilis clinic; and social service . . . plus the strong arm 
of the local public health officials, become two of the most important of 
research implements in this field of modern medicine." 

The State Department of Public Health is so convinced of the impor- 
tance of social service as a function of the venereal disease clinic that it 
will look with disfavor upon the establishment of any new clinic which 
does not provide for it, and with distrust upon any existing clinic which 
continues to ignore social service. N. N. 

"The Strong Arm of the Local Public Health Officials". — This phrase from 

the quotation of 
Dr. Stokes in the editorial above made us wince when we read it. Begin- 
ning in 1925, syphilis and gonorrhea were made reportable to the local 
boards of health in Massachusetts rather than to the State Department 
of Public Health as formerly. Almost immediately both syphilis and gon- 
orrhea began to "disappear" from several communities. Twenty cities of 
from fifteen to sixty thousand population have shown remarkable reduc- 
tions in syphilis and thirty-one cities of from ten to sixty thousand popu- 
lation have begun to "wipe out" gonorrhea. We are tempted to publish 
our findings under the catchy title "A New Method for the Eradication 
of Syphilis and Gonorrhea". 

The lack of interest on the part of public health officials in a disease 
such as syphilis which ranked third as a cause of death in Massachusetts 
in 1927, and which causes more than 8 per cent of the insanity in our 
State institutions, is deplorable. And Stokes says that gonorrhea is 
"almost as common as measles" and is a disease which "affects 50 to 60 
per cent of males at some time in their life history, and whose complica- 
tions are responsible for a considerable part of the specialties of gynecol- 
ogy and urology." N. N. 

School Hygiene in the Summer School. — Another successful session of the 

annual Summer School at Hyan- 
nis has just been completed. As has been the case for several years past, 



66 

courses have been offered for school nurses and for teachers. This year, 
for the first time, a course was given for dental hygienists. 

Our conviction is strengthened, year by year, that in the summer school 
there is an unrivalled agency for slowly but surely raising the standard 
of school hygiene. State-wide compulsory school nursing service such as 
we have in Massachusetts is not an unmixed blessing unless there exist 
methods for keeping up professional standards. With the rapidly in- 
creasing interest in dental hygiene, the same holds true in the case of 
the dental hygienist, though the services of the latter are not obligatory 
on the towns. 

One other conviction is equally emergent. Success in promoting school 
hygiene is dependent upon whole-hearted co-operation between health and 
school authorities, whether state or local. In this respect the Massachu- 
setts Department of Public Health has been most fortunate since in every 
aspect of its school hygiene activities, whether at the summer school or 
in the field, it has met with complete co-operation from the Department 
of Education. 



67 

ACTIVE IMMUNIZATION AGAINST DIPHTHERIA 
Present-Day Methods and Recommendations 

By Clarence L. Scamman, M.D., and Benjamin White, Ph.D. 

The experience gained during the past ten years of diphtheria preven- 
tion work has yielded much additional knowledge concerning the preva- 
lence of the disease, the cause of its continuance, the proportion of sus- 
ceptibles in various communities and the results that may be expected by 
the practice of active immunization with diphtheria toxin-antitoxin mix- 
tures. This knowledge, in turn, has led to improvements and refinements 
in the materials for the Schick test, in the toxin-antitoxin mixtures and 
in their use. 

It now seems desirable to make certain modifications in previous recom- 
mendations, and in order that physicians may have the most recent in- 
formation concerning the Schick test and active immunization with toxin- 
antitoxin mixtures this article has been prepared. Schick tests performed 
on children of all ages throughout the State show that the great majority 
give a positive reaction and, therefore, are susceptible to diphtheria. 
Among the school children of Boston has been found the lowest proportion 
of susceptibles, approximately one-half of all those tested giving a posi- 
tive Schick test. This proportion rises as we test children in other cities, 
while in towns and some country districts only a small minority of the 
children are found to be naturally immune to diphtheria. Therefore, it 
is a safe assertion that throughout the State many more children are 
susceptible to diphtheria than are immune. This fact makes it seem 
preferable, as a rule, to do a preliminary Schick test on all children under 
six months or over ten years of age and to give all other children three 
injections of toxin-antitoxin mixture without a preliminary Schick test. 
In this way the number of injections is reduced by one, possible inaccu- 
racies in the test are eliminated, and only a comparatively small number 
of immune children will receive the immunizing treatment, and in their 
cases it will tend to strengthen and prolong their immunity. 

The present recommendations are as follows: 

I. The Schick Test 

Whether the Schick test is given preliminary or subsequent to toxin- 
antitoxin immunization there are certain precautions to be taken, and an 
exact technic must be followed if the results are to be accurate and re- 
liable. 

1. The Schick Outfit: 

Outfits for the Schick test can be obtained free from local Boards of 
Health or their distributing agencies or from the State Department of 
Public Health, Room 527, State House, Boston. They should be obtained 
just prior to use and kept continuously in an ice cold place. In the pack- 
age (Schick outfit) is one vial in which is one capillary tube, containing 
a definite amount (2M.L.D.) of aged diphtheria toxin; one bottle marked 
"10 c.c Sterile Salt Solution for Toxin Dilution", and one bottle marked 
"10 c.c Heated toxin dilution, Control". 

2. To make dilution: 

Wipe off with alcohol the capillary tube of toxin, and with sterile gauze 
or forceps break off the end of the tube at the score mark at the fused 
portion of the tube; then break the other end of the tube at the score 
mark in a similar manner, being careful not to lose any part of the con- 
tents, and insert this end into the smaller end of a rubber bulb. With one 
finger over the hole in the bulb, expel the entire contents of this capillary 
tube into the bottle of salt solution marked "Toxin Dilution". Shake 
thoroughly for at least 60 seconds. Make up the dilution just before 



68 

using, and do not keep it longer than four hours — it loses potency. The 
heated toxin dilution for the control test is supplied ready for use. Keep 
a record of the lot number. 

3. The Test: 

The skin of the flexor surface of both arms is cleansed with alcohol, 
acetone or ether. On the left arm exactly one-tenth of a cubic centimeter 
of the "Heated Toxin Dilution" is injected into the epidermal layers of 
the skin. This is best accomplished by means of a short, sharp-pointed 
26 or 27 gauge (% inch) needle. Either the 1 c.c "Vim Schick Syringe", 
the "Luer" or "Record", or other tuberculin syringe graduated in one- 
tenths is well adapted for this purpose. On the right arm exactly one- 
tenth of a cubic centimeter of the "Toxin Dilution" is similarly injected 
intracutaneously. Measure exactly the one-tenth cubic centimeter in- 
jected in both cases. Do not guess at the amount from the size of the 
bleb or wheal producted by the injection. If the point of the needle has 
been properly inserted, with the lumen uppermost and visible through 
the skin, the injection should produce a small, slightly raised white area 
or wheal, which should move with the skin and disappear in about one- 
half hour. The test will fail if the injection is made under the skin. The 
injection causes little or no pain; it is not followed by constitutional symp- 
toms; and the site of injection requires no subsequent care. 

4. The Negative Reaction: 

The results of the test should be observed on the fourth day — oftener 
if possible. 

Following the injection no signs are present on either arm except the 
slight and fleeting mark incident to the insertion of the needle. If the 
test has been properly done, with the proper toxin dilution, the absence 
of reaction indicates immunity to diphtheria. 

5. The Positive Reaction: 

A positive reaction begins to appear on the right arm ("Toxin Dilu- 
tion" injection) in 24 to 36 hours and is characterized by a circumscribed 
area of redness and slight infiltration, which measures 1 to 2 centimeters 
in diameter. It develops gradually, reaches its greatest intensity on or 
about the fourth day, then fades very slowly, leaving a scaly, brownish 
pigmented spot, which eventually disappears. There is no reaction at 
the site of the injection of the "Heated Toxin Dilution". The positive 
result of the test signifies that the individual possesses little or no anti- 
toxin in the blood, and therefore may contract the disease. 

6. The Pseudoreaction: 

In some individuals, particularly in adults, a reaction develops which 
may be confused with a positive reaction. Owing to a hypersensitiveness 
of some persons to the protein of the diphtheria bacillus present in the 
toxin, a local reaction may appear at the point of injection. This reaction 
is differentiated from the true positive reaction by means of the injection 
of the heated toxin dilution. If a reaction develops at the same time at 
the sites of both injections, runs a similar course, reaching a maximum 
of intensity on the third day and then fading, the reaction is classed as 
a pseudoreaction — the individual is hypersensitive to the protein of the 
diphtheria bacillus but is immune to diphtheria. 

7. The Combined Reaction: 

If a combined reaction is present, the redness and infiltration at the 
site of the "Toxin Dilution" injection will be more marked at the end of 
twenty-four hours than at the site of the "Heated Toxin Dilution" injec- 
tion. At seventy-two hours the positive reaction will be quite distinct, 
while the control test will show only a blotchy area of pigmentation rep- 
resenting the pseudoreaction elements of the test. If the test is positive, 



69 

the reaction at the end of 96 hours will be much more marked at the site 
of the unheated toxin injection. The negative and the pseudoreactions 
indicate immunity, the positive and the combined reactions, susceptibility 
to diphtheria. A short experience in reading the reactions will suffice to 
enable one to make a correct interpretation of the results. 

If there is any doubt concerning the nature of the reaction, call it posi- 
tive. 

II. Toxin- Antitoxin Mixture 

1. The Material: 

The preparation now supplied by the State Department of Public Health 
is one-tenth L plus mixture. It is supplied in boxes containing three 
1 c.c ampoules and in 20 c.c vials. This preparation can be obtained free 
from local Boards of Health or their distributors or from the State De- 
partment of Public Health, Room 527, State House, Boston. Keep the 
package cold and return if not used before the expiration date stamped 
on the label. Keep a record of the lot number on the labels. 

2. Dosage: 

Three injections of 1 c.c each at 7 day intervals. Measure the dose in 
a 1 or 2 c.c syringe, and never use a syringe of more than 5 c.c capacity. 
Do not inject more than 1 c.c. 

The injections should be given subcutaneously, preferably over the in- 
sertion of the deltoid muscle. Paint the skin at the site of injection with 
tincture of iodine immediately before the injection, and observe rigid 
aseptic precautions throughout. 

3. Appearance of Immunity: 

The immunity produced in response to this method develops slowly and 
it may require a period of 2 to 6 months for a sufficient amount of anti- 
toxin to develop to inhibit the Schick test. Six months after the last in- 
jection all persons should be retested with the Schick test, because a small 
percentage fail to become immune. Such persons (those who still show 
a positive Schick reaction) should be given another course of 3 injections 
of diphtheria toxin-antitoxin and again retested 6 months after the last 
injection. 

If the Schick test is properly done, with a proper toxin dilution, a nega- 
tive reaction shows that sufficient antitoxin is present in the body to 
render that person immune to diphtheria. 

4. Duration of Immunity: 

The immunity produced by the proper injection of toxin-antitoxin mix- 
ture, as a rule, lasts for more than 7 years. At the end of this time, it 
is advisable to determine the possible return of susceptibility by means 
of the Schick test. 

The recent administration of diphtheria antitoxin to an individual in- 
terferes with and retards the development of active immunity following 
the injection of toxin-antitoxin mixture. In such cases wait six weeks 
before giving toxin-antitoxin mixture. 

III. Recommendations 

1. Children under six months of age should have a Schick test per- 
formed and if negative, they should be retested between six months and 
one year of age. If they give a positive reaction, they should be im- 
munized with diphtheria toxin-antitoxin mixture. 

2. All children between the ages of six months and ten years should 
be immunized with three injections of diphtheria toxin-antitoxin mixture, 
one week apart, without having a preliminary Schick test. The majority 
of children of this group are susceptible and therefore the Schick test 
is not necessary. 



70 

3. All children between ten years and eighteen years of age should 
have the Schick test and if it is positive they should receive three injec- 
tions of diphtheria toxin-antitoxin mixture, unless they show a com- 
bined reaction, when the toxin-antitoxin mixture may be given in di- 
vided doses beginning with 0.1 c.c, then 0.2, 0.5 and l.c.c. at weekly 
intervals. 

4. All individuals above eighteen years of age who are exposed to 
diphtheria or may come in contact with it should have the Schick test 
performed and be immunized with diphtheria toxin-antitoxin mixture 
with the same provision, however, as stated in the previous paragraph. 

5. All persons receiving three doses of diphtheria toxin-antitoxin 
mixture should be retested with the Schick test six months after the 
last injection, and if they should still give a positive reaction, they 
should receive three more injections of diphtheria toxin-antitoxin mix- 
ture and be again retested six months after the last injection. 

The percentage of children immunized by one series of three injec- 
tions of toxin-antitoxin mixture will vary with the age and social 
groups, and will also depend upon the previous prevalence of diphtheria 
in the community in which the child lives. As a rule a large proportion 
will be immunized. 

Any alleged reactions following the use of the Schick test or toxin- 
antitoxin and any alleged cases of diphtheria occurring in individuals 
originally Schick negative or negative after toxin-antitoxin treatment 
should be immediately and thoroughly investigated and every such case 
reported to the State Department of Public Health. 

In order to avoid any undesirable reactions, to secure the most re- 
liable results and to immunize the highest percentage of immune per- 
sons after toxin-antitoxin treatment, follow precisely all the directions 
given above and contained in the directions furnished with every pack- 
age of these products. 

REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of April, May, and June, 1928, samples were col- 
lected in 190 cities and towns. 

There were 2,507 samples of milk examined, of which 654 were below 
standard; from 68 samples the cream had been in part removed; 58 
samples contained added water; and 1 sample which had the cream re- 
moved also contained added water. 

There were 169 samples of food examined, of which 46 were adulter- 
ated. These consisted of 3 samples sold as butter which proved to be 
oleomargarine, and 4 samples of buttered pop corn which contained 
oleomargarine; 17 samples of clams which contained added water; 10 
samples of maple syrup which contained cane sugar; 2 samples of 
sausage, 1 of which contained a compound of sulphur dioxide not prop- 
erly labeled, and the other sample contained coloring matter; 6 samples 
of olive oil, 5 of which contained cottonseed oil, and 1 sample was 
rancid; 2 samples of cream which were below the legal standard in 
fat; 1 sample of eggs which was sold as fresh eggs but was not fresh; 
and 1 sample of maple sugar adulterated with cane sugar other than 
maple. 

During the month of June, there were 19 bacteriological examina- 
tions made of clams in the shell, of which 5 were sewage polluted, and 
14 unpolluted; and 26 bacteriological examinations were made of 
shucked clams, of which 5 were polluted, and 21 unpolluted ; making an 
average of 22.2% of polluted clams. 

There were 23 samples of drugs examined, of which 4 were adulter- 
ated. These consisted of 1 sample of camphorated oil, 1 sample of 
spirit of nitrous ether, and 2 samples of spirit of peppermint, all of 
which were deficient in the active ingredient. 

The police departments submitted 1,951 samples of liquor for exami- 



71 

nation, 1,928 of which were above 0.5% in alcohol. The police depart- 
ments also submitted 14 samples of narcotics, etc. for examination, 7 of 
which were morphine, 1 ethyl benzoate, 1 opium, 1 heroin, and 4 
samples which were examined for poison with negative results. 

There were 43 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 157 inspections of plants, operated for the pasteurization 
of milk. 

There were 61 convictions for violations of the law, $1,287 in fines 
being imposed. 

Morris Charney and Louis Janopoulos of Chelsea; Jerome C. Har- 
rington of Belmont; George McAvoy of Cambridge; Ferdinando 
Rechichi and Antonio Pappas of Watertown ; Charles Conairis, John C. 
Sweeney, and Frank Tieuli, all of Milford; Charles Gorgos, and Day & 
Night Lunch, Incorporated, of Springfield; Frank R. Mederos, Peter 
Ratsy, and James Reid, Jr., all of Taunton; John Mendoza of Assonet; 
Levi H. Thompson of Greenfield; John Tritor and Charles Athanasios 
of Middleboro; Frank Frangoulis of Natick; Oliver Ormandrioli of 
Concord Junction; Louis George and Thurphile Tremblay of Stur- 
bridge; Maynard S. Harriman of West Acton; William McGlone, Peter 
Vrattos, and Isaac Proulx of Walpole; Joseph McManus of Wrentham; 
Eugene L. Peabody of Foxboro; Ugo Arrighi of Adams; Edmund Belle- 
rose, 2 cases, of Southbridge; Chris Contsibos and J. J. Costello of 
Franklin; John Meszcenski of West Oxford; and George A. Plakias of 
Medford, were all convicted for violations of the milk laws. Frank R. 
Mederos of Taunton ; Levi, H. Thompson of Greenfield ; Louis George of 
Sturbridge; and Joseph McManus of Wrentham, all appealed their 
cases. 

Edgar Lessard of Hampton, New Hampshire; Antonio Drinkwater 
of Chelsea; John Mannolidis and Paul C. Sykes of Cambridge; Thomas 
Deconies and United Importers, Incorporated, of Providence, Rhode 
Island; and Louis Janopoulos of Dedham, were all convicted for viola- 
tions of the food laws. Antonio Drinkwater of Chelsea, and United 
Importers, Incorporated of Providence, R. L, appealed their cases. 

Peter Doomsalis and John Pride of Framingham; Peter Manjoratos 
of Natick; and Nicholas Kanelos of Adams, were all convicted for 
false advertising. 

Henry Arnold of Agawam; Alphonse Barrafaldi and Edward O'Neil 
of West Springfield; Leo Gubola of North Wilbraham; Hazen K. Rich- 
ardson of Middleton; and Thomas F. Walpole of Haydenville, were all 
convicted for violations of the milk pasteurization laws. 

James Maspo and Louis Brown of Springfield; Louis Gould, 2 cases, 
of Clinton; Salim Davis of Agawam; and Walter Cole, 2 cases, and 
Marshall E. Chaplin, of Berlin, were all convicted for violations of the 
slaughtering laws. 

William Goldberg of Dorchester was convicted for violation of the 
mattress law. 

In accordance with Section 25, Chapter III of the General Laws, the 
following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers : 

Milk which contained added water was produced as follows: 13 sam- 
ples, by Simon Dastuge of Sudbury; 7 samples, by Klemens Kulesga of 
South Hadley Centre; 2 samples, by Eugene L. Peabody of Foxboro; and 
1 sample, by John Lewis of Westport. 

Cream which was below the legal standard in fat was obtained as 
follows : 

1 sample each, from Meaders Lunch and George Wuth, both of Clinton. 

Two samples of buttered pop corn which contained oleomargarine were 
obtained from Nicholas Kanelos of Adams. 

One sample of maple sugar adulterated with cane sugar other than 
maple was obtained from Nicholas Kanelos of Adams. 



72 

Maple Syrup which contained cane sugar was obtained as follows: 

1 sample each, from Cafe Boulevard of Allston; Puritan Lunch and 
Apostolu Brothers, both of Nantasket. 

Olive Oil which contained cottonseed oil was obtained as follows: 

1 sample each, from V. Pereoca of Cambridge; and American Italian 
Grocers of Holyoke. 

One sample of sausage which contained a compound of sulphur dioxide 
not properly labeled was obtained from Frank Bartz of Framingham. 

One sample of sausage which was colored was obtained from Roberts 
& Withington, Incorporated, of Providence, It. I. 

There were twelve confiscations, consisting of 285 pounds of tubercu- 
lous beef, 75 pounds of abscessed beef, 52 pounds of tainted beef, 17 
pounds of tainted chickens, 75 pounds of decomposed chickens ; 60 pounds 
of pork livers, 14% pounds of decomposed pigs' livers, 1 pound of de- 
composed pig's lights, 15 pounds of decomposed veal, 125 pounds of tainted 
miscellaneous meats, and 60 gallons of decomposed oysters. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of March, 1928: — 725,010 
dozens of case eggs; 437,277 pounds of broken out eggs; 602,275 pounds 
of butter; 1,060,748 pounds of poultry; 5,131,998 pounds of fresh meat 
and fresh meat products; and 1,184,050 pounds of fresh food fish. 

There was on hand April 1, 1928: — 667,740 dozens of case eggs; 
765,030% pounds of broken out eggs; 650,333 pounds of butter; 7,325,- 
801% pounds of poultry; 18,751,737% pounds of fresh meat and fresh 
meat products; and 2,840,331 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of April, 1928: — 3,700,140 
dozens of case eggs ; 430,850 pounds of broken out eggs ; 186,705% pounds 
of butter; 728,556 pounds of poultry; 3,025,984 pounds of fresh meat and 
fresh meat products ; and 2,083,826 pounds of fresh food fish. 

There was on hand May 1, 1928: — 4,203,210 dozens of case eggs; 
878,050 pounds of broken out eggs; 385,917% pounds of butter; 5,477,638 
pounds of poultry; 16,442,452% pounds of fresh meat and fresh meat 
products; and 3,795,108 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of May, 1928: — 4,059,420 
dozens of case eggs; 580,706 pounds of broken out eggs; 774,563 pounds 
of butter; 900,835% pounds of poultry; 3,480,208 pounds of fresh meat 
and fresh meat products ; and 7,667,074 pounds of fresh food fish. 

There was on hand June 1, 1928 : — 7,928,940 dozens of case eggs ; 
1,087,742 pounds of broken out eggs; 792,503 pounds of butter; 4,487,055 
pounds of poultry ; 15,472,536 pounds of fresh meat and fresh meat prod- 
ucts; and 10,421,688 pounds of fresh food fish. 



73 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration 
Division of Sanitary Engineering 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Division of Communicable Diseases Director, 

Clarence L. Scamman, M.D. 



Division of Water and Sewage Lab- 
oratories . 
Division of Biologic Laboratories . 

Division of Food and Drugs . 

Division of Hygiene 

Division of Tuberculosis 



Director and Chemist, H. W. Clark. 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 

The Southeastern District 



The Metropolitan District 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District . 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., Lowell. 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



Publication of this Document approved by the Commission on Administration and Finance 
5M. 9-'28. Order 3337. 



— 



THE 
COMMONHEALTH 



°7f> 



Volume 15 
No. 4 




OCT.-NOV.-DEC. 
1928 



NUTRITION 



MASSACHUSETTS i 
DEPARTMENT OF PUBLIC HEALTH 



<k 



THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of 
Public Health 

Sent Free to any Citizen of the State 

Merrill E. Champion, M.D., Director of Division of Hygiene, Editor. 
Room 546, State House, Boston, Mass. 



CONTENTS 



PAGE 

The Plan of Nutrition in the School Program, by Lydia J. Roberts . 77 

The Nurse and the Nutritionist, by Clyde B. Schuman ... 79 
The Mental Side of Nutrition, by Henry B. Elkind, M.D. . . .82 

The Home Demonstration Agent as a Nutritionist, by May E. Foley 84 

A Food Lesson for Children as it is Given in the Boston Dispensary, 

by Mary Pfaffmann ....... 86 

Nutrition Work of the Ten Year Program, by Esther V. Erickson . 88 

The Health Program of the Dental Clinic, by Ruth L. White, S. B. 90 
The Program in Nutrition at the Summer Session, Fitchburg, 1928, 
for Vocational and Continuation Teachers, by Martha 

Wonson ......... 92 

Nutrition Work in Adult Classes, by Gertrude C. Lowe ... 95 

Nutrition Work with Vocational Students of High School Age, by 

Kathleen Hogan ........ 96 

Nutrition Through the Senior High School Lunch, by Agnes M. 

Bridges . . .- 98 

Progress of the Franklin County Demonstration, by Susan M. Coffin, 

M.D. 100 

Editorial Comment: 

Meet the Nutritionist ........ 102 

School Hygiene Conferences ..... . 102 

A Correction ......... 102 

Child Health Day Material ....... 102 

Some Pre-School Nutritional Facts ..... 103 

Nutrition from the Nurse's Point of View .... 103 

Mrs. Deland's Article — A Contrast ... 104 

"I Didn't Know", by Margaret Deland .105 

Report of Division of Food and Drugs, July, August, September, 1928 107 

Index ........... Ill 



77 

THE PLAN OF NUTRITION IN THE SCHOOL PROGRAM* 

By Lydia J. Roberts 

Assistant Professor of Home Economics, The University of Chicago 

During the past decade nutrition, in some form or other, has found its 
way into many of our public schools. In few, if any, however, has there 
been developed a consistent, all-round program of instruction and school 
practice such as the importance of the subject justifies. In some schools 
the nutrition program consists solely of weighing and measuring and a 
mid-morning milk lunch; in some a nutrition worker from some outside 
organization conducts nutrition classes for the most underweight chil- 
dren; in others some educational work is done throughout the school. 
Even in schools with so-called nutrition programs, however, the sins both 
of omission and commission may be so many or of such a nature as to 
negate, almost if not entirely, the school's own nutritional efforts. In 
view of the limitations of space these failings can not be enumerated here. 
Instead, this article will attempt to outline a school situation in which 
nutrition and health do occupy their normal place and receive their de- 
served emphasis. 

In an ideal situation nutrition is a part of the all-school health program 
rather than a special measure for a few underweights. If special atten- 
tion is needed for these it should be a later development to supplement 
the basic nutrition program for all children rather than the sole nutri- 
tional effort. This, combined nutrition-health program is moreover con- 
sidered of first importance and is given a fundamental place in the school 
program. To insure this ideal situation demands at least the following 
conditions : 

A Staff with Proper Attitudes and Training 

Of first importance in a successful nutrition program is the attitude 
and training of the staff; and of special concern is the attitude of the 
school principal. He in particular must believe whole-heartedly in 
"Health First" not only as a matter of theory but of actual practice. 
With this viewpoint and conviction he will choose teachers with an in- 
terest in health and some training in it, and he will make further training 
possible; he will see that emphasis on the different aspects of the school 
program is properly placed; he will make it professionally a distinction 
to excel in health work as in other lines; and he will make it adminis- 
tratively possible for the health program to be carried out. The attitude 
of the principal, in brief, will largely determine the attitude and the 
efforts of the teachers and consequently the success of their work. 

For effective nutrition work a special director of nutrition and health 
education is essential. This supervisor should occupy the same relation 
to the school system as do the supervisors of art, music, and other special- 
ties. She will outline and unify the work throughout the school system, 
supply subject matter and teaching suggestions to the teachers in the 
lower grades, and teach lessons herself in the upper grades where more 
specialized knowledge of subject matter is required. She will also check 
the various activities and practices of the school to make sure that they 
are conducive to health, not detrimental to it, as is often found to be the 
case. To do all this requires a highly specialized training in nutrition 
and the various aspects of health, and the superintendent or principal 
should see to it that only a person with such training is secured. The 
failure of many a "nutrition program" in the past has been due to the 
inadequate training of the so-called nutrition worker to whom the work 
was intrusted. 



* The author has written in greater detail on this subject in "Nutrition 
Work with Children." 



78 
Adequate Time in the School Program 

An adequate allotment of time in the school program is a second re- 
quirement for success. In the past health has usually been considered an 
extra, to be squeezed in for occasional periods or taught incidentally at 
the option of the individual teacher. This is entirely wrong. If health 
belongs in the school program at all it should have its own legitimate 
place. There should be a definite time which belongs to health instruc- 
tion, to weighing, and to other health essentials, without stealing it from 
other activities. It is true that much of health material and of practice 
can best be taught in connection with other school activities, but it is 
not safe to trust entirely to these. In the lower grades one period per 
week is adequate for special attention to health problems. This, together 
with a few minutes daily for checking up on the observance of health 
rules, is usually all that is needed — in addition to the incidental teaching 
— for successful work. In the upper grades, where nutrition-health work 
is taught as a regular course, it will require the same amount of time as 
any other subject, plus any additional time which may be required for 
weighing, checking health records, and otherwise determining the extent 
to which the work actually functions in the children's living. 

A Well Planned and Graded Nutrition-Health Program For the Entire 

School 

A complete nutrition program consists of certain activities, plus health 
education. In the former group are included the weighing and meas- 
uring, the medical examinations, and other parts of the school health 
survey; in the latter, the instruction and the various techniques for in- 
stilling the desired habits. 

It is now agreed that every child should be weighed and measured at 
the beginning of the year, and weighed at least every month thereafter. 
This can be done by the room teachers, and time for it should be allowed 
in the school program. 

If possible, every child should also receive a complete physical exami- 
nation by a physician. If this is not expedient the teachers can be trained 
to check for other signs of nutrition besides weight, and for gross physi- 
cal defects. Medical examinations can then usually be secured for the 
ones judged most in need of attention by this method, even if it is not 
possible for the entire school. Teachers, nurses, nutritionist, and all con- 
cerned should then concentrate their attention on the problem of remedy- 
ing the defects found. 

Of special importance also are the nutrition and health habit records 
of the children. These can be secured by the individual teachers under 
the direction of the nutrition supervisor, and the results used as a basis 
for the educational program. 

The object of the nutrition and health instruction is the formation of 
right habits. While the final objectives, therefore, may be practically the 
same throughout the school, the method of attaining these at the different 
levels will differ greatly. In the lowest grades a simple talk or story to 
introduce the new health rule and to create the right attitude toward it 
is the nearest we come to formal instruction. Beyond this the teacher's 
say-so that the habit is good, plus her daily checkings and incidental 
teaching, are sufficient in the hands of the right teacher to insure success. 
In the intermediate grades more specialized lessons, which teach the chil- 
dren some simple but accurate "reasons why" for the things they are 
asked to do, are essential if children are to be convinced to the point of 
changing their conduct. In the upper grades, nutrition and health should 
be taught as are other sciences, save that they must be available to every 
child. 

It is evident from the above that a well-planned, progressive outline for 
health and nutrition work must be worked out for the entire school if the 






79 

interest and respect of the children are to be maintained and the best of 
results secured. The developing of such an outline is the joint task of 
the health-nutrition supervisor and the teachers concerned. 

School's Practices Consistent with Health and Good Nutrition 

It is not enough for the school to teach the essentials of health ; it must 
also be sure that the conditions it imposes on children make the practice 
of its health teachings possible. The school, for example, teaches its 
children the importance of sleep and the proper hours' of sleep for the 
different ages; it must, then make sure thereafter that every school en- 
tertainment, party, or other activity is given at such an hour as to make 
conformity to these teachings possible. It teaches the children what con- 
stitutes a good lunch ; it should be certain that adequate, palatable lunches 
are served in its own lunchroom and that the children are actually eating 
them. It advises the children to spend long hours out-of-doors daily; it 
must then consistently see to it that children do play out-of-doors at re- 
cesses and noons and that home work — if any — is so restricted as to* 
allow for outdoor play after school, as well as an early bedtime. It teaches- 
children the desirability of attaining their optimum weight, and the part 
played by over-exercise and fatigue in hampering this ; it ought then to> 
check the effect of its own physical training, its "field days", its parties,, 
and other special events on the nutrition of the children, as judged by 
weight and other signs, and to modify them accordingly. The rule sug- 
gested by Gray could well be applied here, that unless the weight lost in 
exercise is fully regained by the same hour next day, such exercise should 
be regarded as too severe for that particular child. 

Numerous other illustrations might be given, but the above are suffi- 
cient to show the many ways in which the school's own practices must be 
carefully checked to be certain they are consistent with the requirements 
of good nutrition and good health. 

Results Judged by "Doing" 

A considerable body of knowledge will necessarily be acquired in the 
nutrition-health course; its acquisition is indeed one aim of the work. 
The ultimate test of success, however, is not merely knowledge but doing. 
No matter how glibly the children may recite the health rules and give 
the reasons therefor, the health work cannot be considered successful un- 
less it has carried over into practice. In the last analysis, then, each 
teacher's work should be judged by the number of children who drink 
•sufficient milk, who like and eat vegetables and fruits, who brush their 
teeth, and go to bed regularly at the required hour, who have all remedial 
defects cared for, and who are up to the optimum weight for their height, 
age, and body build. And the success of the whole school program will 
likewise be determined by these same factors for the entire school. 

THE NURSE AND THE NUTRITIONIST 

By Clyde B. Schuman 

Director Nutrition Science, American Red Cross, Washington, D. C. 

The subject of this paper takes the writer back about ten years ago to 
an early morning journey through a certain section of New York City to 
an old dingy room with drab walls, boxed in windows, and a floor that 
one longed to scrub. In this room a few women discussed an experiment 
in health. Annie W. Goodrich, Ph.D., then Director of Nurses, Henry 
Street Settlement, New York City, now Dean of School of Nursing, Yale 
University, with her usual vision, had sensed the need of this experiment. 
She vividly described existing home conditions and family life which 
made her feel there was the need of a new person, a nutrition worker 
(nutritionist) in the health and social service field to work with the 



80 

nurses, physicians, social workers, schools, industrial groups, and men, 
women, and children in their homes. 

In time, through the vision and hard work of Dr. Goodrich and others, 
this "talked of experiment in health" became a reality. The dingy room 
was transformed into an attractive center which housed the work. The 
center was blessed with a corps of nurses, two nutritionists and part-time 
service of physicians. This group worked together as one family, for the 
good of their larger family — the people in the section where Morris 
Avenue experiment was established. Soon the people in the community 
began to feel at home in the center, and to warmly welcome the nurses 
and nutritionists in their homes. Soon individuals and families in the 
community were calling for and welcoming, at the center and in their 
homes, the kind of help from the nutritionists that Dr. Goodrich felt they 
needed and would want. 

Four years later, October 1922, Dr. Goodrich was asked to discuss, at 
the annual convention of the American Red Cross, the Nurse and the Nu- 
tritionist. Unfortunately, she was unable to attend the meeting but she 
sent the following statement which was read at the meeting : 

"I regret that I cannot be present in person to urge the need of 
the rapid development of the nutrition program in conjunction 
with the visiting nurse organizations. 

No careful observer of the homes to which the visiting nurse 
is called could fail to realize that not only is the remedy of the 
immediate situation dependent in no small measure upon a prop- 
erly selected and prepared diet but that the larger problem of the 
family health is tied up in the question of nutrition as expressed 
in properly selected and prepared foods and the not less im- 
portant item of a wisely applied budget. The body of scientific 
knowledge concerning this problem of nutrition with all its rami- 
fications is available through the rapidly increasing number of 
highly qualified nutrition workers. No health program today, 
therefore, can be complete which does not provide that the public 
health nurse can relate the nutrition specialist to the family. 

It is true that the education of the family can be carried on to 
a certain extent in the health center or station, but further than 
that nutrition workers should be available for expert instruc- 
tions and advice in special cases of sickness or in homes where 
the situation does not permit that the mother shall come to the 
center, or where she would not profit by group instruction. 

The experiment in Morris Avenue, where the Red Cross car- 
ried our nursing service in conjunction with the nutrition work 
through nutrition workers, confirmed our opinion that the visit- 
ing nurse's work is immeasurably forwarded by the provision of 
a nutrition worker for a given unit of population. 

The number of nutrition workers needed at present is prob- 
ably less than the number of visiting nurses. I shall not say 
what the proportion should be as that is for the nutrition work- 
ers themselves to determine, but their place is so definitely estab- 
lished that it is my belief that even the foreigners who are in 
our midst will soon call and pay for such services as they now 
do for the service of the nurse." 

Organizations Employing Nutritionists 

Great progress has been made in nutrition during the past ten years. 
Today, through the vision of nurses, social workers, physicians, oral 
hygienists, school groups, and other leaders and groups, the nutritionist 
has been called, along with other community workers, to work in cities, 
towns, and rural communities. Today, among other places we find the 
nutritionists on the staff of State Departments of Health, State Exten- 



81 

sion Divisions of the Department of Agriculture, Visiting Nurse Asso- 
ciations, Welfare Organizations, "Out" and "In" Patient Departments in 
hospitals, health units, city and county Departments of Health, commer- 
cial and industrial associations, in public schools and colleges, and as 
community workers covering cities, towns, and counties. 

Today, true to the prophesy of Dr. Goodrich and other leaders, we find 
a Welfare Organization such as the Association for Improving the Con- 
dition of the Poor in New York City, employing nutritionists just as 
they do nurses, physicians, dentists, and social workers, to help with their 
fine quality of family work. 

Nutritionist with a Visiting Nurse Association 

Today, we find the nutritionist working side by side with the nurses, 
in very much the same manner as described by Dr. Goodrich in the Visit- 
ing Nurse Association in York, Pa. On Armistice Day, if you had 
been fortunate enough to have been a visitor in the historic old city of 
York, you would have enjoyed, as did others, the well ordered and beauti- 
ful parade that extended for two miles down the leading street. Quite 
prominent in this parade you would have found the Nutrition Float, 
bringing the message of Food for thought and health. You would have 
found on the side of the float the sign of the Visiting Nurse Association 
and the American Red Cross of York, for the nutrition work is being 
supported as a joint service by these two. The nutrition work in York 
was started about four years ago when a Red Cross nutritionist was 
brought in to work with the nurses, physicians, social workers, schools, 
mothers' clubs and others in improving the nutrition in York. The Visit- 
ing Nurse Association furnishes two thirds of the salary of the nutri- 
tionist, and in addition to that, all other expenses. The York County 
Chapter of the Red Cross pays one third of the salary of the nutritionist, 
and gives help through regular visits from the Director of Nutrition 
Service from the American National Red Cross. In York, the demon- 
strations for the expectant mothers who come to the center include regu- 
lar talks and demonstrations in nutrition by the nutritionist on the sub- 
ject of body building through food. Nutrition classes for pre-school 
groups and their mothers who come together once a week to the Visiting 
Nurse Association, are held by the nutritionist. Nurses, social workers, 
home service workers from the Red Cross and physicians refer cases to 
the center. In addition to the work at the Visiting Nurse Association, 
the nutritionist is giving the Red Cross Food and Nutrition Course to 
groups of mothers in the city. 

The dietitian at the city hospital, with the help of the nutritionist, is 
giving the Red Cross Food and Nutrition Course to the student nurses. 
The work in York has been so planned that concentrated work in nutri- 
tion is being carried on in two school districts through pre-school classes, 
mothers' classes, talks to groups of parents, conferences at the schools, 
and visits by the nutritionist to the homes where problem cases are found. 
The value of the work and the need of farther extending the work is being 
studied by checks and evaluations that are being worked out. In York, 
as was suggested ten years ago by Dr. Goodrich, the nutritionist is giving 
help to the family and groups in properly selected and prepared food and 
a wisely applied budget. In York, the nurse and social worker daily call 
the nutritionist as a co-worker to go to the homes when help is needed. 
The families served are in homes of greater as well as lesser wealth. 

Nurse's Interest in Obtaining Nutritionist 

In other places we find the nurse showing the need of and asking for 
the nutritionist to work with the schools. In such programs the nutri- 
tionist teaches all children in the graded schools or in certain chosen 
schools if she cannot handle all because of the great number. She also 



82 
teaches groups of mothers and teachers. She visits the homes where 
there are problem nutrition cases and holds conferences with parents and 
others at the schools or some other chosen center. In many communities, 
the local Chapter of the Red Cross, through the annual Roll Call, pays 
all, or a part of the salary and other expenses of Red Cross nutritionists 
to carry on school and pre-school work, or other phases of the work. The 
nutritionist and the nurse are making a fine team, and finding the day 
more than full meeting the calls of the physicians, schools and families. 
The call for Red Cross nutritionists to work in communities has increased 
rapidly during the last three, four and five years. This increase has, no 
doubt, been largely due to the genuine interest of the nurses in having 
qualified nutritionists as co-workers in their communities. Letters, visits 
and conferences with nurses show that many have worked, and many are 
now working along the following lines to bring their communities to see 
the need of and to want qualified nutritionists: 

1. Stimulating schools to want nutrition taught by a qualified nutri- 
tionist, who is trained to teach it to teachers, children and parents, as 
graded subject matter with the same standards that other subjects are 
taught. 

2. Stimulating parents and others to see that they need daily reliable 
working information on nutrition and budgets, and to want community 
nutritionists who have the knowledge and time to give them the help they 
need through home visits, group instruction, conferences, etc. 

3. Concentrating through her general health work, which undoubtedly 
contributes markedly to nutrition, on showing the need of nutrition in 
her community, and the advantages and desirability of having nutrition- 
ists well trained in food and nutrition, as co-workers in her community. 

4. Creating interest in having nutritionists to help with prenatal, pre- 
school, and abnormal nutrition and encouraging physicians, social work- 
ers, schools and families to seek such help. The nurses have not only 
helped to stimulate the need of the services of nutritionists, but they 
have also worked with nutritionists, physicians and others in their com- 
munities in helping to study ways and means to evaluate the nutrition 
work. In the opinion of the writer, intelligent thought should be given 
to this. 

Although nutritionists are found in many more communities today than 
ten years ago, there is still great need of calling them into being in 
greater number, and in many places where they are not yet known. With 
statistics showing that more than three million people in the United 
States are ill daily, and unable to do their life's work, and with the grow- 
ing recognition of the relation of nutrition to health and economic well 
being, the physicians, nurses and nutritionists, feel it is urgent that the 
next ten years keep pace and step ahead of the progress made in nutri- 
tion during the past ten years, as gratifying as that is. Such progress 
can be brought about in part by recognition of the forcef ulness and truth 
of the following statement by Dr. E. V. McCollum of Johns Hopkins Uni- 
versity: "The right kind of diet is the most important single factor in 
promoting public health; it is the material with which to build the foun- 
dations of success." 

THE MENTAL SIDE OF NUTRITION 

By Henry B. Elkind, M.D. 

Medical Director, Massachusetts Society for Mental Hygiene 

When interest in nutrition became more or less universal, quality and 
quantity of food were emphasized. Diets were ordered on the basis of 
kind and amount of food, and programs of hygiene were arranged in the 
individual case according to the physical condition of the child. But gen- 
erally these programs went no further than to regularize the hours of 
feeding and the establishment of rest periods. 



83 

Excellent results have come from this movement; the general level of 
the health of our children has been everywhere raised. On the other 
hand, one need not question the value of nutrition work to point out that 
the pre-school years have presented the greatest difficulties, and that even 
at the present time work with children of these years still remains at an 
unsatisfactory level. Apparently the supervision of the school room is 
essential to success, although now and then refractory cases are met with 
among children of school age. 

As soon as the importance of nutrition in the pre-school years was 
realized, the significance of mental factors came to be more generally 
recognized. It became evident that even when the quality and quantity 
of food were regulated, malnutrition was not necessarily relieved nor was 
good nutrition gained. It became quite clear that what was perhaps 
more essential than the kind and amount of food was the manner of tak- 
ing it. 

Later the relation of improper habits growing out of the feeding of 
children to unfortunate attitudes and habits of later life came also to be 
noted. The importance of the mental side of nutrition, therefore, looms 
large. 

Pediatricians tell us that food fussing is perhaps the most common dis- 
order of childhood, especially in the pre-school and early school years. 
Frequently associated with this disorder is the condition of temper tan- 
trums. New, temporary, and short-lived spells of both food fussing and 
temper tantrums are probably of no lasting consequence, but, if neglected, 
lead to difficulties not only of malnutrition, but of behavior often serious 
and permanent in nature. 

Food fussing needs no description. Almost everyone, surely most par- 
ents, are acquainted with this condition. The severe cases drive most 
parents to distraction and the wise doctor, nutritionist or nurse wins 
everlasting gratitude when through understanding and proper handling 
of the situation they develop better attitudes on the part of the children. 
But cure is much more difficult than prevention; and the latter is always 
to be preferred. On the other hand, even with the best of intentions on 
the part of parents, many children get beyond their control and attempts 
at cure must be made. 

