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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 

XA  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  wajr  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  }rears  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  jrear  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. 


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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  y2  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- 


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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 


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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,- 
800y2  pounds  of  poultry;  13,879,988y2  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;  14,676,0101/2  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 


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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  21/2  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.  