Probable Causes of Fussiness 

The following explanation of why children fuss over their food will, I 
hope, suggest the remedy, or better, the measures of prevention. Chil- 
dren are fussy when physically ill or when coming down with fever or 
some acute illness. Therefore, think of the possibility of physical illness 
before suspecting non-physical causes of the food fussing. When physical 
illness does not exist, the food fussing is an attempt on the part of the 
child to be a nuisance to his parents or others in order to 

1. Avoid what is unpleasant to him; or 

2. Gain something desired, but denied; or 

3. Gain attention, to obtain sympathy, or to be the center of 
attraction. 

Again, a child will not fuss over his food without an audience. Here, 
you have the secret: parents allow^ themselves to be played upon by the 
child to satisfy his own ends. 

Preventive Measures 

The remedy (or preferably a program of prevention) presents itself: 
Do not let a child use his mealtime except to eat. Allow him preferences 
of food that are good for him, but do not permit him any motive other 
than that to eat. Give him twenty to thirty minutes to eat. If he is not 
finished within that time, take his food away. Give him no food until his 
next regular meal. Give the child to understand you mean what you say. 
Do not be angry with him, but be calm and impersonal. Do not be afraid 



84 
the child will starve to death if he does not eat for a day or two. A glass 
of milk at bedtime may be offered. 

At the same time, make the meal hour pleasant for the child. Prepare 
tasty foods and serve them attractively. Surround the child with pleasant 
table talk, and remember that excessive emotion of any sort interferes 
with digestion. Radiate with happiness, for good cheer is contagious. 
DO NOT TALK ABOUT FOOD. 

If these suggestions fail you after an honest trial (and rare is the in- 
stance when they do), it is advisable to secure the advice of a pediatrician 
or a psychiatrist trained in child psychiatry, or to take the child to an 
out-patient clinic or habit. 

THE HOME DEMONSTRATION AGENT AS A NUTRITIONIST 

By May E. Foley 

Nutrition Specialist in Extension, Massachusetts Agricultural College 

A woman living just north of Boston was so enthused about the help 
which the home demonstration agent had given her in working out bal- 
anced meals for her family, that she sent in this comment : "I am fond of 
nearly everything, also my husband." This is one of the most amusing, 
if not enlightening, comments we have seen in regard to the work of the 
home demonstration agent as a nutritionist. 

In order to understand the part which she plays as a nutritionist, it 
may be well to explain who the home demonstration agent is. She is a 
home economics trained person representing the County Extension Serv- 
ice, the State Agricultural College, and the United States Department of 
Agriculture. The extension service is organized in every state in the 
union. Each county in Massachusetts, with the exception of Suffolk and 
the islands (Dukes and Martha's Vineyard) maintains two or three. 
Each county has for its working unit, a town and sometimes a community 
organization. Most towns have a town director, a woman responsible for 
heaeding up the work in her town. Many of the communities within the 
town have community leaders. These directors and leaders are generally 
appointed by the extension service, though in Barnstable County the 
director is chosen at the town election. 

The duty of the home demonstration agent is to give the homemakers 
of her county the very highest possible conception of the profession of 
homemaking and instruct them in the subject matter of its various phases. 
As nutrition is fundamental and very important to the health and happi- 
ness of all members of the household, each home demonstration agent not 
only stands ready to give assistance in nutrition problems in the home, 
but also urges groups of mothers to study this subject. Classes are or- 
ganized, generally with the help of the community leader or town direc- 
tor, and these groups are met regularly for a series of meetings. 

Nutrition Projects 

The two projects which are being emphasized in the state at this time 
are Child Feeding and Food Selection. The Child Feeding Project covers 
a series of two or three meetings, according to the wishes of the com- 
munity, and is, of course, of primary interest to the mother of young 
children. Although in two or three meetings, one can only outline briefly 
the principles in Child Feeding, yet we feel it is better to have too few 
meetings rather than too many, because it is usually difficult for a mother 
of young children to get out to a series of even two meetings. Often a 
mother wants help on one particular problem; as, for instance, the time 
and methods of introducing vegetables into the infant's diet. She may 
get this help in one meeting. We have a series of five printed leaflets, 
covering all phases of Child Feeding, beginning with the prenatal period, 
through adolescence. These are simply stated and can be referred to for 
points not brought out at the meeting. 



85 

The importance of the right diet from the prenatal period through 
adolescence is explained. Factors other than food as they affect good nu- 
trition, good food habits, and the child's appetite come in for their share 
of discussion. The daily diet recommended for all ages is: One quart of 
milk, two vegetables besides potato — one of which should be green or raw, 
two fruits, a dark cereal or bread, one serving of meat or meat substitute 
and plenty of water. Oranges and tomatoes are recommended twice 
weekly. Emphasis is put upon simple, easily prepared foods for all mem- 
bers of the family. 

The Food Selection Project is divided into nine outlines, one for each 
lesson. Generally four from the nine are chosen for a series of meetings. 
A luncheon or samples of food are served at each meeting. Foods stressed 
are milk, vegetables, fruit, dark cereals, eggs and meat substitutes. 
Recipes for the use of these various foods are furnished at each meeting. 
The topics covered in the series are balancing of the diet, planning and 
serving meals, food for the sick and convalescent, food budgets, school 
lunches, community meals, factors other than food in good nutrition; and 
overweight, underweight and constipation as they are influenced by the 
diet. 

Community Suppers Improved 

In the recent mail of a home demonstration agent was a letter from 
one of our chairmen containing some clippings concerning two community 
meals. The first menu included : 

Chop Suey 

Potato Salad Baked Beans 

Rolls Cheese 

Pie Coffee 

and the second: 

Chicken Salad 
Mashed Potato Creamed Carrots and Peas 

Cabbage Salad Rolls 

Cranberry Sauce 
Coffee Pie 

These were the comments accompanying the clipping. "B had nutri- 
tion work, A had not. Compare the two suppers, please. So many said: 
'A wonderful supper!' Some said 'A wonderful supper, but different 
some way!' We tried to plan the menu in keeping with your teachings. 
We hope we have set the ball rolling; and that others will follow. As 
Mrs. F — is president this year, she will do her best to see that all sup- 
pers are well planned." 

Other communities in the state have given, through their community 
suppers, practical demonstrations of what a well balanced meal may be. 

Family Reformation 

A letter from a homemaker in Berkshire County is indicative of the 
help which we hope hundreds of homemakers in the state are getting. "I 
feel that this is the most beneficial course I have taken. I haven't words 
to express my appreciation of the value of this knowledge. My own health 
has been improved greatly as is also my husband's. My son of twenty- 
three has overcome his dislike for vegetables (his diet was one of meat 
and potatoes) and now eats everything in the way of vegetables that is 
set before him. This alone has made me deeply grateful. A teacher who 
is boarding with us started taking a pint bottle of milk for her lunch 
every day. The children followed her example and now every child, I be- 
lieve that there are fourteen, has added a bottle of milk to his or her 
lunch and enjoys so much drinking it through straws provided by their 
teacher. This teacher is gradually overcoming her dislike for the plainer 
vegetables such as cabbage and carrots, and has gained three pounds since 



86 
the opening of this course. My whole family feel deeply indebted for the 
knowledge thus passed on to them, and when I have overcome my desire 
for sweets between meals with which I am struggling just now, I think 
I shall be able to present a clean bill of health." 

A FOOD LESSON FOR CHILDREN AS IT IS GIVEN IN THE 
BOSTON DISPENSARY 

By Mary Pfaffmann 
Health Educator, Boston Dispensary 

The science of nutrition touches us nearly. The relations of food to 
the living body, — flesh, blood and bones, — which affect so deeply the 
happy and successful outcome of life, demand to be known. Calcium, 
phosphorus, iron, protein, carbohydrate, vitamin are terms with signifi- 
cance for every human being. Some of the knowledge that scientific re- 
search has yielded concerning these food factors and their part in the 
body's composition, growth and activities has been stripped of complexi- 
ties and brought into the child's world, as in the case of the elements of 
other sciences. 

Once in an out-patient clinic, where children were waiting, as usual, 
apprehensively and for a tediously long period, for doctor or dentist to 
call them, one who reflected upon the situation said, "It is an opportunity, 
with mothers looking on, to use in the interests of education in food and 
health habits." That was the beginning of what is now a systematic 
procedure in The Boston Dispensary.* Here is a sketch of a morning 
under the organized program for health education. 

A teacher finds, in a clinic waiting-room, children who are eager to 
answer the diverting call to gather around her. With this ungraded 
group, and in distracting environment, she must make a special appeal to 
interest, imagination, the sense of fun and love of play, and she must find 
the plain and striking form of statement that will stick in the memory- 
This morning she will talk about calcium — what it is, how our bones and 
teeth are made of it mostly, and where the body can get it. She has 
illustrative materials, both familiar and unusual: powdered lime, a firm, 
straight bone (the thigh bone of a roast fowl), and the facsimile of a 
perfect set of teeth (contributed by a dental supply company), to help 
the child to visualize calcium and the results of its good work in the 
body; chalk, a shell, coral and a fragment of polished marble, to show 
calcium in different forms; pictures and especially the foods that are 
important for their calcium content arranged on a tray to look their de- 
lectable best, and with the bottle of milk prominent among them. 

First there are pictures to look at and discuss. Here is one of a new- 
born baby whose small sister bends over him, but seems not to dare to 
touch him. Why not? Yes, he is so very young — his bones are so soft. 
But in the next picture he is as much as six months old, and he is sitting 
up in bed without other help than what his own backbone gives him. 
What has been making his backbone, all of his bones, so much firmer? 
Yes, his food. And what has been his food ever since he was born? 
Milk. Then what have we found out about milk? Yes, there is some- 
thing in milk that will make bones hard and firm. What is it? 

The teacher writes the important word on the blackboard — Calcium! 
She makes a great deal of it, as a word to remember. 

But what is calcium? Have you ever seen it? There is no response to 
these questions. But when the powdered lime is shown, named, and de- 
scribed as one kind of calcium, a child may ask, "Isn't that what they use 



* See The Commonhealth — Health Education Number, Oct.-Nov.-Dec. 1926, 
Education for Health — The opportunities in a medical institution, by Frances 
Stern. 






87 
to make plaster, when they build houses?" Yes! There is calcium in 
these very walls, helping to make them hard and firm. There is calcium 
also in these, and as the teacher shows the chalk, shells, coral, and the 
piece of marble, the children watch intently, eye and mind absorbed in 
the proceedings. Sometimes there are excursions into the realm of cor- 
relations — to the chalk cliffs of England and France, the atolls of the 
Pacific, which are really islands of calcium. And what in your body is 
a little like this shining white marble? The teeth! The bones! Your 
teeth and your bones are made mostly of calcium! 

But here is a tooth (obtained from the dental clinic) with a hole in it! 
What was the matter? Not enough calcium in it to make it so firm and 
sound that it would resist decay. And it had to be pulled out. And the 
child whose legs are bowed like this — why didn't the legs grow straight? 
Just because they didn't get enough calcium to make them firm and hard. 

That's how important calcium is to the body. (Perhaps now will come 
the good question, where can we get calcium?) Where do you think? 
Yes, from milk. There's more calcium in milk than in any other food 
you have in a meal. It's the great bone builder. (Here is opportunity to, 
emphasize four glasses of milk a day for every child, if possible, to the 
older people who are "listening in.") 

But other foods contain calcium. What are these on the tray? Vege- 
tables — fruit — an egg — cheese — whole grain bread and cereal. The cal- 
cium that you get in these foods will help to give you firm, straight bones, 
like this one (the thigh bone) and thirty-two sound, perfect teeth like 
these. 

The teacher shows the picture of a smiling child, standing out-of- 
doors. Straight, sturdy legs. Surely he has had, always, plenty of the 
foods that contain calcium. What are they? And you can see something 
else in the picture. Yes, sunlight. Sunlight, touching the bare skin, has 
a wonderful way of helping calcium to make firm, straight bones, and to 
do its work in the body. Have you little brothers and sisters at home? 

Then, to show that calcium can be present and yet not be visible, the 
teacher performs a simple, always captivating experiment. She has a 
glass test tube containing, she says, lime water, which she states has 
calcium in it. The children can see no trace of calcium. The teacher 
blows into the tube through a pipette, and — the calcium comes out of its 
hiding and turns the water milky white. Marvelous! Then comes the 
clinching statement : In the same way calcium hides in these foods. You 
can't see it, but it is always there. 

Sometimes the children play "Calcium! Calcium! Find the calcium," 
in the manner of "Button ! Button ! Who has the button ? While a child 
is selected who is not to look, a calcium-containing object is hidden. Then 
the group helps him to find it by their comments as he moves — "Cool!" 
"Warm!" "Hot!" 

A story is told, or a moving picture shown, perhaps about milk or the 
teeth. The story of Baucis and Philemon, as told by Hawthorne, can 
be made to emphasize all the important calcium-containing foods. A 
precious gift to the old couple, from the divine strangers whom they had 
entertained so kindly, was the pitcher of milk that filled by its own act 
as soon as it was emptied. 

Then a piece of handwork is devised, which the children are most happy 
in doing, and this they may carry home. 

This repetition of the thought in varied forms, through illustrative 
material, experiment, game, story and handwork, enables the child who 
can stay but a few minutes in the group to understand the purpose of 
the talk. 

Thus the child is using eye, mind and hand in gaining true ideas and 
knowledge concerning food and health habits while waiting in the clinic 
to which he has come for medical or dental or food treatment. It is 
health education in the place where health service is given. 



88 l 

NUTRITION WORK OF THE TEN YEAR PROGRAM 

By Esther V. Erickson 
Consultant in Nutrition, Massachusetts Department of Public Health 

Since according to Holt "There cannot be health without normal nu- 
trition" a program planned for the improved health of any group should 
focus much of its attention on the nutritive betterment of the group. 
The Ten Year Program for the prevention of tuberculosis carried on by 
the Massachusetts State Department of Public Health bears out this 
principle. The original plan of the clinic was to examine only those chil- 
dren 10% or more underweight, those who were known to be tuberculosis 
contacts and those who for other reasons might be suspected of having 
the disease itself. After three years' work, with a compilation of sta- 
tistics on the correlation of underweight and tuberculous infection, re- 
sults showed that the condition of underweight was not a predisposing 
factor to tuberculosis but rather tended to be a result. In light of these 
figures, a change in plan was made to examine in each community all the 
school children who presented written consents from their parents. In 
the organization, there are two groups of clinics: the "First," which 
makes the initial examination; and the "Follow- Up," which goes back 
each year to the community for the examination of those cases recom- 
mended for supervision; i.e., those diagnosed as suspicious, hilum or 
pulmonary. 

Before elaborating on the nutrition work of the plan, some idea of the 
procedure at the clinic would be of interest. After the social history has 
been taken, the weighing and measuring completed with deviation from 
average noted, the child is sent on to the physicians. Following a thor- 
ough physical examination, the child is given a Von Pirquet skin test. 
Last of all, the nutrition interview is given. Nutritional needs are 
taught to the group individually through the conference method by three 
nutritionists on the first clinics and one on the follow-up. Posters are 
displayed and printed nutrition material distributed. Exhibits are often 
used, depending upon the rooms available. A very complete history of 
foods eaten is made, recommendations written out and a copy of this 
record form given to the parent. In addition, a copy is given to the 
school nurse for her follow-up work and one kept on file for reference and 
comparison at the time of the follow-up clinic. 

Consultation with Parents Necessary 

Since very little nutrition work can succeed without the cooperation of 
the home, special effort is made to encourage parents to attend the con- 
ference. The child may be convinced that he should eat certain foods but 
not unless the parent is present do we have the opportunity to convince 
her that the needs should be met. There may be an economic problem, 
not admitted or understood by the child. This the nutritionist should 
know. There may be racial differences, best discussed through consul- 
tation with the parent. The diet problem often times boiled down may 
be one of poor psychology of training and while the nutritionists do not 
pretend to be psychologists they can give much practical help. Then, too, 
we still have the type of parent like one, who, much perturbed when told 
her child should eat vegetables felt that to be, in light of the child's 
heredity, an impossible demand — "his grandfather (deceased before the 
child was born) never would eat vegetables." 

The attendance of parents at the conference depends greatly on the 
activity of the local nurse doing the advance work, her home contacts, 
publicity, powers of persuasion, and general educational methods; on the 
type of community, industrial towns having a lower per cent because of 
working mothers. Where a large foreign group exists, attendance is 
lower because of lack of understanding, inability to cope with the Ian- 



89 
guage and a feeling perhaps that the school will take the responsibility. 
A few communities bring in mothers to the extent of 100%. Taking the 
average of all towns and cities, the high and the low, the number is nearer 
50%. Needless to say, we are trying to increase this. One town just 
completed averaged 80%. 

Nutrition Follow-Up 

No health program is any better than its follow-up work. This is an 
oft repeated statement but we health workers are in the position of a 
negro preacher who gave the following plan for a sermon, "First ah takes 
a tex'; then ah tells 'em what ah is goin' to tell 'em; then ah tells 'em 
what ah wants to tell 'em; then ah tells 'em what ah done tol' 'em." 

In organizing this state wide program, it was felt that for best results 
it would be advisable for the local communities to accept the responsi- 
bility for continuing the program after the first examination by the State. 
To be sure, the State follows up with a second clinic to check, examine 
and give additional nutrition information if necessary. But during the 
intervening year, upon whom can we depend? Local tuberculosis associ- 
ations, boards of health, child welfare organizations, dispensaries, city 
governments, local officials and most important the schools, including the 
school nurse. By law, every town in the State is required to provide 
nursing facilities for its schools. This furnishes, then, an agency for 
making the necessary contact with the home. A certain number of cases 
are referred to the State sanatoria but a larger per cent can benefit suffi- 
ciently by good home surroundings, intelligent home care and nutrition 
supervision. It is the latter group upon whom our attention is focused. 
With so many communities unable to provide sufficient nurses for the 
school population, the time of the nurse is so taken up with other details 
of her work that she finds little time for nutrition follow-up. We grant 
that these cases referred by the State clinic are as a rule those which 
would ordinarily be known to the health worker and are already having 
some supervision. However, many a nurse has reported that in her mass 
of work she does need a specialist in nutrition to whom she may refer 
her most difficult cases, including budget problems. This service is avail- 
able only in one community, with the exception of Boston. Six lesson 
courses in nutrition are given by the State consultant in nutrition to 
organized groups of nurses throughout the State to help tide over the 
situation until more towns are convinced of the place of the nutrition 
worker in the follow-up program. 

As a stimulus to the recognition of nutrition as a necessary component 
of health and as a means of finding out the number of those following 
the recommendations made by the clinic nutritionists, a survey last year 
was made of twenty-six towns. This was not a scientific study and is 
offered for what it is worth. The person giving the information was the 
local school or tuberculosis nurse. The number of cases diagnosed as un- 
improved at the follow-up State clinic was 316. Of this number 48.8% 
were not following recommendations for various reasons, the outstand- 
ing one being that of lack of cooperation in 61.3% of the cases. Lack of 
cooperation, they maintained, was due to language difficulties, to igno- 
rance of the value of nutrition, of the what and how of nutrition, of food 
preparation, of home control, to poor understanding of the clinic itself, 
to failure on the part of the nurse to have adequate time to educate the 
parent in some of the above essentials — one visit to the clinic is insuffi- 
cient. 

Schools' Part in Follow-Up 

Our whole program is one of education! Since 1546 when the first 
public school was opened in Dedham, we have had available the public 
school system. For the formal health education of the large majority of 
children, the school is or should be the agency. Through the school lunch, 



90 

established in about 65% of our communities, proper foods and food 
habits should be taught. One encouraging point is that a few schools 
are arranging rooms and cots where the malnourished may rest before 
or after lunch or both. The rest period, so important in our treatment 
of hilum tuberculosis, more essential in the final analysis than diet, is in 
too large a number of cases a snag. The school has more control over 
the children, more discipline, and because sleep becomes a group activity, 
can teach by practice the need for daytime relaxation, if not sleep. In 
some schools instead of physical education rest is required where recom- 
mended by the physician. Through the home economics department and 
vocational schools, where older sister has been taught the balancing of 
diet as well as preparation, many a hilum case has at last been provided 
with and has learned to eat, the foods advised. Upon the classroom 
teacher rests the greatest responsibility, for all children come under her 
influence during a longer period of time than that with the specialist. 
By correlation with other studies or as a unit in itself she is indeed in 
the most logical situation for teaching and convincing the child that he 
himself must attempt to acquire optimum health. 

The Ten Year Program simply starts the ball rolling when it provides 
for the mother and child a conference with the State nutritionist. She 
does her duty thoroughly and well, giving to both the best of her knowl- 
edge, experience and judgment. To make of value this short interview, 
we depend on the local community, trusting that enough momentum has 
been gathered to cause it to draw on all its resources: — home, school, 
health and social agencies — to work together to make productive of last- 
ing results the State's effort to prevent tuberculosis. 

THE HEALTH PROGRAM OF THE DENTAL CLINIC 

By Ruth L. White, S. B. 
Supervisor, Food and Habit Clinic, Forsyth Dental Infirmary 

For the dental institution with a program of true prevention, atten- 
tion to mere mouth treatment and hygiene appears inadequate. Both 
clinical experience and the findings of the research laboratory offer ample 
evidence that filling, extraction and prophylaxis can constitute only part 
of a service which aims to reduce dental caries. The Forsyth Infirmary 
therefore, in the belief that improvement in general physical condition 
reacts favorably on the development and preservation of sound teeth, 
embodies health supervision in its plan. 

The focus point of the general program of the Institution is the age 
period between two and seven years, when the first teeth need examina- 
tion and the second teeth are forming. There is a steadily increasing 
realization of the necessity of early and regular dental care, 1598 treat- 
ments having been made in 1928 from January to October inclusive, in 
the weekly half day set aside for pre-school children. Since, in the same 
age group, medical supervision and the formation of healthful habits are 
fundamental, the emphasis of the medical program is here also. Older 
boys and girls who first came for treatment several years ago are found 
in the clinics to be sure, but as no new case above the second grade may 
now be registered, the younger patients predominate. 

Health Examinations 

On the day of the completion of his dental work, the child is given a 
special examination, at which such items as the following are noted: — 
Color and tone of gingivae, progressive or non-progressive caries, nor- 
malcy of eruption, arch development and shape, spacing of temporary 
teeth, hypoplasia, and evidences of oral hygiene. This examination 
enables the dentist to note mouth conditions which may be due to pres- 
ence or lack of nutritional balance. The mother's teeth are also examined 



91 

at this time so that some indication may be obtained as to her general 
oral condition during pregnancy. 

If under no other medical supervision, the child is then given an ap- 
pointment for the Pediatric Clinic, usually for the following week. Here 
are obtained brief social data and a medical history, including informa- 
tion as to general condition, diet and hygiene of the mother during preg- 
nancy, infant feeding, and diseases, with sequelae. The medical exami- 
nation follows with particular attention to any condition suggested by 
the dental record, and with recommendations for supervision by the nu- 
tritionist, for examination by the nose and throat specialist, or for both. 
Tonsil and adenoid operations are performed at the Infirmary on three 
days a week. 

In the Food and Habit Clinic, an individual interview with each mother 
and child gives the detailed account of the daily program which is at 
least a factor in producing the dental condition found. With emphasis 
on foods which build and protect the teeth, the mother is helped to re- 
adjust the diet with the needs of her child as an individual in mind. 
Attention must also be given to habits of sleep, daytime rest, sunshine, 
elimination, activity, and regularity, universally acknowledged to make a 
contribution as great as that of food, to good nutrition. By the use of 
illustrative material, simple reporting system, and other teaching meth- 
ods adapted to his age, an attempt is made to arouse in the child him- 
self, interest in the establishment of health practices. 

Return visits to both the Pediatric and the Food and Habit Clinics take 
place with a frequency varying with the condition of the child. Resources 
offered by outside organizations are often relied upon as supervision con- 
tinues. At six month intervals, mouth conditions are rechecked by the 
dentist who made the initial examination. 

Instead of following the above routine passage through the various 
clinics, a child showing an acute mouth condition such as inflamed or 
spongy gums, or lack of calcification, may be referred directly to the 
Pediatric or Food and Habit Clinic, even though his dental work be in- 
complete. 

Student Training 

The training of its students must be an integral part of the program 
of any institution. In addition to strictly dental subjects, courses in 
physiology, general hygiene, pediatrics, dietetics and principles of health 
education are included in the curriculum of the dental hygienist. Con- 
tributing probably in even more vital way than classroom lectures and 
discussions is the opportunity for observation in the Infirmary clinics, 
where the influence which the social and economic background and the 
daily habits have on the general physical condition and on the teeth, 
may be studied. 

In the Pediatric Clinic, the hygienist is taught by the physician in 
charge to note the well developed muscles, alert expression, and erect 
posture of the child who has also sound teeth as an indication of health. 
On the other hand she learns to recognize the most obvious signs of devi- 
ation from bodily fitness. 

In the Food and Habit Clinic, her presence at interviews between the 
patients and nutritionist gives her familiarity with common dietary 
weaknesses, and with methods of interesting both child and parent in re- 
adjustment. Here also she assists in group teaching, in planning hand- 
work and in using illustrative material. She makes a notebook in which 
she mounts, throughout her course, leaflets which will later prove of 
practical value to her in the office, clinic or school room. While the dental 
hygienist does not become a trained dietitian, she gains a working knowl- 
edge of the relationship of nutrition to teeth which enables her to take 
her place among the various specialists who are health teachers. 

To the internes also opportunity is given for a short period of clinic 
observation. Their lecture courses include one in nutrition with special 



92 

emphasis on normal dietaries for the various age groups, and on sound 
health material available for children's work. A consciousness of oral 
conditions as affected by poor or good nutrition is developed through their 
year's experience. 

Among the regular part-time students of the Pediatric and Food and 
Habit Clinics, are those from the Medical and Household Economics 
groups, both assisting in the clinic procedure. From the fields of insti- 
tutional dietetics, kindergarten teaching, etc., other students are frequent 
observers. 

The periods when Infirmary patients are waiting for doctor or dentist, 
offer a strategic teaching opportunity. About a brightly colored table, 
a dozen children may dramatize (in impromptu fashion without costumes 
or scenery, but with real esprit de corps nevertheless), the marketing 
trip, each one "buying for health" as he purchases from the beaming 
storekeeper milk, fruits, and vegetables, to fill the "shopping' basket" 
which he has made. Or, an illustrated account from the research labora- 
tory of what orange juice does for the guinea pig's teeth may introduce 
a lesson on the need of daily fruit for the teeth of boys and girls. In 
either case, hygienists, mothers and frequently fathers, are interested 
listeners and participants. In the waiting room downstairs, it is often 
difficult to hold a lesson period due to the large and constantly changing 
groups, but there too handwork is done, related always to some health 
habits. Apart from its intrinsic educational value, this practice is a tre- 
mendous aid in relieving the strain on the child and in making the visit 
to the dental clinic an experience, not of terror, but of real interest and 
pleasure for even the youngest. 

The relation of sound teeth to physical well being has long been recog- 
nized. Is it not time to give at least equal emphasis to the contribution 
which optimal health can make to the prevention of dental decay? On 
the positive answer to this inquiry, the health program of the Forsyth 
Dental Infirmary is based. 

THE PROGRAM IN NUTRITION AT THE SUMMER SESSION, 

FITCHBURG, 1928 FOR VOCATIONAL AND 

CONTINUATION TEACHERS 

By Martha Wonson 

Assistant Supervisor, Division of Vocational Education, Massachusetts 
Department of Education 

The nutrition work at Fitchburg during the past summer session was 
conducted for the first two weeks by Miss Emma Wetherbee of the Health 
Department. It consisted of lectures, sometimes illustrated, which were 
based upon the following outline: 
Health and nutrition 
Diet in relation to physical well-being 
Classification of foods according to function in the body 

Food for the Baby, the Pre-school Child, the School Child, the Ado- 
lescent and the Family as a unit were discussed; also the various causes 
and methods of prevention of malnutrition. The methods of training 
the child in proper food habits were emphasized. The important part the 
school lunchroom manager has in training children, and often the parent, 
in the proper selection of food, was also brought out. 

A most important subject "Foods of the Foreign Born" was discussed 
with typical menus of the different nationalities and with points for con- 
sideration in making their diet adequate. These discussions helped many 
of us to realize that the "stranger within our gates" often has sugges- 
tions for us concerning food selection, if we are broad-minded enough to 
see and acknowledge them. The fact that a teacher has seen the good 
points in many of her foreign children's diets and encouraged the con- 



93 

tinuance of those things which are good, has been a means of introducing 
some of our own foods into the homes of these people. By this means, a 
gradual adjustment is being made to the many strange foods which they 
find in this new country. Is not the great variety of fruits and vege- 
tables now seen in our markets proof that we have profited by the de- 
mand of the foreign born for their native foods ? 

The last two weeks of the course were carried out on a plan which had 
proven successful in the New Bedford Evening Practical Arts Classes 
conducted by Mrs. Gertrude Lowe. Mrs. Lowe gave the course at Fitch- 
burg in much the same way that she conducted her evening classes. Mrs. 
Lowe combined the lecture and demonstration method in the presentation 
of her subject. She first pointed out the nutritive value of the menu 
which she gave the class af each meeting and then proceeded to demon- 
strate the preparation of a few chosen recipes. This gave the members 
of the class an opportunity to see and taste the finished product, thus 
bringing out more clearly the points in nutrition which she was stressing 
and also demonstrating that a menu, based upon the knowledge of nu- 
tritive value, could be attractive, taste good and require no more time or 
money than any other type of menu. 

A list of questions were given the class based upon the lesson, which 
they were asked to study and answer. 

A lesson or two, taken from Mrs. Lowe's outline, may serve to show 
just how the work was conducted. These may prove suggestive for the 
teacher who is anxious to put more nutrition into the teaching of foods. 
The existing lack of interest of members of her classes may be due to 
want of knowledge of food values and a feeling that the acquisition of 
such knowledge may require much time and study. 

The following lessons illustrate Mrs. Lowe's methods: — 

Course in Foods and Nutrition 
Dried Fruits Homemaking Work for Adults 

Contain quantities of iron which is a necessary part of all good blood. 
Natural sugar is in a more concentrated form. Approximately three- 
fourths of the weight is sugar. Valuable as roughage, especially the 
seedy ones such as figs. 
Bananas 

One of our most nutritious fruits. 

Should be thoroughly ripened. 

Should be scraped before eaten. 

Should not be sliced long before eating or they will become discolored. 

Addition of lemon juice will prevent discoloring. 
Grape Fruit 

Citrus fruits valuable for keeping the blood in an alkaline condition. 

Do not use sugar on grape fruit, a little salt will neutralize the acid. 

Lemon juice and bicarbonate of soda are good for colds. 

If orange is used, it should not be strained. 
Malt Breakfast Food with Dates 

Coarse cereals contain more vitamins and minerals than the highly 
refined ones. 

Food value is increased by the addition of raisins, dates, figs, etc. 

If any sugar is used brown is better than white. 
Toast 

Should be served dry and buttered as eaten. Dry food massages the 
gums and exercises the teeth. 
Poached Egg 

Eggs should be kept at a temperature below the boiling point as 
boiling toughens the egg white and makes it more difficult of 
digestion. Egg yolk has more nutritive value, contains more fat, 
. ash and vitamin A. 



94 

Cocoa or Milk 

Hot milk will take the place of coffee with many who feel that a hot 
beverage is a breakfast necessity. One fourth cup of coffee will 
flavor the hot milk and be more acceptable to some. 

Mrs. Lowe selects and demonstrates some of the recipes given in the 
lesson. The teacher may, if she chooses, let different members of the class 
prepare the recipes. 

Questions are based partly on notes given the class and partly on ma- 
terial from Red Cross Text Book on Food and Nutrition. 
A demonstration menu for a luncheon is also suggestive: 
Cream of Spinach Soup — Croutons 
Raw Vegetable Salad 
Oatmeal Muffins — Butter 
Nut Cake 

The discussion at the end of this meal is as follows: 
Value of cream soups in the diet. 
Why we need green vegetables daily. 
Do we need sweets? 

Meals — Good and Poor Selection 

A wise choice of food can be made only when one is thoroughly familiar 
with the various food elements, proper combinations of materials and the 
place they have in keeping the body in a normal healthy condition. 

Many housekeepers choose food which by itself is perfectly good and 
wholesome but which in combination with other foods produces undesir- 
able results in the process of digestion and assimilation. 

Some simple rules to remember: 
Eat sparingly of meat. 
Eat plenty of fresh vegetables. 
Eat fresh fruit daily. 
Eat whole wheat and other dark breads. 

Use plenty of milk (1 qt. for each growing child, 1 pt. for each adult) . 
Eat simple desserts. 
Avoid rich pastry. 
Drink at least six glasses of water daily. 

Breakfast 
Good Selection Poor Selection 

Cinnamon prunes Fried egg 

Pettijohns and top milk Fried potatoes 

Poached egg White bread 

Graham muffins — butter Butter 

Milk or cocoa . Coffee 

Luncheon 
Corn chowder Frankfort and roll 

Peanut butter sandwiches Bar of chocolate 

Apple Bottle of tonic 

Dinner 
Roast lamb Roast lamb 

Duchess potatoes Mashed potatoes 

Vegetable salad Macaroni and cheese 

Dark bread and butter White bread 

Lemon shortcake Cornstarch pudding — Whipped cream 

Meal planning, good and poor, is a very good way of impressing upon 
the people in our classes the fact that it is just as easy to provide the 



95 

right type of meal, if they have a little knowledge of food values, as it is 
to plan any kind of meal. 

The vocational department is anxious to have this type of work de- 
veloped in its practical art classes for women, that those who attend the 
foods classes may get the broadest comprehension of this most important 
subject of foods and nutrition. 

NUTRITION WORK IN ADULT CLASSES 

By Gertrude C. Lowe 
Teacher of Foods and Nutrition, New Bedford Vocational School 

There has never been a time when women gave more intelligent and 
earnest consideration to the problem of homemaking and the scientific 
preparation of food than at present. The housekeeper of today realizes 
that to a marked degree the food she provides for her family may not only 
nourish their bodies, but in some mysterious way also fits them to make 
a success in life and be a credit to the home and nation. 

The question now arises: How may we teach the women of our com- 
munities to combine the proper amounts and kinds of food to give them- 
selves, and those for whom they provide, the most satisfactory results, 
both from the standpoint of nutritive value and economic worth? Obvi- 
ously the method must be adapted to the persons who desire the instruc- 
tion, but there is hardly any community so small that a good constructive 
program cannot be carried out, provided an enthusiastic and capable 
leader is secured, and a place found where the work may be conducted. 
If a school kitchen or laboratory is available the problem is quite simple. 
Failing that, kitchens in churches, clubs, community houses, or even a 
private home, if the group is not too large, would be entirely satisfactory. 

Creating Interest 

In order for the work to be effective it must be made vital and interest- 
ing. In most cases the women who are eager for the instruction are at 
business all day, either in their own homes or in shops and offices. In 
any case they are tired and will not be attracted by a course that is en- 
tirely theoretical; but if some preparation of food is included in the 
program at each meeting, attention will be held and interest stimulated. 
When the women are able to see and taste foods prepared in such a way 
that most of the food value is retained, and are convinced at first hand 
that certain combinations are not only nutritious, but are appetizing and 
attractive as well, they are always inspired to try them at home. 

Reports brought in by the pupils will make interesting and helpful 
topics for discussion. Not the least of these will be the reaction of the 
various members of the families toward the new ideas of cookery. It is 
generally a surprise to the wives to find their husbands interested and 
willing victims of these new experiments. 

Organization of Classes 

If it seemed advisable in any community, separate groups could be 
organized under some such headings as "Young Mothers", "Business 
Women", "Housekeepers' Nutrition Clubs", etc. By this method the 
work would possibly reach a larger number of women and offer instruc- 
tion along the particular line in which they are most interested. 

The American Red Cross through its nutrition service is very glad to 
assist in forming study classes. Through them a text book may be ob- 
tained, and helpful ideas about the content of courses secured. They will 
also recommend any person as leader who fulfills the requirements as a 
foods and nutrition teacher; and to the women who complete the work in 
a satisfactory manner, certificates to that effect will be issued. 

There is an unusual opportunity for the development of leadership 



96 

along the various lines of nutrition work. Classes for adult women in the 
preparation of food have been maintained for some time throughout the 
country. In Massachusetts, these have in many cases been conducted 
jointly by the State and city, who cooperate in arranging courses and in 
financing them. It is only recently that some definite instruction in nu- 
trition has been attempted. 

At the New Bedford Vocational School this work is carried on as a 
part of its regular Evening Practical Arts program. A room in which 
to conduct the class was fitted up with a gas stove ; a kitchen cabinet and 
table — these last two articles made in the boys' carpentry department — 
were added and the needed utensils necessary for work were procured. 
Owing to the fact that the room had to be used for other purposes during 
the daytime it could not be arranged for individual work by the pupils. 
The problem of how to give some illustration of the foods under discus- 
sion is met by the teacher conducting a demonstration at eaeh meeting. 
The women in the class take notes and ask questions as the demonstration 
proceeds, and later they assist in serving the food which has been pre- 
pared. They also take charge of clearing away and putting the room in 
order. This affords the teacher an opportunity to stress good house- 
keeping methods as well as proper food preparation. The last fifteen 
minutes of the session is spent in talking over personal problems. This 
establishes a friendly feeling between instructor and pupils (a very neces- 
sary factor in any successful teaching). 

The group to whom this work is given have in some instances completed 
a course in "Home Hygiene and Care of the Sick" or one in "Food Prepa- 
ration." Both courses are a part of our Evening Practical Arts work. 
The first class in Foods and Nutrition was organized as the direct result 
of a wish on the part of these women for more information about scien- 
tific food facts. Eleven women reported the first meeting of the class, 
at the second lesson each person brought one or more friends with her, 
thus increasing the class to twenty-three members. 

Application of Acquired Knowledge 

In several instances the women have been able to put their instruction 
to definite use in their various professions. Some are "doing practical 
nursing and find that they are able to provide more adequate diets for 
their patients. Others are doing some kind of welfare work among chil- 
dren and are assisting them to form better food habits. Still others are 
applying the subject in their homes and the families are reaping the 
benefit. 

We feel that we have made only a beginning in "spreading the gospel" 
of better foods and more adequate nutrition, but if we have aroused in 
some of the women in oUr city a feeling for the need of such a course we 
feel that something has been accomplished. The interest shown has been 
sufficient to assure us of a bright future for more scientific study of the 
home and its problems. 

NUTRITION WORK WITH VOCATIONAL STUDENTS OF HIGH 

SCHOOL AGE 

By Kathleen Hogan 
Instructor, Vocational School, Lowell, Mass. 

All our health experts are talking about nutrition. Current magazines 
are publishing articles on health and nutrition. Manufacturers are is- 
suing health foods. Food demonstrators are lecturing on the importance 
of this or that food from the point of view of nutrition. What is more 
necessary than that our children should be taught the principles and ap- 
plications of nutrition? 

In our schools we can readily find children who are excellent examples 



97 

of both kinds of nutrition. On the one side are the children who are 
enjoying life to the full, products of intelligent, progressive parents. 
These are the children who may be described in a word picture such as 
follows, — bright, clear eyes; clear, soft, smooth, slightly moist and gen- 
erally pink skin; abundant, lustrous hair; red tongue; well formed, well 
enameled, even teeth ; firm, subcutaneous fat ; strong, firm muscles ; broad, 
deep chest; straight arms and legs; happy, alert expression; a posture 
indicating vigor and the ability to indulge in healthy exercise. Greatly 
outnumbering these children are the ones coming into the class suffering 
from malnutrition. The causes of the latter condition are many. In 
some cases it is due to the lack of knowledge; in others to the failure to 
apply what knowledge there is; in a third it is due to the lack of money 
to purchase the desirable foods; and finally, in a majority of cases to 
faulty food habits. 

In the homes from which vocational students come the various causes 
of malnutrition are found to be true. It is with the hope that many of 
these homes will become producers of the optimal child that the study of 
nutrition is undertaken. The children of today are the adults of to- 
morrow and by the thorough training of these children the next genera- 
tion is protected. 

In the nutrition class great interest is aroused through a comparison 
of health habits, rest, exercise, water intake, food likes and dislikes, and 
attractive ways of serving desirable foods. One of the most important 
lessons is that on the value of water, its uses and the amount needed. 
Fifty per cent of a class will be found to be taking less than two glasses 
of water a day. Many students present will find it difficult to remember 
when they had a glass of water. Various methods may be used to stimu- 
late the taking of water but a careful check-up is necessary. Quite grati- 
fying strides may be made but periodic reminders are needed. In some 
cases the low water intake will be due merely to failure to think of it. 
In other instances, however, students have a decided distaste for water 
which should be overcome. Students suffering from acne and other skin 
troubles as well as those subject to constipation are actively interested 
in the beneficial effects of water. 

So far it has not been difficult to attain the proper milk intake. Milk 
and cocoa are served at the school each day. Many students bring 
thermos bottles of milk or cocoa with their lunches. It has not been 
necessary to urge the drinking of milk to any great extent. Few students 
had any knowledge as to how much milk they should take but upon learn- 
ing that one quart was advisable, quickly responded. This all indicated 
a decided liking for milk. In addition, chowders, cream soups and cus- 
tards soon became popular articles of food with the student customers. 
_ The introduction of fruit and vegetables into the daily menu is a more 
difficult task. Only a small percentage of students are accustomed to 
fruit of any kind for breakfast. Fruit desserts, such as custards, salads 
and gelatines are rather new dishes to the students. Fruit as a rule is 
served plain only in the homes. Vegetables on the other hand play a large 
part in the usual household menu. Vegetables are served often and in 
quantity. Here, however, is an outstanding faulty food habit: the chil- 
dren do not eat the vegetables. Instructions as to the correct methods of 
cooking the vegetables are very necessary. The importance of boiling 
water and only a small amount is not readily appreciated. It is also a 
problem to cultivate the habit of serving and eating raw vegetables reg- 
ularly. Raw vegetables in a gelatine salad may be used as a beginning. 

Faulty food habits in desserts are particularly hard to correct. A long 
established appetite for doughnuts, pies, fancy pastries and cakes is diffi- 
cult to change. An entering wedge may be made by healthy custard basis 
ice creams. Hermits, oatmeal cookies and filled cookies eventually take the 
place of the doughnut and pastry. 

Gradually the influence of the nutrition class becomes known. After 



98 
the first few months students who previously would refuse all vegetables 
will rather adroitly inquire when such a vegetable is to be served again 
or will ask if the recipe for a certain vegetable dish is available. The 
case of one student may be cited. During the first weeks of school she 
would deliberately throw vegetable soup away without even tasting it. 
Through discussion she was gradually persuaded to try to eat it. When 
an "Achievement Page" was added to the notebooks this student's first 
entry was "I ate all my vegetable soup." 

Some work is done with the study of diets for certain conditions. It is 
largely individual work. Girls suffering from acne become interested in 
the diets advisable for them. Anaemic girls by learning of the foods rich 
in iron can do much to improve their condition. Underweight girls an- 
nounce all gains quite proudly. The addition of scales to the department 
this year is expected to increase interest and produce more specific gains. 

That the nutrition work is carrying over into the home is frequently 
illustrated. One student surprised her family one evening with a loaf of 
dark bread in place of the usual white bread. She reported that they 
said it was "all right." Not long afterward she said that her mother had 
dark bread in the house all the time and her brothers and sister "loved" 
it. Another student introduced cooked cereals successfully while a third 
girl after several attempts developed in her younger sisters and brothers 
a liking for prunes. 

The value and the results of the nutrition class can not be measured. 
Its success cannot be questioned. Teach the children the correct food and 
health habits and help them to live up to the rules of the game of health. 

NUTRITION THROUGH THE SENIOR HIGH SCHOOL LUNCH 

By Agnes M. Bridges 

Supervisor of Home Economics, Public Schools, Norwood, Mass. 

When the matter of providing the noonday meal for high school pupils 
becomes the responsibility of the Home Economics supervisor, she accepts 
this duty as one of the educational projects of her department. Analyzing 
the problem, she quite naturally arrives at the following conclusion: The 
lunch proposition is an organization within the school. Why therefore 
should its aims be anything but educational ? "Feeding for Health" must 
be our slogan and to teach pupils to select nutritious meals our first ob- 
jective. This point of view is probably more naturally maintained by a 
Home Economics educator than by the dietitian whose interests may have 
been trained to commercial ends. 

Interest Pupils 

To insure patronage from pupils we must first popularize the lunch- 
room. When we have their interest we are able to proceed with a nutri- 
tion program. The atmosphere of the lunchroom may easily attract or 
repel our customers. They will be happy in an inviting, homelike atmos- 
phere of a well-ventilated, cheerful room provided with comfortable 
chairs, where all may enjoy leisurely either the lunch from home or that 
purchased at school. The writer believes that an arrangement of tables, 
seating from four to six allows for small social groups, eliminates the un- 
desirable bench or "bread line" atmosphere, answers largely the problems 
of discipline and tends toward bringing about a spirit of refinement and 
a display of creditable manners. When proper dining room etiquette 
prevails pupils unconsciously enjoy the environment of the lunchroom. 
Once attracted to the lunchroom, pupils will be tempted to buy food which 
is pleasingly served and displayed. If the food passes the rigid censor- 
ship of critical pupils, many of whom are victims of personal idiosyn- 
crasies in regard to eating habits, another obstacle is overcome and 
patronizing the counter becomes a habit. 



99 
Teach Food Selection 

With the management of the High School Cafeteria under the control 
of a person trained to provide inexpensive, nourishing, well-balanced 
meals the problem of the menu should be simple. There should be no 
need to deplore the types of food served or preferred by pupils. The 
chief problem seems to be the training of our pupils in the fundamentals 
of food selection. This indeed is a vague proposition when we are not 
able to meet all pupils for instruction in nutrition. It remains for us 
therefore to instill within our pupils a sense of proper choice and selec- 
tion of food through their everyday contact with our menus. By con- 
stantly placing before them foods containing the essential life-giving 
elements in the form of balanced menus we gradually induce them to eat 
proper meals and consequently educate their tastes through the daily 
routine of example. They unconsciously think in terms of food values 
and proper digestion. We depend largely upon our menu arrangement 
to educate in a subtle way to proper food combination, balanced diet, food 
values and variety in diet. Haphazard habits of choice may be largely 
overcome by a logical display of food. Our menu follows the generally 
accepted arrangement for the full course meal and the display of food 
follows the same sequence as the menu. Thus the power of suggestion 
is utilized by the placement of the food. By passing the main courses 
first pupils are likely to be tempted and will purchase the hot soup, main 
dish or salad in preference to desserts. 

The type of menu which represents a full meal and yet allows varied 
choice is most suited to the general need of pupils. From this type of 
menu simple combinations for light lunches, supplementary lunches or a 
full meal may evolve. No menu can be considered satisfactory that can- 
not stand the test of variety. No menu need be repeated as a whole and 
there is no reason why customers should associate any particular dish 
with a certain day. The popularity of various dishes must necessarily 
be considered but can be regarded in relation to the needs of the pupils. 
Their tastes should be so moulded that what they need becomes what they 
like. The process of eliminating gradually, or better, never including the 
less desirable pastries, confections, frankforts, etc. may be carried on to 
the satisfaction of pupils when tempting substitutes are offered and there 
need be no feeling dominant that certain articles are being refused. 
Prices must be low in order that pupils may receive a satisfying lunch at 
a nominal sum and menus must be kept to standard if desired results 
are to be obtained. Fresh vegetables, salads, fruits and dairy products 
appear daily on our menu. By including the vegetable with meat and 
potato on our club plate pupils are likely to try the vegetable and develop 
a liking for it. We sell sweet chocolate during the last ten minutes of 
recess and since the pupils have to make a special trip to the counter to 
purchase it they are likely to make a desirable choice of other food with- 
out waiting for the chocolate. Dishes of dietetic preference we often 
sell below cost, prepare attractively and place in a conspicuous place. 

Not wishing to economize in anything which makes for the better 
health of pupils, we serve foods of only A No. 1 quality. In addition to 
quality, neat, quiet, quick and efficient service are factors in a nutrition 
program. Our student helpers are selected for their qualifications as to 
type, poise, dignity, school standing, etc., and it has become an honor in 
our school to serve the school. This spirit raises the standard of labor 
and brings about the desired attitude toward employees. We encourage 
pupils to become acquainted with the conditions under which their food 
is prepared. Both employees and pupils show a most satisfactory in- 
terest in this part of the school organization. 

In our desire to teach correct food habits we should not overlook the 
excellent background which the lunchroom affords for training in self- 
direction, quick decision, promptness, good building spirit, responsibility, 
courtesy, etiquette, good manners, relaxation and social intercourse. 



100 
Correlate With Other Subjects 

Aside from the psychological and mechanical means employed in teach- 
ing our pupils desirable food habits are the many direct opportunities 
for correlating this feature of the educational program with other de- 
partments of the school. Where cooperation and administration permit, 
a resourceful manager will be ever ready to recognize and avail herself 
of the numerous opportunities for correlation with the Home Economics, 
Health, Science, and Art Departments, activity periods, assemblies, Stu- 
dent-Government and Parent-Teacher organizations. Practical applica- 
tion can be made through special attention to over and under-weight 
pupils; personal supervision of pupils' selection of lunches; serving mid- 
morning lunches; drives for correct eating; discussions of lunch menus 
in food classes and posters depicting food values, well-balanced meals, 
proper choice of food and wise expenditure of money, various types of 
lunches, right eating habits, the relation between diet and health, etc. 
Food questionnaires offer valuable material for working out helpful sug- 
gestions. 

Can we expect immediate results through procedures and policies de- 
scribed? Yes. When a pupil tells me that our salads are delicious, that 
she could not be persuaded to touch lettuce or salad before coming to 
High School, but now takes the salad daily from choice, it is satisfaction 
enough that we are helping pupils and meeting a need. 

The school lunch should be a vital factor in any school health program 
and has a very definite part to play in the general education of pupils. 
When pupils assemble from choice in a school cafeteria with health and 
educational standards, eat heartily, glow with health and seem genuinely 
happy they are of necessity profiting from contact, example, and from 
eating good food; and a school system which sponsors a health cafeteria 
may well feel that an important contribution is being made to the future 
health of the nation. 

PROGRESS OF THE FRANKLIN COUNTY DEMONSTRATION 

By Susan M. Coffin, M.D. 
Massachusetts Department of Public Health 

In 1927 and 1928 Well Child Conferences were held in all of the towns 
in Franklin County (except Greenfield) as part of the Franklin County 
Demonstration plan and 1,972 examinations were made. 

The main objects of this effort are to develop more interest in child 
hygiene, to increase activities along this line, such as adequate general 
nursing service for all these towns and to get the defects of pre-school 
children corrected before school entrance. 

Some of these towns are really remote geographically and socially — 
"Mormon Hollow" had only one mother brave enough to "come out for 
the clinic." She was told by her neighbors that "those state folks took 
your children off if they wasn't all right." We found many a frightened 
child was crying because older children had told them doctors always 
"cut your throat out." In such crises the presence of "clinic toys" has 
a calming effect. Old superstitions die hard in small communities and 
are often difficult to overcome: boiled milk is still "poisonous," toast 
"dries the blood," "camphor bags" both cure and prevent the wicked com- 
mon cold. 

Mothers here as everywhere conscientiously boil water for fear of 
"germs" but cheerfully let cow's milk go down raw, accompanied by all 
the bacteria collected during its transit from unwashed udders milked 
by unwashed hands to the baby's bottle, by way of none too clean milk 
pails and pans. Many a mother who would be shocked by the suggestion 
to give her child raw meat never realizes the dangers of raw milk from, 
untested cows. 



101 

Health teaching filters back steadily from the schools, among Polish 
families as well as among the American families. A Polish mother tells 
us, "My Mary, she say school nurse tell her we must sleep with windows 
open all night. Her father say no, night air bad and anyway too cold. 
Mary she wait everybody sleep, she open all windows little bit." Tooth- 
brushes may still be individual or shared or absent, according to the 
family income and standards. 

Of the 1,291 children examined 975, or 76 per cent, showed defects. 
Very bad teeth are often common at an extremely early age in some of 
the rural places. The mothers are still very ignorant of what constitutes 
adequate prenatal diet or what the nursing mother should eat. They lose 
their own teeth during pregnancy and have little to give the baby to 
build his. Obstructive or diseased tonsils, and adenoids, are painfully 
common and combined with pus-discharging teeth frequently account for 
a condition of poor nutrition. If dentists who refuse to do early den- 
tistry could have a set of these teeth to use for a week or two, I feel ab- 
solutely sure their theory of the value of leaving decayed first teeth 
alone would collapse automatically. We are impressing it upon parents 
that badly decayed teeth must be removed before the tonsil and adenoid 
operation can be safely performed. 

We find our constant task, as it deals directly with parents, is to teach 
child hygiene principles over and over, to constantly seek new ways of 
making them more vivid, to arouse a desire that will bolster up the effort 
necessary to bring the satisfaction of visible success. 



102 



Editorial Comment 



Meet the Nutritionist. A new health worker has come to town — at least 

she has been in town for a comparatively short 
time. She is the nutrition worker or "nutritionist" and is one of the 
best trained of the public health group. Her relatives the dietitian and 
the home economics teacher have been with us longer but they have not 
as a rule identified themselves particularly with the public health move- 
ment. 

There is always occasion for thought when a new worker appears. 
What new specific function is she to call her own? What is to be her re- 
lationship to health workers already in the health field? 

Time only will tell with regard to the nutritionist. That she as a well- 
trained specialist has something definite and worth while to offer there is 
no manner of doubt. That there is a possible danger of duplication of 
effort as the result of her coming there is also no doubt. 

There seems to be no real necessity for duplication, however. The key 
to her place in the scheme of things is the fact that she is a specialist. 
This means that she will be of greatest use if she serves as a consultant 
and advisor to the generalist, that is to the public health nurse, and to 
the school teacher. The home contacts will still, with rare exceptions, be 
the responsibility of the nurse. 

School Hygiene Conferences. "Time will tell" — how often we hear that 

expression concerning the outcome of 
some phase of human activity. And time does tell — though not always 
what we most wish to be told. Sometimes it tells us that our work was 
poorly conceived and ineffectively carried out. Sometimes it tells us — 
only too rarely — that it was good. 

In the latter group may be placed, we like to believe, the annual school 
hygiene conferences conducted by the State Department of Education and 
the State Department of Public Health. The seventh series has just been 
completed. Interest has not flagged in the slightest during the seven 
years but in fact has grown stronger. The basic subjects of nutrition 
and dental hygiene were taken up this year and discussed freely by those 
in attendance. Much was accomplished, it is hoped, not only by adding 
to the information of those present but also by defining more clearly the 
relationships of the various special workers in the public health field. 

A Correction. In the last issue of The Commonhealth, in the editorial 
entitled "The Strong Arm of the Local Public Health Offi- 
cials," the statement was made that syphilis ranked third as a cause of 
death in Massachusetts in 1927. This is incorrect. The statement should 
have read "syphilis ranked third among all reportable diseases as a cause 
of death in Massachusetts in 1927. The death rate for all forms of 
syphilis was 9.8 per 100,000 population. 

Child Health Day Material. Yes — again this year you can get the 

three health tags from the State Depart- 
ment of Public Health, and much earlier. In fact all the Child Health 
Day material is either at or on the way to print at this very day. This 
early preparation has been spurred on by the many requests and in- 
quiries concerning the Child Health Day material available for this year. 

There are two health plays picked from the group sent in last year that 
are suitable for intermediate and junior or senior high school production. 
A pantomime with plenty of action is especially appropriate for the little 
folks. 

The Department of Education has' given us splendid suggestions for 






103 
carrying on a Play Day, and by the way, Health Through Play is the 
popular slogan for 1929. 

The material offered for the dental campaign consists of the Notifica- 
tion of Dental Defects cards, the Dental Certificate, Classroom Record 
card and a Dental Honor Roll. 

And best of all we shall have a Child Health Day poster for free dis- 
tribution. Child Health Day is in large letters at the top, an attractive 
cut of children at play in the center, and a space for indicating the day, 
time and place of your celebration at the bottom. 

The new material will all be ready by February at the latest and may 
be secured by writing directly to the Division of Hygiene. A.P.M. 

Some Pre-School Nutritional Facts. An interesting glance at the pre- 
school nutrition problem is por- 
trayed by the recommendations given to 889 mothers who attended the 
Well Child Conferences this year. 

Teeth received more attention than any other item; that is, these 
mothers on the whole needed to be told of the value of the early care of 
teeth, of the importance of first teeth, the location and significance of the 
six year molar and of the care of the gums. The story of dark bread in 
the diet received second consideration. Two vegetables a day, or at least 
one besides potato or a potato substitute, rather surprisingly ranked 
third in the nutritional recommendations. Very little candy, a daily rest, 
proper breakfast and nothing between meals received instructions in the 
order stated. In the very small towns (1,000 population and under) bet- 
ter care of the teeth, use of dark bread and more frequent use of vege- 
tables were stressed, while in the larger towns (7,000 population and 
over) less candy, more milk and a daily rest needed the greatest consid- 
eration. A.P.M. 

Nutrition from the Nurse's Point of View. The most important factor 

in a nutrition program is 
the reaching of the mother by means of Well Child Conferences and home 
visits. In both of these instances one should keep in mind that simplicity 
should be the keynote. This is especially true of the matter of posters 
which often fail to make the desired impression because of the attempt 
to cover every phase of the subject at one time. This holds true also of 
home visiting and it should be the aim of the visitor to take up with the 
mother one point at a time. Otherwise the visit will tend to confuse her 
rather than to help her. 

Now, who should do the home visiting? Naturally, a nutritionist is 
the person having a wealth of material to give on nutrition but it is not 
possible for every community to employ such a trained worker. At Well 
Child Conferences, after the physical examination is made, a check-up of 
the findings often brings to light the outstanding need for advice in the 
selection, planning and preparation .of foods for the family. At such con- 
ferences a nutritionist is particularly necessary, but in many communi- 
ties where it is not possible to employ a nutritionist, we must turn to the 
nurse as the person to give this instruction during her home visits, be- 
cause, after all, the best teaching can best be done in the home. The 
mother, because of her visit to the clinic, is ready and eager to get this 
information. Many mothers have it pointed out to them that because 
of faulty food habits and improper diet and poor planning, their, children 
are underweight and not up to par generally. Therefore, the nurse should 
make it a point to keep in touch with the latest information on nutrition. 

As an ultimate aim in our public health program, should we not look 
for increased teaching of nutrition in the home? For the best results 
a community should make available a trained nutritionist who may be 
consulted by the nurse or who may follow up cases which the latter wishes 
to refer to her. H.M.H. 



104 

Mrs. Deland's Article — A Contrast. Mrs. Margaret Deland has very 

kindly given us permission to re- 
print the following article by her which first appeared in the Ladies Home 
Journal of March 1907. This was written only after considerable per- 
suasion by Mr. Bok and Mr. Deland. It is astonishing now to realize that 
this article lost the Ladies Home Journal many thousands of subscribers 
and that vituperative epithets were hurled at Mrs. Deland. 

It is surprising after twenty-one years how aptly the article presents 
the need of educating the parents on how to educate their children. This 
is one of the major activities of the Massachusetts Society for Social 
Hygiene which is working in close cooperation with this Department. 

We are profoundly grateful to Mrs. Deland for allowing us to use this 
article at this time. 



105 

"I DIDN'T KNOW" 

By Margaret Deland 

It was a certain dark December morning in Boston some twenty-five 
years ago. There had been a heavy snow storm, and the little crooked 
streets of the North End were choked with grimy snowbanks, that, melt- 
ing, spread an icy film over the uneven brick pavement. The day was 
gray and lowering, and there was not a gleam of cold sunshine to strike 
a sparkle from the icicles that fringed the eaves of the high-pitched roofs 
of the old houses — roofs which had once sheltered the dignity and intelli- 
gence and integrity of Boston. The houses, with their pillared doorways 
and curving, wrought-iron handrails, still had dignity, in spite of the 
squalid uses of adversity; but the human lives huddled in the stately, 
dirty old rooms, like rabbits in a warren, had only the dignity of the 
elemental passions — love and fear and the desire for life. As for intelli- 
gence, there was little enough of that in the whole run-down locality. 
And without intelligence, one need hardly look for integrity. 

From one of these old houses, swarming with tenants, had come early 
that morning an appeal ; it was written in lead pencil, on a crumpled scrap 
of paper, and it was very brief: 

"Pleas com an help us for Mamie's sak. She's in trouble." 

When I reached Number 42, where "Mamie's" family rented one room 
which they called "home," I pushed open the battered, unlatched front 
door, under its leaded fanlight, and went up the staircase. On the second 
flight I had to feel my way along its beautiful curves in darkness and 
evil odors. The fourth flight was lighter, and on the top floor was the 
tenement to which I had been summoned. It was a very small, clean gar- 
ret, with two dormer windows, from which one had a glimpse of crowding 
chimney-pots and trails of soot on the snow of steeply sloping roofs that 
spread below. The dull winter daylight was helped out by a lamp burn- 
ing on the table. There were four persons in the room, a mother, gaunt 
and heavy-eyed, sitting with her worn hands for once idle in her lap; 
she was rocking mechanically back and forth; sometimes she spoke softly 
to herself; sometimes a tear trickled down her face. Standing opposite 
her, one foot on a chair, his elbow on his knee, his unshaven chin upon 
his fist, was the father. He spoke only once, and then it was to swear 
at a boy of nearly sixteen who stood in sulky silence between them. This 
boy was turning his cap round and round in his hands; occasionally he 
kicked stealthily at the braided red and black rug in front of the stove. 
He would not look at either the father or the mother, nor would he look 
at a little girl who stood beside him. She was just fourteen ; her skirts 
were still short, her hair in two pigtails down her back ; her thin, childish 
hands were twisting together; once or twice she glanced at her father 
and mother, and the lines of bewildered fright in her small, sick face 
sharpened curiously. She shuffled from one foot to the other, and her 
lips contracted with pain. 

Her mother, without looking at her, said, dully and with evident effort, 
"Better sit down, Mame." Then, turning to me, she added, drearily, 
"Her baby'll be born next month. Yes — that there boy is the father." 

"I'd like to take the hide off him!" said the man, under his breath." 

"His folks feel 'bout as bad as we do over it," the woman said, as if 
trying to be just; "they're nice folks, real genteel. They live on the first 
floor and have a piano, — on installments. His father give him a whalin' 
— but there! What was the use? The trouble's made." 

So this was the "trouble" which the poor little crumpled note had not 
been able to put into words. It was for this hopeless situation that help 
had been asked. 

In blank dismay I sat staring at the unhappy group. Help them ! Could 
any "help" bring back to the father and mother their lost opportunity? 



106 
Could it save a child of fourteen from the responsibilities of maternity? 
How was she to be helped to live, to suffer, to bear the solemn human 
burden of giving life? Not by reproaches, certainly. The terrified, sick 
little girl did not know what was happening to her. When the mother 
suddenly broke out into piercing ejaculations of shame, Mamie only said, 
in a faint, frightened voice, "I didn't know — " Nor could anything be 
accomplished by reproaching the sulky, ignorant boy, who, with a show 
of impudence to hide his fear, made the same response. "Well, I wasn't 
thinking that — that anything would happen. I didn't know." — One 
could not appeal to shame — these children did not know the meaning of 
the word. There cannot be shame — cleansing, cauterizing, saving shame ! 
— unless there is knowledge of righteousness. No; the shame was not 
for the children — it was for the parents, for they "knew," and had never 
shared their knowledge! Nor was it a moment to talk of sin — to the 
children. 

These two poor babies were not sinners; they were as far from sin 
as they were from virtue; they were simply two joyful little animals, not 
immoral, but unmoral, as all animals are, and their untrained instinct 
had led them into a situation in which is rooted the deepest moralities of 
the race, namely, the relation of father and mother to another human 
being. It is absurd to classify as "wicked" the race impulse, which be- 
comes moral or immoral only when knowledge is added to it. No; the 
children were not to blame. As for the father and mother, that is another 
story ! 

It was this scene of childish fright and pain, and of helpless adult 
anger and shame, that came into my mind when I read Judge Lindsey's 
article published in the January number of the Ladies' Home Journal. 
And I knew that not one word of its warning was exaggerated. To be 
sure, the reply may be made that in Mamie's walk of life girls are espe- 
cially defenceless; that children of more fortunate parents would not 
need the protection of knowledge to keep them from the results of joyous, 
unmoral animalism. Of course it is true that Mamie's unguarded poverty 
did leave her peculiarly undefended. But that was not altogether why 
this baby of fourteen was going to bring another baby into her bitter 
world of penury and toil. It was because, as she so pathetically reiter- 
ated, she "didn't know." When this same statement is made by girls in 
a better class — girls whose fathers are clerks, business men, professional 
men — one stands appalled at the amount of avoidable misery which crashes 
into family life. Ignorance! Not viciousness. Very few children are 
vicious; they have no more wickedness than puppies, but they have the 
instinct of puppies — and demi-gods! They have the creative instinct, 
which, informed, becomes solemn and beautiful and tender, and makes us 
a little lower than the angels ; but uninformed may drag us far below the 
puppies. 

And what of the more guarded children — the children whose fathers 
and mothers do not belong to the class that finds the subject of Life 
either jocose or shameful? If guarded, these children may be safe from 
degradation of the body, but what of the unguarded mind? The school 
gossip of well-brought-up boys is the answer to that — gossip that spills 
over into girls' ears, so that the soul is left unclean. 

One hesitates to generalize on such a subject, but I think I may say 
that of more than one hundred girls (most of them mothers before they 
were twenty of illegitimate children) who had told me more or less of 
their wretched story, ninety per cent "didn't know." 

What are we to do? Certainly we are not to let the children "know" 
by the inexorable teaching of experience, as poor Mamie knew. We are 
to take very solemnly to our consciences this fact, that fathers and moth- 
ers are stewards of the mystery of Life. It is for them to keep the mys- 
tery sacred in their children's minds, defending it by the knowledge, the 
honor, the dignity, and the tenderness of Truth! 



107 

REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of July, August, and September, 1928, samples were 
collected in 161 cities and towns. 

There were 2,207 samples of milk examined, of which 721 were below 
standard ; from 85 samples the cream had been in part removed, 2 samples 
of which also contained added water; 54 samples contained added water; 
and 1 sample of skimmed milk which was below the legal standard. 

There were 183 samples of food examined, of which 51 were adulter- 
ated. These consisted of 6 samples of butter which were below the legal 
standard for fat; 10 samples of clams which contained added water; 21 
samples of eggs, 3 of which were decomposed, 15 were sold as fresh eggs 
but were not fresh, and 3 were cold storage not marked; 10 samples of 
maple syrup which contained cane sugar; 3 samples of hamburg steak 
which contained a compound of sulphur dioxide not properly labeled; and 
1 sample of dulse which contained insects. 

There were 16 bacteriological examinations made of clams in the shell, 
of which 5 were sewage polluted, and 11 unpolluted; and 18 bacteriologi- 
cal examinations were made of shucked clams, of which 4 were polluted, 
and 14 unpolluted; making an average of 26.5% of polluted clams. 

There were 34 samples of drugs examined, of which 9 were adulterated. 
These consisted of 8 samples of spirit of nitrous ether, and 1 sample of 
cresol, all of which were deficient in the active ingredient. 

The police departments submitted 2,600 samples of liquor for examina- 
tion, 2,550 of which were above 0.5% in alcohol. The police departments 
also submitted 17 samples of narcotics, etc., for examination, 2 of which 
were ergot, 1 quinine, 3 opium, 6 morphine, 1 tincture of iodine, and 4 
samples which were examined for poison with negative results. 

There were 66 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 55 cities and towns visited for the inspection of pasteur- 
izing plants, and 77 plants were inspected. 

There were 65 convictions for violations of the law, $1,160 in fines 
being imposed. 

Simon Dastugue of Sudbury; Augustine Forncari of Framingham; 
Lawrence F. Hanley, Charles Ernst, and Howard H. Fiske, 2 cases, all 
of Cambridge; Klemens Kulesza of South Hadley; John Pappas of 
Dedham; Frank Bassett, 2 cases, and Paul E. Prentice, 2 cases, both of 
Greenfield; Rene Delande, Lewis M. Flockes, Charles Pelletier, Sterios 
Dimetropolos, Phillip Gold, George Goulos, Lewis Porter, William Rich- 
ardson, John L. Sheehan, and George Vasilakos, all of Salem; Joseph 
De Vito of Stoughton; Antoni Gratta, Ferdinand Richards, 2 cases, 
George Varrouletos, and Joseph M. Vucassovich, all of Hull; Hagop Me- 
sakian of Watertown; Peter Stairopoulis of Springfield; Sotirio Velinusi 
of Nantucket; Josephine Di Girgori, Elly G. Hashem, and John J. Klink 
of Revere; Nicholas T. Eaton and Eric Fern of Newburyport; Charles 
Angelis and Nicholas Milona of Chelsea ; Ina Cantoni and Egbert Webster 
of Plymouth; Helaier Cournoyer, The E. F. Dakin Company, and Vassel 
Metro, all of Southbridge; Mike Zack of Hadley; John Frank of Salis- 
bury; Manuel Silvia of Provincetown ; and Frederick Thompson of West- 
wood, were all convicted for violations of the milk laws. Peter Stairo- 
poulis of Springfield, and Mike Zack of Hadley, both appealed their cases. 

Herman Urquart of Fall River; Samuel C. Doane of South Boston; 
George S. Mclntire of Essex; and The Great Atlantic and Pacific Tea 
Company of Watertown, were all convicted for violations of the food laws. 
Samuel C. Doane of South Boston, and George S. Mclntire of Essex, both 
appealed their cases. 

Philip Fonrkritis of Bridgewater; Christos Pappas, George Apostolu, 
and Peter Georgenes, all of Hull; Arthur Wright and Benjamin Levine 
of Newton; Charles Angelos and Steven Diamond of Chelsea; Appro- 



108 
cratis Sotiriow of Stoughton; Charles W. Burch of Provincetown ; The 
Great Atlantic & Pacific Tea Company of Newtonville; and The Great 
Atlantic & Pacific Tea Company of Cambridge, were all convicted for 
false advertising. 

Baker Brothers and Ellis Wood, each on 2 counts, of Lanesboro, were 
convicted for violations of the milk pasteurization laws. 

In accordance with Section 25, Chapter 111 of the General Laws, the 
following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers : 

Milk which contained added water was produced as follows : 6 samples, 
by Thomas Gojda of Westport; 4 samples, by Frederick Thompson of 
Westwood; 3 samples, by John Wesolishi of Cheshire; 2 samples each, by 
Floyd Holmes of West Bridgewater, and Joseph Hill of Framingham. 

Milk which had the cream removed was produced as follows : 3 samples, 
by Thomas Gavin of Sherborn; 2 samples each, by Nathan Schnider, and 
Joseph Hill, both of Framingham; and 1 sample each, by Charles West- 
gate of Medway, Mrs. P. J. Connors of Medfield, and Ernest Schoufelden 
of Cheshire. 

Two samples of milk which had the cream removed and also contained 
added water were produced by Joseph Hill of Framingham. 

Butter which was below the legal standard in fat was produced as 
follows : 

1 sample each, by Rabinovitz Creamery of Chelsea, Lynn, and Everett; 
H. Tannenbaum, Widlansky Brothers, and Springfield Butter Company, 
all of Springfield. 

Clams which contained added water were obtained as follows : 2 sam- 
ples each, from H. L. Dakin, Incorporated, of Worcester ; Manhattan Mar- 
ket of Cambridge; and H. 0. Atwood & Company of South Boston; and 
1 sample each, from Whitman Ward & Lee, Arthur E. Dorr Company, 
Incorporated, Shattuck & Jones, and Guy P. Hale, Incorporated, all of 
Boston. 

Hamburg steak which contained a compound of sulphur dioxide not 
properly labeled was obtained as follows : 

1 sample each, from The Great Atlantic & Pacific Tea Company of 
Cohasset, and North Weymouth; and Frank S. Hollis of Chelsea. 

Maple syrup which contained cane sugar was obtained as follows: 1 
sample each, from Colonial Lunch of Hingham; Royal American & 
Chinese Restaurant of Northampton; Busy Bee Lunch of Gloucester; 
William Ripley of Oak Bluffs ; Babe's Sea Grill of Southbridge ; King Joy 
Company of Lynn; S. Allen McLaughlin of Brockton; and Monument 
Lunch of Nantasket; and 2 samples from Wentworth Lunch of Boston. 
• Dr. Drury and Dr. Stirrett were in Lee during the epidemic for a 
period of nearly 3 weeks. 

There were five confiscations, consisting of 318 pounds of decomposed 
beef; 23 pounds of decomposed veal; 5 pounds of decomposed pigs' feet; 
25 pounds of decomposed frankforts; and 116 pounds of decomposed 
ducks. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of June, 1928: — 2,797,950 
dozens of case eggs; 912,391 pounds of broken out eggs; 5,525,096 pounds 
of butter; 863,547 pounds of poultry; 4,678,401% pounds of fresh meat 
and fresh meat products; and 8,562,684 pounds of fresh food fish. 

There was on hand July 1, 1928: — 10,345,500 dozens of case eggs; 
1,602,501 pounds of broken out eggs; 5,868,069 pounds of butter; 3,955,- 
471 pounds of poultry; 15,777,691 pounds of fresh meat and fresh meat 
products; and 17,806,365 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of July, 1928: — 1,324,950 
dozens of case eggs ; 896,970 pounds of broken out eggs ; 6,799,495 pounds 



109 
of butter; 1,380,150 pounds of poultry; 4,669,083 pounds of fresh meat 
and fresh meat products; and 6,100,665 pounds of fresh food fish. 

There was on hand August 1, 1928: — 10,964,870 dozens of case eggs; 
2,050,653 pounds of broken out eggs; 11,828,188 pounds of butter; 4,165,- 
105 pounds of poultry; 15,213,137% pounds of fresh meat and fresh meat 
products; and 22,240,154 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of August, 1928: — 844,740 
dozens of case eggs ; 754,302 pounds of broken out eggs ; 4,354,080 pounds 
of butter; 859,892% pounds of poultry; 4,540,331 1 / 4 pounds of fresh meat 
and fresh meat products ; and 3,259,696 pounds of fresh food fish. 

There was on hand September 1, 1928 : — 10,055,550 dozens of case eggs ; 
2,206,968 pounds of broken out eggs; 14,351,732 pounds of butter; 3,550,- 
938% pounds of poultry; 12,767,154 pounds of fresh meat and fresh meat 
products; and 23,274,402 pounds of fresh food fish. 



110 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration 
Division of Sanitary Engineering . 

Division of Communicable Diseases 

Division of Water and Sewage Lab- 
oratories ..... 
Division of Biologic Laboratories 

Division of Food and Drugs . 

Division of Hygiene 

Division of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark. 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, 

Merrill E. Champion, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 

The Southeastern District 



The Metropolitan District 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District . 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., Lowell. 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



Ill 



INDEX 

American Child Health Association Study . . . 

Barney, J. Dellinger, Treatment of Gonorrhea in the Male 
Bigelow, George H. and Frank B. Cummings, Rabies Control in 
Massachusetts ..... 

Boston Dispensary, A Food Lesson as it is Given at the, by Mary 

Pfaffmann . . 

Bridges, Agnes M., Nutrition Through the Senior High School Lunch 
Cancer Campaign ........ 

Cancer, Help Fight ........ 

Canine Rabies, by Hugh F. Dailey ..... 

Champion, Merrill, The Law Says ..... 

Cheever, Austin W., Treatment of Syphilis .... 

Child Health Day Material . . .... 

Coffin, Susan M., Progress of the Franklin County Demonstration 
Correction ......... 

Cummings, Frank B. and George H. Bigelow, Rabies Control in 

Massachusetts . . 

Dailey, Hugh F., Canine Rabies ..... 

Deland, Margaret, I Didn't Know .... 

Dental Clinic, The Health Program of the, by Ruth L. White 

Dental Hygiene, Regional Consultants in 

Dental Program, Developing the Prenatal and Pre-school Aspects of 

a Community, by F. M. Erlenbach . 
Diphtheria, Active Immunization Against, by Clarence L. Scamman 

and Benjamin White ... 

District Health Officer, by Edward A. Lane .... 

Drinker, Cecil K., The Massachusetts Society for Social Hygiene 
Editorial Comment: 

A Correction ...... 

American Child Health Association Study 

Cancer Campaign ..... 

Child Health Day Material .... 

Gonorrhea in the Female, Criterion of Cure of 

Law — and Persuasion ..... 

Mrs. Deland's Article — a Contrast 

Nutrition from the Nurse's Point of View 

Nutritionist, Meet the .... 

Plea for More Follow-up in the Homes . 

Public Health Institute .... 

Regional Consultants in Dental Hygiene 

School Hygiene in the Summer School . 

School Nurse, Choosing the .... 

Sentimentality in Public Health, The Role of . 

Social Worker and the Venereal Disease Clinic 

Ten Year Program, Results of 

"The Directory" 

"The Strong Arm of the Local Public Health Officials" 
Elkind, Henry B., The Mental Side of Nutrition 
Erickson, Esther V., Nutrition Work of the Ten Year Program 
Erlenbach, F. M., Developing the Prenatal and Pre-school Aspects 

of a Community Dental Program .... 
Everett, Madeline C, The Role of the Social Worker in the Treat 

ment of Gonorrhea ..... 
Foley, May E., Home Demonstration Agent as a Nutritionist 
Food and Drugs, Report of Division of 

January, February, March 1928 .... 

April, May June 1928 . . 

July, August, September 1928 .... 



112 

PAGE 

Food Lesson for Children as it is Given in the Boston Dispensary, 

by Mary Pfaffmann ....... 86 

Franklin County Demonstration, Progress Through the, by Susan 
M. Coffin 

Frothingham, Langdon, The Laboratory Diagnosis of Rabies 

Gonorrhea and Syphilis in Holyoke, Mass., by Helen I. D. McGilli- 
cuddy, and N. A. Nelson ..... 

Gonorrhea in the Female, by A. K. Paine .... 

Gonorrhea in the Female, Criterion of Cure of 

Gonorrhea in the Male, The Treatment of, by J. Dellinger Barney 

Gonorrhea, The Role of the Social Worker in the Treatment of, by 
Madeline C. Everett .... 

Goodnough, X. H., Rural Sanitation with Special Reference to Water 
Supply 

Health Program of the Dental Clinic, by Ruth L. White 

Hogan, Kathleen, Nutrition Work with Vocational Students of High 
School Age ........ 

Home Demonstration Agent as a Nutritionist, by May E. Foley 

I Didn't Know, by Margaret Deland ..... 

Immunization Against Diphtheria, by Clarence L. Scamman and 
Benjamin White ..... 

Lane, Edward A., The District Health Officer 

Law — and Persuasion ..... 

Law Says, The, by Merrill Champion . 

Lowe, Gertrude C, Nutrition Work in Adult Classes 

Massachusetts Association of School Dental Workers 

Massachusetts Society for Social Hygiene by Cecil K. Drinker 

Maternal Deaths in Massachusetts During 1927, A Statistical Sum- 
mary ...... 

May Day — Child Health Day, by Albertine C. Parker 

McGillicuddy, Helen I. D., and N. A. Nelson, A Study of Syphilis 
and Gonorrhea in Holyoke, Mass. . 

Mental Side of Nutrition, by Henry B. Elkind 

Miner, Harold E., The Control of Nuisances . 

Mrs. Deland's Article — A Contrast 

Nelson, N. A. and Helen I. D. McGillicuddy, A Study of Syphilis and 
Gonorrhea in Holyoke, Mass. 

Nuisances, Control of, by Harold E. Miner . 

Nurse and the Nutritionist, by Clyde B. Schuman . 

Nutrition from the Nurse's Point of View . 

Nutrition in the School Program, by Lydia J. Roberts 

Nutrition Program at the Summer Session at Fitchburg for Voca- 
tional and Continuation Teachers, by Martha Wonson 

Nutrition, The Mental Side of, by Henry B. Elkind 

Nutrition Through the Senior High School Lunch, by Agnes M. 
Bridges ........ 

Nutrition Work in Adult Classes, by Gertrude C. Lowe . 

Nutrition Work of the Ten Year Program, by Esther V. Erickson 

Nutrition Work with Vocational Students of High School Age, by 
Kathleen Hogan ....... 

Nutritionist, Home Demonstration Agent as a, by May E. Foley 

Nutritionist, Meet the ..... 

Nutritionist, The Nurse and the, by Clyde B. Schuman 

Paine, A. K., Gonorrhea in the Female . 

Parker, Albertine C, May Day — Child Health Day 

Pfaffmann, Mary, A Food Lesson as it is Given at the Boston Dis 
pensary ...... 

Pre-school Nutritional Facts .... 

Public Health Institute ..... 

Public Health Officials, The Strong Arm of the Local 



113 

PAGE 

Rabies, Canine, by Hugh F. Dailey ... 35 
Rabies Control in Massachusetts, by George H. Bigelow and Frank 

B. Cummings ..... 37 

Rabies, The Laboratory Diagnosis of, by Langdon Frothingham 32 
Rabies, The Treatment of Wounds and Prevention of the Disease, 

by M. J. Rosenau 27 

Regional Consultants in Dental Hygiene ..... 23 

Roberts, Lydia J., The Plan of Nutrition in the School Program 77 
Rosenau, M. J., Rabies, The Treatment of Wounds and Prevention 

of the Disease ........ 27 

Sanitation (Rural) with Special Reference to Water Supply, by X. 

H. Goodnough ........ 3 

Scamman, Clarence L. and Benjamin White, Active Immunization 

Against Diphtheria ....... 67 

School Hygiene Conferences .' . 102 
School Hygiene in the Summer School . .65 
School Lunch, Nutrition Through the Senior High, by Agnes M. 

Bridges 98 

School Nurse, Choosing the ....... 39 

Schuman, Clyde B., The Nurse and the Nutritionist ... 79 

Score Card, The Teacher's Own Health ..... 18 

Sentimentality in Public Health, The Role of .39 

Social Work and Syphilis, by Maida H. Solomon .... 57 

Social Worker and the Venereal Disease Clinic .... 65 

Social Worker, The Role of the, in the Treatment of Gonorrhea by 

Madeline C. Everett 59 

Solomon, Maida H., Social Work and Syphilis ?• 57 
Summer School Courses — Announcement ... .24 
Syphilis and Gonorrhea in Holyoke, Mass., by Helen I. D. McGilli- 

cuddy and N. A. Nelson ...... 62 

Syphilis, Social Work and, by Maida H. Solomon .... 57 

Syphilis, Treatment of, by Austin W. Cheever .... 54 

Teacher's Own Health Score Card ..... 18 

Ten Year Program — A Plea for More Follow-up in the Homes 22 

Ten Year Program, Nutrition Work of the, by Esther V. Erickson . 88 
Ten Year Program, Results of . .23 

"The Directory" 40 

Venereal Disease Clinic, Social Worker and the .... 65 
Water Supply, Rural Sanitation with Special Reference to, by X. H. 

Goodnough .......... 3 

Well Child Demonstration Conference, Summary of, Nov. 30, 1926 — 

Dec. 1, 1927 25 

White, Benjamin, and Clarence L. Scammon, Active Immunization 

Against Diphtheria ....... 67 

White, Ruth L., The Health Program of the Dental Clinic 90 
Wonson, Martha, The Program in Nutrition at the Summer Ses- 
sion at Fitchburg, 1928, for Vocational and Continuation 

Teachers 92 



Publication op this Document approved by the Commission dN Administration and Finance 
5003 12-'28— Order 4108 



THE 
COMMONHEALTH 



Volume 16 
No. 1 




JAN.-FEB.-MAR. 
1929 



MILK 



MASSACHUSETTS '• 
DEPARTMENT OF PUBLIC HEALTH 



^ 



"""IHKlth 



Quarterly Bulletin of«ithe- Massachusetts Department of 
Public Health 

Sent Free to, any X%ti&&^p£-jfee State 



tree to any. XJzt 





M. Luise Diez, M.D., Director of Division of Hygiene, Editor. 
Room 546 State House, Boston Mass. 



CONTENTS 



PAGE 

Milk Legislation, by George H. Bigelow, M.D 3 

Bovine Tuberculosis Eradication in Massachusetts, by Evan H. Rich- 
ardson . .4 

Milk Production, by Joseph C. Cort .5 

Milk as a Food, by Esther V. Erickson ...... 7 

A Brief History of Milk-Borne Disease in Massachusetts, by Filip C. 

Forsbeck, M.D 10 

What is Pasteurized Milk? by M. J. Rosenau, M.D 12 

Social Infection and the Community, by Bishop Lawrence . 14 

Editorial Comment: 

Should Health Officers Recommend Milk? .20 

Bishop Lawrence's Lecture ....... 20 

The Summer Round-Up ...... 21 

Correcting Defects in School Children . 21 

The Broadening Field of Cancer Education .21 

The New England He&Ith Institute .22 

The Gorgas Memorial Essay Contest . . .23 

To the Memory of Fred B. Forbes .24 

Report of the division of Food and Drugs, October, November and 

December, 1928 . ; .25 






1-r 



\r -.- 
3 -nrl, l£? 

MILK LEGISLATION 

By George H. Bigelow, M.D., 

Commissioner, Massachusetts Debarment of Public Health 

His Excellency, Governor Allen, pointed out in his inaugural address 
that there were three phases to an adequate milk supply : healthy animals ; 
clean methods of handling; and adequate cooling and pasteurization. This 
gives three distinct approaches to the improvement of our milk. 

(1) Healthy Animals. The two bovine diseases known to be spread to 
man are tuberculosis and undulant fever. We will hear more of the latter 
disease in the future. For the fourth consecutive year, the Department 
of Public Health is asking (House Bill 56) that eventually (except in the 
smallest communities where the matter is optional) all milk be either pas- 
teurized or from non-tuberculous cattle. The increase in remuneration to 
farmers for their infected cattle as authorized last year was a great help 
in this direction. His Excellency has in his budget an additional $100,000 
for this purpose. By June, Barnstable will be a "clean" county as far as 
tuberculosis is concerned. Fifty-six per cent of our population have been 
protected as our bill would protect them by rules and regulations promul- 
gated by their alert local boards of health. But this protected population 
is in less than a quarter of our cities and towns. At this rate it would 
take thirty years for the rest of the towns to come into line of their own 
initiative. Since we have the highest proportoin of tuberculous cattle of 
any state in the Union, this is not fast enough. The hypocrisy of infect- 
ing our children through milk in the name of nutrition and health must 
stop! 

(2) Adequate Inspection. Cleanliness of the cow, the milker's hands, 
the containers and all utensils, the separate milking room, automatic cap- 
ping (may all children be defended from the abomination of hand cap- 
ping) , the sterilization of containers — all this and much more are of vast 
importance since milk dissolves infected material with which it comes in 
contact. This will not take care of itself. Filth is cheap; scrupulous 
cleanliness is at the price of constant vigil! We never know where the 
disease germs may gain access. Also the milk must be promptly cooled. 
At body temperature it is said that the bacteria double every fifteen 
minutes. Before long the milk should be able to walk by itself ! 

To assure a wholesome product we must have competent, conscientious, 
tactful, courageous milk inspectors. Some persons seem to think a veteri- 
narian can go to a farm in the morning and be as "hard boiled" as the 
public interests demand, and still be asked by the same farmer to come 
out in the afternoon in a private capacity and give professional service. 
It's too bad to disturb such persons. They probably still believe in Santa 
Claus ! The only solution is, has, and will be full-time milk inspectors 
with adequate laboratory resources. But small communities cannot afford 
them. The solution is pooling of health resources by adjacent towns as is 
allowed in the permissive Health Union District Bill (House Bill 175). 
Barnstable County already has this inspection on a county basis and their 
enviable tuberculosis eradication record is a tribute to their excellent milk 
inspector. A similar solution would be given Berkshire County in House 
Bill 260 or House Bill 524. Either of these would accomplish great things 
provided the right personnel and adequate funds were obtained. Either 
bill would be a parody without them. 

(3) Pasteurization. In an astonishingly brief and comprehensive state- 
ment reprinted in this number of "The Commonhealth" Dr. Milton J. 
Rosenau of Harvard tells the whats and whys of pasteurization and Mr. 
Hermann C. Lythgoe of this Department reports the enormous improve- 
ment in the commercial application of this process since the passage of 
pasteurization plant licensing legislation two years ago. 

Boston has set the rest of the State an example by demanding that now 
all milk be either pasteurized or certified. Thus, over 99 per cent of Bos- 



ton's milk supply has the enormous protection afforded by pasteurization. 
The Department's bill (House 56) would require that all dealers through- 
out the State selling two hundred quarts or more shall have this milk 
either pasteurized or certified. It is, of course, true that disease can be 
spread by smaller quantities, but to a smaller number. Also, in the pres- 
ent state of manufacture, apparatus for pasteurizing smaller quantities 
economically is not available. At two hundred quarts pasteurization adds 
about two cents to the cost per quart, at one thousand quarts about one 
cent, and so on at a decreasing amount per quart. The housewife must be 
willing to pay this for the safety of her family since a raw milk that can 
underbid a pasteurized milk is an unsafe milk. Also, remember that had 
House Bill 56 been a law last summer and been enforced, the devastating 
epidemic of septic sore throat in the Berkshires would not have occurred. 
Finally, remember Dr. Rosenau's statement that milk-borne disease has 
never been spread by adequately pasteurized milk. 

BOVINE TUBERCULOSIS ERADICATION IN MASSACHUSETTS 

By Evan H. Richardson, 

Director, Division of Animal Industry, Massachusetts Department of 

Conservation 

In presenting an article on this subject I should like to give a bird's-eye 
view of conditions as I found them in Massachusetts on the first of June, 
1928. 

With a cattle population of about 188,000, only 17% were under State 
supervision for eradication of tuberculosis. Tuberculin testing at this 
time was confined mostly to retesting herds already under supervision, as 
cattle owners who were contemplating tuberculin testing under State 
supervision were holding off until the first of December when the law 
allowing increased indemnity was to go into effect. 

Pressure by the Division of Animal Industry was not brought to bear 
upon those who were awaiting that date, as on the average, under the law 
then in force, the owners of cattle were losing from forty to sixty dollars 
per animal, and as in an important step of this kind for the benefit of the 
public as a whole, the farmer is certainly doing more than his share to 
assure the public of a healthy milk supply. 

In comparison with other states, Massachusetts stands at the bottom 
of the list in percentage of cattle under test. North Carolina on June 1, 
1928, was 100% free from tuberculosis, and many of the large cattle states 
were from 60% to 80% under test. In New England we find Maine with 
about 90%, and New Hampshire, Connecticut, and Vermont approxi- 
mately 50%. Conditions responsible for this low standing in Massachu- 
setts were to a certain extent, first, the so-called cattle fraud cases that 
were an upset to the work, and second, the fact that Massachusetts is an 
importing State bringing in from other States around 25,000 cattle per 
year. You can readily see that in the surrounding States which are so 
far advanced in this work the dealers in cattle, shipping into Massachu- 
setts would not all be over-particular in the kind of cows they send. 

It is also true that in the surrounding States the farmers are more 
nearly reimbursed for the value of their reactors. 

These conditions have been improved during the last few months so 
that at the present time we are making progress in a cleanup campaign, 
and with the program of good work going on, Massachusetts should soon 
advance to a better standing among her sister states. Conditions that 
have made this possible are first, the increased indemnity that went into 
effect December 1, 1928, which increase adds from $20 to $25 on reim- 
bursement for each reactor, and secondly, the drive which has been made 
by some of the milk contractors in their desire to buy milk from tubercu- 
lin tested cows ; also the rules and regulations that are being put in force 
by the local boards of health who are demanding in many cases that all 



milk sold in their respective cities or towns be either pasteurized or from 
tuberculin tested cows. 

The Brighton Market, the only market of its kind in the United States 
and which handles from 200 to 500 dairy cows per week, has improved 
during the last few months, and the dairy farmers of the State can be 
assured by using the information that is freely offered them by the offi- 
cials at Brighton, of getting the kind of cows they desire. All dairy cows 
are entitled to either a white or pink certificate, the white certificate indi- 
cating that the cow is eligible for entrance to a herd under supervision, 
and the pink certificate that the animal cannot be added without addi- 
tional test. All trucks bringing reactors into the Brighton Market are 
required to be cleansed and disinfected before leaving that Market. Since 
January 1st preventive hemorrhagic septicemia or shipping fever treat- 
ment has been supplied to the Brighton dealers with a minimum cost to 
them. 

The greatest problem at the present time is to persuade the dealers in 
dairy cattle, scattered all over Massachusetts, to exercise the care and 
precaution that is necessary in furnishing replacements to farmers whose 
herds are under supervision. We believe that it is only a question of time 
when those dealers will be of considerable assistance to us in this prob- 
lem. At the present time they are making inquiries and considering 
methods by which they may best serve the man who wants to buy clean 
cows. 

In November and December of 1928 over 18,000 cows were tuberculin 
tested, and of this number 8,000 were in herds that had never been under 
supervision before. Requests for tests are coming in so rapidly that we 
find it difficult to keep up with the demand. In June about 17% of the 
cattle in Massachusetts were under supervision, the first of December 
over 21%, and at the present time over 25%. About 95% of the pure- 
bred cattle in this State are under test, for the man who is commercially 
interested in their breeding is under the necessity of maintaining a clean 
herd if he wants to do business. The farmers of the State are becoming 
more interested and are beginning to realize the importance of producing 
milk from tuberculin tested cows. 

At the present time there are over a million cows a month tested in the 
United States. Iowa has 2,689,962 cows under supervision, Wisconsin 
2,469,026, and there are six other states — New York, Illinois, Indiana, 
Michigan, Minnesota and Ohio — that have well over a million under super- 
vision. Over $20,000,000 including Federal and State appropriations, are 
spent yearly in the United States in this work, and when we realize that 
North Carolina is clean and many of the large cattle states are well over 
70% clean with our immediate neighbors Connecticut, New Hampshire 
and Vermont over 50%, and Maine at the present time with 236,145 cattle 
under supervision and the expectation of reaching the 100% mark next 
June, it behooves Massachusetts to make considerable effort to keep up 
with the other states in their progress in the eradication of bovine tu- 
berculosis. 



MILK PRODUCTION 

By Joseph C. Cort, 

Director, Division of Dairying omd Animal Husbandry, Massachusetts 
Department of Agriculture 

From the earliest records of history the cow and goat have held most 
important roles in the lives of man. The very existence of the people of 
olden times depended solely upon the milk and cheese given them by their 
herds. Perhaps the gravest mistake made by our Pilgrim Fathers was in 
not bringing with them a few cows. The sickness and loss of life would, 
no doubt, have been lessened during the first few years by the use of milk. 
Later dairy cattle were brought here from Holland and England and have 



since taken their rightful place which they have held all during the ages 
in the lives of man. 

New England has been developing as a dairy region as fast as popula- 
tion has increased. Twenty-five or thirty years ago Northern New Eng- 
land and Western Massachusetts were producing butter and cheese. Now 
these regions are sending fluid milk to the cities, and only remote places 
without adequate transportation facilities continue to produce butter and 
cheese. The population of New England is centered in the southern por- 
tion which could not be supplied by locally produced milk in sufficient 
quantities. The result is a constant widening of the area from which the 
product is drawn. In 1900 Massachusetts and Southern New Hampshire 
supplied most of Boston's milk, but today the supply comes mainly from 
Vermont, Maine, New Hampshire, Canada and New York. The secondary 
markets like Worcester, Springfield, Fall River, New Bedford and the 
Merrimac River cities still get the larger proportion of their milk from 
nearby territory, while the smaller cities and towns of the State get their 
entire supply locally. Massachusetts produces only 23 per cent of the en- 
tire amount of milk produced in New England, but in contrast has nearly 
52 per cent of the population. 

The trend of the dairy cow population in Massachusetts has been down- 
ward for the past twenty years. During the War period a temporary 
comeback was made until 1922 when the decline was continued to the 
present low level. It is interesting to note that in the meantime the aver- 
age production per cow has steadily increased. This increased efficiency 
of the dairy cow is due to several factors ; among these are : 

1. Improved breeding 

2. Better feeding 

3. More careful management 

The use and influence of pure bred sires on common or grade cattle has 
been very marked. The constant selection of sires from dams with su- 
perior producing ability has stamped this characteristic on the offspring. 
The percentage of pure bred cattle to the total number is small, but the 
improvement in the quality of the average cow as a result of the breeding 
up process has been remarkable. Massachusetts ranks rather high in the 
per cent of pure bred cattle ; some of the most famous breeding establish- 
ments in the country are located here. The principal breeds of dairy cat- 
tle are : Holstein imported from Holland ; Ayrshire from Scotland ; Guern- 
sey from the island of Guernsey; Jersey from the island of Jersey and 
Brown Swiss from Switzerland. 

The New England dairyman, in most cases, has abundant pasturage and 
can raise hay and other roughages for his needs. Grains for the most 
part are brought from the West, as it is cheaper to buy than to grow. 

The development of the science of livestock feeding has been rather 
recent. Maximum production cannot be obtained without the use of bal- 
anced rations, containing the proper combinations of the various elements 
necessary to nutrition. These are carbohydrates, proteins, fats, minerals 
and vitamins. Modern dairy rations are carefully mixed so that they meet 
the needs of the animal for growth, maintenance and milk production. 

The use of labor saving machinery and equipment such as tractors, 
trucks, milking machines and cooling apparatus has helped to bring about 
more profitable production. The application of business methods involv- 
ing the weighing and testing of the milk from each cow and the keeping 
of records and accounts has been one of the progressive steps. The elimi- 
nation of low producers has been a means of raising the herd average. 

In spite of the improvement made by dairymen, many find it difficult to 
get adequate returns from their investment. The cost of production is 
high and the price received is not always sufficient to cover this cost. The 
industry has at times been handicapped because of the reluctance on the 
part of dealers to raise the price of milk. The dealers have feared that 



the reaction of the consumers to one cent raise in the price of a quart of 
milk would be a decreased demand. Producers' organizations have been 
greatly strengthened in recent years and have been presenting the farm- 
er's case to the public in such a fair way that little feeling now exists to 
price fluctuations. 

The public is rightly demanding that in return for a fair price the 
farmers must produce a product that measures up to certain definite qual- 
ity standards. In order to insure this high quality, milk inspection both 
in the country and in the city plants has been established. Milk inspec- 
tion was first started in the United States in 1858 when Massachusetts 
passed laws forbidding the adulteration of milk. Since this beginning the 
system has developed until now the Federal Government, State Govern- 
ments, municipalities and private milk companies are engaged in the work 
of inspecting the milk supply. Most of the responsibility falls on the city 
Boards of Health who establish laboratories and employ men qualified to 
carry on the work. 

A set of rules and regulations governing the various points essential in 
the control of the production and handling of milk is usually adopted. The 
object is to insure a clean, safe supply. The following are the more im- 
portant things that should be included in a good milk inspection program : 

Cows — The health of the herd is vital and must receive first consid- 
eration. All diseased or abnormal animals should be eliminated. Especial 
care should be taken to examine the udders for lumps, unsound quarters, 
inflammation, etc. That the sides, flanks and udder should be clean and 
free from dirt and manure is obvious. 

Milker — The personal element is responsible for a great variation in 
the bacteria count of the final product. Disease carriers should be pro- 
hibited from working on dairy farms. 

Stables — The conditions under which livestock are housed has influ- 
ence upon the quality of the product. Stables should be well lighted, ven- 
tilated and have tight, smooth walls, ceilings and floors. They should be 
kept clean and supplied with sufficient light and air. 

Milk Room — A suitable milk room is necessary for the proper care 
and handling of milk. It should be clean and provided with equipment 
for adequate cooling and storing. 

Utensils — Milk pails, cans and other utensils used in handling milk 
should be properly constructed and kept clean. Sterilization is the only 
way to insure sanitation. 

Cooling — Immediate cooling to a temperature of 50° fahrenheit or 
lower is the best way to hold the bacteria count down. It must also be 
held at a low temperature while at the farm or during the period of trans- 
portation to the City Milk Plant. A supply of ice is needed during most 
of the season. The best method is the installation of electric cooling 
equipment. In many instances this has proved cheaper and certainly is 
the most effective way of getting results. 

The consumer prefers to have milk that is clean instead of milk that 
has been cleaned. In other words it is best to keep the dirt out of the 
milk than to take it out by straining or filtering. The better farmers of 
Massachusetts are in hearty accord with a program that calls for the im- 
provement in the quality of milk. They realize that their market depends 
upon satisfied customers and are willing to make any reasonable altera- 
tions and go to considerable expense to meet the demands. 

MILK AS A FOOD 

By Esther V. Erickson, 

Consultant in Nutrition, Massachusetts Department of Public Health 

"Forasmuch as children's stomachs and old men's bodies and consumed 
men's natures be so weak that not only the flesh and the fish, but also the 
fruits of the earth are burdensome to their tender and weak bowels ; God 



tendering the growing of the one and preservation of the other, and 
the restoration of the third, hath therefore appointed milk; which the 
youngest child and weariest old man, and such as weakness has consumed, 
may easily digest. Cow's milk nourisheth plentifully, increaseth the 
brain, feedeth the body and restoreth the flesh." 

That milk is of value to the human body is not a recent development or 
propaganda of health workers. The above quotation is taken from a cook- 
book published over 250 years ago. A bit quaint in expression but hardly 
so in truth. 

Let's take a modern setting. Picture a group of interested mothers, 
eagerly listening to a lecture on food selection. The speaker may be a 
nutritionist, a home demonstration agent or a home economics teacher. 

"Milk should be included in the diet of every normal person: 1 quart 
daily for the child ; 1 pint for the adult. Or, to quote Sherman, 'A quart 
for every boy baby until he is full grown and a quart a day for every girl 
baby until she has weaned her last child' ", forcefully states the lecturer. 

Her audience becomes querulous. "Oh, but milk is so expensive!" "I'm 
fat enough without it!" "Isn't there some other food that will take the 
place of it?" "My family won't drink it!" 

What are the answers? 

Food Necessary for Body Functions 

The body, to be adequately nourished and healthy, requires from its food 
that it should be furnished energy for activity; protein for building and 
repairing; minerals for building and regulating; vitamins for health and 
growth; roughage for regulation. The diet as a whole then should meet 
those needs. Milk alone will not do it entirely but is the one food which 
fulfills most completely our needs. It has no one substitute in food value. 
Though most foods are interchangeable to a certain extent, milk is an ex- 
ception. 

Milk is not Expensive 

Consider the protective food, milk, from the standpoint of each of the 
above requirements of the body. The energy or caloric value of milk is 
675 calories to the quart. For this we pay fifteen cents, as an average 
price. Compared to cereals, our cheapest source of energy, this is expen- 
sive. Fifteen cents will buy in the form of rolled oats about 3,713 calories. 
However, compared with foods of its own class ; i. e., protein foods — which 
as a group are expensive sources of energy — milk furnishes inexpensive 
energy. For instance, it is equivalent in fuel value to nine eggs, worth 
at this time approximately fifty cents. Factors other than energy must 
be considered, the quality of the diet as well as quantity. 

As a protein food, milk ranks among the highest. Not only does it 
furnish a large amount of this substance but gives a type of protein most 
suitable for the consumption of the human being. We know these foods 
add protein to the diet: milk, eggs, cheese, meat, fish, dried beans and 
peas, nuts and whole grain cereals. The foods from animal sources ; i. e., 
milk, egg, cheese, meat and fish contain protein of the most adequate type. 
Because of this quality they are used often to supplement proteins from 
vegetable sources, as milk with cereal or cheese with macaroni. 

Milk a Builder of Bones and Teeth 

The minerals with which we are most concerned in our dietary plans 
are calcium or lime, phosphorus, and iron. Milk is our one most reliable 
source of calcium, the substance needed especially during the growth 
period when bones and teeth are forming — the prenatal, infant, pre-school 
and school periods of the individual. The question of the influence of 
adult feeding on the condition of that adult's teeth is yet to be decided. 
We do know, however, that calcium as a regulator is still needed by the 
adult and such is best furnished in a pint of milk daily. The child with 



an increased demand because of growth can best be supplied this lime by 
a quart of milk. The food is the best protection and the most economical 
for calcium or lime needs. 

Another builder of bones and teeth and a regulator is phosphorus, ade- 
quate amounts of which are easily furnished by the same quantity of milk 
as stated above. Some other foods, as oatmeal, dried beans and peas, 
graham bread, are less expensive means of obtaining phosphorus, but com- 
pared with white bread, cabbage, raisins, eggs, meat, milk is an econom- 
ical means of assuring a sufficient supply of this mineral. 

Iron is present in milk in small amounts, this being the one deficiency 
of the food. The iron present appears to be exceptionally well utilized, 
but even so, we are all aware that cases of milk anaemia do occur. Ex- 
periments to increase the amount of iron in milk by varying the food of 
the animal have proved unsuccessful. It is important, then, to remember 
that iron foods must be furnished. Nature provides the newly born in- 
fant with an abundant storage of iron in his liver that he may draw on 
this supply while his diet is largely made up of milk. This supply is de- 
pleted by about the ninth month, hence the need for the addition to the 
diet before that time of foods furnishing the necessary iron. 

The vitamins in milk depend much upon the food of the cow and there- 
fore vary according to the season and the pasturage. Vitamin A — needed 
for growth, prevention against respiratory infections and against an eye 
disease — is present in the fat of the milk in comparatively large amounts. 
Whole milk should be stressed. Vitamin B — concerned with growth, ap- 
petite, intestinal health and prevention against beri-beri — is also found 
in milk. For a source of Vitamin C, we cannot depend upon milk for a 
satisfactory supply as the amount varies greatly with the food of the cow. 
Experimenters have found that animals on pasture have produced milk 
twice as rich in Vitamin C as those stall fed, even when silage was fur- 
nished the latter. This vitamin, which is, of course, the scurvy preven- 
tive, is easily destroyed by heat in the presence of oxygen. The pasteuri- 
zation process probably destroys much of it. Fresh fruits and vegetables 
will add to the diet an adequate amount of Vitamin C. But small amounts 
of Vitamin D, the anti-rachitic factor, occur in milk. Hence, the use of 
cod liver oil or sunlight for the protection of the infant. Milk contains a 
small quantity of Vitamin E, concerned with the nutrition of the embryo 
and sperm. 

To sum up the nutritive and economical value of milk, we may say that 
this food is an economical source of adequate protein, calcium, phosphorus, 
Vitamin A and B. It also furnishes an easily digested fat and sugar, some 
iron and very small amounts of Vitamin C, D, and E. 

Methods of Using Milk 

To the housewife, it is oftentimes a problem to bring about the con- 
sumption of the amounts of milk recommended. That one must drink this 
whole allotment is a mistaken idea. Much of it can be used in cooking in 
combination with other foods. Leftovers may be disguised or made more 
attractive with milk. 

Suggestive methods of using milk: — 

Creamed dishes: creamed vegetables, fish, meat, eggs. 

Scalloped dishes: scalloped vegetables, fish, meat, eggs, cheese. 

Cream soups: carrot, tomato, celery, potato, etc. 

Chowders: fish, corn, vegetable, clam, etc. 

With cereals: macaroni and cheese, rice and cheese, to replace half of 
liquid in which breakfast cereal is cooked, rice pudding, tapioca pudding. 

Milk desserts: custards, blanc mange, ice cream, junket, bread pudding. 

Beverages : cocoa, egg nog. 

With ingenuity, milk can be introduced into many prepared foods with 
which perhaps we are not accustomed to associate it. 



10 
Milk Alone not an Adequate Diet 

With milk as a basis for the adequate and optimum diet, what addi- 
tional foods are required to bring about an optimum diet? Milk alone 
will not do it! To be assured that his needs for protein, minerals, vita- 
mins and energy are met, the individual should include daily in his diet 
the following: milk as stated above, 1 quart for the child, 1 pint for the 
adult; vegetables, two servings besides potato, one of these preferably 
raw; fruits, two servings, one raw; whole grain cereal, one serving; meat, 
one serving only; 1 egg. Additional servings of energy foods, cereals or 
bread, butter and sweets as molasses, honey, jellies, will probably be 
needed to fill this need. 

Where we have a low income family with a minimum to spend for food, 
we must make a definite attempt to insure a diet, adequate if not optimum. 
With few exceptions when the food budget is low, the food first to be 
affected is milk. It seems expensive and only a drink. This is poor 
reasoning and logic when we consider the protective qualities of the food 
that it in itself best and most economically provides the factors which are 
essential to life and growth. In such a family the minimum milk allow- 
ance should be one and one-half pints daily for each child and one and one- 
half cups for each adult. In this case, too, special emphasis is needed on 
whole grain cereals, sources of minerals which are often lacking in a mini- 
mum diet. 

Supply Safe Milk! 

Since "cow's milk nourisheth plentifully, increaseth the brain, feedeth 
the body and restoreth the flesh" and is essential during the whole life 
span of the human from the prenatal stage to old age, there should be 
available in every community a supply of clean milk, of good quality and 
under adequate sanitary supervision. 



A BRIEF HISTORY OF MILK-BORNE DISEASE IN 
MASSACHUSETTS 

By Filip C. Forsbeck, M.D., Epidemiologist 

No reference is made to milk in the short first annual report of the 
"State Board of Health." The secretary, Dr. George Derby, contributes 
an article on "The Prevention of Disease," and indulges in the statement 
that, "The epidemic of fever at the Maplewood Institute in Pittsfield a 
few years ago was caused by an accumulation of filth, and ceased on re- 
moval of the cause." . . . "deadly gases of the sewers may escape in the 
very rooms in which we sleep," it is stated, but no mention is made of 
milk as a vehicle of infection or in any other connection. Times have 
changed. Sewer gas has been almost forgotten, but the battle against 
dirty and infected milk is at its peak. In the Second Annual Report one 
may read a sixty-nine page report (1871 Annual Report, p. 120), entitled 
"An Inquiry into the Causes of Typhoid Fever, as it Occurs in Massachu- 
setts." Here are truths, half-truths, and fiction, knitted together with 
verbiage. Evidently it is beginning to be realized that water is important 
as a health problem, but not any more than pigsties, manure heaps, putrid 
air, rotting vegetables and bad drains. Milk is not mentioned as a source 
of typhoid fever in this article, but on page 426 is an article on "The 
Effects of the Use of Milk from Cows Affected with Aphtha Epizootica." 
This is the first report of a milk-borne outbreak in Massachusetts. In the 
summary we read: 

"1. It is proved that Aphtha Epizootica may be communicated to man 
through the medium of diseased milk, as well as by direct contagion. 

"2. The disease produced in human beings by the use of this milk is not 
usually to be dreaded, for it is by no means formidable; it is generally 



11 

limited to a sore mouth, and in very rare instances is accompanied by an 
eruption on the surface of the body. The use of such milk by feeble per- 
sons and young children might however be followed by more serious con- 
sequences." 

* * * * * 

"In accordance with the general law that animal poisons are destroyed 
when subjected to a very high temperature, we are justified in believing 
that the affection can never be communicated to man through the medium 
of the meat provided it be thoroughly cooked, and upon the same principle 
the milk might be rendered innocuous by being boiled." 

It seems strange, as we look back, that this outbreak of hoof and mouth 
disease transmitted through milk should not have startled health authori- 
ties into an investigation which might have revealed the real part that 
milk must have been playing in the transmission of communicable disease. 
Milk is not mentioned in the 1872 report, but in the 1873 report there 
is an article on "The Adulteration of Milk." No mention is made of milk- 
borne disease, nor is milk mentioned again until in the 1877 report. On 
page 122 an epidemic occurring in England is described, in which milk 
apparently had either been diluted with polluted water or the milk cans 
had been washed with said water. In the 1878 report on page 325 it is 
stated: "Much evidence has been presented by several observers to show 
that milk forms a favorable medium for the transmission of the 'germs' 
of different diseases, such as typhoid and scarlet fever. That it has been 
the vehicle by means of which the latter disease has been conveyed to 
many persons, seems indicated by the following evidence." Reference 
then is made to an apparently milk-borne epidemic of scarlet fever in 
England. It seems amazing that with this evidence no milk-borne out- 
break should have been described up to 1877 in Massachusetts except the 
one of hoof and mouth disease in 1871. In this same volume on page 485 
is described an outbreak of typhoid fever in Taunton. By reasoning 
which would not hold water with our present knowledge of the disease, 
milk as a vehicle of infection is eliminated. As a matter of fact, there 
were but seven cases among four or five hundred supplied with this milk 
while during the same period there were twelve other cases of typhoid 
fever in Taunton. Statistically, it is true, it would be impossible to con- 
demn the milk as the mode of infection, but there is some evidence indi- 
cating that a portion of the milk may have been infected. 

In 1883 the first annual report of milk inspection is made, but no refer- 
ence is made to milk-borne disease! 

In 1886 the second milk-borne outbreak of disease is reported, fifty 
cases of typhoid fever being definitely traced to milk. The statement is 
made, however, that the infection may have been due to washing the milk 
cans with polluted water. 

The next year the first outbreaks of scarlet fever and diphtheria are 
reported. In this report milk is admitted to be firmly established as a 
vehicle of infection. In 1889, emphasis is placed on the danger of disease 
being transmitted by milk both from humans and from cattle (1889 An- 
nual Report, p. lxi). In the 1890 report, p. 570, Waltham proposes "to 
make provision before hot weather whereby sterilized milk shall be on 
sale under the guaranty of the board." In 1890 (Annual Report, p. 676), 
pasteurized milk is mentioned as a public health measure. During the 
period 1891-1896, seven outbreaks of milk-borne disease are described, 
thanks in most instances to the enthusiasm of Sedgwick. In October, 
1898 a medical inspector was appointed by the Board of Health. This 
appointment is followed by a quadrupling of the number of reported milk- 
borne outbreaks in the following few years. In 1900 (Annual Report, p. 
800) , it is stated, "The increasing frequency of epidemics of typhoid fever 
which are traced to the use of milk from dairy farms at which unsanitary 
conditions are found on inspection, is worthy of special note." 

The number of reported milk-borne outbreaks increased at the rate of 



12 

about 7 per cent per year from 1898 until 1914 when the peak was reached, 
thirteen outbreaks being reported. From that year to the present the 
rate of decrease has been about 15 per cent per year. There has been very 
little decrease, however, in the past eight or ten years. Part of this de- 
crease has been probably due to the total decrease in diphtheria and ty- 
phoid fever, but the great increase in the use of pasteurized milk has un- 
doubtedly played the largest part. It is worthy of note that of about one 
hundred and seventy-five reported milk-borne outbreaks in Massachusetts, 
not a single one has been traced to pasteurized milk. 

About 60 per cent of the milk consumed in Massachusetts is pasteurized. 
Further progress in the elimination of milk-borne disease will depend 
upon the rate that the percentage of pasteurized milk increases. 



The following statement by Dr. Rosenau, with the accompanying cut of 
thermometer, is available in leaflet form for distribution from the Massa- 
chusetts Department of Public Health to boards of health, physicians and 
others interested. 



WHAT IS PASTEURIZED MILK? 

Definition. Pasteurized milk is defined by state law as milk heated to 
140°-145° F. for thirty minutes. 

Object. The only object of pasteurization is to destroy the disease 
germs which are sometimes found in milk. 

Milk-Borne Diseases. The following diseases are known to be milk- 
borne: tuberculosis, typhoid fever, scarlet fever, diphtheria, septic sore 
throat, foot-and-mouth disease, dysentery, and other intestinal troubles, 
especially in infants. To this long list has recently been added epidemic 
arthritic erythema and undulant fever. Three small outbreaks of infan- 
tile paralysis have been traced to raw milk. 

In the last twenty years over six hundred milk-borne epidemics have 
been reported in this country. Who can say how many have occurred un- 
recognized? 

Pasteurization spells protection so far as these diseases are concerned. 

Official Supervision. Our regulations provide ample authority to insure 
adequate pasteurization. They also safeguard the cleanliness of milk be- 
fore pasteurization. Both the local and state health authorities are re- 
sponsible for the enforcement of our pasteurization laws. 

Inspection. Milk should be inspected even though pasteurized. Pas- 
teurization does not remove the need of sound cows, healthy milkers and 
clean dairy methods. Milk is subject to official inspection from pasture 
to pail and from pail to palate. Through inspection our milk supply is 
steadily improving. Inspection provides for cleaner, fresher and better 
milk, but not necessarily safe milk. Raw milk, however carefully handled, 
has frequently caused disease. THERE IS NO RECORD OF MILK- 
BORNE EPIDEMIC DUE TO PROPERLY PASTEURIZED MILK. 

Digestibility. Pasteurized milk is quite as digestible as raw milk; in 
fact, the heat of pasteurization produces no appreciable physical or chem- 
ical change. Pasteurized milk is quite as nourishing. 

Pasteurization and the Vitamins. Pasteurized milk is a good source of 
some of our vitamins. Whether milk for infants is raw or pasteurized it 
should be supplemented with orange or tomato juice to prevent scurvy, 
and sunshine and cod liver oil to prevent rickets. There can be no more 
objection to the heating of milk than there is to the cooking of meat. 

Pasteurization is the simplest, cheapest and most effective way of giv- 
ing you and your family protection of your most important single food 
product. PASTEURIZATION SAVES LIVES AND PREVENTS SICK- 
NESS. 



13 



HOW PASTEURIZATION SAFEGUARDS 
YOUR MILK SUPPLY 



Vitamin C destroyed 



Slight reduction in Vitamin C 
Tuberculosis germ killed 

Septic sore throat germ killed 



Maximum Legal Temperature 
after Pasteurisation 



iero 



179 



50 






212 



160 



130 



Boiling point 



(Pasteurised milk is not 

Boiled or Cooked milk) 



Cooking commences 



}PASTEURIZATION 

Tuphoid and Dt^senter^ germs killed 
Diphtheria germ killed 



Bodu, Temperature 
(germs multipluj 



32 Freesing 



* Pasteurised milk is natural cow's milk not more than seventy- two hours 
old, when pasteurised, subjected for a period of not less than thirtu, minutes to 
a temperature of not less than one hundred and fortu., nor more than one 
Hundred and fortu-five degrees Fahrenheit, and immediately thereafter 
cooled to a temperature of fif tt^ degrees Fahrenheit or lower. 



14 

SOCIAL INFECTION AND THE COMMUNITY 

Lecture by Bishop Lawrence at the Harvard Medical School, 
Sunday, January 6, 1929 

In the spring and summer of 1927 the parents of little children through- 
out the State were anxious, and some of them panicky, for public notice 
had been given that an epidemic of infantile paralysis was probable : and 
who that has watched even one case of a paralytic victim can wonder at 
the dread? The epidemic came and went, resulting in 1,189 cases, with 
169 deaths. 

Meanwhile, and during that same year, and for many preceding years, 
two diseases were sweeping through the State, killing at least 504 vic- 
tims each year and sending 243 into the insane asylums. Yet with all this 
devastation there was hardly a whisper of the scourge in the public 
prints ; and though tens of thousands of men and women talked privately 
of it, and thousands of people were indirectly affected, silence upon the 
dread disease was good form : the lid was clamped down. 

To go further, throughout the nation there were reported in 40 states 
2,520 cases of infantile paralysis, and in the same year 200,534 cases of 
one of these diseases alone, entitled by Dr. Osier, "the greatest killing 
disease." 

These venereal diseases are not mentioned in polite society. There is a 
common consent of silence. Newspapers and periodicals which do not 
want to lose their circulation are careful not to offend their readers. 
Meanwhile, the carnage goes on and we live in a fool's paradise. You 
know already their names, but you do not speak them. They are syphilis 
and gonorrhea. 

Soon after we entered the war and the recruits came into camp, the 
problem of their health, social welfare and moral protection, and that of 
the women of the neighborhood also, arose. There were hearings at the 
State House, and new laws were passed. 

As I was walking down Beacon Street from one of these hearings, my 
companion, an army officer, said, "I tell you, Bishop, when the physical 
and moral welfare of our boys in camp is at stake, the legislators and 
people take notice." "True," I replied, "if we are going to build up an 
army and beat the Germans, we must keep the men from disease, clean 
and vigorous. But," I added, "do you think, General, that the moral and 
physical welfare of our boys and men is of any more value to their parents 
and the community in war than in peace? Some of us have been up to 
the State House on this job several years with very meagre results. Have 
we got to have a war to make legislators sit up and take notice?" 

The work of our country in camp protection is one of the great records 
of the war. Two years before, a few months of encampment on the Mexi- 
can border, with its horror of immorality and disease, some of it brought 
back into our villages and homes, frightened those in authority. The sac- 
rifice was almost worth while ; for it set military and civil administration 
upon a great undertaking. How vividly I recall standing in the office of 
the Secretary of War, Mr. Baker, in Washington, when he said to me as 
I asked him what was going to be done in France to carry out the protec- 
tive policy in our home camps, "Bishop, we are going to give the boys the 
same, if possible, better protection in France. We are going to send across 
every agency, medical, moral, social and religious. We are going to draw 
upon the finest men and women in the land, young women, not old maids, 
to carry out the purpose." And the Nation did it. In the doing of it, 
through discipline, moral leadership and medical skill was found good suc- 
cess in prevention and alleviation. The recruits who came from homes 
and cities diseased were as a whole made clean and fit soldiers. It was one 
of the elements in the winning of the war. 

It so happened that among the ten thousand voices upon the subject, I 
gave in one of these Sunday afternoon courses a lecture which, through 



15 

the commendation of Surgeon-General Gorgas, was distributed widely- 
through the army. Dr. Bigelow, the Commissioner of our State Depart- 
ment of Health, knowing this, asked me to give this lecture today to help 
meet the conditions in peace. I acceded to his request, not by preference, 
for the subject is not a pleasant one, but as a public duty. 

The fact is that since the War there has been a decline in moral and 
physical welfare along the line of these diseases: but it now seems as if 
we had reached the beginning of an upward curve, whose upward move- 
ment, however, depends upon the intelligence and support of the people. 

My purpose in discussing the relation of these venereal diseases to the 
communities is first to state a few facts, and then to recall some of our 
present social conditions, and finally to suggest a few lines of beneficent 
action. 

First as to facts. While several of the most dreaded diseases have been 
deprived of some of their terrors during the past generation, we still have 
a quickening fear of diphtheria and typhoid fever. In the year 1926 
there were in 46 states 41,377 cases of typhoid fever; in 47 states 93,425 
cases of diphtheria; and in 41 states 200,524 cases of syphilis alone. In 
Massachusetts, only communicable forms of disease have to be reported 
and it is estimated that for obvious reasons only 15 per cent to 25 per cent 
of the two venereal diseases are reported; yet during the last ten years 
there have been reported annually 8,300 cases. 

Or turning to the death roll in this State : in 1927 there were from ty- 
phoid 44, measles 87, infantile paralysis 169, diphtheria 268, influenza 326, 
and syphilis 417. (Note that gonorrhea is not included.) 

In other words, the two venereal diseases claim the greatest number of 
victims of any of these communicable diseases, both in sickness and by 
death. And yet we live on, silent, unmoved, with heads buried in the sand. 

Let us look a little deeper into the problem. 

There is a common notion that these diseases are found in the slums, 
among prostitutes and brutal beings, but not among the more refined. We 
know enough of all diseases these days to be aware that they are not re- 
specters of persons. 

While the common prostitute is being driven to cover by the modern 
police, the carriers of these diseases are in our apartments, boarding 
houses, and homes. We dread the carrier of typhoid ; there are other car- 
riers. Is there any social group or circle in which it is not whispered that 
so and so's illness is really not arthritis, or locomotor ataxia, or imbecility, 
but is due to some shady event ? A boy from the best of homes finds him- 
self one evening with a lively crowd of boys and girls: he takes two or 
three drinks, loses his head and in a few days finds that he is diseased and 
in such a way as to harm him for years, drag him down for life, or send 
him to the insane asylum. No one but the doctor and his family know 
the real cause. 

Let me tell you of a family Of well-to-do people in this State. The two 
children must get medical advice for the rest of their lives on account of 
their inherited taint, the wife and mother is in a sanitarium, and the 
father is changed in appearance almost beyond recognition, because in a 
moment of stupidity or passion before marriage he contracted syphilis. 

The first knowledge of an attractive girl of one year's marriage of the 
dread word may be the warning of her doctor that the little baby is 
diseased, perhaps for life, by her husband through her. 

A high authority writes, "The commonest single cause of abdominal op- 
eration in women during the first year of their marriage is gonorrheal in- 
fection from the husband, who may have thought he was cured : and word 
goes out to friends that it was inflammation of the bowels, or chronic 
appendicitis. Dr. H. C. Solomon estimates that in the United States about 
75 per cent of all syphilis in females is in married women; in large part 
through their husbands. At the Boston Dispensary of 554 cases of gon- 
orrhea 44 per cent were in married women with no probable extra-marital 



16 
source, and 8 per cent in children; thus 52 per cent were innocently in- 
fected. 

One turns with sorrow, and sometimes horror, from the tragic stories 
which multiply upon us. The harvest of wild oats is a field of desolation 
and wild oats are carried by wind and transported to green fields and in- 
nocent corners. 

Herein is the tragedy of it. If only the wilful and the guilty would 
suffer for their sins ! But the ignorant boys and girls, the helpless women, 
and more than all, the little children blinded for life, the youth pallid and 
lifeless, and the mother watching the waning strength of her only child! 
Do we know the hidden shame of an attractive, refined girl who suspects 
that she inherits the taint, and fears that her friends suspect it? In pity 
for the innocent we cannot sit still and clamp down the lid. 

From the economic point of view we catch some suggestions. In the 
war our dominant note was efficiency; the computation of guns was on, 
and that involved the men behind the guns. No colonel would send 
diseased men into camp or battle. 

We know well that the competition of nations is still on ; for trade, for 
prosperity, for power. And he is a fool who thinks that the times of peace 
are safe times for slackness. Of two factories running on even terms, the 
factory which has the larger per cent of hands free from disease, alert, 
strong, will win out. Figures show that the leading age for contracting 
these two diseases are from 15 to 29, centering at 20 to 21, just when the 
boys and girls from our homes, schools and colleges are beginning to win 
their wages and make their way in life. And even though the cases be 
light, they, if they do their duty by their families and the community, lose 
heavy money and much time in illness and medical treatment ; more than 
in any other common diseases. The national expense in loss of time, loss 
of strength, care in insane asylums and poor houses, in private homes, and 
by imbeciltiy and pauperism, is untold. 

Congenital blindness has drawn a heavy toll. Massachusetts work is 
now so effective that total blindness of children from this cause is un- 
known, but with tragic frequency infants' eyes are still damaged irre- 
parably by gonorrheal infection. 

Who knows of the tragedies of social isolation of men and women of 
high character suffering from inherited disease? Who knows which are 
guilty, which innocent? And the innocent often of the finer grain suffer 
the most. 

Are our social changes leading us to more hopeful conditions? On the 
favorable side we have the opportunity of greater medical skill and fuller 
knowledge : physicians are more alert to the inroads of the disease ; boards 
of health are moving forward; police regulations are more severe; com- 
mon prostitution is less; playgrounds, athletics and greater freedom be- 
tween the sexes help to a degree. 

On the other hand, the massing of young unmarried men and women 
in cities, shops and boarding houses, the dance hall, and the freedom which 
gives opportunity are increasing dangers. 

"We don't have to go to prostitutes in these days," said a young man, 
"we get what we want in our own crowd." And there are thousands of 
young people who are between the conventional and the immoral groups 
open to temptations and invitations to which we, who are protected by tra- 
dition are utter strangers. A few years ago we were talking of bringing 
men up to the single standard, the standard of women. Now the question 
is asked whether the women who have taken men's places in many walks 
of life are not dropping to the men's standard. 

Generalizing from one's limited knowledge of people is unreliable; but 
as we recall the statistics and realize that perhaps only ten per cent of the 
diseased are reported, and then as we add those far larger numbers who 
are more or less loose in their lives, occasionally or frequently promiscu- 
ous, we have what we cannot help thinking are alarming social and moral 
conditions, conditions common to all social groups. 



17 
What then should our lines of action be? As this is a medical lecture,. 
I speak chiefly from a medical and physical point of view. 

First, we must have facts, not social prejudices or traditions or exple- 
tives of horror, but facts. These are coming on apace through our modern 
social students and studies. 

There is no use in facts unless they get through the experts and doctors 
to the people. The lid of silence must come off. 

Let me give you a bit of personal history. I can well remember when 
a boy I first saw a consumptive. A thin, pallid girl was standing on the 
sidewalk, alone, desolate in look, and my playmate pointing at her, said, 
"She's got the consumption!" 

The word "consumption" was always spoken in undertone; and there 
was something to be shunned in the consumptive, although its infectious 
characteristic was unknown. This silence may have been due to the fact 
that it was then a fatal disease, and one did not like to have the relatives 
or the patient hear it. There was more than that. Because the word was 
unspoken and the disease a silent one, there was something uncanny, un- 
social or shameful about it. At all events, science, intelligence, mercy 
came to the rescue; and now through the driving power of campaigns, 
tuberculosis has its place in everyday life, and the word is repeated as 
freely as is measles. 

It is only a very few years since the word "cancer" was taboo; prob- 
ably for the same reasons as was consumption, and even today there is a 
silence and reserve which suggests something mysterious. It is associ- 
ated in many minds with something dubious, possibly shameful. Silence 
and repression of subjects which belong to the whole people excite un- 
healthy curiosity, breed old women's fables, and arouse undue interest. 
With a fuller knowledge of cancer the lid of silence is gradually rising, 
and we are all of us, those who have had it come close home, the happier 
and wiser for it. 

As to the venereal diseases, there are difficulties which cannot be asso- 
ciated with these other two; the problem is intertwined with sex, the sex 
passion, with love and illicit love. I do not minimize the difficulty of pub- 
licity, of education, especially of the youth. Next, every one of us from 
the remembrance of his own youth and his knowledge of the youth of to- 
day is aware of the persistent and prurient curiosity about sex, which 
like a pestilential atmosphere poisons the mind and imagination of boys 
and girls. Those who by hearsay or foul books have some inside knowl- 
edge of sex experience have become centres of inquisitive groups. The 
danger here and throughout young manhood and womanhood is not so 
much infection of the body as of the mind and imagination ; the very fact 
of the silence and the mystery increases the whisperings, talks and foul 
acts. While all this cannot be stopped, it can, I believe, be checked and 
the talk and thought of youth be put on a healthier plane. 

In the past I have distrusted the advice of those who have pressed for 
common education in sex; but in spite of tradition, prejudice and taste, 
I have been driven to the conclusion that the lid of silence must be 
wrenched off, and the subject treated in its fullness, as embodying facts 
of physical, social, moral and spiritual truth. 

How shall this be done, you ask. I do not know. I know only that it 
must be done, and that a beginning is being made by leaders in physiology, 
sociology, ethics and religion. Of experiments there are many; failures 
and worse than failures not a few; successes also. 

Shall young men be given talks upon the subject in the mass; in col- 
leges, in great industrial shops? Young women also? Perhaps so, if the 
talker be very wise and very fine in character and if you cannot do any 
better. Better, however, the sane talker in a small group. 

Shall the boys also have talks? Yes, when the conditions are good: 
better a small group. 

Shall the children be taught? "What," says the conservative parent or 
teacher, "give that obscene stuff to little children? I can't and won't." 



18 
Rightly spoken by the right person, the child sees no obscenity; to him 
the whole subject is as simple and natural as any of Nature's actions. In- 
deed the best medical and educational movements seem to me to be 
towards bringing the education down to the little child from three to nine 
years old, taught by his mother as he has been taught other facts by her. 

How few, how very few mothers can do this! True, but they can be 
multiplied in time. And what I am trying to do is to present the best of 
today in order to work towards a better in the future. Meanwhile, unless 
we move in some direction and act along some lines, these two horrible 
diseases are eating into the vitals of our physical, social and spiritual life. 

As a problem of citizenship, health and economy, the State has definite 
responsibilities in connection with these diseases. Its chief, though not 
its only agency, is the State Department of Health. Before and during 
the war positive action was planned and pressed, and with peace began a 
more systematic development of the reporting of cases and of clinics. Of 
course, the purpose of the Department is in no way punitive — that is the 
job of the police — but purely medical, preventive and curative. Because 
of shame, ignorance and other causes improvement in reporting is very 
slow, perhaps not more than 15 per cent of cases, and yet without reports 
efficient help is impossible ; and too sharp pressure on the part of the De- 
partment drives the victims of the disease to silence or to quacks. Then 
again, faithful visits to the clinics mean time and loss of wages; for in- 
stance, a common case of gonorrhea demands twenty-five visits : the aver- 
age number is not over ten, which means that a large proportion are not 
cured and remain a menace to the community. The truth is that these 
diseases are very serious, and even in their lighter forms may develop 
dangerous infection years after. 

Syphilis, the more serious, can be through recent discoveries the more 
adequately handled. But for successful treatment not less than fifty visits 
spread over at least two years are necessary. 

Gonorrhea is by some victims passed off as a joke; they learn otherwise 
later. Medical science has not yet been able to give absolute assurance of 
sure cure even after a long period of treatment. The toll of gonorrhea is 
not in deaths, but in the tragedy of lives of invalidism, suffering and 
misery. Thousands on thousands of women who would otherwise have 
been vigorous, buoyant and happy, are dragging through life weak, de- 
pressed and hopeless. 

Again, most general practitioners, family doctors, are naturally averse 
to taking such cases, which if many, injure their regular practice and 
bring them into uncomfortable associations. How can you blame the 
practitioner with the limited equipment of a private office hesitating to 
attempt the treatment of acute, infectious cases of these diseases because 
of possible menace to his other patients? 

The Department of Health has now developed, with the assistance of 
local Boards, clinics over the State. These should be multiplied and thus 
made more convenient to the victims. Any person who wants information 
as to these resources can obtain it from the State Department of Health. 

At present the laws bearing on these diseases are sufficient, but as is 
the case with most of our laws, their execution is imperfect. The cases, 
the patients, must be followed up. There are now being organized by the 
Department social workers, who will have the tact and skill to follow up 
the patients to their homes and associations, discover their heritage, 
whether pure or diseased, look up the sources of infection, and see that 
visits to the clinic are regular and sufficient. 

It is essential that people learn not only how serious these diseases are, 
and how to avoid them, but also what should be done for complete cure if 
they are infected. Conscious that official and State service has its limi- 
tations without the voluntary help of citizens, the Department has behind 
it the Society of Social Hygiene, which is now entering upon a larger work 
of education; and through its agency men and women skilled in instruc- 
tion will respond to calls from school teachers, clubs, industrial leaders, 



19 
and others to talk to groups of men or women, or boys or girls. Super- 
intendents of schools, teachers and other citizens are already bombarding 
the Society for such service. Wise and helpful leaders must be and will 
be found. The budget will grow steadily. The office of the Massachusetts 
Society of Social Hygiene is 41 Mt. Vernon Street. 

Who can guess the number of tragedies in our homes, our high schools, 
and elsewhere among boys and girls who from ignorance bring themselves 
and their families into sorrow and disgrace? Their response is a true 
one: "We didn't know." Who stands responsible, these two children, or 
their parents and the community? 

These and a hundred other instrumentalities, which the State, with the 
support of towns and citizens should carry through, cost money. The 
parents of our children, all citizens, will do well to see that larger appro- 
priations are made for these purposes, and that playgrounds and other 
means for building of sound bodies and employing leisure hours be created 
and supported. 

Medical experts to whom I have read this paper have warned me that 
the tone is too moderate and the figures too low ; for in reporting diseases 
many doctors will give any other cause if they can, and families are nat- 
urally relieved to have their shame hidden; and in case of death the im- 
mediate cause is frequently a disease which is not venereal but which has 
been caused by it. 

May I in closing turn from the medical phase of this subject with three 
remarks. 

1. We (and I like to include myself in the present and younger genera- 
tion) have broken away from the rather encrusted conventions of the Vic- 
torian era, have reacted from many uncomfortable traditions and have 
issued a declaration of independence for more individuality, fuller liberty 
of thought, habit and life, and a right to do as we please or to think as 
we please; a healthy reaction on the whole, provided we keep in mind one 
essential condition. 

Personal liberty cannot be long sustained without a sense of personal 
responsibilty. Slaves do not need character, but freemen do. Freedom 
involves self-government, self-control, conviction, moral courage, and a 
realization of the seriousness of life. Bursting out of the school doors for 
recess is great fun ; and the freedom from restraint is healthy ; neverthe- 
less school hours do have their value. 

In our break for personal liberty have we developed with equal rapidity 
the elements which make up what we call character? A capacity really 
to use and rationally enjoy our freedom? Have we the self-control, the 
moral courage, the chivalry, and the unselfishness to be in command of 
ourselves and our liberty? 

2. In this study of venereal diseases and the infection of the commu- 
nity, I have been startled at the bare statistics, but I have been more 
deeply shocked and saddened by the revelation of loose living and immoral- 
ity in this our American population. When one multiplies the incidents 
of disease with the probable incidents of illicit vice and the promiscuous- 
ness of men and women, especially the younger, one wonders whether our 
institutions and our liberties can stand the strain. 

3. This problem is not an isolated one. Like all human interests, it is 
bound up with the whole problem of man and life. The physical, social, 
moral and religious conditions are inextricably interwoven : every boy and 
girl, every man and woman is a unit, a most interesting, mysterious and 
priceless unit. If we are to serve this generation, doctors, social workers 
and ministers must work together ; parents, children, old and young must 
understand each other; whether the family live in a house, apartment or 
basement ; in hovel or palace ; the family is still a family, and upon mutual 
loyalties, loves and sacrifices our health, happiness and liberties depend. 



20 

Editorial Comment 

With this issue we welcome Dr. M. Luise Diez as Director of the Divi- 
sion of Hygiene in the Department and editor of The Commonhealth. 
Dr. Champion has held this position for ten years while the field of Child 
Hygiene has grown almost as Topsy did. During this time enthusiasms 
have waxed and waned. Projects have been started and never finished. 
But what is more inexcusable, efforts at evaluation have seemed at times 
to be not only neglected but actually discouraged lest futilities be demon- 
strated. In all this pother Dr. Champion has builded a small, sincere, 
effective organization. With his very great practical experience as well 
as his fondness for teaching, Dr. Champion has much to give and The 
Commonhealth wishes him well in whatever his next field of endeavor 
may be. 

Admission to the broad field of Child Hygiene through the portal of 
extensive clinical experience is unfortunately sufficiently rare to warrant 
attention. This attention Dr. Diez merits. In addition she has had six 
years of administrative experience with the New York State Department 
of Health where they do so many things so admirably in the same field 
which she came to us to direct. Finally, wherever she has been she has 
commanded respect, confidence and enthusiasm for her ability to see 
things as they are and for her ingenuity, tact and perseverance in helping 
them on the road to become what they should be. Surely we are fortunate 
in being able to attract such as Dr. Diez. 

Should Health Officers Recommend Milk? Since milk is a fluid and there- 
fore absorbs and dissolves 
every contamination with which it comes in contact and as it is one of the 
few animal foods consumed raw, it is particularly vulnerable to infection. 
Because of this a sincere health officer has suggested that we in public 
health should stop our masquerading and come out frankly advising 
against its use as a food. He points out that through soy beans and other 
substitutes the nutritional value of this product may be obtained in other 
ways. It would seem to us that the same argument could be used against 
the use of illuminating gas, the swimming pool, the automobile and other 
things which have become an integral part of our complex modern life. 
These things all kill and therefore why not eliminate them? Milk has 
become such an integral part of the modern diet that I doubt if even the 
accomplished cigarette advertisers could persuade people to give it up. 
Also, as we all know, in addition to its caloric value it contains chemicals 
and vitamins of great value. It therefore behooves all of us to bend every 
effort to make this most important single article of food safe rather than 
consider that we have done a day's work by taking the easier ostrich 
method of advising against its use. — G. H. B. 

Bishop Lawrence' s Lecture. It was stimulating to listen to Bishop Wil- 
liam Lawrence as he challegend the people of 
Massachusetts to do something about the control of the venereal diseases, 
in a public lecture at* the Harvard Medical School on Sunday, January 6. 
It is encouraging to know that a leader among the clergy, a man well 
known and highly respected as a citizen of 'the Commonwealth, has not 
lost sight of a problem which has been somewhat out of the public mind 
since the War. There is hope for venereal disease control when such a 
notable personality is willing to declare that it is as important to keep our 
young men and women fit for life, as to fit them to fight. 

The Harvard Alumni Bulletin of January 17 and the New England 
Journal of Medicine of the same date, carried the Bishop's lecture in full. 
The censored newspaper reports of the talk may be prophetic of the day 
when the problem of syphilis and gonorrhea will be solved by publicity 
instead of being increased by the hypocrisy of prudery and false modesty. 



21 
The success of any attempt to safeguard the public health is in direct 
proportion to the extent to which the public is informed. Smallpox, diph- 
theria, typhoid fever and other dangerous communicable diseases are con- 
trollable because people know about them and demand their control. 
Syphilis and gonorrhea have become the most prevalent of communicable 
diseases, excepting the common cold and possibly the pneumonia, because 
few people realize hew extensively they affect the population. Multiply 
the country's infantile paralysis cases in a year by eighty, or smallpox by 
six, or diphtheria by two and a quarter, and you will have the number of 
cases of syphilis reported in a year, — approximately 200,000. Gonorrhea is 
estimated to be from three to five times as prevalent as syphilis. — N. A. N. 

The Summer Rowid-Up. Plans for the 1929 Summer Round-Up are al- 
ready on the way. The Division of Hygiene is 
now arranging for a series of meetings similar to those held last year, in 
towns all over the State. 

These meetings will be for the express purpose of increasing interest 
in Child Health Day activities and helping the towns to get started on 
their annual Summer Round-Up plans. A part of the program at each 
meeting will deal directly with the Summer Round-Up and its message 
will be right to the point : "Get your child ready for school. Begin early ! 
See that he has a thorough physical examination by your family physician 
and dentist or at your local Summer Round-Up conference. See that all 
remedial defects found are corrected before September first. Have vac- 
cination and toxin-antitoxin done in the spring or early summer, if you 
have not already done so. Send your child to school a healthy, happy 
youngster. Make him a 'physically fit first grader.' " 

Eight thousand children in Massachusetts repeated the first grade in 
1928 (at a cost of $96.76 each). By having routine yearly physical ex- 
amination and prompt correction of common defects, think how this num- 
ber would drop! 

"Now, all together!"— S. M. C. 

Correcting Defects in School Children. A study of the defects of school 

children made recently in a town 
near Boston raises a number of interesting questions, which are not easily 
answerable. For example; why do certain defects tend to increase with 
advance in grade while others tend to disappear? 

It was found that defects of vision and of teeth decrease while defects 
of nutrition and posture increase as the child goes forward in school. 
Why? Several obvious explanations immediately come to mind. Con- 
tinued exposure to quite universal unhygienic seating arrangements 
makes good posture difficult if not impossible. As the child approaches 
adolescence not only increased home study but a multitude of social ac- 
tivities and stimuli overdraw the child's bank account of vitality. Irre- 
futable statements. But what of the fact that while the use of the eyes 
becomes more constant with advance in grade, vision defects are increas- 
ingly corrected? 

Some additional explanation is needed. Possibly it is this: Defects of 
vision are easily corrected; to correct defects of teeth requires also but 
a single effort, while to prevent or to correct defects of posture or nutri- 
tion requires thought and energy over a long period of time. Is it possible 
that doctors, nurses, educators and parents are capable of effort when it 
is short and concentrated, but not when it must be long sustained ? — F. M. 

The Broadening Field of Cancer Education. In 1926 the Department was 

faced with the necessity of 
finding some way to bring the few facts which everyone should know about 
early cancer to the attention of all adults among our four million citizens, 
and to present these facts not only in understandable form, but with such 
compelling force that the information on reaching its goal — the individual 
affected — would arouse that person to immediate action. 



22 

It was promptly agreed that no better way could be found to bring about 
permanent results than by enlisting the aid of able and interested citizens 
in each community. 

Accordingly an associate or education committee, made up of a few out- 
standing public-spirited citizens has been formed in each one of the cities 
and towns in which a state-aided cancer clinic has been opened. The work 
of these committees has proved to be one of the strongest features of the 
cancer program. The amount of work accomplished by some of them is 
surprising and most gratifying. 

The members of these committees once having applied their abilities to 
this huge task of reducing the death toll from cancer, far from feeling 
discouraged, are going on with increasing enthusiasm, knowing, notwith- 
standing it may be years before actual results become apparent. 

Last Spring an intensive drive was made to arouse the people to a 
realizing sense that certain forms of cancer in an early stage can be 
brought under control. During this campaign more than 12,200 people 
consulted physicians regarding symptoms which they had reason to sus- 
pect might indicate cancer, among whom 1,780 were found to have cancer. 
For every patient who came to a clinic, twenty-two went to some physi- 
cian's office. 

This year the Massachusetts Medical Society is planning to offer to the 
medical profession of the State a brief graduate course on cancer. This 
will be held April 23, 24 and 25, and will consist of clinics and demonstra- 
tions at the different Boston hospitals, discussions, lectures by well-known 
local and visiting physicians and a banquet at which the Governor has 
promised to be present. 

Now, after two full years of popular education, some of the people are 
saying they have heard enough of the word cancer, and that they know 
the early signs full well. This year, therefore, the field of cancer educa- 
tion is broadening to include the outstanding health problems of that un- 
defined period spoken of as "middle age." "Middle age" has been aptly 
described by one writer as the time in life "when one can pass the candy 
box without lightening it." It is roughly between the ages of forty and 
sixty that many of the physical afflictions of later years gain a subtle hold 
before a person is aware of anything wrong. In many of these conditions 
early discovery followed by an adjustment of living habits to recognized 
limitations may lead to a longer life and a happier — but only through in- 
telligent understanding and a willing submission to a hygienic regime. 
In other words, people must know — and we must help them to learn the 
earliest signs. 

It is by the periodic examination while still in apparent health more 
than in any other way, that one may hope to recognize the earliest signs 
of trouble. The examination itself, is merely the stepping-stone from 
which one may make a fresh start toward a well-ordered manner of living, 
in which health, for its own sake, is in no wise the dominant end and aim, 
but in which health is persistently sought and wisely held as the all-essen- 
tial means by which the true purposes of one's life may be attained. 

"Not health, but life itself; to live most and serve best, this is the 
goal.*— M. R. L. 

The New England Health Institute. The New England Health Institute 

for the year 1929 is to be held in 
Hartford, Connecticut from April 22 to 26. 

Every effort is made at these Institutes to present public health prob- 
lems in such a manner that the health officers, physicians, sanitary engi- 
neers, public health nurses and other health workers present can use the 
information given by the faculty of the Institute in a practical manner. 

The Institute is held under the auspices of the State Health Depart- 
ments of New England, the United States Public Health Service, Harvard 

♦Jesse F. Williams — Personal Hygiene Applied. 



23 
and Yale Medical Schools, Massachusetts Institute of Technology and the 
New England Conference on Tuberculosis. 

Following is a list of the schedule of courses and the section chairmen : 

I. Public Health Administration C-E. A. Winslow, D.P.H. 



II. Preventable Diseases 

III. Sanitary Engineering 

IV. Tuberculosis 

V. Venereal Diseases 

VI. Child Hygiene 

VII. Public Health Nursing 

VIII. Laboratory 

IX. Mental Hygiene 

X. Industrial Hygiene 

XL Foods and Food Control 

XII. Nutrition 

XIII. Vital Statistics 

XIV. Health Education 



M. J. Rosenau, M.D. 
James A. Newlands, B.S. 
Stephen J. Maher, M.D. 
Thomas J. Parran, Jr., M.D. 
S. J. Crumbine, M.D. 
Annie W. Goodrich, Sc. D. 
Benjamin White, Ph. D. 
Roy L. Leak, M.D. 
Philip Drinker, S.B. 
Hermann C. Lythgoe, B.S. 
Lafayette B. Mendel, Ph. D. 
Timothy F. Murphy, Ph. D. 
Clair E. Turner, D.P.H. 



Preliminary programs have been received by the Massachusetts Depart- 
ment of Public Health. These may be had upon request to the Division of 
Hygiene, Room 545, State House, Boston. 

The Gorgas Memorial Essay Contest. The Gorgas Memorial Institute is 

conducting a nation-wide contest 
among high schools. This represents an effort to reach the younger gen- 
erations with proper and useful health educational information. 

The awards and dates for the contest are as follows : 
High School, Gorgas Medallion, January 15 to March 1. 
State, $20 in cash, March 1 to April 15. 
National, First prize — $500 in cash with $250 travel allowance 

to Washington D. C. to receive prize; second prize — $150 

in cash, April 15 to May 15. 

The contest is open to all students in junior or senior classes. 

The subject of the essay, which is not to exceed 1500 words, is "The 
Life and Achievements of William Crawford Gorgas and Their Relation 
to Our Health." 

General topics recommended for study are: Yellow Fever, Malaria, 
Mosquitoes, The Periodic Health Examination, Sanitation, and The Pan- 
ama Canal. 

Further information regarding the rules of the contest, etc., may be se- 
cured from the Gorgas Memorial Institute, 1331 G. Street, Northwest, 
Washington, D. C. 

The State Department of Public Health has some material on file which 
may be consulted by contestants. Call at the Library, Room 546, State 
House, Boston, Massachusetts, and inquire. 



24 



Ota ilje firman} of 

Fred B. Forbes 

WHEREAS, after serving the Commonwealth first' on the staff of the 
State Board of Health and later on the staff of the Department of Public 
Health, from July, 1893 until his death on January 26, 1929, and 

WHEREAS, after preliminary service at the Chemical Laboratory of 
the State Experiment Station at Lawrence, he became chief assistant and 
later chief of laboratory at the State House, and 

WHEREAS, his service has throughout been marked by those qualities 
found only in a person of sound training, clear thinking, loyalty, conscien- 
tiousness and profound self-effacement, 

Be it Resolved, That the Public Health Council express its profound 
sense of appreciation and loss in the passing of Fred B. Forbes, and do 
spread this resolve upon the records of the Council, and do direct that a 
copy be sent to his family. 



25 
REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of October, November, and December, 1928, samples 
were collected in 238 cities and towns. 

There were 2,687 samples of milk examined, of which 428 were below 
standard ; from 40 samples the cream had been in part removed, 2 samples 
of which also contained added water; 72 samples contained added water; 
and 1 sample of skimmed milk was obtained which was above the legal 
standard. 

There were 423 samples of food examined, of which 149 were adulter- 
ated. These consisted of 8 samples sold as butter which proved to be oleo- 
margarine; 6 samples of clams which contained added water; 6 samples 
of dried fruits which contained sulphur dioxide not properly labeled; 104 
samples of eggs, 4 of which were decomposed, 31 were sold as fresh eggs 
but were not fresh, and 69 were cold storage not marked ; 13 samples of 
maple syrup which contained cane sugar; 2 samples of maple sugar adul- 
terated with cane sugar other than maple; 7 samples of hamburg steak, 
5 of which contained a compound of sulphur dioxide not properly labeled, 
and 2 were decomposed \ 1 sample of sausage which contained a compound 
of sulphur dioxide ; 1 sample of olive oil which contained some foreign oil, 
the identity of which has not been determined; and 1 sample of scallops 
which contained added water. 

There were 16 samples of drugs examined, of which 2 were adulterated. 
These consisted of 2 samples of spirit of nitrous ether which were defi- 
cient in the active ingredient. 

The police departments submitted 2,131 samples of liquor for examina- 
tion, 2,117 of which were above 0.5 per cent in alcohol. The police depart- 
ments also submitted 28 samples of narcotics, etc., for examination, 18 of 
which were morphine, 6 opium, 1 lead arsenate, and 3 samples which were 
examined for poison with negative results. 

Twenty-four samples of clams were examined for pollution, 22 of which 
were found to be unpolluted, and 2 were found to be polluted. 

Two samples of water used for washing clams were examined for sew- 
age pollution with negative results. 

Eighteen samples of milk were examined for bacterial content, 10 being 
pasteurized milk, all of which contained less than 50,000 bacteria per cubic 
centimeter; the balance was raw milk, of which 5 samples contained from 
144,000 to 550,000 bacteria per cubic centimeter; the balance contained 
less than 100,000 bacteria per cubic centimeter. 

There were 37 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 67 cities and towns visited for the inspection of pasteur- 
izing plants, and 154 plants were inspected. 

There were 97 convictions for violations of the law, $1,863 in fines being 
imposed. 

Theodore G. Barkas and Monson L. Witherell of Gloucester; James 
Skaliotis and Naum Spiros of Peabody; Busy Bee Confectionery Com- 
pany of Chelsea; Frank H. Capen, Lena Paine, Water Peterson Estate, 
and Ada Sherman, all of Marshfield; John A. Carter of North Wey- 
mouth; George Moore of East Weymouth; Thomas Goja of Westport; 
Nicholas Lagadinos of Worcester; John McLean, Frank Mirisola, Harry 
Porter, and Nelson H. Huntley, all of Wilmington; James A. Fiske 
of Cliftondale; Clara Soullre of Attleboro; Floyd Holmes of West 
Bridgewater; Richard D. Kuhn of Southampton; Parnell's Lunch of 
Northampton ; Peter Liopes, Arakel Pashoogian, Hunter Blackburn, Harry 
P. Gouzoules, and John J. Joyce, all of Lynn; Frank C. Newhall of Lynn- 
field; Victor Pietrasink of Easthampton; Harold B. Drury and Ellie W. 
Burnham of Athol; Nathan Snider of Framingham; John Geanakos of 
Salem; Edward F. Walsh of Arlington; Frank D. Brogan of Hyannis; 
Joseph Stampien of Dracut; Arthur Stathopulos of Beverly; Joseph Cin- 
cotta and Mary Ristuccia of Waltham; John Wesolouski of Cheshire; 



26 

Anthony Troupakes of Cambridge; John Zahos of Maiden; Henri Geboult 
of Sturbridge; Louis Blanchard of Duxbury; Fred Boraschi of Kevere; 
Daniel J. Mulvaney and Michael J. Houlihan of Ware; Ernest L. Deline 
of Sutton, Vermont; and Walter Dyer, 2 cases, of Natick, were all con- 
victed for violations of the milk laws. Frank H. Capen of Marshfield, 
Nicholas Lagadinos of Worcester, James A. Fiske of Cliftondale, Clara 
Soullre of Attleboro, Richard D. Kuhn of Southampton, Harold B. Drury 
of Athol, and John Geanakos of Salem, all appealed their cases. 

Dairymaid Creamery Company of Allston; Frank S. Hollis of Chelsea; 
William E. Finn, 2 cases, of Middleboro; Joseph Duffy of Revere; Joseph 
Burg of Quincy; and Bernard W. Stark of Roxbury, were all convicted for 
violations of the food laws. William E. Finn of Middleboro appealed one 
of his cases. 

Bay State Tea & Butter Corporation and Samuel Kronick of Athol; 
A. H. Phillips, Incorporated of Easthampton; United Food Shop, Incor- 
porated, of Watertown; John Zicko of Natick; Albert F. Noble of New- 
ton; Cloverdale Company and Peter Marinos of Plymouth; Manhattan 
Five & Ten Cent Store, Incorporated, of Cambridge; Wilbur A. Girard of 
Southbridge ; Peter G. Grammas of Gloucester ; Paul Wong of Northamp- 
ton ; William H. Marshall of Chelsea ; Angelos Maravelias, Philip Rodakis, 
Harry Shtung, and James Kenneally, all of Lynn; Mitchell Seretely of 
Hyannis; and George L. Steers of Waltham, were all convicted for false 
advertising. Cloverdale Company and Peter Marinos of Plymouth, both 
appealed their cases. 

The Imperial Drug Company of Fitchburg ; and John Clark of Athol, 
were convicted for violations of the drug laws. 

Jaddus Noel, Pale Pralenski, and Stanley Gabrs, all of Athol; Abraham 
Shore of Chelsea; Ludger Valcourt, Jake Bazer, Wolf Feldman, and 
Charles Salenikas, all of Lynn; Samuel Bender of Roxbury; Henry Fugere 
of Ware; Stephen Herb of Lawrence; Lambi Krespane of Natick; and 
Walter L. Whipple of Providence, R. I., were all convicted for violations 
of the cold storage laws. Stephen Herb of Lawrence appealed his case. 

Frank Fockett of East Woodstock, Connecticut, was convicted for vio- 
lation of the slaughtering laws. 

Louis Green, 4 cases, of East Boston, was convicted for violations of 
the mattress law. 

In accordance with Section 25, Chapter 111 of the General Laws, the 
following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers: 

Milk which contained added water was produced as follows : 6 samples, 
by Joel T. Whitney Estate of Framingham ; 5 samples, by Ellie W. Burn- 
ham of Athol; 4 samples, by Joseph Stampien of Dracut; 3 samples each, 
by Frank Czurcny of Three Rivers, and Albert and Clara Soullre of Paw- 
tucket, R. I. ; 2 samples, by James K. Axtell of Huntington ; and 1 sample 
each, by Moore Farm of Huntington, and Frank George of Portsmouth, 
R. I. 

One sample of milk which had the cream removed was produced by True 
G. Rice of North Orange. 

Clams which contained added water were obtained as follows : 2 samples, 
from J. A. Stubbs of Boston; 1 sample each, from Prime Fish Company 
of Boston, Joseph Duffy of Revere, The Great Atlantic & Pacific Tea Com- 
pany, Incorporated, of Cambridge, and Pierce Fish Market of Medford. 

Dried Fruits which contained sulphur dioxide not properly labeled, were 
obtained as follows: 

1 sample each, from The Great Atlantic & Pacific Tea Company, A. H. 
Phillips, Incorporated, and First National Stores, Incorporated, of 
Palmer; Red & White Store, and Wheeler's Market of Marlboro; and 
Economy Store of Roxbury. 



27 

Hamburg steak which contained a compound of sulphur dioxide not 
properly labeled was obtained as follows: 

1 sample each, from Alex Goldstine of Worcester; United Butchers of 
Haverhill; and Bernard W. Stark of Roxbury. 

One sample of hamburg steak which was decomposed was obtained from 
Quincy Public Market of Quincy. 

One sample of sausage which contained a compound of sulphur dioxide 
not properly labeled was obtained from Brockelman Brothers of Fitchburg. 

Maple sugar adulterated with cane sugar other than maple was ob- 
tained as follows: 

1 sample each, from Peter Eliopulos of Salem, and Peter Koomaris of 
Lynn. 

Maple syrup which contained cane sugar was obtained as follows : 

2 samples each, from Williams' Restaurant of Quincy; and Purity Res- 
taurant of Hyannis; and 1 sample each, from Walter's Lunch of Dor- 
chester, Flag Lunch, Victoria Lunch, and Plaza Dairy Lunch, all of Lynn ; 
Friendly Lunch of Waltham; Ideal Lunch, Cafe Francis, and Mayflower 
Restaurant, of Hyannis; and Central Cafe of Plymouth. 

One sample of scallops which contained added water was obtained from 
the Atlantic & Pacific Tea Company of Brookline. 

There were twelve confiscations, consisting of the carcass of one hog, 
weighing 100 pounds, afflicted with hog cholera; 50 pounds of decomposed 
beef kidneys; 25 pounds of sour calves' livers; 60 pounds of decomposed 
pork brains; 110 pounds of decomposed pork tenderloins; 30 pounds of 
decomposed broilers; 57 pounds of decomposed chickens; 120 pounds of 
decomposed fowls; 160 pounds of decomposed roasters; 199 pounds of 
decomposed miscellaneous sausage; and 37 pounds of decomposed salmon. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of September, 1928: — 494,100 
dozens of case eggs ; 173,323 pounds of broken out eggs ; 2,002,720 pounds 
of butter; 497,886 pounds of poultry; 3,829,079 pounds of fresh meat and 
fresh meat products ; and 3,429,844 pounds of fresh food fish. 

There was on hand October 1, 1928: — 8,347,470 dozens of case eggs; 
1,663,556 pounds of broken out eggs; 14,018,241 pounds of butter; 2,066,- 
420 pounds of poultry; ll,192,627 1 /2 pounds of fresh meat and fresh meat 
products; and 23,815,904 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of 
food placed in storage during the month of October, 1928: — 465,360 
dozens of case eggs; 575,881 pounds of broken out eggs; 1,115,822 pounds 
of butter; 1,692,569 pounds of poultry; 3,084,880 pounds of fresh meat 
and fresh meat products; and 3,047,846 pounds of fresh food fish. 

There was on hand November 1, 1928 : — 5,970,690 dozens of case eggs ; 
1,522,350 pounds of broken out eggs; 11,685,228 pounds of butter; 3,910,- 
640 pounds of poultry; 9,062,183 1 /2 pounds of fresh meat and fresh meat 
products; and 21,886,469 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts of 
food placed in storage during the month of November, 1928: — 342,270 
dozens of case eggs; 311,151 pounds of broken out eggs; 679,317 pounds 
of butter; 1,536,066% pounds of poultry; 3,895,419 pounds of fresh meat 
and fresh meat products; and 3,071,330 pounds of fresh food fish. 

There was on hand December 1, 1928: — 3,367,845 dozens of case eggs; 
1,263,459 pounds of broken out eggs; 8,652,495 pounds of butter; 
4,559,307% pounds of poultry; 8,397,726 1 /2 pounds of fresh meat and 
fresh meat products; and 20,059,293 pounds of fresh food fish. 



28 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration . 
Division of Sanitary Engineering . 

Division of Communicable Diseases 

Division of Water and Sewage Lab- 
oratories . 
Division of Biologic Laboratories . 

Division of Food and Drugs . 

Division of Hygiene 
Division of Tuberculosis 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. G00DN0UGH, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director'and Chemist, H. W. Clark 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, M. Luise Diez, M.D. 
Director, Sumner H. Remick, M.D. 



State District Health Officers 

The Southeastern District 



The Metropolitan District 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District . 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., Lowell. 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



PUBLICATION OF THIS DOCUMENT AFTROVED BY THE COMMISSION ON ADMINISTRATION AND FINANCE 

BM. 3-'29. Order 4977. 



THE 
COMMONHEALTH 



Volume 16 

No. 2 




APR.-MAY-JUNE 
1929 



SCHOOL HYGIENE 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 



THE COMMONHEALTH 

Quarterly Bulletin of the Massachusetts Department of 
Public Health 

Sent Free to any Citizen of the State 

M. Luise Diez, M.D., Director, Division of Child Hygiene, Editor. 
Room 546 State House, Boston, Mass. 



CONTENTS 



PAGE 
Controlling Communicable Diseases in the School, by Edward A. 

Lane, M.D . .31 



What Milk in the Schools? by George H. Bigelow, M.D. . 
Physical Education in the Schools, by Carl Schrader 
A Health Program in the Schools, by Elizabeth H. Sampson . 
The Value and Results of a Health Program in the Schools, by Wil 
liam H. Slayton ....... 

The Need for Health Education in Junior and Senior High Schools 
by Jean 0. Latimer ...... 

Educating the Handicapped Child, by Arthur B. Lord 
Psychiatric School Clinics for the Examination of Retarded Children 
by Neil A. Dayton, M.D. ...... 

Habit Clinics and Their Purpose, by Olive A. Cooper, M.D. 
Report of the Consultant in Dental Hygiene .... 

Editorial Comment: 

Why School Hygiene ....... 

Smallpox and Vaccination ...... 

The Return to School after Absence with Communicable Disease 

Reorganization of the School Clinics ..... 

Ten Years' Progress in Dental Hygiene, 1919-1929 

Health Education ........ 

The School Lunch ........ 

Eye and Ear Testing in the Schools . 

School Health Survey Service ...... 

May Day and the Summer Round-Up ..... 

Franklin County Five Year Demonstration 
News Notes: 

The Thomas William Salmon Memorial .... 

"The Growth of Our Children" 

New Publication ........ 

Report of the division of Food and Drugs, January, February and 
March, 1929 



34 
35 
37 

39 

41 
43 

46 

47 
49 

55 

55 
56 
56 
57 
58 
59 
59 
59 
60 
60 

61 
61 
61 

63 



31 

CONTROLLING COMMUNICABLE DISEASES IN THE SCHOOL 

By Edward A. Lane, M.D., 

Assistant Director, Divisicm of Communicable Diseases 
Massachusetts Department of Public Health 

The control of communicable diseases in schools calls for a clear under- 
standing on the part of teachers, school nurses, and school physicians of 
the part to be played by each. The most effective control will be se- 
cured only when these individuals are properly organized and work in the 
closest harmony. It is the responsibility of the school physician in 
charge to see that the teachers and nurses are properly instructed in 
their duties and function effectively. 

The control of communicable diseases in the schools is a part of the 
larger problem of communicable disease control in the community. Where 
the school health service is independent of the local public health author- 
ities, the closest kind of co-operation will be necessary if the work of 
each is to be most effective. 

The manner in which the work is carried on will depend upon the size 
and quality of the local' teaching and health personnel. Certain duties 
will fall to the lot of teachers, school nurses, or school physicians de- 
pending upon the circumstances in a particular case. 

Routine Control Procedure 

Ordinarily in routine control procedure the teacher will form the 
first line of defense. She should inspect all her pupils regularly at the 
beginning of each morning and afternoon session with this idea particu- 
larly in mind. This inspection may be quite informal and unknown to 
the pupils as they sit in their seats engaged in work. The important 
thing is that the teacher make a conscious mental note of each child's 
general appearance and behavior. Such inspection calls for no special 
knowledge of the communicable diseases as the signs which would be 
present and be noticed would be merely those of general indisposition such 
as lassitude; flushed, hot face suggestive of fever; nausea and vomit- 
ing; cough; running nose; watery or inflamed eyes; skin eruption; or 
frequent visits to the toilet. Occasionally a child may voluntarily com- 
plain of illness. 

Any child who presented one or more of the foregoing or other sus- 
picious symptoms and signs would either be sent home immediately with 
a note for attention by a private physician, or isolated at school until 
examined by the school nurse. The nurse, in accordance with her 
judgment and the circumstances of the case, could advise dismissal, hold 
the child for examination by the school physician, keep him for obser- 
vation in the rest room, or return him to his classroom. Such cases 
would be referred to the school physician only when the nurse did not 
feel justified in assuming the responsibility for a final decision. 

While the necessity for so doing may with good reason be questioned, 
it is usually easier and more reassuring to destroy the school paraphen- 
alia of a pupil excluded for communicable disease when such material 
is the property of the School Department and has been left in the school. 
It will also do no harm, if little good, to wipe off the pupil's desk and 
clean the floor adjacent thereto with some antiseptic solution. 

No pupil excluded as a known or suspected case of communicable 
disease or as a carrier of such disease should be re-admitted without the 
written permission of the Board of Health or the School Physician. More- 
over, the local health authorities should be given immediate notification 
of all exclusions for known or suspected communicable disease or for the 
carrier condition, and they in turn should immediately notify the proper 
school authority of all family or other outside contacts for exclusion 
from the school. 



32 

All absences, where the child is reported by the other children or by 
the attendance officer to be ill, should be investigated by the school nurse 
to discover unrecognized or concealed cases of communicable disease. 

It is assumed that the school complies with the generally acceptable 
sanitary standards and is conducted in a hygienic manner. This implies 
the absence of overcrowding, the prohibition of the common towel and 
common drinking cup, and the elimination of commonly used articles 
such as books, pencils, pens. 

Adequate provision should be made by the school health service for 
the instruction of the children in the rudiments of communicable disease 
control with special emphasis upon the protective value of proper personal 
hygiene. Such verbal instruction by the school nurse or school physician 
in the classroom can be supplemented by the distribution of literature 
upon the subject. Some of this literature will reach the homes and may 
be productive of beneficial results. The State Department of Public 
Health, Room 546, State House, Boston, will supply such available liter- 
ature on request. 

Special Epidemic Control Measures 

In the presence of an epidemic, the teacher's daily observation of her 
pupils would be made more formal and thorough, or replaced by daily 
examination by the school nurse. If the circumstances justify it and 
local conditions permit, it may occasionally be advisable for school phy- 
sicians to conduct the daily examination of pupils until the outbreak 
subsides. Temporary additions to the nursing and medical personnel 
may at times be justified if the regular medical service proves inadequate 
for an emergency. 

It is seldom if ever advisable except under strictly rural conditions 
to consider closing the schools for the purpose of trying to control an 
outbreak of communicable disease. Not only does such a step fail to 
yield the desired result, but valuable opportunity to keep close check on 
the community school population and weed out for isolation early and 
suspicious cases is lost. Two legitimate reasons for closing the schools 
would be: (1) A totally inadequate or ineffective school medical service; 
or (2) so extensive an outbreak that the small percentage of children 
able to attend school would not justify keeping them open. The former 
reason should never hold true; the latter, but very rarely. 

When the examination includes the taking of the temperature, a strict 
antiseptic technique should be followed in the use of the clincal thermo- 
meter. Should an early or suspicious case have been handled, the hands 
should be washed before passing to the next child. 

Diphtheria 

The control of diphtheria in the schools depends upon: 

1. Immunization with toxin-antitoxin. 

2. Exclusion of cases and carriers. 

1. Public immunization with toxin-antitoxin is a proper function of 
the local health authorities and is usually carried on under their direc- 
tion. The school authorities can cooperate in this work by furnishing 
suitable quarters for school clinics and by distributing literature and 
otherwise making the object and value of the work known through the 
schools. 

While the treatment should be given all children whose parents request 
it, special effort should be made to treat the pupils in the entering 
classes regularly each year. 

A Schick test may be performed on all children to eliminate those 
naturally immune, before administering toxin-antitoxin. When, how- 
ever, children are to be treated in large numbers, this preliminary test 
may be dispensed with in the case of children under ten years of age, 



33 

both because of the relatively few immunes ordinarily found among 
younger children and because of the greater ease, administratively, in 
conducting the work by so doing. 

All children treated with toxin-antitoxin should be given the Schick 
test not earlier than six months after the treatment was administered. 
This will serve as a check upon the efficacy of the work and discover the 
small number, usually not more than 10-15 per cent, who require more 
than one course of treatment to be rendered Schick negative. 

Detailed directions for administering toxin-antitoxin and for per- 
forming the Schick test are distributed by the State Biologic Laboratory 
with its products. 

Complete, accurate records of all toxin-antitoxin immunization work 
should be kept by the responsible agency. Such records are in addition 
to the information recorded on the pupil's school physical record card 
relative to toxin-antitoxin administration and Schick testing. 

2. School nurses or physicians will examine the throats of all pupils 
who are ill. Any evidence of sore throat calls for the taking of a culture 
and exclusion of the pupil until the presence of a mild or beginning 
diphtheria or other infectious condition can be ruled out. Such culturing 
may be done by the school or public health authorities or by a private 
physician. 

When a pupil develops diphtheria, all the other pupils in the same 
classroom in the larger schools, and all the pupils in the smaller schools 
should have nose and throat cultures examined for possible carriers and 
incipient cases. 

Scarlet Fever 

The control of scarlet fever is made very difficult by the occurence of 
what may be extremely mild missed cases. Some cases with little or no rash 
may be considered to be simple tonsillitis. Added to this is the lack of 
any ready, reliable method to detect carriers. It is not, therefore, at all 
surprising that scarlet fever should be so difficult to stamp out when it 
once appears in a relatively susceptible juvenile population. 

. When scarlet fever is prevalent, every sore throat is to be viewed 
with suspicion with the burden of proof on the side of the negative diag- 
nosis. Furthermore, it is very desirable at such times for the entire 
community nursing service to cooperate closely in an endeavor to dis- 
cover mild unrecognized or concealed cases among infant and pre-school 
brothers and sisters of school children. 

While it is not felt that the Dick test to determine immunity to scarlet 
fever and active immunization with the scarlet fever toxin have been 
sufficiently perfected to justify recommending them to local health au- 
thorities for general use, they may be of sufficient value to be employed 
in juvenile institutions where children live in constant intimate asso- 
ciation and are under complete control. 

Measles 

Measles presents another difficult control problem because of the almost 
universal susceptibility to a first attack, the high degree of contagious- 
ness and the uncertainty of the diagnosis in the early, pre-eruptive, ca- 
tarrhal stage when it is most infectious. It has even been suggested, in 
view of the relatively low fatality over three years of age, that all sus- 
ceptible pupils having brothers or sisters under three be excluded from 
school during an outbreak, the children otherwise being allowed to take 
their chances of contracting the disease. 

During a measles epidemic, any catarrhal symptoms of the upper 
respiratory tract should be viewed with suspicion and all children pre- 
senting such symptoms, isolated for observation. Koplik spots will be of 
value in the early diagnosis of a small percentage of cases. 

The identity of the causative organism or virus is still a matter of some 
uncertainty, and there is no specific preventive measure yet available. 



34 
Whooping Cough 

Here again the difficulty of making an early diagnosis greatly hampers 
the effectiveness of our control measures. It is known through bacter- 
iological studies that a progressively larger number of patients lose their 
infectiousness or acquire a lowered degree of infectivity as the disease 
progresses. 

Attention is centered upon the detection of the early cases bearing in 
mind that the prodromal and early catarrhal symptoms are those of an 
ordinary cold. 

Whooping cough vaccines, while not generally considered to be of 
much if any value in the treatment of the disease, are thought by some 
to be of value in its prevention when properly employed. Should an 
attack not be entirely prevented, it may be aborted or modified. The ad- 
visability of employing this measure will be determined by the physician 
in attendance and the parents. 

Minor and Infrequent Diseases 

The minor communicable diseases, German measles, chicken-pox and 
mumps, require no special mention as the measures for their control con- 
form in a general way with the routine and epidemic measures applicable 
to any of the communicable diseases. There is no specific means of pre- 
vention for any of them. Their chief importance from the public health 
point of view lies in the field of diagnosis. Scarlet fever and measles 
may be mistaken for German measles, while smallpox may be confused 
with chicken-pox. The latter of these two difficulties would, however, 
be obviated in the public schools if the compulsory vaccination law is 
complied with. 

Certain other more serious diseases such as cerebro-spinal meningitis, 
poliomyelitis, and septic sore throat are of relatively infrequent occur- 
rence. Should they occur in anything approaching epidemic proportions, 
the advice and assistance of the local health authorities or State Depart- 
ment of Public Health should be sought. Their recognition often calls 
for expert diagnosis and special laboratory methods. 

Local Regulations 

School physicians and school nurses should be familiar with all com- 
municable disease regulations of the local health authorities so that their 
work may be conducted in conformity therewith. The responsibility 
for the control of communicable diseases in a community is vested by law 
in the local health department. The school health service while carrying on 
work of this character functions for and as a part of the local community 
public health service and is subject to the regulations and direction of 
the latter service. Especially in time of epidemics whether in school or 
community, divided control and independent action might be fatal to the 
welfare of the community. This possible danger has been foreseen and 
provided for in the general laws relating to the public health. 

WHAT MILK IN THE SCHOOLS? 

By George H. Bigelow, M.D., 

Commissioner of Public Health 

We all talk of the importance of milk in the diet, particularly for 
children, and urge that more and still more be consumed. But some of 
our milk is far from safe, because it may spread tuberculosis, scarlet 
fever, septic sore throat, typhoid fever and the like. One hundred and 
seventy known epidemics of milk borne disease in Massachusetts in the 
last fifty years should make us hesitate to accept as a safe standard any 
white fluid from any cow. 



35 

What then is the minimum standard of safety and decency that we 
should insist on for milk to be offered to our children in our schools ? The 
cleanness and wholesomeness of the milk depends upon the healthiness 
and cleanliness of the animals and the methods of collection, handling and 
cooling. This can be assured only through adequate inspection which is 
too expensive for many small communities alone. Freedom from disease 
germs can most effectively be assured through pasteurization of the milk, 
which is controlled by a state law. There are various levels of protection. 
At the bottom is just plain milk which may be almost anything and is 
often sold under alluring names such as "Special Baby Milk", "Shady 
Nook Farm Milk", or other titles connoting pristine purity to the unin- 
itiated. These special brands of milk receive just about as much protec- 
tion as the conscience of the producer dictates and in many instances 
merely mean that a few cents more is being paid for the cap bearing the 
special name. Then there is raw milk from tuberculin tested cattle which 
protects against bovine tuberculosis only of the many diseases spread by 
milk. The safest raw milk is certified milk. Around this milk is thrown 
all the protection, except heat, that can be devised. Next comes pas- 
teurization, which protects against all these diseases. As Dr. Rosenau 
says, there has never been an epidemic of milk borne disease traced to 
properly pasteurized milk. One step higher is pastuerized milk from non- 
tuberculous cattle. This removes any danger of bovine tuberculosis should 
there be a slip in the pasteurization technique. Finally at the pinnacle 
of safe and wholesome milk comes certified milk that has been pasteurized. 
This is the last word in the art of milk production and distribution. 

Now where in this ascending scale of safety should we at present insist 
that the line be drawn, saying that nothing below this shall be served in 
our schools? Calamitous experience would indicate that the Department 
of Public Health cannot with any show of honesty recommend that any- 
thing less than a pasteurized milk be used. To this should be added as 
much in the way of healthy animals and scrupulous handling as the 
economics and the local milk supply allow. School authorities should 
consult with their local health authorities as to the cleanest pasteurized 
milk available. For it is the responsibility of the local board of health to 
know more about the local milk supply than anyone else in the world. 

But what if pasteurized milk is not available? Man does not live by 
milk alone and neither do children. The parody of offering a potentially 
dangerous milk in the name of health must stop. The raw milk can be 
pasteurized in the school and if this is not done a substitute for unsafe 
milk should be offered such as cocoa, cream soups, fruit juices and the like. 

PHYSICAL EDUCATION IN THE SCHOOLS 

By Carl Schrader 

Supervisor of Physical Education, Massachusetts Department of 

Education 

A hygiene or health program in the schools, to net lasting results, must 
of necessity be an activity program that aims toward establishing correct 
habits of living. The basis of health is no longer looked upon as a proc- 
ess of taking something, but rather as one of doing something. We are 
expected then, as teachers, to establish constructive habits that may serve 
a life time. Habits, we say, are the results of frequently repeated acts. 
They may be bad or they may be good. That admitted, it requires some- 
one to direct, to set right those that are wrong and keep those right that 
are right. This someone is the teacher who, to be sure, herself must be 
guided by and portray habits that are consistent with her teaching. 

Physical education has a very distinct contribution to make to the 
program of hygiene in schools. Without making hygiene or health a 
specific objective in physical education, exercises — particularly in the 
garb of pleasure, carry these health results as a necessary accompaniment. 



36 

Exercise perfects a desire for certain hygienic practices which, when 
frequently repeated, fasten themselves upon us as habits. Exercise worthy 
of the name that calls for exertion rather than exhaustion, gives rise to 
a craving for food which can be assimilated better because of the created 
need; it commands sleep because of the physical tiredness that results 
rather than that mental weary condition; it invites the bath for comfort 
but which in addition also serves as a tonic, and finally it makes for a 
happier frame of mind, and this rounds out what has well been called 
a healthy personality. 

Whatever we may hope to achieve educationally in this field must have 
its origin in the early school years, at least. We need but to accept 
nature's challenge as it manifests itself through the children. The crav- 
ing for activity, the love for the out of doors, the keen imagination that 
serves as a self starter for action; all of these manifestations are as 
natural in a healthy child as the craving for food. All this points to the 
significance of play. It has been well said that children do not play be- 
cause they are young, but that they are young so that they may play. 
Children are rarely more in earnest and so wholly absorbed as while at 
play. This earnestness of purpose needs be capitalized and utilized in 
education, particularly during the first six years of school. 

The possible related connection between activity and hygiene is by no 
means vague. It is not difficult to have children appreciate that success 
on the playfield depends in a large measure on right living. Hence, the 
training regulations in high schools and colleges. A splendid opportunity 
opens up here for motivating health rules: — all we are anxious for chil- 
dren to know about food, about eating, about rest, about personal clean- 
liness, etc., etc., may be closely related to their desire to excel in physical 
achievements. Not health for health's sake, but health for the sake of 
achievement for a more abundant life. 

In play, particularly the competitive kind, there is a display of emotions 
which to control is a weighty factor in mental hygiene and should be 
taken cognizance of by those supervising play. 

There is, then, a very definite contribution that the right sort of physi- 
cal education makes to the general health of a people. The extent to 
which this is realized in school depends mainly upon three essential fac- 
tors — time, facilities, and leadership. A physical education program in 
the elementary schools should command at least twenty minutes every 
day, particularly for the last four grades. For the first two grades, we 
need from two to three ten-minute breaks each day. The time should be 
spent out of doors whenever possible, and when weather conditions dic- 
tate staying in, the classroom windows should be opened to permit as 
much fresh air to stream in as possible. It is to be deplored that teachers 
are made to believe that the newer heating and ventilating systems for- 
bid the opening of windows. The temperature of rooms at all times 
should be regulated for the comfort of the children, not for the comfort 
of the teachers. It is a selfish attitude for a teacher who is dressed in 
thin silks to regulate the heat accordingly and have the children, who are 
dressed in woolens, suffer in the many times over-heated and nauseating 
atmosphere. 

At best, conducting physical education in a classroom is a primitive 
hang-over. It was never intended that the classroom with its fixed fur- 
niture serve as a gymnasium. We are the only country in the world that 
practices so foolish a procedure. Our facilities, then, need careful check- 
ing up and no effort should be spared to utilize available space for activ- 
ity purposes, at the same time stressing the need for better facilities. 
If there is an assembly room, the breakable decorations and lights may 
be protected by nets and so serve as a play room; corridors lend them- 
selves for use and even basement rooms — but only as a last resort. The 
movable furniture now frequently used also permits of at least some 
open space where stunts may be performed with at least a modest degree 
of freedom. 



37 

The leadership must be intelligent. The teacher must recognize and 
appreciate the new concept of physical education, namely, that it is an 
endeavor to teach through the physical rather than for the physical. She 
must see the activities as tools through which to achieve the objectives, 
whether they be of health or behavior. While the program content can- 
not be definitely classified as to grade or age, there is usually a gradual 
building process that leads from fundamentals to the finished product. 
The eventual dance, the ultimate complicated game, the eventual intricate 
technique necessary for field and track and gymnastic purposes, are the 
goals toward which the healthy youth will strive. It is on the journey to 
these that the habits for better living and better doing, for keener and 
more accurate reactions, are cultivated. 

While we are concentrating on health and physical education in the 
schools, the ultimate result must be measured by the extent to which the 
established habits prevail in adult life. To this end must the efforts of all 
who contribute be coordinated. When leisure time is so utilized that it will 
increase the productive value of man during his working periods, instead 
of reducing it, we will be on a fair way of understanding the Art of 
Living. 

A HEALTH PROGRAM IN THE SCHOOLS 

By Elizabeth H. Sampson, 
Principal, Hedge School, Plymouth, Massachusetts 

All modern teaching is based upon the interest of the child, connecting 
the subject to be taught with real life situations whenever possible. In 
order that the teaching of health should be no exception, it is necessary 
for the classroom teachers to have an understanding of the vital need of 
health education and to have the results to be accomplished clearly and 
definitely in mind. They must have enthusiasm and a spirit of cooper- 
ation. The principal of a school must not only possess these qualities 
but must be ready with suggestions, help plan special activities, see that 
late publications and other health material are available for the teachers' 
use, help organize programs which shall be wisely broken up into proper 
periods of study, recitation, rest and exercise, and be a leading factor in 
enlisting the cooperation of the parents and the community. 

The school physician hehps put the work on an intelligent basis by 
holding a series of conferences with the teachers throughout the year. 
The school nurse does the follow-up work, but the responsibility for the 
teaching of health and a healthful condition in the schoolroom rests upon 
the classroom teacher for she is with the children many hours a day, thus 
having a better opportunity than anyone else to observe and study the 
physical needs of her pupils. It is she who must attend to such matters 
as correct ventilation, lighting and seating, and it is very essential for 
her to be familiar with the data given by the school physician and nurse 
that she may intelligently cooperate with them for the success of their 
work. 

Realizing that the teacher's program is already over-crowded, a definite 
outline has been provided for our schools. The chief objective is to teach 
health habits to the boys and girls, appealing to their desire to look well, 
to their love of animals, and to their interest in "doing" things. At the 
same time, in order that health teaching may not become an added burden, 
the amount of time which the teacher has to spend in preparing her les- 
sons has been reduced to a minimum amount. To quote from The Out- 
line for Teaching Health and Hygiene in the First and Second Grades: — 
"Six essential elements of practical hygiene have been selected and made 
the basis of instruction; namely, Cleanliness, Nutrition, Body Mechanics 
and Rest, Clothing, Safety and Mental Health. Each element is developed 
in terms of what the child should know about it. For instance, the first 
element is used as follows : 



38 
I. What the Child Should Know About Cleanliness : 

1. That a clean child is attractive and popular. 

2. That bathing helps to keep children well and happy. 

3. That animals keep themselves clean. 

The topics are not to be taught verbatim, but are intended to give the 
teacher the idea which she interprets to the children with the help of the 
material which is given under (a) songs, stories, rhymes and games; (b) 
pictures; (c) dramatizations; (d) demonstrations; (e) projects." 

The songs, stories and rhymes have been chosen from books which are 
easily accessible for the teachers, not only the titles given but, in most 
cases, the number of the page. Much of the other material is given in 
full. These are merely suggestive and teachers are encouraged to supple- 
ment with additional material of their own. Detailed directions are given 
for carrying out the Outline through activities connected with a doll 
house, a doll family and a sandtable. Description is also given for mak- 
ing a health "movie" which would represent the year's work. To enlist 
the interest of the home, it is suggested that at some time near the com- 
pletion of the course a Health Party be given to which the mothers are 
invited. An interesting program could be made which would serve to 
show what the children had learned about health. A bibliography and a 
list of sources from which further information- may be obtained are 
given at the end of the Outline. The second and third grades supplement 
the Outline with reading from Health Primers. Grades four, five and 
six use one of the fine series of health textbooks which has recently been 
published as a basis of instruction. One reward is offered to encourage 
the formation of good habits in all grades. On Health Day the pupils 
who are 100% in health and hygiene are presented with a bronze medal. 
It means something to have won this because before receiving it a child 
must have passed a physical examination by the school physician, made 
progress in school work satisfactory to the teacher, and shown interest 
in and taken an active part in the health program of his school including 
personal hygiene. 

The time allotted to Health Education in itself is not sufficient for so 
important a subject. Therefore the question arises, "How then can it be 
done?" The problem has been solved in my own school in this way: A 
committee of four is appointed to plan the special health activities for a 
year. When their plans are completed they are presented to the other 
members of the faculty for discussion and suggestions, and adopted when 
satisfactory to all. Much has been accomplished as a result of organizing 
the work in this manner, including Good Health Soldier parades with the 
cleanest child as Captain, campaigns and drives of all sorts, and intensive 
work with underweights. At least once during the year each room has 
constructed a health project on the sandtable which has been unusual 
and original. At the weekly assemblies health news about classes and in- 
dividuals has been announced. Publicity is a big incentive for young 
people. 

The special activities planned for this year are: (1) Health News- 
paper, (2) Classroom Inspection, (3) Modern Health Crusade, (4) Cor- 
relation, (5) School Health Book, (6) Health Around the World. 

The Health Newspaper under the leadership of a sixth grade teacher 
is published monthly and a separate staff is chosen for each issue to give 
all the pupils in the class a chance to select and arrange material. The 
news is collected by reporters who visit all of the rooms to find out what 
health work is being done. The children are eager to do something that 
is worth putting in the paper. Such items as "Every child in our room 
has a toothbrush," "We have no underweights in our room" starts a good- 
natured rivalry. The results of classroom inspection, good menus, re- 
sults of weighing and measuring, the names of the 100% children, suit- 
able clothing for the different seasons, everything, in fact, that is of 
general interest is printed. These papers reaching many of the homes 
give the parents a good idea of the work that is being done. 



39 

For Classroom Inspection five pupils from the fifth and sixth grades 
are chosen to act as health officers. Twice a month, at unexpected times, 
they visit each room to check the twelve items selected for personal clean- 
liness and neatness of the schoolroom. Plans of the classrooms are put 
upon the bulletin boards in the two main corridors with a printed list of 
the articles under inspection. The scores are recorded upon these in the 
space allotted to each grade and the class having 100% is rewarded by 
having a star placed above its score. 

The Modern Health Crusade is always helpful. It appeals to the social 
instinct of children when they know that millions of boys and girls are 
members. It appeals to their desire to achieve success as they master one 
chore after another and it appeals to their love of the spectacular when 
they march through the streets arrayed in white helmets and capes dec- 
orated with red crosses, heralded by a trumpeter dressed in the gor- 
geous costume of a knight, music playing and banners flying, conspic- 
uous among them one bearing the inscription "100% in Health and Hy- 
giene." It appears to their spirit of hero worship when at the Accolade 
ceremony the Grand Master dubs them squires, knights, and knight ban- 
nerets. To them it is real as is shown by the sweet solemnity of their 
faces when the sword touches their shoulders. 

To obtain the best results, the teaching of health must be present in 
the whole of the daily program. In written English, original stories, 
plays and rhymes take care of sentence formation, capitalization, punc- 
tuation and spelling. Debates on health subjects can be used for oral 
English; for example, "Resolved that milk is better for girls and boys 
than tea or coffee." A question like, "What can school children do to im- 
prove the health conditions of the community?" will cause much discus- 
sion and often start a class off on an intensive health campaign, and 
nothing can be better for oral work than two-minute speeches on some 
phase of health work. What more interesting in history than to trace 
the history of the potato suggested by the study of Sir Walter Raleigh, 
to learn why corn played such an important part in the life of the Pil- 
grims, or what made the Greeks so strong and beautiful? The teacher 
who has a keen interest in health will find endless opportunities of cor- 
relating it with every subject. 

Health Around the World, suggested by the large number of foreign 
children in the school, has become a fascinating and extensive activity. 
Each class has chosen a country for the purpose of learning what foods 
are eaten by the people and what is being done to promote health. The 
children are reproducing scenes from these countries on the sandtables, 
making booklets and collecting pictures and representative articles. When 
the study is completed an exhibit is to be given to which the parents will 
be invited. Each class will have a booth in the Assembly Hall and chil- 
dren dressed in the costume of their chosen country will act as hostesses 
and guides. The entertainment will consist of a series of pictures in 
color, "Around the World in Sixty Minutes" and a play entitled "Making 
the World Fit." 

To conclude — we try by purposeful activities and practical demonstra- 
tions to make the teaching of health pleasurable so that the children will 
want to be healthy. 

THE VALUE AND RESULTS OF A HEALTH PROGRAM IN THE 

SCHOOLS 

By William H. Slayton, 

Superintendent of Schools, Waltham, Mass. 

The public elementary school children of Waltham have just com- 
pleted the third year of their organized health work and have held for 
the second year public exercises in the way of demonstration of their 
school and personal achievement along the line of health habits. 



40 

It has been my good fortune to see all of the demonstrations as they 
have been given at the different school buildings, fourteen in all. The 
programs were prepared by the principals and teachers in accordance 
with their own idea and conception of what they desired to present. I 
can say, after having seen these demonstrations, that, in my opinion, 
this effort in putting over a program of health and in the inculcation in 
these children of health habits, is one of the most important pieces of 
school work which we are at present doing. 

In the nature of the work it is possible to vitalize and motivate the 
efforts of the children because the matter of personal health is such a 
real issue in the case of every single one. The children have been in- 
terested to work for a record for their school and for their building as 
well as to make a fine record individually. This has resulted in a cer- 
tain community of interest which makes the health program a very defi- 
nite piece of work in civics. 

Throughout the year the teachers with their pupils have been empha- 
sizing matters of weight, posture and care of the teeth. All children 
have been weighed monthly, gains or losses have been noted, and re- 
ports have been sent each month to the parents for their consideration. 
We use the Henryson Height and Weight Chart with the usual allow- 
ances for both above standard and below standard. The terms "over- 
weight" and "underweight" are not used, but rather the terms "above 
standard" and "below standard." The advantage of this is to prevent 
any feeling of inferiority on the part of the child. Most ingenious 
graphical representations have been devised by teachers and children 
to show the several weight groupings, and in this connection, of course, 
there has been a great effort on the part of the children to regulate 
their eating, sleeping and general living habits in order that they might 
correspond to a given standard. 

The posture work has been very definitely connected with the Physi- 
cal Education Department program, which is under expert direction 
and is presented as a regular part of the daily school program. Exami- 
nations for the posture badge were given by the Director of Physical 
Education, and in this examination consideration was made for sitting, 
standing and walking posture of the child as he went about his daily 
work in the school room. Some children who showed good posture be- 
fore the Physical Education Director failed to receive their badge be- 
cause of poor record in the school room. 

Dental badges were given to children who presented a certificate 
from their own dentists or from the school dentist, or who, as a result 
of examination by the school nurse, showed that their teeth were in as 
good condition as was required by the standards for the dental badge. 
In some rooms a remarkable result was produced, as, for example, in a 
second grade where twenty-eight out of thirty-five children presented 
dental certificates. Greatest eagerness was shown by the children to 
qualify with regard to the condition of their teeth although the dental 
badge is one of the most difficult to obtain, chiefly on account of the ex- 
pense entailed in treatment of the teeth. 

To those children who received the Weight, Posture and Dental 
badges was given the privilege and honor of carrying a United States 
flag at the conclusion of the school exercises, these flags being returned 
at the end of the exercises and in their place a flag certificate being 
given to the child, which indicated that he had made all the require- 
ments in personal health, and that he had carried the United States flag 
in the May Health Demonstration. 

Unquestionably, the effect of this program upon children, teachers 
and parents has been extremely helpful. We may consider that the in- 
vestment of our time and effort in this health program has given nota- 
ble immediate returns as well as deferred returns. The immediate re- 
turns have to do with the present excellent health of the children, their 
improved morale, their better attendance at school and the hearty co- 



41 
operation of a large number of parents. The deferred returns cannot 
be at present evaluated, but it is within the region of safety to say that 
these boys and girls who are actually practicing health habits are going 
to be strong and healthy citizens of tomorrow. 

The State law requires that instruction be given in the evil effects of 
narcotics and alcoholic stimulants. A definite program is being carried 
out along this line, but in my personal opinion the very best instruction 
that is being given in temperance, so-called, is this positive inculcation 
of health habits in these children. Narcotics and alcoholic stimulants 
are very foreign to the experience of a large percentage of these chil- 
dren. On the other hand, milk, vegetables, fruit and other wholesome 
foods are very much a part of their daily experience. 

I believe a positive health program that is capable of being measured 
as definitely as our health program is measured is going to make a far 
greater and more lasting impression upon our children than any other 
that can be undertaken. 

Not the least important phase of this program of good health is the 
part taken by the parents. I have never seen greater interest in any 
school activity than has been shown by the numbers of parents visiting 
our demonstrations, by the warm commendations which have been 
given, and their constant desire to cooperate in all that we are project- 
ing. 

During the present school year the health program which has been 
carried on in the elementary schools for about three years has been ex- 
tended more definitely into the junior high schools, and while we have 
modified the scheme of badge awards, the pupils have been no less con- 
scious of the achievements which have been made in the health habits 
which they have practiced. This has been shown by the assembly pro- 
grams which were given in both of the junior high schools. 

I have no doubt whatever that if the continuance of the health pro- 
gram was to be left to the decision of the children themselves it would 
be approved by a very great majority opinion. As far as the teachers 
and administrative officers are concerned, I am sure they see not only 
the excellent effects upon the children, but also the deeper underlying 
economic considerations which assure them that the work they have 
been following out has been worthwhile. 

THE NEED FOR HEALTH EDUCATION IN JUNIOR AND SENIOR 

HIGH SCHOOLS 

By Jean O. Latimer, 
Educational Secretary, Massachusetts Tuberculosis League, Boston 

The importance of health need not be argued since it is unquestion- 
ably one of the basic factors of determining the value of any individual 
to himself or his community. It should not here be necessary to formu- 
late a philosophy of education as to why the school must undertake its 
share of health education, for again and again, in searching through 
the literature of the re-makers of the curriculum, invariably we find 
health listed as the first objective of general education. 

While we are still in a more or less loosely organized state in the 
teaching of health in the elementary schools, it is generally conceded 
that in the teaching of health, we have made more progress in the lower 
grades than we have in the junior and senior high schools. The high 
school at present represents the neglected field in child health educa- 
tion, and in the country as a whole, less attention is being given to the 
health of the individual student, and less is being done in the way of 
health teaching, and inculcating standards for healthful behavior in 
the secondary than in the elementary schools. Again, health education 
workers who have studied the high school problem have agreed that an 
extension of the same type of program which has proved successful in 



42 

the elementary school is not what is needed, but that a different ap- 
proach is required. It is well to remember that psychologists tell us 
that high school age students have the same mental capacity as adults. 
Hence, health education material which is over-simplified and adapted 
to childish intelligence will not hold their interest or gain their respect. 
Health propaganda which is exaggerated and over-emotional in its ap- 
peal is seldom effective and the exhortative method of attempting to 
inculcate health habits frequently has an adverse effect. 

In order to analyze the need for a more adequate type of health edu- 
cation in the high school, we should think briefly of three different 
phases. First — the promotion of a physical environment which tends to 
conserve and promote health ; second — the supervision of the health of 
the individual students, with emphasis on the correction of physical de- 
fects; third — inculcating standards and ideals for healthful behavior 
with adequate scientific knowledge on which to base them. 

To discuss each in order: — The provision of a healthful physical en- 
vironment is probably the side on which the greatest progress has been 
made. As the new high schools have been built throughout the State, 
it is gratifying to note that in most instances they conform to the best 
standards. While many of the older buildings leave much to be desired 
as to sanitation, the serious lacks in healthful environment are far 
more common because of the failure to make the best use of existing 
facilities, than because conditions are so bad as to make a healthful 
environment impossible. The almost universally poor ventilation and 
very frequently poor lighting to be found in the classrooms are more 
common because of a lack of standards for healthful ventilation and 
lighting on the part of the faculty and students than because of any 
defect in the planning of the building. 

The second and third phases must receive more attention. 

One of our great needs at present is for the extension of medical in- 
spection to the high schools. We cannot have a well-rounded program 
for the protection of our children solely by having physical examina- 
tions and a follow-up program for the correction of defects for the 
younger children, important as this is. Surveys here in Massachusetts 
of certain school systems where a preventive health program has been 
in operation over a period of some years have revealed the fact that 
about the same per cent of physical defects are to be found throughout 
the grades — this research would seem to indicate that as the child 
grows older certain physical defects decrease, while new types appear. 
Moreover, we should bear in mind that while the death rate from all 
causes for the age represented by the entrance to the high school is 
lower than for any other period, it is nearly double for the next five 
years. Especially, there seems to be need of finding out whether the 
members of athletic teams have been examined by physicians, and how 
complete these examinations were. It should not be hard to make peo- 
ple see the necessity for a thorough chest examination before partici- 
pation in athletic contests. With this as a start, we should work towards 
the student's having a complete physical examination at least twice dur- 
ing his time in high school. 

In this connection, besides the physical examinations, we need also 
a more adequate type of health service in the high school. It is obvious 
that with departmental work, unless some one person heads such ser- 
vice, efficiency of operation cannot be expected. Significant is the de- 
velopment which is taking place in some of our more progressive high 
schools, in that a special nurse is now being assigned for such work. 
In other schools, a new type of personnel work is developing, by the 
appointment of a special health counsellor who coordinates all health 
work. In some of the smaller high schools where at present such spe- 
cialized health service is not possible, the need is being met by the ap- 
pointment of a faculty health committee, composed of teachers them- 
selves, with a chairman. In the average high school of approximately 



43 

two hundred pupils, it should be possible for some member of the fac- 
ulty to discharge the work of the health counsellor, if given two free 
periods a day to develop the work. Certainly we need a demonstration 
of a more unified type of health work in the high school. 

Experience shows that the technique of follow-up work with high 
school students for the purpose of having defects corrected should be 
different from that in the elementary grades. Sending a note home by 
the student to the parent is not an effective way of getting results. The 
most important thing is to interest the student himself in having the 
corrections made. This should be tied up with the health teaching part 
of the program and be part of a plan to give the students a rational in- 
terest in health. A visit from the nurse to the home may be very useful 
in helping the student to interest his parents. 

Finally, the third phase of high school health work which should re- 
ceive more attention is that of inculcating standards and ideals for 
healthful behavior with adequate scientific knowledge on which to base 
them. Not only health habit training but some scientific knowledge in 
regard to health is needed in the high school. We have at present 
swung far from the old fashioned type of physiology which taught the 
child the names and number of all the bones in his body. However, pos- 
sibly the pendulum has swung too far away from the knowledge side. 
Physiology and hygiene, while not to be taught for the sake of the 
sciences themselves, are necessary in order that the child may practice 
intelligently personal hygiene. The older child must understand some 
of the basic scientific facts in regard to the functioning of his body — 
for it is by making use of the growing scientific curiosity of the ado- 
lescent that we are most able to interest the child in the performance of 
health habits. 

But it should be also recognized that positive health education in 
high schools cannot be confined to one department. In addition to the 
regular hygiene teaching, instruction must be supplemented by the 
health instruction given in Home Economics, Biology, Physics, Chem- 
istry and Social Science, where health is shown in its proper relation. 
This does not mean, however, that it is safe to leave the teaching of 
health to such haphazard allusions as the teachers of the various de- 
partments may see fit to give to it, but rather that certain teachers 
should be assigned definite health lesson units for development. This 
is to say that effective health teaching must be inter-departmental. 

The health work in the high school cannot be neglected — it must be- 
come the culmination of the training which the children have begun in 
the elementary school. Moreover, the community must realize that 
since a large per cent of boys and girls complete their education either 
in junior or senior high school, they must be equipped to meet their 
responsibilities not only for personal but for community health. By 
training high school boys and girls in health knowledge, habits and at- 
titudes, we are also training the parents of the next generation. Our 
immediate responsibilities would seem to undertake some research as to 
the actual physical conditions found among adolescents, and finally in 
a demonstration as to what is the best type of health education for the 
high school. 

EDUCATING THE HANDICAPPED CHILD 

By Arthur B. Lord, 

Supervisor of Special Schools and Classes, Massachusetts Department of 

Education 

Since 1825 Massachusetts has made some provision for the education 
of deaf children. At first pupils were placed in the "Asylum for the Deaf 
and Dumb" at Hartford, Connecticut. Later, after the establishment of 
schools for the deaf within the State, a part of the pupils were sent to 
these schools. 



44 

Existing laws of Massachusetts relating to the education of the deaf 
provide for the placing of such children in boarding schools and day 
classes for the deaf at the expense of the Commonwealth. The law pro- 
vides that the Department of Education "shall direct and supervise the 
education of all such pupils". 

During the present school year the State is educating 420 deaf children 
placed in the American School for the Deaf, West Hartford, Connecticut; 
Beverly School for the Deaf, Beverly; Boston School for the Deaf, Ran- 
dolph; Clarke School for the Deaf, Northampton; the Horace Mann 
School, Boston (day school), and the day classes for the deaf at Lynn, 
Worcester, and Springfield. 

Many of these children have never heard the human voice and are un- 
able to talk. In these schools they not only learn to speak but also to 
read speech from the lips of the speaker. It takes about ten years for a 
pupil to learn speech and speech-reading and to complete the work of the 
elementary school. The pupil is then prepared to enter high or vocational 
school and take up the work with children of normal hearing. 

The day classes for the deaf are all located in school buildings with 
regular classes. The children, in some instances, are successfully taking 
handwork and physical education with normal children in other classes 
of their own chronological age. The academic work in these classes is 
limited to the primary grades. The pupils are transferred to the Horace 
Mann School or to a boarding school after completing the work offered. 

Such handwork as is offered in the schools for the deaf is given pri- 
marily for its pre-vocational values, as is the work in our junior high 
schools. The definite teaching of vocations is not attempted. We have 
realized that some system of vocational training should be offered these 
pupils after they complete the course in the special schools. The Division 
of Vocational Education, through its Rehabilitation Section, has, in part, 
met this need. During the past seven years 131 pupils have received 
training. The Section assists pupils in getting jobs and, when necessary, 
trains pupils for some particular work. 

Several pupils, who were graduated from schools for the deaf last 
June, are now being trained in the Massachusetts vocational schools. It 
is hoped that more and more of those pupils who do not go into high 
schools may receive worth-while vocational training. Such training will 
assure them a secure place in their community when they may become 
self-supporting, self-respecting and respected citizens. 

As we review the work with the deaf during the past ten years here in 
Massachusetts, we see an increase in the number of teachers with special 
training; the beginning of systematic home training with children of 
pre-school age; the establishment of a department of research at Clarke 
School; a start in vocational training; and increased facilities through 
the opening of day classes. 

The next ten years will see an increased emphasis on : pre-school work, 
research, and vocational training and guidance. 

In 1832 the State made its first appropriation for the education of the 
blind and since that time has increased its support until today there are 
183 pupils in Perkins Institution for the Blind placed there by the Com- 
monwealth. As in the case of the deaf the law provides that the Depart- 
ment of Education "shall direct and supervise the education of all such 
pupils". Under the Division of the Blind the Department cooperates with 
towns maintaining sight-saving classes in the public schools for the edu- 
cation of children needing such attention. There are now 31 classes 
offering instruction to 370 children. 

There are other types of education for handicapped children which are 
maintained locally by towns and cities, the State giving only such finan- 
cial aid as is given towards the maintenance of the regular classes. In 
this group we find the work with the hard-of-hearing. These children 
by the aid of lip reading are able to remain in the public schools and go 
forward with their education. Teachers of lip reading are employed in 



45 
Boston, Lynn, Cambridge, Somerville, Fall River, Springfield, and West 
Springfield. An extension of this work will undoubtedly be made to 
several other cities at the beginning of the next school year. Testing 
hearing by means of the Audiometer is proving very effective in discov- 
ering those children who need this help. 

Classes for crippled children are maintained in some cities and the 
itinerant teachers employed at Holyoke and Melrose spend their time 
going from home to home giving instruction to crippled children. Chil- 
dren from those towns and cities where there is no opportunity locally 
for their instruction may be sent to the Massachusetts Hospital School 
at Canton where they will be educated at the expense of the State or to 
the Industrial School for Crippled and Deformed Children at 241 St. 
Botolph Street, Boston, which is a day school for crippled children. 

Open air classes for the anemic and those who might be susceptible 
to tuberculosis are found in many cities. 

Physical differences among children are apparent to everyone. In fact, 
no two individuals are exactly alike, physically. There are just as marked 
differences mentally. Retardation in mental development makes neces- 
sary a special type of training for many children. 

The first special class for mentally retarded children in Massachusetts 
was opened in Springfield in 1898. Boston, a few months later, estab- 
lished a class, and in 1899, Worcester provided a similar opportunity for 
such pupils. From then to 1919, there was a steady increase in the num- 
ber of special classes. 

In 1919 the legislature enacted a law requiring that every town and 
city having ten children of school age three or more years mentally re- 
tarded shall establish a special class for their instruction. The law pro- 
vides for the annual examination of children believed to be so retarded by 
the State Departments of Education and Mental Diseases, or by exam- 
iners approved by these departments. Fourteen traveling clinics have 
been established with headquarters in various State institutions. These 
clinics make use of a physician, a psychiatrist, and a social worker or 
school nurse. The examination covers the so-called "ten-point scale". 

The "ten-point scale" covers very thoroughly the following fields: 
physical examination, family history, personal and developmental history, 
school progress, examinations in school work, practical knowledge and 
general information, social history and reactions, economic efficiency, 
moral reactions, mental examinations. 

The evidence in no one field may be conclusive by itself, but the sum 
of the findings will be convincing for or against a diagnosis of mental 
deficiency. It has been very clearly demonstrated that mental tests 
alone are insufficient in determining mental retardation. 

Only those pupils who are able to profit by the instruction offered are 
considered for special classes. Children who properly belong in an in- 
stitution for the feeble-minded are excluded from the public schools. 
Such children are provided for in State institutions so far as room per- 
mits. The clinics have examined approximately 28,000 children. They 
have found approximately 18,000 pupils to be three or more years men- 
tally retarded. This is about 1% per cent of the school population in the 
towns and cities where children have been examined. 

Special classes for mentally retarded children are maintained in 118 
towns and cities, with a total of 467 special classes and an enrollment 
of 6,699 children. Many of the larger cities have special supervisors for 
this work. 

In most of the cities and larger towns the classes are housed as a 
part of a public school with classes of normal children of the same chron- 
ological age — the younger children in the elementary schools and the 
older groups in junior high schools. The special class pupils are a part 
of the school life. They take part in assemblies, clubs, athletics, and 
other activities. We believe a fairly large percentage of these children in 



46 
adult life will become self-respecting, self-supporting citizens in the com- 
munity and should, therefore, mingle with normal children in school. 

In 1927 a manual was published by the State Department of Education. 
This manual gives the regulations for the establishment of such classes, 
suggestions for organization and administration, and a suggested course 
of study. 

The State offers a six-week training course for teachers of special 
classes at the summer session of the State Normal School at Hyannis. At 
the State Normal School at Salem a three-year training course is offered. 
The first two years of the course are the same as the regular course 
offered for all teachers. The third year offers specialization for the teach- 
ing of mentally retarded children. 

During the past three years the Department has held annually a series 
of regional conferences for teachers of mentally retarded children. 

The single special class in the small school system is often just as 
successful as the classes in a city system. Some of our outstanding classes 
are found in rural communities. 

These classes with not over 18 pupils and an average of 15 give the 
boys and girls individual instruction based on a study of their abilities 
and needs. 

Massachusetts is substituting habits of success for habits of failure, 
thus making sure this group of children will in adult life be an asset 
rather than a liability in the community. 

PSYCHIATRIC SCHOOL CLINICS FOR THE EXAMINATION OF 
RETARDED CHILDREN 

By Neil A. Dayton, M.D., 

Director, Division of Mental Deficiency, Massachusetts Department of 

Mental Diseases 

Retarded children in the public schools of Massachusetts are exam- 
ined through clinics operating under the supervision of the Department 
of Mental Diseases. At the present time there are fifteen of these trav- 
eling psychiatric school clinics which visit the schools at the request of 
the local superintendent and examine all children referred because of 
retardation. 

During the year 1928 these clinics visited 156 towns, cities and vil- 
lages in Massachusetts and examined 6,285 retarded children. Each 
clinic consists of a psychiatrist, a psychologist and a social worker, and 
they are assisted in their work by one of the local teachers and the 
school nurse. 

A very comprehensive examination is conducted which embraces the 
following points: Physical examination, family history, personal and 
developmental history, school progress, examination in school work, 
practical knowledge and general information, social history and reac- 
tions, economic efficiency, moral reactions, mental examination. At the 
conclusion of this examination the clinic psychiatrist summarizes the 
findings, makes a diagnosis of the case and offers recommendations to 
the school superintendent. They also confer with parents of the chil- 
dren concerned and give advice as to the way of best meeting problems 
which arise in connection with the environment, such as personality de- 
viations or conduct disturbances. 

The clinics started from a very humble beginning in 1916 when 126 
cases were examined. They have grown in leaps and bounds until well 
over 6,000 cases are being examined annually at the present time. At 
the end of 1928 over 38,000 examinations had been made by the various 
clinics. 

The benefit lies in the early discovery of cases of mental retardation 
in children at an early age when a constructive program for the child's 
welfare can be laid out. It gives the parents a complete understanding 



47 
of the child and also enables the teacher to deal with the child intelli- 
gently in the light of his various physical and mental shortcomings. 
Re-examinations are conducted from time to time so that a check is kept 
on the progress of the individual child. 

HABIT CLINICS AND THEIR PURPOSE 

By Olive A. Cooper, M.D., 

Assistant to Director, Division of Mental Hygiene, Massachusetts 
Department of Mental Diseases 

The time is past when one thinks only of the physical side of the 
child's life. Today one appreciates that it is but a single phase of his 
development and that the emotional or mental side commands as much 
attention, if not more, than the physical. One reason for this is that a 
child's later efficiency is determined to a greater extent by his early 
mental training than by his physical development. This fact is borne 
out all about us in the innumerable cases we see of individuals who, 
although perhaps possessing adequate physical endowment, are failing 
to make the grade in life by reason of a warped personality and faulty 
attitude toward life, both of which have resulted from incorrect mental 
training at an early period. Conversely this is observed in cases where 
persons, even though bearing a serious physical handicap, are able to 
make a successful adaptation to life in all its phases having been ade- 
quately trained mentally so that suitable compensations for the physi- 
cal defect have been established. 

In our eagerness to obtain the desired physical results for children 
it is easy to lose sight of the fact that these cannot be achieved without 
due consideration of the mental factors or habits involved. We must 
keep in mind always, the close relationship between the mental and 
physical phases, remembering that one is dependent upon the other for 
its successful development and that physical standards are determined 
largely by habits. 

An example of this is seen in a child who is underweight. Investi- 
gation reveals that he is capricious about food and will only accept that 
food for which he has a particular fondness. All others are refused 
even though they may be the most nourishing. The reason for his mal- 
nutrition is quite apparent to us and we at once say it is due" to an un- 
suitable diet; yet from the parents' standpoint it is impossible to have 
him eat those foods which would be more beneficial. Underlying this 
whole situation is a psychological problem in which we find that the 
child's refusal to eat certain foods is due to undesirable eating habits 
based on a faulty attitude. In a situation of this kind all methods are 
unavailing until the child's habits of eating and general attitude toward 
the problem have been changed and until this is effected one cannot 
hope to have him attain the desired physical goal. 

Very early in life a child exhibits definite ways of reacting to the 
more fundamental problems of life such as eating, sleeping and elimi- 
nating and his manner of reacting toward these determine, in a great 
degree, what his later attitude toward life's problems will be. There- 
fore, one assumes that if a child has satisfactorily established these 
three basic habits, he is in a fair way to continue in a successful emo- 
tional or mental development. On the other hand, in the cases of those 
children who have failed in the successful establishment of these three 
problems we may expect to find many and varied manifestations of an 
allied maladjustment. 

Frequently one finds among cases of first grade failures, children, 
who, having been unable to conquer the simple problems of childhood, 
were unequipped to meet the complex situations in the schoolroom and 
as a result of this spent the entire year in an attempt to adapt them- 
selves to the others. This unfortunately was done at the sacrifice of a 



48 
year's progress in the scholastic field. One is justified in concluding 
that there is an unquestionable correlation between the fundamental 
habits of sleeping, eating and eliminating and later behavior patterns. 
Gradually people are beginning to realize that as physical defects 
had their beginning in early life, so likewise did personality difficulties 
and associated maladjustments noted in adult life get their start some- 
time in childhood and very often as early as in the period of infancy. 
It is further realized that many of the apparently simple habits of in- 
fancy and early childhood should not be ignored nor considered as self 
eliminating due to the already mentioned close relationship which they 
bear to the more serious handicaps of life. 

In the physical realm we recognize certain undesirable conditions 
which we do not permit to exist, knowing them to be fore-runners of 
more serious physical handicaps. Among these are such factors as 
poor posture, enlarged tonsils, malnutrition, etc. So likewise, on the 
mental side, do we have what are considered as handicaps or danger 
signals, if you will, conditions that are not favored because of the pos- 
sibility of their hampering the child's mental and physical development. 
These are referred to as neurotic traits and should be accepted as dis- 
tinct obstacles in the child's pathway to success. They include such 
conditions as nail biting, thumb sucking, temper tantrums, food ca- 
priciousness, enuresis (bed wetting), masturbation, night terrors, mor- 
bid fears, lying, stealing and various forms of disobedience. These 
neurotic traits are very frequently found in combinations and tend to 
serve as obstructors in the child's development. While we permit them 
to remain uncorrected we are not giving sufficient attention to the 
child's welfare as a whole and he may be handicapped in making the 
desired progress which he might otherwise make were these undesira- 
ble habits not present. 

Every parent, teacher and other individual responsible for the child's 
development should strive to develop the mental life of the child so that 
he may acquire habits such as will not only promote good physical 
health but will also be conducive to happy and efficient living in adult 
life. 

There are situated in and about Boston, several specialized clinics 
conducted by the Massachusetts Division of Mental Hygiene, where 
children between the ages of two and eight years may be taken for 
habit training and where parents may receive help in the methods of 
child training. 

The following is a schedule of the clinics: 



Wednesday 
Thursday 
Thursday 
Friday 



2:30 to 5 P.M. 
9:30 to 12 A.M. 
2:30 to 5 P.M. 
2:30 to 5 P.M. 



1st Tuesday 

9:30 to 12 A.M. 
2nd Wednesday 

9:30 to 12 A.M. 
3rd Wednesday 

9:30 to 12 A.M. 



Weekly 

West End Health Unit ■ [ 

Boston Dispensary 
Woodward Institute, Quincy 
Lawrence General Hospital, Lawrence 

Monthly 
Grouard House, School St., Reading 

Beverly Health Center, Cabot St., Beverly 

North End Consultant Clinic, Play School, 
No. Bennet St., Boston 



For further information one may call or write the Massachusetts Di- 
vision of Mental Hygiene, Room 106, State House, Boston, Massachu- 
setts. 



49 

REPORT OF THE CONSULTANT IN DENTAL HYGIENE— 1928 

Massachusetts Department of Public Health 

This past year has been one of rapid growth for the State Dental 
Hygiene Program. Practically every plan suggested in last year's report 
has been fulfilled, organization has become highly centralized and the 
new projects that have been launched have met with splendid response 
throughout the State. 

Dental Advisory Committee 

As all new projects in dental hygiene come before this Committee for 
discussion we will begin this report with a brief summary of its organi- 
zation and of its activities for the past three years. 

Several new members have been added to the Committee so that it now 
includes representatives of every organized group in the State interested 
in dental public health work. This organization is represented as 
follows : 

Two specialists in Children's Dentistry. 

Director, Forsyth Infirmary 

President, Dental Hygiene Council 

President, Massachusetts Association of Dental Hygienists 

Dean, Harvard Dental School 

Dean, Tufts Dental School 

President, Mass. Association of School Dental Workers 

President, Mass. Dental Society 

Chairman, Public Health Committee 

Six Regional Consultants 

Members Representing 

Dr. William Rice Tufts College Dental School 

Dr. Leroy M. S. Miner Harvard Dental School 

Dr. Frank A. Delabarre Specialist in Children's Dentistry 

Dr. Percy A. Howe Forsyth Dental Infirmary 

Dr. Charles W. Hammett Massachusetts Dental Society 

Dr. John T. Timlin Massachusetts Dental Hygiene Council 

Dr. Francis J. Marrs Massachusetts Association of School Dental 

Workers 
Dr. Edwin N. Kent Specialist in Childrens' Dentistry 

Mrs. M. Elta LeBlanc Massachusetts Dental Hygienists' Association 

The following rules and regulations were adopted for this Committee 
in 1926: 

1. That all questions concerning dental hygiene be unanimously 
endorsed by the Committee. 

2. In case the decision is not unanimous that a month be allowed 
for the delegates to discuss the question at hand with their 
organizations. That a majority vote carry the second con- 
sideration. 

3. That matters discussed at the meetings of this Committee be 
reported by the members to their respective organizations. 

4. That notices concerning this Committee and its purpose, and 
reports of its meetings be placed in the The Commonhealth 
and in the Bulletin of the Massachusetts Dental Society. 

Report of Meetings 

Topics Discussed 
1926 — 2 meetings 

May Dental Policy and Recommendations to the Dental Hy- 

giene Council. 
November Discussion of annual report and plans for coming year. 



50 

1927 — 1 meeting 

December Discussion of annual report; Endorsement of bulletin 
on "The Toothbrush Drill" and endorsement of changes 
in the Dental Policy. 
1928 — 4 meetings 

February Announcement of new Regional Consultants; Report of 
new Association of School Dental Workers; Recom- 
mendations concerning traveling dental clinic service; 
Discussion of plans for the state-wide dental cam- 
paigns (endorsed) ; Report of new ruling concerning 
Civil Service positions for dental hygienists. 

May Rules and regulations concerning dental service in tuber- 

culosis sanatoria (endorsed). 

October Delineascope film, "Beautiful Teeth", shown and en- 
dorsed; Changes concerning dental campaign mater- 
ial (endorsed) ; Report of summer school course for 
graduate hygienists; Discussion of question, "Should 
Vincent's Angina be made reportable?" (Committee 
decided in the negative). 

November Proposed amendment to the School Hygiene Laws (en- 
dorsed) ; Proposed addition to the Dental Policy of 
the Department (endorsed). 

Regional Dental Consultants 

Following the plan used in Pennsylvania the Department has ap- 
pointed six dentists to serve as Regional Consultants in each of the six 
health districts in the State. These Consultants were recommended by 
the President of the Massachusetts Dental Society as members of the 
profession who would be willing to advise the Department concerning 
dental problems in their districts and to interpret the state programs 
and policies to the local dentists. 

Several of the Consultants helped with the school campaigns last 
spring. More frequent visits from the Department should be made this 
year as most of the Regional Representatives are not able to get to the 
Advisory Committee meetings. This scheme has splendid possibilities 
but will take some time to develop. We hope that these consultants will 
be able to help us extend our pre-school dental program as we are still 
faced with the problem of the dentist who does not care for deciduous 
teeth. 

Massachusetts Association of School Dental Workers 

In February, with the help of Merrill Champion, M.D., and several 
members of the Advisory Committee, a meeting of all school dentists, 
dental hygienists and dental assistants was called and the Massachu- 
setts Association of School Dental Workers was formed. The purpose 
of this association is to promote better community dental programs. Its 
organization includes a chairman and secretary from each of the six 
health districts besides the regular officers. Its present membership of 
345 includes approximately 213 school dentists, 48 dental hygienists and 
84 dental assistants (including some school nurses). 

The first annual meeting was held in May on the first day of the an- 
nual meeting of the State Dental Society. A standard report for com- 
munity dental programs and a bulletin stating "what a dental certifi- 
cate should mean" drawn up by the Executive Committee were endorsed 
by the Association at this meeting. 

Short informal district meetings were held in the fall at the close of 
the school hygiene conferences held by the Departments of Public 
Health and Education. New pieces of campaign material were endorsed 
at these meetings. 

Seven numbers of the monthly bulletin of the association have been 



51 

compiled and edited by the Dental Consultant of the Department, who 
is secretary and editor of the association, ex-officio. This bulletin con- 
tains general news and announcements of the state-wide programs and 
meetings, book reviews, addresses for dental health educational ma- 
terial, reports of dental campaigns and news of local dental programs 
throughout the State. This bulletin gives the Department a splendid 
contact with this large group of field workers. 

The Dental Hygienist ' 

The Department has realized for several years that dental hygienists 
interested in school work should have some training in public health 
procedures and in teaching methods so that they will know how to fit 
their programs into an already complicated community health plan and 
so that they will be able to work with teachers intelligently. 

A short course of two weeks was held at Forsyth Infirmary in 1926 
and 1927. Approximately ten students enrolled each year. This course 
was a step in the right direction. 

This last summer a six weeks' course was offered by the Departments 
of Public Health and Education at the summer session of the Hyannis 
State Normal School. This course included work in "Teaching Methods 
Applied to Health Subjects" by Miss May Hale, State Normal School, 
Keene, New Hampshire. We gave the students a course combining lec- 
tures on "School Dental Procedures and General Public Health Meth- 
ods." Eight dental hygienists were enrolled. 

The class in School Dental Procedures worked out a list of objectives 
for dental health education work in the schools. These objectives were 
presented at the symposium on dental hygiene at the combined meeting 
of the American Child Health Association and the American Public 
Health Association at Chicago in October. 

Several superintendents of schools visited the class and interviewed 
various members with regard to positions. We hope to stimulate more 
interest on the part of our superintendents in demanding well-trained 
dental hygienists by offering a regular registry service here at the De- 
partment for hygienists interested in school positions. 

It will always be impossible for some of the hygienists now in the 
field to attend the Hyannis course, so it is hoped some arrangement can 
be made to have! these subjects included in the under-graduate course 
at Forsyth or as an extension course for extra training for the under- 
graduates interested in going into public health work. 

There is a real place in the larger school systems for hygienists with 
this training, to inspect mouths, conduct a yearly campaign for correc- 
tion of dental defects and to prepare definite lesson material with the 
teachers on dental health education. A position of this type should be 
under the school committee as is that of the school nurse. For this rea- 
son, the Department is proposing an amendment to the present school 
hygiene law giving permission to the school committee to employ a den- 
tal hygienist with special training in teaching methods, and has drawn 
up an outline of what her program should be if employed by a school 
committee, to explain this legislation. 

Pre-natal and Pre-school Work 

We are sorry to report that there have been practically no new devel- 
opments in the Department's pre-natal and pre-school dental program. 
There is an increasing interest in this group in the field and two of our 
larger cities have started dental clinics for pre-school children. These 
are both under a private organization. 

The follow-up report sheet for the Department's Well Child Confer- 
ences, planned last year, has been used in only a few cases so that it is 
still not possible to give statistics on what percentage of these children 



52 

has followed our recommendations and what percentage the dentists 
refuse to work with. 

The need of some practical plan for getting dental service to this 
group is the most urgent problem facing us this year. Communities 
seem to be very slow to establish pre-school dental clinics. We think 
that more can be done with the communities now carrying on summer 
i-ound-up for children entering school in the fall. 

Dental Work in Tuberculosis Sanatoria 

A survey was made of the dental service in the Tuberculosis Sana- 
toria supported by this Department and a set of recommendations drawn 
up for improving this service. These recommendations are similar to 
those drawn up by Dr. William R. Davis of Michigan and have to do 
mostly with standardizing supplies, records, technique of procedure and 
general policy for the program. There is need for more educational 
work in the Sanatoria specializing with children; but as yet no practical 
plan has been developed for this work. 

Educational Work 

A special bulletin explaining our recommendations concerning root 
canal work on clinics was drawn up by a member of the Dental Advi- 
sory Committee and sent to all school dentists. 

A new delineascope film, "Beautiful Teeth", for use with adult groups 
was produced this last year. This film is a general outline of the main 
factors in building and maintaining a healthy set of teeth with special 
emphasis on the pre-natal, pre-school and school periods. 

A one-page flyer entitled, "Baby's First Teeth", has been enlarged to 
include diagrams to show why certain habits are harmful and to include 
a page on the first permanent molar. 

A new one-page flyer on "Your Teeth" giving diagrams to show the 
time of eruption for reference use among nurses and teachers is ready 
for the press. 

A new file of the dental health work in local communities is being 
prepared as it is considered that we should make every effort to have 
this material easily available for reference and as up to date as pos- 
sible. The new file will be in book form with two pages allowed to each 
community so that we will have a permanent record of the dental staff, 
clinic service and campaign progress for five years. This will give us 
a more complete picture of the local work and will enable us to compare 
progress over a period of time which has not been possible with the old 
system of card files. 

Field Program 

State-Wide Dental Campaign Program 

During 1926 and 1927 much time was spent recommending a preven- 
tive rather than a reparative policy for our numerous dental clinics. At 
the end of last year it was apparent that community dental programs 
were woefully one-sided. Dental service for the poorer children seemed 
to be their only thought. The educational side of the program was 
being neglected. Statistics show that there was a high percentage of 
dental caries and generally unhealthy mouths among children not eligi- 
ble for the dental clinics. Some scheme was needed to interest these 
children in taking care of their teeth, so a campaign to clean up existing 
dental defects by working for dental certificates (a card stating all nec- 
essary dental work has been completed) was launched as part of the May 
Day Program. This plan was approved by the Dental Advisory Commit- 
tee and was explained at the annual meeting of the Association of 
School Dental Workers and at eighteen district meetings held to arouse 
interest in May Day — Child Health Day celebrations. 



53 

Campaign Material 

The Department issued an outline of procedure (which has been re- 
cently enlarged for the 1929 campaign), dental notification cards, den- 
tal certificates and individual reward tags. Classroom Record Charts 
for use by teachers at the time of the dental examination and Dental 
Honor Rolls for the pupils having received dental certificates, are being 
printed for the 1929 campaign. We hope that this scheme will 

1. Increase the dental educational work done by the teachers, 
nurses and dental workers. 

2. Help communities to realize that a part-time clinic does not 
solve the problem of dental defects. 

3. Help to clean up existing dental defects especially among 
younger children. 

4. Interest communities having no dental health programs at 
the present time. 

The dental certificate should be a basis for every community dental pro- 
gram and should be used from year to year to show the increase in the 
correction of defects. 

Two hundred communities ordered dental campaign material. Sev- 
enty-eight communities were able to make a definite report of the num- 
ber of certificates awarded. 

Group Per cent of defects corrected 

Highest Lowest Average 

100- 500 98 7V 2 39 

500-1,000 99 11 43 

1,000-5,000 81 3 44 

These reports of the campaigns will be published by the Department 
from year to year and communities will be rated according to the per- 
centage of correction of defects among children included in the cam- 
paign. The entire school population, dental staff and clinic service will 
also be considered. 

In the 78 communities making a report, 25,949 children were included 
in the campaign and 6,309 were reported as under treatment. The 
larger cities, with their big clinics, including Boston, Worcester, Fall 
River, New Bedford, Lawrence, Lowell, and Springfield did not partici- 
pate in the campaign. 

Local Developments 

The most outstanding development in the field during the last year 
has been the number of new communities that we have interested 
through the scheme of a dental campaign. This year we hope to keep 
up this interest and to convince the communities of the necessity of 
making more complete reports so that eventually we will be able to say 
what percentage of children with defective teeth are taken care of each 
year throughout the State. The communities need this information to 
measure results and it will give us more interesting light on how much 
good our community dental clinics are doing. 

Communities are slow in realizing that educational work is the per- 
manent part of any dental program. It is the desire to repair obvious 
defects rather than interest children and parents to take care of the 
matter regularly themselves that holds back this part of our program. 
We have succeeded in convincing most of our communities that it is nec- 
essary to concentrate on the younger school children if a clinic is to be 
preventive. We must now interest them in the problem of the pre- 
school child and the significance of educating the children instead of 
merely patching up their defects. 



54 
Analysis of Local Situation 



A complete questionnaire was not sent out this 


year. The following 


report shows the growth of the clinic program. 






Number of Towns 




1927 1928 


I. Permanent Clinics .... 


. 119 140 


II. Traveling Clinics .... 


20 37 


III. Dental Service ..... 


61 36 


IV. Planning program for 1929 . 


19 


V. Staff: 




Dentists ...... 


. 168 213 


Dental Hygienists .... 


39 48 


Dental Assistants (including many school : 


nurses) 28 84 



Recommendations and Plans for 1929 

1. To stress the importance of extending our local dental clinic ser- 
vice to the pre-school children. 

2. To develop lecture service among the normal schools and nurses, 
as much of the present dental educational program is in their hands. 

3. To prepare material concerning objective and subject matter for 
dental health education in the schools. 

The original consulting service to communities has now grown to in- 
clude: 

1. Organization of dental campaigns. 

2. Organization, proper policies and practical details of den- 
tal clinics. 

3. Helping dental hygienists with planning year's program 
and educational work. 

4. Organization and conference work with the staff nursing 
consultants, Dental Advisory Committee, Executive Board 
of the Massachusetts Association of School Dental Work- 
ers and Regional Consultants. 

It has developed so rapidly that it is going to be necessary during the 
next year to limit the dental lecture service and discourage the starting 
of any new projects. 

In spite of the fact it is a tremendously large program for one worker 
to try and supervise much progress has been made because of the splen- 
did cooperation of the Nursing Consultants and the Dental Advisory 
Committee. 



55 

Editorial Comment 

Why School Hygiene. The answer is given by the general interest on 
the part of educators and health workers in the 
health of the school child. No longer are we satisfied with the perfunc- 
tory inspection of the child on entrance to school with an occasional 
note sent home to the parents stating Johnny's tonsils are large or 
Mary's teeth need attention and consider this medical service. 

We have come to realize the importance of health in relation to edu- 
cation and we are engaged with the problem of giving sufficient and effi- 
cient medical service to the schools throughout the State so that all may 
benefit in equal measure. There are many handicaps to overcome, 
largely economic, but these are not insurmountable and much can be 
done to overcome these difficulties by standardization. 

We insist upon standards for almost everything, even living — why not 
health standards. This subject has been, and is, engaging the attention 
of all who are interested in public health activities. Particularly is this 
so in relation to the school medical service. Methods and practices 
should be comparable and results obtained possible to evaluate. 

Some may say too much emphasis is placed upon standardization and 
there is some danger that we may become mere robots — but in matters 
pertaining to health there is too much individualism ever to fear that 
danger. 

Physical examinations of each school child throughout his school life, 
following an accepted method, done within a certain length of time with 
the skilled assistance of the school nurse and keeping well planned rec- 
ords will increase the efficiency of the service to the child in the schools. 

There should be a well planned program throughout all grades and 
age groups including the junior and senior high and normal schools. 

The school dentist and school dental hygienist should cooperate in the 
health work with proper emphasis on the preventive side of dentistry. 
The superintendent, principals and teachers should be interested and 
should correlate health with their classroom activities. Frequent con- 
ferences and discussions by the various groups are necessary. The in- 
terest and cooperation of the parents should be obtained by the school 
nurse and the teacher — thereby carrying the message of good health 
into the home and arousing community interest. 

Smallpox and Vaccination. In 1928 the New England States reported 

300 cases of smallpox. So far this year, 241 
cases have been reported in Massachusetts; of these, 223 occurred in 
one community. Of these 223 cases, only two had ever been previously 
successfully vaccinated and these more than thirty years ago. 

At a school vaccination clinic in this community, held on account of 
the outbreak of smallpox just mentioned, 1,498 children were vacci- 
nated, and 1,432, or 95.5 per cent, had successful "takes". This fact in- 
dicates that relatively few of these children had ever been previously 
successfully vaccinated, and yet section 15 of chapter 76, General Laws, 
states in substance that no unvaccinated child shall be admitted to a 
public school. There is, of course, the exemption clause in connection 
with this statute. 

The responsibility for the enforcement of this statute is laid upon the 
shoulders of the local school committee. In the above-mentioned in- 
stance this responsibility was, without question, evaded. 

It is true that at the present time the community mentioned above is 
probably the best vaccinated community in Massachusetts, but all this 
is locking the barn after the proverbial horse is stolen. 

The actual cost to the community, to the State, and to the individuals 
who suffered from this outbreak of smallpox can only be estimated at 
the moment, but surely $10,000 is not too large a figure. Then, there is 



56 

the stigma which attaches to a community as the result of such an oc- 
currence. This may hurt not only local pride but local business as well. 

The efficacy of vaccination as a protection against smallpox has been 
proven in so many places and at so many different times that the occur- 
rence of the disease might well be considered a reflection upon the in- 
dividual and community intelligence. 

Mild smallpox is unusually prevalent in Massachusetts at the present 
time. The only effective means of controlling this disease is by vaccin- 
ation and re vaccination. 

The generally recommended practice with regard to vaccination is to 
have children vaccinated at about one year of age and again just before 
entering school. Vaccination should be performed on any individual who 
has been a "contact" with a case of smallpox or when the disease is 
epidemic in the community. 

The Return to School after Absence with Communicable Disease. A not 

unnat- 
ural confusion occasionally arises in regard to the return to school of 
children who have been absent with communicable disease. 

The law states that those children may be re-admitted only through 
certificate from the board of health or the school physician. A statement 
from the family physician is not acceptable but the family physician may 
return to school, children who have been in contact with others ill with 
communicable disease, if, in his opinion, they will not be a menace to the 
other children. 

Reorganization of the School Clinics. Five years ago, the State started 

a ten year study of the physical 
condition of school children, with the special purpose of finding those 
children who have early signs of tuberculous infection, making a diag- 
nosis and starting treatment while the condition was still in the glandu- 
lar form, when it is easy to effect a permanent cure. One hundred thou- 
sand children have now been examined. Those who have shown any 
gland involvement have been put under the care of their family doctors, 
followed up by State supervision. It is, in fact, a Diagnostic Clinic. Up 
to the present time, the method of work has been to get the consent of 
the parents for the examination to be given, then take the histories of 
all the children who have obtained the consent, give them all the physical 
examination, give them all the Tuberculin Test, then X-ray those who are 
positive after the test. 

It has been found that the labor of taking many thousands of histories 
and giving physical examinations to all of the children, is too great a 
load to carry in the future. The clinic has become entirely too popular. 
As parents have come to understand the work, the percentage of con- 
sents has doubled and more in many cases. It now becomes necessary 
to find a more rapid means of working and to limit the work of the 
Clinic largely to locating the early, curable tuberculosis. For this reason, 
next year the Clinic will change its method of work. The consents will 
be taken as usual, but when they are in, the first thing the doctors will 
do will be to give the Tuberculin test, then those found to be positive 
will be X-rayed; and if the X-ray shows any condition in the chest that 
needs special attention, the child will then be given a physical examina- 
tion, the X-ray and history gone over with the family doctor and local 
school workers in order that the child may have immediate care. 

It is very important that the citizens of Massachusetts understand 
clearly that early glandular tuberculosis is very curable, that a child 
with this early infection can go to school, be with other children, and in 
no way be a menace to the health of others, that these early cases of 
tuberculosis are the ones that in adolescence break down if they are not 
cared for, producing the pulmonary type that is so difficult and danger- 
ous. As Dr. H. D. Chadwick says, "If we can only examine all of the 



57 
children in the State, in ten per cent of them we will find this early type 
of curable tuberculosis which, if neglected will produce in the adoles- 
cent young manhood and womanhood 75% of the pulmonary tuberculo- 
sis in ten years to twenty years from now." 

In closing, the new way of carrying on the Clinic will cause very little 
disturbance in the schools. One doctor and one stenographer will need 
a single assembly room to do the first part of the work, for the last part 
a small examining room and some room near the main switchboard for 
the X-ray will be all that is required. Two hundred children will be ex- 
amined each day so that the amount of time that will be taken in each 
school will be shorter as well as the space required being much less. 
All of the work will be completed and the reports back in hand in about 
two weeks. 

Ten Years' Progress in Dental Hygiene, 1919-1929. The dental hy- 
giene program of 
the State Department of Public Health will be ten years old in October 
of this year. In a field as new as that of child health work ten years is 
long enough to show real progress as well as rapid development. Dirty, 
unhealthy mouths were so common in 1919 that even a limited program 
meant immediate improvement and in some cases astonishing results. 

Just how much has been accomplished in ten years? How many teeth 
have been saved? How many children have been made healthier? 
These are questions we cannot answer. We cannot even tell how many 
children go through our many dental clinics each year, how many go to 
their own dentists or how many clean their teeth faithfully day by day 
for it is only within the last few years that we have used methods that 
will give us these figures. Reports of clinic operations have been kept 
faithfully for many years but all too often the most important item, dis- 
missals, has not been recorded. There are, however, some very definite 
comments that can be made at this time which we believe will be of in- 
terest to the readers of The Commonhealth and members of our State 
Dental Society. 

From the point of view of the program of the State Department of 
Public Health some of the tangible results are as follows: In 1919 Doc- 
tor Kent organized a definite program of consulting service to offer all 
communities and made plans for educational material to be distributed 
throughout the State. The program has grown rapidly along both these 
lines. A full-time dental consultant has been employed, with the excep- 
tion of one year, since 1919. The Advisory Committee, which determines 
general policies for the Department's program, has grown from one to 
nine members representing the following organizations : 

Massaschusetts Dental Society. 

Massachusetts Dental Hygienists' Association. 

Forsyth Dental Infirmary. 

Harvard Dental College. 

Tufts Dental College. 

Massachusetts Association of School Dental Workers. 

Two specialists in children's dentistry. 

Massachusetts Dental Hygiene Council. 
Six regional dental consultants have been appointed by the Department 
at the suggestion of the State Dental Society. 

Four moving pictures have been purchased. Several exhibits and twenty 
dental posters have been made to loan to communities. Ten pieces of 
literature have been written and 1,817,875 of these have been distributed. 
Practically every community in the State has been helped in some way 
with its dental problems. 

Progress in the field is even more evident. There were several com- 
munities that started dental clinics as early as 1910-1915. In 1919 there 
were 43 communities in the State with a definite school dental program. 
This number has now increased to 223. Dental campaigns in 1928 were 



58 
held in 182 communities, encouraging children to go to their family den- 
tists as well as to the clinics. In these celebrations 50,000 children were 
reported as receiving tags for good teeth. For the celebrations this 
spring 135,000 of these tags were distributed, making an increase of 
nearly 200% in one year. These figures do not include the big city 
clinics, such as Forsyth Dental Infirmary in Boston, where approximately 
10,000 children are dismissed each year. 

The number of school dentists has grown from approximately 50 to 
250. In 1919, Miss Evelyn Schmidt was the only dental hygienist in 
public health work in Massachusetts. There are now 50 hygienists doing 
school work in various communities. Where there are no dental workers, 
school nurses are giving as much time to the problem of dental hygiene 
as is possible. These 300 school dental workers have formed a state asso- 
ciation, which holds a regular annual meeting and publishes a monthly 
bulletin which keeps the members in touch with each other's work. 

There are still many communities (approximately 132) that do not offer 
dental clinic service to their poorer children. Most of these communities 
are under 5,000 population. There are still many schools which do not 
use the dental campaign scheme to round up all children, urging them to 
see their own dentists and to have all defects corrected by a certain time. 

The most rapid progress in the field program has come as a result of 
the adoption of the Forsyth policy for prevention of dental caries in the 
school clinics. 

The increase in interest in good teeth among children and parents and 
increased interest among dentists in working for little children is hard 
to estimate but herein lies our true progress. 

May 1939 find every community in Massachusetts with some definite 
plan for solving the problem of dental care for poor children, may every 
clinic be running on a preventive basis, may more families be properly 
fed and larger percentage of our 688,214 school children leave school with 
sound teeth in clean mouths at the end of the next ten years. 

Health Education Material. In 1926 two health educational programs 

were started by the Division of Hygiene. 
The first program was the establishment of a state-wide standard health 
poster campaign in the schools. This program was carefully planned 
for the first six grades — simple in execution and elastic enough to work 
in with any supervisor's program. Sheets of printed slogans were pre- 
pared to enable the children to complete a poster in one lesson. The 
outline completed, Mr. Royal Bailey Farnum, Dirctor of Art in Massa- 
chusetts, was interviewed and the plan discussed in detail. He heartily 
endorsed it. 

During the 1926-27 school year 333 cities and towns were visited. 
Personal interviews were had with 137 drawing supervisors and the 
outline explained in detail. The supervisor's cooperation was splendid 
and all but two towns used the slogans. A total of 206,000 sheets were 
requested. New slogans were added to the outline in both 1927 and 
1928. The growing demand for these slogans is best illustrated by the 
following summary: 

Towns Average 

Year Visited per town 

1926 333 619 

1927 290 628 

1928 282 638 

1929 130 705 

The program is now well established and with a few exceptions per- 
sonal contacts need be made with only new supervisors not acquainted 
with the outline. 

The second program was concerned with interviewing the school su- 
perintendents and through them acquainting the teachers with the 



59 

health material distributed by the Department. Order blanks listing 
the names of our health pamphlets carefully graded and containing sug- 
gestions, were distributed to the teachers. The result for 1927 was 
551,314 pamphlets requested by the teachers. In 1928 one new pam- 
phlet was added to the list and five discontinued. The result for 1928 
was 523,833 requested. For the first four months of 1929, 185,974 pam- 
phlets have been requested. 

The cooperation of the school officials has been most gratifying and 
reflects a fervent effort on their part to further the health education 
movement. 

The School Lunch. Massachusetts is providing hot lunch for its pupils 
in 58% of its cities and towns. This is an increase 
of 20% within the last year. In communities where all the children go 
home at noon, no provision need be made for the lunch. Wherever the 
children must remain for the noon meal, there should be facilities for 
the preparation of a hot food. 

Certain points should be remembered when the school undertakes a 
lunch plan. Equipment may be very simple and inexpensive. In rural 
districts much of it oftentimes is donated. Enthusiasm and interest of 
the school authorities is a requisite. The cooperation of the community 
is a big factor in the success of the lunch. The food served should add 
to the optimum diet of the child. The whole project should be a part of 
the nutrition and health education program of the school. Instructions 
as to the proper lunch to carry from home is included in the health teach- 
ing. The person in charge should have some knowledge of foods and an 
interest in children. Not profit, but the preparation of an adequate 
meal should be the aim of the lunch. The question of selling candy 
raises a great deal of discussion. It is never legitimate to foster the 
sale of this product to raise money for trips or equipment. Money may 
be raised in other ways. 

Make your school lunch part of your educational system. 

Eye and Ear Testing in. the. Schools. The eye and ear testing in Mas- 
sachusetts must by law be done 
by the teachers. There is nothing to prevent the nurse or the school 
physician from checking up on these tests, if it seems advisable. 

The tests should be made at the very beginning of the school year. Ade- 
quate time for it should be very definitely taken. The teachers should 
familiarize themselves with the technique and should be careful that they 
employ it. 

When the school physician is willing to meet the teachers early in the 
fall to demonstrate to them the best methods of testing, it is found to be 
very helpful. 

Both tests for the eyes and ears are rather crude. Fortunately there is 
an instrument for testing the ears, the audiometer, which gives accurate 
standardized results. Unfortunately the cost of the machine is prohibi- 
tive for the smaller towns, but all the cities and larger towns ought to 
own one, and possibly smaller towns will eventually combine to buy one. 
As 40 children can be tested at once, the machine is a great time saver. 
Further information concerning it may be obtained from the Speech 
Headers Guild, 339 Commonwealth Avenue, Boston, Mass. 

School Health Survey Service. For several years the Department of 

Public Health has been offering to school 
departments a school health survey service which may be had without 
charge upon request. The superintendents who have had it have felt it 
to be of great value to them. This service is to be again offered next 
winter. As only a limited number of surveys can be made during the 
winter, superintendents desiring one should put in their application 
early in the season. Any further information concerning them may be 



60 

obtained by writing to the Department of Public Health, State House, 
Boston, Mass. 

May Day and Summer Round-Up. All over the country Child Health 

Day is being celebrated during the 
months of May and June. Starting as a "May Day" celebration only, the 
idea has grown to be more than a single day to remind us of the im- 
portance of health to children's growth and happiness. It has become 
both a climax for the year's health work in the schools and a starting 
point for future plans for both school and pre-school groups. 

In Massachusetts, Child Health Day is closely allied to the Summer 
Round-Up. By means of Summer Round-Up the pre-school child gets 
his share of benefit from this great movement. The Summer Round-Up 
falls close upon Child Health Day celebrations in many towns and is a 
fitting "next step" in the plan to make Massachusetts a good place to 
grow up in. 

Arrangements for necessary dental work is one of the many plans that 
grows out of Child Health Day activities, and more and more pre-school 
children are being considered in planning dental service for the commun- 
ity. The cost of private dental service for young children is still pro- 
hibitive in a huge number of families. We look for the day when through 
proper pre- and post-natal care teeth will be built that do not require re- 
parative dental work almost before the child can talk. Meantime, good 
and reasonable dental service is badly needed. 

Child Health Day aims to include every child in the community in its 
plans, if not as an actual performer on the day's program, surely as a 
participant in the good results coming from the interest aroused in giving 
every child the best chance possible to become a healthy and happy citizen 
in "our United States". 

Franklin County Five Year Demonstration. This demonstration has 

been carried on for two 
years. The Well Child Conference is going into the Franklin County 
towns examining all the six months to six year old children for the third 
time this spring. The two year results show that about 24% of the de- 
fects have been improved while a mere 3% are corrected. One sad fig- 
ure states that nearly half are returned with new defects in addition to 
the old defects still uncorrected. 

Believing that a more complete and more general understanding of 
the aims and procedures of the demonstration would tend to increase 
the attendance, bring more repeating children and perhaps secure a 
greater effort for the correction of defects — a plan for concentrated 
publicity was carried out. 

The county key people and all the nurses met to discuss the plan and 
favored its immediate execution. Many names of the key people in each 
town were secured from state organizations and from our public health 
nursing consultant. In each town the selectmen, the superintendent of 
schools, the chairman of the child health committee, the doctors, the 
nurses, the presidents and leaders of the various organizations and 
clubs, the priests, the ministers, the town clerk, the librarian and the 
local correspondents of all the newspapers were interviewed. Posters 
carrying the date of the Well Child Conference were placed in all the 
stores, town rooms and library. 

In the ten towns visited 121 persons were interviewed. In five towns 
a talk was given before a definite group. Consequently 285 people 
heard directly of the Franklin County Demonstration. Seven news- 
papers gave space liberally. 

Attempts were made for local organization in each town. A commit- 
tee for transportation and one for conference hospitality and assistance 
were suggested. Transportation is indeed a problem as so few women 
drive cars and most of the men were busy at work. 



61 

The Well Child Conference has followed the publicity work in four 
towns. Some of the desired results were in evidence — keener interest, 
slightly better organization with transportation and assistance and in- 
creased numbers in attendance. All of this — a slight contribution to 
that immeasurable result of achieving greater public health knowledge 
and understanding. 

NEWS NOTES 

The Thomas William Salmon Memorial 

Hon. George W. Wickersham announces the establishment of the 
Thomas William Salmon Memorial to provide recognition to the scientist 
who has made the greatest contribution in the fight against mental dis- 
ease during each year. Awards are to be national and international and 
will provide for the wider dissemination of the knowledge of mental hy- 
giene and insanity through cooperation with the New York Academy of 
Medicine, in whose hands the administration of the $100,000 fund is to 
be placed. 

"The plan provides for a series of lectures to be given in various cities 
in the United States under the auspices of accredited scientific, medical 
or educational organizations. Provision will also be made for the pub- 
lication and distribution of the lectures from year to year in order to 
make possible the maximum use of scientific knowledge which is being 
gained annually through the expenditure of millions of dollars on re- 
search and study in the field of psychiatry and mental hygiene by state 
departments, universities, foundations and individuals, which is now 
lost or obscure and not made available as readily and quickly as it should," 
said Dr. William L. Russell, Professor of Psychiatry of Cornell Univer- 
sity, and Vice-Chairman of the Memorial Committee. 

Universities, Medical schools, scientific societies, hospital services, 
and independent workers in this country and abroad are to be surveyed 
annually in a search for the worker, prominent or obscure, whose original 
work promises most in the line of relief to the states, municipalities, pri- 
vate organizations and individuals confronting the economic and humane 
problems incident to the rapidly increasing number of people suffering 
from mental and nervous diseases. 

The Growth of Our Children 

A very attractive leaflet has been issued by the Home Life Committee 
of the Brookline Teachers' Club called "The Growth of Our Children". 

The rules are simply stated, easy for the child to understand and fol- 
low. It states "how to help their bodies grow", "what will help their 
characters grow" and "what to remember while they grow". 

This committee is to be congratulated. 

NEW PUBLICATIONS 

The following articles have been published this year by the Department 
of Public Health and may be had upon request at Room 546, State House, 
Boston, Mass., until the supply is exhausted: 

Division of Communicable Diseases: 

Anterior Poliomyelitis. An instructive sheet for distribution to local 
boards of health and parents. 

Pasteurization — by M. J. Rosenau, M. D. — a reprint. 

Pasteurization — a flier. 

Septic Sore Throat in 1928 in Massachusetts; Epidemiology by H. L. 
Lombard, M. D. — a reprint. 

Epidemic Septic Sore Throat — a booklet containing following reprints : 
I. Historical Review by Benjamin White, Ph.D., II. A Clinical Study of 
an Epidemic of Septic Sore Throat by May S. Holmes, M.D., III. Review 



62 

of the 1928 Epidemic in Massachusetts by George H. Bigelow, M.D. and 
Benjamin White, Ph.D. 

Milk Bulletin — Data relative to milk from the standpoint of Public 
Health. 

Typhoid Fever in Massachusetts by George H. Bigelow, M.D. and Carl 
R. Doering, M.D. — a reprint. 
Venereal Diseases: 

I Didn't Know by Margaret Deland — a reprint. 

Social Infection and the Community by Bishop Lawrence — a reprint. 

The Management of Syphilis in General Practice by Joseph E. Moore, 

M.D. — a reprint. 
Minimum Standards for Diagnosis, Treatment and Control of 
Syphilis. 
Summer Camps — Recommended Health Standards. 
Smallpox and Chickenpox — The Differential Diagnosis by Frank W. 
Laidlaw — a reprint. 

Division of Biologic Laboratories: 

Serums and Vaccines in the Prevention and Treatment of Infectious 
Diseases — a critical review by Benjamin White, Ph.D. — a reprint. 

Division of Tuberculosis: 

The Incidence of Tuberculous Infection in School Children by Henry 
D. Chadwick, M.D. and David Zacks, M.D. — a reprint. 

Hilum Tuberculosis — Relative value of symptoms, physical signs and 
roentgen-ray findings in the diagnosis of bronchial gland tuberculosis by 
David Zacks, M.D. — a reprint. 

Observations in the Underweight Clinics in Massachusetts by Henry 
D. Chadwick, M.D. and David Zacks, M.D. — a reprint. 

Division of Adult Hygiene: 

The Enlarging Cancer Program — a booklet containing nine addresses 
given at the meetings at the Pondville Hospital November 14 and 19, 
1928 — for physicians and those interested in the cancer program. 

Is the State's Cancer Program State Medicine? by George H. Bigelow, 
M.D. — for physicians only. 

What the Public Health Nurse Should Do About Cancer. 

Division of Child Hygiene: 

Your Teeth — for mothers and public health workers interested in better 

teeth for children. 
Save Those Baby Teeth. 

Brownie Health Rides — for Kindergarten and first and second grades. 
Health Suggestions for Window Displays. 
Plays — Take Care — suitable for junior or senior high school girls 

Slim Princess — suitable for fifth and sixth grades. 
Pantomime — Cleanella Cleans Up — for first and second grades. 
Suggestions for a Child Health Day Play Festival. 
Protecting the Mind of Childhood by Esther Loring Richards, M.D. — 

a reprint. 
Problem of Sweets for Children by Henry C. Sherman — a reprint. 

Division of Water and Sewage Laboratories: 

Iodine in the Public Water Supplies of Massachusetts — reprinted from 
the New England Water Works Association Journal. 

Sludge Digestion and pH Control — reprinted from the Journal of In- 
dustrial and Engineering Chemistry. 

Division of Food and Drugs: 

Milk Laws — new edition. 



63 

REPORT OF DIVISION OF FOOD AND DRUGS 

During the months of January, February, and March, 1929, samples 
were collected in 205 cities and towns. 

There were 2,076 samples of milk examined, of which 397 were below 
standard; from 28 samples the cream had been in part removed, and 34 
samples contained added water. 

There were 502 samples of food examined, of which 81 were adulter- 
ated. These consisted of 11 samples of clams, and 10 samples of scal- 
lops, all of which contained added water; 1 sample of cream which was 
below the legal standard in fat; 2 samples of dried fruits which con- 
tained sulphur dioxide not properly labeled; 10 samples of eggs, 3 sam- 
ples of which were sold as fresh eggs but were not fresh, and 7 samples 
which were cold storage not so marked; 5 samples of maple syrup which 
contained cane sugar; 7 samples of hamburg steak, and 3 samples of 
sausage, all of which contained a compound of sulphur dioxide and were 
not properly labeled; 9 samples of sausage which contained starch in 
excess of 2 per cent, and 3 samples of sausage which contained coloring 
matter; 2 samples of olive oil which contained cottonseed oil; 15 sam- 
ples of vinegar, all of which were low in acetic acid; and 1 sample of 
butter which was low in fat. 

There were 24 samples of drugs examined, of which 6 were adulter- 
ated. These consisted of 6 samples of spirit of nitrous ether which 
were deficient in the active ingredient. 

The police departments submitted 1,975 samples of liquor for exami- 
nation, 1,950 of which were above 0.5% in alcohol. The police depart- 
ments also submitted 28 samples of narcotics, etc., for examination, 8 of 
which were morphine, 3 opium, 4 strychnine, 1 ergot, and 12 samples 
which were examined for poison with negative results. 

There were 469 bacteriological examinations made of milk. 

There were 39 bacteriological examinations of soft shell clams made, 
22 samples in the shell, and 13 shucked, all of which were unpolluted, 
and 3 samples in the shell, and 1 shucked, all of which were polluted; 
and there were 9 bacteriological examinations made of hard shell clams, 
all of which were unpolluted. 

There were 51 hearings held pertaining to violation of the Food and 
Drug Laws. 

There were 7 hearings held pertaining to violations of the Pasteur- 
izing Laws. 

There were 59 cities and towns visited for the inspection of pasteur- 
izing plants, and 115 plants were inspected. 

There were 65 convictions for violations of the law, $1,393 in fines 
being imposed. 

William C. Bloss of Melrose; Frank Borowiec of Brimfield; Jennie 
Briggs and James C. Javos of Reading; Roy W. Busby, 3 cases, of Great 
Barrington; Simon M. Simon of Pittsfield; Frank Czupryna of Belcher- 
town; Charles Nichols of Ashland; Clarence L. Smith of Monson; Ada- 
lord J. Daigneault of Millers Falls; Edward Evans of Wilbraham; 
James A. Fiske and Thomas P. Cahill of Saugus; Benjamin Martin of 
Deerfield; Edmund Gilbert of Dedham; Charles Markos of East Ded- 
ham; Fred R. Perkins of Montague; John Scoulogenos and Ralph Troop 
of Salem; John Silva of Hudson; Mildred Gover and Turner Centre Sys- 
tem, Incorporated, of Lynn; and Oliver Mandrioli of West Concord, 
were all convicted for violations of the milk laws. Roy W. Busby of 
Great Barrington appealed his 3 cases. 

Max Rabinovitz of Springfield; Peter Eliopoulos of Salem; A. H. 
Phillips, Incorporated, of Northampton; The Great Atlantic & Pacific 
Tea Company of Brookline; and Joseph Correia of South Dartmouth, 
were all convicted for violations of the food laws. 

Julius Goldman of Worcester; Albert Lacroix of Newton; William D. 



64 

Pappas of Quincy; and Marston Summer Street Store, Incorporated, of 
Boston, were all convicted for false advertising. Julius Goldman of 
Worcester appealed his case. 

A. H. Phillips, Incorporated, of Westfield; and Simon Rosen of 
Worcester, were convicted for misbranding. 

Alfred Boucher of West Brookfield; William Delude of Spencer; Wal- 
ter Dymon of Three Rivers; Economy Grocery Company Stores and 
Patrick J. Halloran of Quincy; Joseph Gula and Antonietta Juskiuwicz 
of Palmer; Camille Monaco, Joseph Monahan, and Dominic Olivo, all of 
Waltham; John Wancki of Thorndike; Frederick Weich of Maiden; 
Patrick Arena and Fred Marzillo of Watertown; Albert Labuda of Wil- 
braham; Anthony Mazzola of Newton; and Frank Soha of Springfield, 
were all convicted for violations of the cold storage laws. 

Alfred Laveille of Chatham; Charles R. Bates and Charles J. Mix of 
Pembroke; and Charles Durham of Highgate, Vermont, were all con- 
victed for violations of the slaughtering laws. 

Arsen Chelengarian of Newton Upper Falls; and Mihran Jigayian 
and Manoog Parazian of Watertown; were all convicted for violations 
of the sanitary food law. 

Arsen Chelengarian of Newton Upper Falls; Mihran Jigayian and 
Manoog Parazian of Watertown; Reuben Kaldusky of Dorchester; and 
Lithuanian National Corporation of Lawrence, were all convicted for 
violations of the bakery laws. 

In accordance with Section 25, Chapter 111 of the General Laws, the 
following is the list of articles of adulterated food collected in original 
packages from manufacturers, wholesalers, or producers: 

Milk which contained added water was produced as follows: 7 sam- 
ples, by Fred B. Draper of Westwood ; 2 samples each, by Edward Evans 
of Wilbraham, and John Silva of Hudson; and 1 sample, by John Bailey 
of Pelham, New Hampshire. 

Clams which contained added water were obtained as follows: 1 sam- 
ple each, from First National Stores, Incorporated, and The Great At- 
lantic & Pacific Tea Company, Incorporated, both of Taunton; J. Frank 
Williams and Harold Petros, both of Lynn; George Stodder, Prior & 
Townsend, H. 0. Atwood, and J. A. Stubbs, all of Boston; Collins & Lee 
Company of Chelsea; Manhattan Provision Company, Incorporated, of 
Dorchester; and The Great Atlantic & Pacific Tea Company of Roslin- 
dale. 

Scallops which contained added water were obtained as follows: 2 
samples, from Russo Brothers of Boston; 1 sample each, from P. H. 
Prior of Boston; Atlantic & Pacific Tea Company, Harry Rosoff, and 
Rhodes Brothers, all of Brookline; and The Mohican Company of Rox- 
bury. 

Maple syrup which contained cane sugar was obtained as follows: 1 
sample each, from Ideal Restaurant of Newburyport; and Centre Lunch 
of West Roxbury. 

Dried Fruits which contained sulphur dioxide not properly labeled, 
were obtained as follows: 1 sample each, from A. H. Phillips, Incorpor- 
ated, of Northampton; and The Cloverdale Company of South Deerfield. 

Sausage which contained starch in excess of 2 per cent was obtained 
as follows : 2 samples each, from Front Street Market, and H. L. Dakin 
Company, of Worcester; Robert Stringer of Lowell; and 1 sample each, 
from J. T. Flebotte of Indian Orchard; Middleton Market of Middleton; 
and F. 0. Porter of Groton. 

Sausage which contained coloring matter was obtained as follows: 
2 samples from Correia & Sons of New Bedford; and 1 sample from Cor- 
reia & Sons of South Dartmouth. 

Hamburg steak which contained a compound of sulphur dioxide not 
properly labeled was obtained as follows: 1 sample each, from Boston 
Cut Price Market, Max Jacobson & Sons, and Jacob Isaacman, all of 
Worcester; The Great Atlantic & Pacific Tea Company of Waltham, Ros- 



65 

lindale, and Cohasset, respectively; and Walter S. Needle, Incorporated, 
of Boston. 

One sample of olive oil which contained cottonseed oil was obtained 
from Frank Simone of West Springfield. 

One sample of butter which was below the legal standard in fat was 
produced by Isaac Widlansky of Springfield. 

There were fifteen confiscations, consisting of 31 pounds of decom- 
posed chickens; 15 pounds of decomposed ducks; 556 pounds of decom- 
posed poultry; 221 pounds of decomposed roasters; 900 pounds of de- 
composed beef knuckles; 20 pounds of tubercular hogs' heads; 1,672 
pounds of decomposed pork loins ; 14% pounds of decomposed pork 
chops and lamb; 30 pounds of dried out venison; 1 quart of decomposed 
clams; 3% pounds of dried, wormy peas; and 8 pounds of wormy choco- 
late candy. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of December, 1928: — 247,860 
dozens of case eggs ; 294,745 pounds of broken out eggs ; 732,830 pounds 
of butter; 3,834,083 pounds of poultry; 6,180,876 3 /4 l pounds of fresh meat 
and fresh meat products; and 3,182,955 pounds of fresh food fish. 

There was on hand January 1, 1929: — 975,795 dozens of case eggs; 
986,214 pounds of broken out eggs; 5,992,195 pounds of butter; 7,254,- 
287 1 / 4 pounds of poultry; 11,801,19414 pounds of fresh meat and fresh 
meat products; and 16,117,176 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of January, 1929: — 231,630 
dozens of case eggs; 440,678 pounds of broken out eggs; 456,171 pounds 
of butter; 1,760,965 pounds of poultry; 7,088,244 pounds of fresh meat 
and fresh meat products; and 2,612,508 pounds of fresh food fish. 

There was on hand February 1, 1929: — 223,740 dozens of case eggs; 
799,684 pounds of broken out eggs; 3,583,516 pounds of butter; 7,305,058 
pounds of poultry; 14,817,462 1 / 4 pounds of fresh meat and fresh meat 
products; and 11,259,216 pounds of fresh food fish. 

The licensed cold storage warehouses reported the following amounts 
of food placed in storage during the month of February, 1929 : — 83,460 
dozens of case eggs; 480,215 pounds of broken out eggs; 406,226 pounds 
of butter; 1,103,521 pounds of poultry; 5,588,678 pounds of fresh meat 
and fresh meat products; and 1,903,375 pounds of fresh food fish. 

There was on hand March 1, 1929 : — 6,420 dozens of case eggs ; 662,- 
934 pounds of broken out eggs; 1,859,190 pounds of butter; 6,883, 056Y2 
pounds of poultry; 17,866,201 3 4 pounds of fresh meat and fresh meat 
products; and 7,455,245 pounds of fresh food fish. 



66 



MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 



Commissioner of Public Health, George H. Bigelow, M.D. 



Public Health Council 

George H. Bigelow, M.D., Chairman 
Roger I. Lee, M.D. Richard P. Strong, M.D. 

Sylvester E. Ryan, M.D. James L. Tighe. 

Francis H. Lally, M.D. Gordon Hutchins. 

Secretary, Alice M. Ethier. 



Division of Administration . 
Division of Sanitary Engineering . 

i 
Division of Communicable Diseases 

Division of Water and Sewage 

Laboratories . 

Division of Biologic Laboratories . 

Division of Food and Drugs. 

Division of Child Hygiene . 
Division of Tuberculosis 
Division of Adult Hygiene . 



Under direction of Commissioner. 
Director and Chief Engineer, 

X. H. Goodnough, C.E. 
Director, 

Clarence L. Scamman, M.D. 

Director and Chemist, H. W. Clark. 
Director and Pathologist, 

Benjamin White, Ph.D. 
Director and Analyst, 

Hermann C. Lythgoe, S.B. 
Director, M. Luise Diez, M.D. 
Director, Sumner H. Remick, M.D. 
Director, 

Herbert L. Lombard, M.D. 



State District Health Officers 

The Southeastern District . 



The Metropolitan District . 
The Northeastern District 
The Worcester County District 
The Connecticut Valley District 

The Berkshire District 



Richard P. MacKnight, M.D., New 
Bedford. 

Edward A. Lane, M.D., Boston. 

George M. Sullivan, M.D., Lowell. 

Oscar A. Dudley, M.D., Worcester. 

Harold E. Miner, M.D., Spring- 
field. 

Leland M. French, M.D., Pitts- 
field. 



Publication of this Documf.nt approved by the Commission on Administration and Finance 
6500. 6-'29. Order 5953. 



_£_ 



THE 
COMMONHEALTH 



Volume 16 

No. 3 




JULY-AUG.-SEPT. 
1929 



Tuberculosi 



MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 






THE COMMONHEALTH 

Quarterly Bulletin op the Massachusetts Department of 
Public Health 

Sent Free to any Citizen of the State 

Entered as second class matter at Postoffiee. 



M. Luise Diez, M.D., Director of Division of Hygiene, Editor. 
Room 546 State House, Boston, Mass. 



CONTENTS 

PAGE 

Tuberculosis Control in Massachusetts, by George H. Bigelow, M.D. . 69 

The Ten Year Program for Children — Progress and Plans, by Henry D. 

Chadwick, M.D 70 

The How and Why of the Chadwick Clinic, by Paul Wakefield, M.D. . 72 

Sanatorium Treatment of Extra-Pulmonary Tuberculosis, by Leon T. 

Alley, M.D 74 

Surgical Treatment of Pulmonary Tuberculosis, by Edward D. Church- 
ill, M.D 78 

Social Service in Tuberculosis, by Eleanor E. Kelly . . . .81 

Graduation Address at the Rutland State Sanatorium Training School 

by Alfred Worcester, M.D. 85 

Organizing a Toxin-Antitoxin Campaign, by A. A. Robertson . . 87 

Diphtheria Statistics for Massachusetts, by Edward A. Lane, M.D. . 89 

Editorial Comment: 

Early Diagnosis of Tuberculosis . . . . . .91 

The Chadwick Clinics ... .... 91 

Admission of Children to State Sanatoria . . . .91 

What the Von Pirquet Test is NOT— and What It IS! . .91 

Book Review. .......... 92 

Sedgwick Medal Award ........ 93 

NEWS NOTE— First International Congress on Mental Hygiene . 94 

Report of Division of Pood and Drugs, April, May, June, 1929 . . 94 



69 

TUBERCULOSIS CONTROL IN MASSACHUSETTS 

By George H. Bigelow, M.D., 
Commissioner of Public Health 

Recently Dr. Chadwick pointed out that from 1898 to 1908 the death 
rate from tuberculosis dropped one-quarter ; in the next ten-year period it 
dropped one-third; and from 1918 to 1928 it dropped one-half. Can this 
decline be maintained? Some are doubtful, but he thinks it can, particu- 
larly with the extension of service to children to which he has contributed 
so much. To bring this about we must have effective case finding, ade- 
quate institutional resources, individualized follow-up, intelligent public 
support, and tuberculosis-free milk. We have none of these in the meas- 
ure that we should, though our lot is better than that of many states. 

Case Finding. Primarily this must depend on the general practitioners 
throughout the State, supplemented by competent, readily available, con- 
sultative chest service. That cases are not being recognized early is 
shown by the fact that 60 per cent of the reported cases die within the 
first year. For each death we get 2.3 cases reported, while if case finding 
was adequate we should have between 5 and 10. In some cities the clinics 
are unbelievably poor. We must do something about it. Set standards? 
But the good already meet them and the poor will merely haggle. Should 
we insult, cajole, or wheedle? If the medical stuff is not there, standards 
are a waste of time. As I see it, in general the specialized medical skill 
can best be found in the tuberculosis hospitals. These hospitals should 
consider the ever-widening of their field of clinic service, perhaps, their 
most important function. The public must be generous in supporting an 
increased medical staff which such service will demand. The examination 
by the State of children in the schools in the Chadwick Clinics is perhaps 
the most significant recent advance in case finding. If children found in 
this way are adequately handled we may see tuberculosis fall from its 
proud place as the principal cause of death in the age group 15 to 39. 

But medical service competent to recognize tuberculosis early is sterile 
if not used, just as it is futile to waste effort dragging suspects to incom- 
petents for examination. All family contacts, all arrested cases periodi- 
cally, and all those showing early suspicious signs must be examined. The 
competent chest man in the private office and clinic must supplement the 
general practitioner in this if the service is to be adequate. Early recog- 
nition means great clinical skill plus X-ray and laboratory resources. To 
bring in these suspects we need the intelligent, resourceful public health 
nurse. We must call a halt to this finding of the advanced case whose 
father died five years ago and who has never previously been examined. 
By such the community is indicted and the physician who took care of the 
father should feel disgraced. We are likely to call such instances a "slip" 
in the machine. Probably there never was any machinery worthy of the 
name. 

Institutions. Just as we seem to be within reach of the standard of one 
bed for every death from pulmonary tuberculosis the wretched National 
Tuberculosis Association goes and doubles the standard. But there are 
many reasons why this should be. First, a standard that can be reached 
is no good. Then, with a steadily increasing proportion of cases demand- 
ing hospitalization, and with the needs of preventorium and sanatorium 
service, the old standard was not adequate as shown by the waiting lists 
of patients all over the State. In our State Sanatoria we need more beds 
for non-pulmonary cases and for children. For adults the counties of 
Worcester and Middlesex are about to build, though no one has yet been 
menaced by the speed at which they are doing it. In the Connecticut Val- 
ley and the Berkshires beds for adults are quite inadequate and all they 
do is a little patching here and there. They do not like our suggested so- 
lution and no local Moses appears to unite them in any constructive plan 
of their own. In all this they are, of course, thoroughly typical of every- 



70 
body else. Boston and Essex County are adding beds and Norfolk did 
this last year. It would seem wise to use the adequate clinical supervision 
available in the hospitals by locating summer health camps near sanatoria. 

Follow-up. Too much of our follow-up work is perfunctory and is really 
little more than overpaid clerical service. What is needed is the adoption 
of the social service technique by the public health nurse, so that the com- 
munity resources may be individualized to the particular case in hand. 
A study of some of the cases seeking readmission to our institutions shows 
the utter absurdity of expecting permanent results with such home con- 
ditions. Yet we have been smugly closing the door on them when they 
left our sanatoria and forgetting them, except for an occasional Christmas 
card, until they again knock at the same door. And how many other tu- 
berculosis hospitals are doing the same? The ostrich hides his head so 
we may not see him blushing at our stupidity. 

Any community giving competent case-finding service will give compe- 
tent follow-up service. The machinery and point of view for both are 
essentially the same. 

I wish that the next legislature would authorize us to pay tuberculosis 
hospital subsidy only to those communities giving a reasonable tubercu- 
losis prevention service. This would save the State $150,000 and through 
MONEY might galvanize some communities into giving a service which 
humanity and common sense cannot influence. 

Intelligent Public Suppo7't. The public must demand adequate funds 
for tuberculosis service in their community. There must be a well- 
equipped clinic with pay for the clinician. For school examinations the 
pupils must be stripped to the waist, with a washable cape for the girls. 
It is easier to run an automobile without gas than to examine a chest 
through clothing. They must not tolerate a board of health which refuses 
to hospitalize the tuberculous through jibber ing economy or haggling 
about settlement. They must insist on adequate number of competent tu- 
berculosis nurses. They must help in placing the ex-tuberculous rather 
than whispering about them from afar as lepers. They must support the 
local tuberculosis association, for which there will always be need, how- 
ever far from futility the official agencies may depart. Finally, in all this, 
the public need not feel they are doing a notably disinterested thing. In 
all this they are merely protecting their own hides and those of their 
children. 

Tuberculosis-free Milk. Still in 1929 a third of the milk supply is raw 
from cows who have not been tested for tuberculosis, and this in the State 
with the highest proportion of infected cattle in the country. Thirty per 
cent of the children at the Lakeville State Sanatorium with bone and joint 
tuberculosis have been infected by milk. Will this never stop? Will we 
never require that all milk in Massachusetts be either pasteurized or from 
non-tuberculous cattle? Local boards of health have all the authority 
necessary to require this at once. The legislature for four years has re- 
fused to give state-wide authority for this protection. That certain raw 
milk interests vilify us for our activity in this regard is the greatest com- 
pliment that could be paid the Department. 

Future progress in tuberculosis, then, depends on all this. We congrat- 
ulate all of you who will take part, for the satisfaction of work well done 
will be enormous. 

THE TEN-YEAR PROGRAM FOR CHILDREN— PROGRESS AND 

PLANS* 

By Henry D. Chadwick, M. D., 

Formerly Chief of Clinics, Massachusetts Department of Public Health 

Since 1924 when the plan was first put into operation approximated 
100,000 children have been examined in Massachusetts. We have learned 
many things as a result of these examinations. Records have been carefully 

♦Reprinted from The New England Journal of Medicine, Vol. 200, No. 22 (May 30, 1929). 



71 

kept and analyses have been made of the figures in many thousands of cases. 

We have learned that infection with the tubercle bacillus is not as common 
as we thought it was. Whether it was ever as common in the United States 
as in Europe is an open question. 

We find in analyzing our figures that when children begin school life 20% 
are infected, i. e., at the age of five, at age ten they are infected to about 
28% and at fifteen years they are infected to about 35%. Roughly there is 
one point increase of infection with each year of life from five to fifteen. It 
would be interesting if we could go on and get some figures above that age. 
We have, however, some information which leads us to believe that even 
adults of this present generation are not universally infected. Formerly we 
did not test adults for infection. This year we have tested and examined 
about one hundred nurses and teachers and I find that only 50% show 
infection. In my opinion where tuberculosis is suspected but not evident 
in adults we should give the tuberculin test just as we do to children. If we 
can rule out tuberculosis in 50% it is indeed very much worthwhile. 

We have learned that children are infected with the tubercle bacillus to 
the same degree regardless of nutrition or nationality if they are exposed to 
an open case of tuberculosis. Fifty per cent of children who were said to 
be contacts reacted to the tuberculin test. We may wonder why more 
than 50% of the contacts were not infected. I think these figures are some- 
what unreliable because some of the histories are incorrect and may show 
the children to be contacts when as a matter of fact the exposure has been 
nil or very slight and would not afford opportunity for infection. Children, 
for instance, who have been exposed to a case of bone or hilum tuberculosis 
have been reported as contacts. My opinion is that when there is definite 
contact with pulmonary tuberculosis children are almost always infected. 

I was talking with Dr. Walter Rathbun a short time ago. After checking 
up the results of his investigations in Chautauqua County he finds, and my 
experience coincides with his, that children with extensive tracheo bronchial 
glands and calcified nodules in the lungs often develop the adult pulmonary 
type of disease a few years later. By these X-ray examinations it is fair to 
say that we can pick out the 10% of the children who will in the next decade 
produce 50% or more of the tuberculosis cases that occur in adolescence and 
early adult life. 

We have also discovered by use of the tuberculin test that only about one- 
third of the diseased cervical glands are tuberculous. These are some of the 
things that we have learned from a study of the children examined in these 
clinics. 

Our clinic plans for the future have been changed because of the knowledge 
we have gained in the past five years. We propose beginning next year to 
reverse our procedure. First the tuberculin test will be given to the children. 
All reactors will be X-rayed. Those showing evidence of tuberculosis or 
other pulmonary conditions in the X-ray film will be examined by one of our 
physicians. A careful history will then be secured and by having before him 
the results of the tuberculin test, X-ray and physical examination, he will be 
able to make an accurate diagnosis of the case and advise the parents to 
consult the physician as to treatment. 

The plan was tested out at East Longmeadow, Massachusetts. The 
nurses of the Hampden County Tuberculosis and Public Health Association 
went to the schools and gave talks to the children in the classrooms. We 
secured splendid co-operation from the health and school departments. The 
teachers sent out the consent blanks to the parents by the children. When 
the reply was negative, the nurses and teachers made an effort to get them 
to change their minds. About 80% of the parents consented. Later Dr. 
Wakefield and Dr. Chase gave the Pirquet test to 430 children in three differ- 
ent schools during the morning session. This shows how rapidly the work 
can be done when properly organized. Three days later one physician in 
three hours saw all the children except the absent ones and recorded the 
result of the tests. An X-ray technician was later sent to X-ray the children 
who were positive reactors. The X-rays were then interpreted and a careful 
physical examination will be made of those children who show any evidence 



72 
of disease in their films. The mother should come with her child so that 
the physician can advise her directly as to the condition found and as to 
the necessity of treatment and removal of defects. 

This is the procedure we hope to carry out next year. It saves a large 
amount of work which the school nurse has had to do. In the past the local 
nurse has had to go into the homes and get the histories from the parents. 
This has been a tremendous task, especially in towns where there is only 
one nurse for about two or three thousand children. By using the method 
described above we are able to do twice as many children in one year with a 
smaller staff. This will mean cutting in half the cost per child of the work 
of the examination. 

The program will be more definitely one for finding tuberculosis. We will 
not be able to list children who have enlarged tonsils, decayed teeth and 
heart disease in the negative cases as has been done in the past. We will 
find, however, more cases of tuberculosis because we are examining twice as 
many children and this is primarily our function. 

The League is sponsoring the examination of a large number of women in 
industry. We would suggest that this survey be carried out in the same 
manner, i. e., first the tuberculin test then the X-ray if reaction is positive, 
and then examine those who show any pathological changes in the lungs. 
The early cases of pulmonary tuberculosis are missed if only a physical exam- 
ination is given. Slight physical signs are difficult to demonstrate while the 
X-ray will show very early changes due to tuberculosis. An effort should 
be made to secure the examination of 100% of the employees in a given 
industry. If the examination is optional, the 15 or 20% that refuse to be 
examined will be the group that will show the most tuberculosis. Those 
who need the examination most will hesitate to have it because they fear 
that there is something wrong and they do not have the courage to face it. 
Arrangements should be made with the employers to get all of the employees 
examined, otherwise the results will not be conclusive as showing the actual 
amount of tuberculosis that exists. 

Sometimes we wonder if all this clinical work is worthwhile. Checking 
up the death rates we find that in 1898 there were 280 deaths per 100,000; 
in 1908 there were 210 deaths per 100,000: in 1918, 146 per 100,000, and in 
1928, 73 deaths per 100,000. From 1898 to 1908 the reduction was one- 
quarter, from 1908 to 1918 the reduction was one-third, and from 1918 to 
1928 the reduction was one-half. What of the next ten years? Some 
people have said that it will be more difficult to bring about a reduction in 
the tuberculosis mortality in the future than it has been in the past. They 
have prophesied a slowing up of the decline in death rate. I do not agree 
with this view. As our efforts are intensified, especially with the children, 
I am very optimistic and expect that the decline in the death rate for tuber- 
culosis will be fully as rapid in the next decade. 

If this prophecy is correct, in 1938 the death rate for all forms of tubercu- 
losis in Massachusetts should be under 40 per 100,000. 

THE HOW AND WHY OF THE CHADWICK CLINIC 

By Paul Wakefield, M. D., 

Supervisor of Clinics, Massachusetts Department of Public Health 

We have learned more about tuberculosis in the last fifty years than was 
learned in fifty centuries before this time. In the last ten years, since the 
X-ray was developed and perfected, we have made more headway in pre- 
vention, in early diagnosis and in the cure of the disease than ever before. 

In the work of prevention of tuberculosis the State of Massachusetts is 
showing the way. 

This is how it all happened. For many years we have known that tuber- 
culosis is desperately fought by the body. All the mechanical and chemical 
defense forces of the body are rushed to overcome the disease germ whenever 
it gains entry. So it is that the tubercle bacillus is pushed into the lymphatic 
vessels (they are the tubes where dangerous germs and poisons that get into 
our bodies are forced by the fighting white blood cells) and driven up through 



73 

a series of lymph glands that act as traps to modify poisons and destroy 
germs. 

We used to find these glands on operation with a cluster of tubercle germs 
in them, surrounded by fighting white cells, and with chalk or lime in all 
stages of hardness around the whole mass. Sometimes we found little, 
hard, pea-like, chalk balls. Crack them open, and in the center a nest of 
tuberculosis germs entombed! DON'T FORGET THAT CHALK. YOU 
ONLY GET IT IN THE GLANDS IN A TUBERCULOSIS FIGHT. 

The problem has been to find the tuberculosis when it is still in the lymph 
glands. If we can make an early diagnosis of tuberculosis while the fight 
is on in the glands, we can give help that will give permanent cure in practi- 
cally every case. Practically always we can keep the germs in the lymph 
system of defense and out of the working part of our bodies. 

In early gland tuberculosis there are no signs or symptoms that make 
diagnosis by any usual methods possible. Of course, children who are weak 
and anaemic, nervous and underweight, have less resistance and are more apt 
to be infected. But fine looking, healthy children may have had milk from 
tuberculous cattle and become infected, or after the grippe or measles or 
other infectious disease with a lowered resistance the tubercle bacillus might 
get foothold. How are we to know? Here is where the chalk and X-ray 
come in. 

We cannot X-ray tuberculosis germs — 50,000 standing in a line, fat ones, 
would make an inch ! But in the lymph glands you remember we have lime 
being packed around the germs to wall them in! We can get an X-ray of 
that lime, and when we get the lime showing in an X-ray we know that at 
the center of the mass there is a tuberculosis fight. 

We have one other thing to help us. That is the anti-tuberculosis serums 
our bodies make in an attempt to destroy the germs when they enter the 
bodjr. We know a great deal about diphtheria antitoxin. We know that 
if we have typhoid once we probably will never get it again, for the anti- 
typhoid serum our body makes to overcome the disease is usually strong 
enough to protect us the rest of our lives. Just so our body makes an anti- 
tuberculosis serum, but the tubercle germ is an armored germ — covered with 
hard wax, and the anti-tuberculosis serum has little effect on the germ. The 
body has to use "second line defense" against this germ — the entombing of 
the germ with lime in the lymph gland. 

However, we use the anti-tuberculosis serum in the body to help us. If 
there is no an ti- tuberculosis body serum, we know that child has never had 
a tuberculosis fight, and is clear of the disease. If we find the body has anti- 
tuberculosis serum, we know that child has fought, or is fighting, tuberculosis 
germs. 

The test is simple. If we take a broth in which tuberculosis germs have 
grown in the laboratory, filter it clear of germs and boil it down to a fairly 
thick syrup, we have what we call "tuberculin." It is, of course, entirely 
free of all germs, as no germ could live through the boiling process, quite aside 
from the filtering. 

If this tuberculin is put on the arm and the epidermis rubbed off so that 
the body serums come in contact with it, we find an interesting result. If 
our body has an anti-tuberculosis serum made by some tuberculosis fight, 
it is rushed to this point where the tuberculin is applied. Our body defense 
system does not propose to take any chances. The anti-tuberculosis serum 
calls on the white blood cells for help — all this shows in a little raised place 
on the skin of the arm where the tuberculin has been applied and looks like 
a mosquito bite. That is all. There is no headache, no sore arm. The 
capillaries are not even injured in applying the test, and the rubbing off the 
small dot of the epidermis tickles more than it scratches. This is called the 
Tuberculin Test. 

As for practical results, — we have examined over 100,000 children in the 
Chadwick Clinic in five years. Id every 100 children we find twenty-eight 
who have fought, or are fighting, the disease. These twenty-eight we X-ray 
and find six in the twenty-eight who are now fighting the disease in the lymph 
glands. 



74 

These children, with the care of their own doctors, are practically all sure 
of winning the fight. The fight is in the lymph tissue, and they cannot 
possibly infect other children. They go to school, play, live normally, and 
get well. All bad teeth and tonsils are fixed. All the fighting forces of the 
body are saved to "clean up" the tuberculosis. 

Rest is very important, and over-tired bodies are filled with poisons from 
overworked body cells. Food should be simple and good — the body not 
overworked getting rid of a lot of stuff it does not need and cannot use. All 
these things the family doctor can watch, and the fight is won. 

In one child in 1,200 we find we are too late. The gland tuberculosis has 
broken through into the lungs. When this happens we have the long fight 
against consumption. 

If we can cure the gland type of tuberculosis in our children, we will 
prevent the pulmonary type of the young adult. As Dr. Chad wick says, 
we have 80% of the pulmonary tuberculosis that will develop in fifteen years 
from now in 10% of the children in the gland type now. If we can get these 
ten children in a hundred and see that the gland type is cured, we will 
prevent 80% of the pulmonary tuberculosis that we will otherwise have in 
Massachusetts in fifteen years from now. 

The work of the clinic is simple. Teachers in the schools send home 
"Consent Slips" for the children's parents to sign. (We will not test any 
child without the consent of the parent.) The test is given, and if a little 
raised spot appears in three or four days, we X-ray the child. If the X-ray 
shows any sign of a fight now on in the chest cavity (the center of the lymph 
system is at the root or hilum of the lungs) the doctor gives a careful physical 
examination to cover essential points, and a full report is sent to the parent 
for the family doctor. All our resources are at his command, and if he wishes 
any help or information we gladly supply it. 

I expect to live to see the day when tuberculosis is virtually unknown 
among the children raised in the State of Massachusetts. And that is not 
a dream. It is all very possible with understanding of the problem and 
reasonable co-operation. 

SANATORIUM TREATMENT OF EXTRA-PULMONARY 
TUBERCULOSIS 

By Leon T. Alley, M.D., 

Superintendent Lakeville State Sanitorium 

Bearing in mind that tuberculosis in any part of the body is but the 
local manifestation of a general constitutional disease, the sanatorium is, 
of course, the proper place to treat this condition whether it manifests 
itself in the lungs or in any other structures of the human body. Local 
treatment alone of tuberculous lesions, disregarding the importance and 
necessity of the general treatment of the patient, cannot produce the com- 
plete and permanent results desired. 

While sanatorium treatment of patients suffering from pulmonary tu- 
berculosis is not new in this State, extra-pulmonary patients were not 
grouped in a sanatorium until November 1925. These cases have for 
years presented a serious problem to the general hospital. The local con- 
dition was recognized and treated, but the general treatment necessary for 
their tuberculosis, could not be adequately handled. 

As we cannot be enthusiastic about any form of treatment until we defi- 
nitely know with what we are dealing, and until our end-results justify 
our procedures, one point of great importance is that of making a positive 
diagnosis of tuberculosis at as early a date as possible, not only for the 
economic reasons but because the patient's entire future frequently de- 
pends upon the prompt and proper management and treatment of his ex- 
isting condition. We are constantly admitting patients with a diagnosis 
of tuberculosis that has not been confirmed. Observation and intensive 
study proves later that the case is not one of tuberculosis, but rather one 
of the following: osteomyelitis, septic arthritis, Legg-Perthes' disease, 
carcinoma, cerebro-spinal syphilis, specific cervical adenitis, specific le- 



75 

sions on rib and sternum, congenital malformation or dislocations, separa- 
tion of the head of the femur, scoliosis from rickets or especially from old 
infantile paralysis. Some of the specific cases had had no Wassermann 
done prior to their admission to the sanatorium. The fallacy of treating 
such cases for tuberculosis is self evident. We must therefore make use of 
every known method at our disposal to arrive at a positive diagnosis in 
these cases in order that we may know with what we are dealing. Each 
one of the methods at our disposal today plays an important part in com- 
pleting the picture: the careful history, symptoms, physical findings, X- 
ray, laboratory for culture work, tissue study and animal inoculation. We 
are finding it necessary to resort more and more to biopsies on doubtful 
and obscure cases, where material for study cannot be obtained by aspira- 
tion. The X-ray and laboratory have been our greatest aids in establish- 
ing diagnosis in bone and joint tuberculosis. 

In the sanatorium treatment of this type of case, with the thought in 
mind that we are dealing with a general constitutional disease, with local 
manifestations regardless of the location of the lesion, a large part of our 
treatment must, of course, be general, with the idea of building up the 
physical condition of our patient by increasing his resistance. To do this, 
we resort to the time-honored methods of sanatorium treatment, applied 
perhaps in a somewhat different way. The fundamental principles of the 
treatment of any form of tuberculosis, must be closely adhered to, if we 
are to expect successful and permanent recovery. 

While much has been said and featured as to the curative value of the 
natural sun's rays, and while we have featured heliotherapy more or less 
in the routine treatment at our clinic at Lakeville, I wish to emphasize the 
fact that we believe that this phase of treatment is hot a cure-all. How- 
ever, when heliotherapy is used, along with the other important measures, 
viz, general rest, fresh air, proper orthopedic management and surgery, it 
occupies a place of prominence in building up and increasing the resist- 
ance of our patients, and thus aiding in the restoration of health. 

The treatment of the various types of cases may be dealt with under 
the following headings: (1) General treatment, and (2) Local treatment. 
All new admissions are kept in bed for at least one month. This is done 
for two reasons; first, it gives the patient a good start in his treatment 
regardless of the type or location of his disease ; and second, it gives the 
opportunity for thorough study and classification. The patient is care- 
fully studied for conditions, other than tuberculosis. His oral condition 
is noted by the dentist, and anything of a suspicious character is elimi- 
nated. Particular attention is paid to the presence of diseased tonsils, 
more especially in those cases with tuberculous cervical adenitis; for, in 
many instances, it is felt that the breaking down, caseation and long con- 
tinued suppuration in some of these cases is unquestionably the result of 
infection with pyogenic organisms from diseased teeth or tonsils. 

By general rest is meant absolute rest in bed. This form of treatment 
is continued for an indefinite period of time, depending on the location 
and severity of the lesion. The treatment of all cases of active bone and 
joint tuberculosis is immobilization. There are ardent followers of those 
who endeavor to arrest disease with restored function in whole or in part, 
as well as those who are firm believers in bony ankylosis as the desired 
end result. In the case of older children and adults with tuberculosis of 
the hip or knee, because of the experience with recurrence of symptoms 
and with multiple lesions which make up practically 20% of the group of 
cases at Lakeville, and which shows the high incidence of metastasis in 
both children and adults, our goal is complete ankylosis. On the other 
hand, in cases of small children with slight or no bony destruction, espe- 
cially in the hands, feet, spine, and in some instances, knees, satisfactory 
results with considerable restoration of function have been obtained by 
prolonged conservative treatment. We may classify the patients in two 
groups (1) Those having bone and joint lesions; (2) Those patients suf- 
fering from other forms of the disease. In the former, which makes up 



76 

the orthopedic group, because of the nature of the disease, general abso- 
lute rest is of necessity continued for much longer periods of time than in 
the second group. In the milder forms, where the general condition is 
good and a response can be noted to the routine treatment and the symp- 
toms are slight, or absent, a prescribed amount of activity is permitted 
after the first month. 

The duration of general rest in the orthopedic case is influenced, almost 
wholly, by the location of the lesion, it being much longer in those cases 
with disease in the weight bearing structures, namely, the spine, hip or 
knee. The proper treatment of a diseased spine or hip required prolonged 
recumbency of the patient, while a diseased upper extremity may be 
treated as effectively with the various forms of apparatus while the pa- 
tient is ambulatory. 

Large porches with a southern exposure, properly protected from winds 
are essential for the satisfactory exposure of the patient to both air and 
sunlight. This is especially true in the sanatorium where air-baths and 
heliotherapy are practised routinely in all seasons of the year. Only by 
effectively protecting the patient from the wind, can exposure of the body 
be carried out during cold weather, and when such protection is afforded, 
complete exposure is possible even at very low temperatures during the 
winter months. This is to be desired as the cold air-bath is one of our 
most effective agents in increasing metabolism which plays such a vital 
part in the recovery of the patient. 

Air baths and heliotherapy when indiscriminately used may be a source 
of extreme discomfort to the patient and in the toxic case may cause irre- 
parable harm. The sun's rays, properly controlled, have a distinct bene- 
ficial effect upon the patient both mentally and physically. There is only 
one contra-indication to heliotherapy and that is met with in all types of 
tuberculous disease, when a patient is very weak, with much toxemia and 
a hectic fever chart. Then we must postpone heliotherapy, until condi- 
tions are more favorable. A safe procedure, in the average non-febrile, 
uncomplicated case, is the Rollier method of heliotherapy, modified to meet 
local and individual conditions. The patient is at first gradually accus- 
tomed to the out-of-door life before exposure to the sun is started. The 
length of time required for this preliminary process depends upon the 
physical condition of the patient and the season of the year. Under favor- 
able conditions, the exposure the first day is restricted to the feet for two 
periods of five minutes each, one period to the anterior and the other to 
the posterior surface. On the second day, exposures to the feet are for 
periods of ten minutes, on the third day fifteen minutes, and so forth. On 
the second day the legs are exposed at the same time as the feet but for 
five minutes. On the third day the thighs are uncovered in a similar 
manner for five minutes, the legs having ten minutes and the feet fifteen. 
The time is thus increased by five minutes to each part, each day, until 
general radiation is obtained for periods of three hours daily, so that each 
surface of the body receives one and one-half hours exposure to the sun. 

This method of gradual exposure avoids any danger of burning and 
produces a pigmentation which has at first a bronze hue, then a copper 
color, and finally a chocolate brown. The skin becomes supple and velvety, 
and free from blemishes. The remarkable physical development and rela- 
tively firm musculature of patients exposed to the sun and air by this 
method who have been in bed for many months is surprising. On open 
lesions the first effect of sun treatment is an increase in the discharge 
which is usually followed by a diminuation of the secretion and the heal- 
ing activity of the tissues becomes evident. 

On chronic ulcerative lesions limited to the outer surfaces of the body 
that do not tend to heal, the concentrated sun's rays are sometimes used 
by means of the Thezac-Porsmeur lens. This means of concentration has 
proven to be more stimulating than the direct rays of the sun alone. 
Ultra-violet rays by means of the Quartz and Carbon Arc lamps are of 
benefit in a few cases, but a.t best are but a poor substitute for direct sun- 



77 
light. This form of artificial heliotherapy when used as a supplement to 
natural heliotherapy frequently produces striking results. 

Beyond stating that a substantial, varied and wholesome diet is indi- 
cated, we know of no reason for special diets for the majority of these 
cases. Patients of this type are inclined to become overweight and this 
should be discouraged so far as possible. 

Local rest is undoubtedly the most important factor in the treatment of 
bone and joint tuberculosis. With no exceptions every case requires local 
rest. As general rest is directed toward the improvement in bodily health, 
local rest deals directly with the diseased part. By rest of the affected 
part we endeavor to assist nature to increase the local resistance and to 
replace diseased bony structure with newly formed granulation and fibrous 
tissue. 

Local rest is best obtained by Fixation and Traction. It is in this type 
of tuberculosis more than in any other that individualization must be 
practised. During the acute stage fixation or immobilization of the 
affected joint and protection of the joint from weight bearing can be best 
secured by the use of plaster casts applied to immobilize joints above and 
below the lesion, the same way as for fractures. Spinal tuberculosis is 
satisfactorily treated by means of anterior and posterior shells which 
allow daily radiation. After the acute symptoms have subsided, these 
casts may be discarded and supplemented by other forms of apparatus best 
suited to the case under consideration. We find traction particularly use- 
ful in cases of hip, knee and high spinal disease. In the hip-joint the 
muscles are in a state of perpetual spasm and they tend to pull the femoral 
head into the socket of the acetabulum; in the knee joint subluxation must 
be prevented and in the spine, angulation with its resultant deformity 
must be avoided. 

Traction is most readily accomplished in the hip and knee by the leather, 
weight and pulley method. In the high dorsal and cervical diseases trac- 
tion is produced in a similar fashion. Traction is continued until all signs 
of activity have disappeared as evidenced by absence of pain on either ac- 
tive or passive motion and no muscle spasm can be detected. In treating 
Potts disease of the spine, however, we depend primarily on the hyper- 
extension frame which produces immobilization, which in turn overcomes 
spasm, and helps to reduce existing as well as to prevent further deform- 
ities. Hyperextended adjustable shells to make pressure on the kyphos 
have been found very useful in treating spinal caries, especially in chil- 
dren. Our observations lead us to the opinion that the cure of Potts 
disease in children depends principally on long continued rest without 
weight bearing. 

We find that cases in which fusion has been done require practically as 
long and careful after-treatment as those without operation ; also that un- 
operated cases when cured have more flexible spines than operated ones. 
We have thus far failed to find a case of complete ankylosis without op- 
eration. 

We feel that we have been able to prevent deformities by means of these 
various forms of apparatus, rather than to correct already existing ones 
to any extent. Anterior shells are provided to maintain the over-corrected 
position while the patient is turned. A patient with a paraplegia is con- 
tinued on a Bradford frame until the return of motor and sensory func- 
tions. The time necessary to arrest active disease varies from six to 
eighteen months. 

It is after many months of sanatorium treatment during which time the 
patient has had the benefit of the general building up of his resistance, his 
local lesion has become inactive with some healing taking place as noted 
by the X-ray and absence of symptoms plus the healing of any abscesses, 
that he is now ready for surgical interference, to re-inforce the affected 
joint and thus prevent a recrudescence of the disease at its original site, 
as well as to avoid metastasis. Prior to operation, however, it is of great 
importance that the patient be made ambulatory for a few weeks. This is 



78 

necessary that his bodily functions may be re-adjusted and to return the 
muscles, and especially the vital structures, to their normal tone. Thus 
his reaction to operation may be a good one, rather than one of various 
degrees of shock, which unfortunately may be of the most severe type in 
a patient previously considered an excellent surgical risk. 

The arthrodesis is to be followed by sanatorium treatment for the nec- 
essary period of time to complete the patient's convalescence. One can- 
not deny that the danger of reactivation of tuberculosis disease is always 
present in a previously damaged and weakened joint when it is called upon 
to withstand undue strain and shock. 

Each year we see many cases come into the hospital with two or more 
tuberculous lesions, revealing the story of an old hip, spine or knee disease 
which had never been permanently fused. They now come in for treat- 
ment for lesions involving other bony structures or soft parts, too many 
presenting the sad picture of Amyloid disease. It is important that we 
do not confuse a long quiescent stage with cure, that is to say a safely 
ankylosed joint which insures a permanently useful limb. 

It is necessary to resort to amputation as a life saving measure in cases 
of tuberculosis of the ankle, knee, wrist and elbow in adults, when the 
disease has hopelessly involved the tissues, and extensive secondary infec- 
tion has occurred. Badly destroyed fingers are removed in larger num- 
bers and with less delay each year. 

In the treatment of a tuberculous abscess per se, our practice is to aspi- 
rate only when the abscess becomes a source of discomfort by its increas- 
ing size, or when secondary infection has occurred. When, in spite of re- 
peated aspirations the abscess fails to absorb and tends to infiltrate sur- 
rounding structures, incision for adequate drainage is necessary. In 
about 70% of cases abscesses are absorbed if left alone. 

The response of the uncomplicated non-orthopedic cases of tuberculosis 
to general treatment is such that but few local measures are necessary. 
Where complications do arise, for example, cystitis in a case of renal tu- 
berculosis, they must be treated symptomatically. Abdominal paracente- 
sis is resorted to in peritonitis with effusion when the accumulation of 
fluid is sufficient to cause respiratory or circulatory embarrassment. This 
applies especially to adults, as children seem to do well without tapping, 
or if tapping is required, one or two generally suffice. Transfusion has 
been given in cases of long standing suppuration with secondary anemia 
and the encouraging results noted certainly justify this procedure. 

SURGICAL TREATMENT OF PULMONARY TUBERCULOSIS 

By Edward D. Churchill, M.D., 

Associate Professor of Surgery, Harvard Medical School, 
Surgical Consultant, Rutland State Sanatorium 

In 1925 Alexander estimated that there were approximately 30,000 per- 
sons in this country with pulmonary tuberculosis presenting suitable indi- 
cations for surgery and who would die of their tuberculosis if not oper- 
ated upon. This statement is startling, but probably an even larger figure 
might be given today for surgery has increased rather than limited its 
strides in the treatment of "hopeless cases" of far advanced consumption. 

The operative measures employed in the treatment of pulmonary tu- 
berculosis are almost without exception forms of "collapse therapy." The 
surgeon does not make a direct attack on the tuberculous lesion but at- 
tempts by operation to create the most favorable conditions under which 
natural healing processes may take place. This means that the operation 
does not cure the disease in the sense that appendicitis is cured by the re- 
moval of the appendix, or that a malignant growth may be cured by ex- 
tirpation. The various forms of collapse therapy bring about an arrest of 
the disease indirectly by the rest, relaxation or compression of the lung 
which they create. Under these circumstances fibrosis and ultimate re- 
placement of the tuberculous tissue by scar takes place. This conception 



79 

of collapse therapy is important to bear in mind as it indicates at once the 
type of case that may reasonably expect help from surgery. 

When operation is offered, the patient must be made to understand that 
he cannot be cured by surgery alone. Surgical measures are to be re- 
garded as "shock troops" which are made available to strengthen and ad- 
vance his own lines of defense in the combat with the disease. With this 
conception in mind he will not rebel against the prolonged rest which is 
so necessary after the operation, and later, if fortunate enough to be able 
to resume his activities, will ever be on his guard against a further out- 
break of the disease. 

Collapse therapy, whether carried out by artificial pneumothorax or by 
operations on the chest wall, involves principles which are directly in line 
with Nature's own methods of healing. Given sufficient time, Nature will 
often go a long way toward effecting a spontaneous collapse of the lung. 
This only happens, however, when the patient possesses a high degree of 
resistance to the disease. In long standing cases of unilateral fibroid 
phthisis the heart and mediastinum are drawn toward the affected side, 
the diaphragm rises and becomes fixed and the ribs overlying the diseased 
lung are drawn closely together. These deformities were noted by Laen- 
nec, the famous French physician to whom we are indebted for the inven- 
tion of the stethescope. An extreme example of spontaneous contracture 
or collapse of the chest is figured in the original edition of his treatise 
"De l'Auscultation Mediate." Laennec observed that when such a collapse 
occurred the outlook for the patient was improved because the chances of 
further outbreaks of the disease were minimal. 

Collapse therapy was introduced in the form of artificial pneumothorax, 
a procedure the results of which completely justify its employment in se- 
lected cases of tuberculosis. When a free pleural cavity permits a com- 
plete collapse of the lung, artificial pneumothorax is still usually the 
method of choice as under favorable circumstances the lung may be al- 
lowed to re-expand after the treatment has been eff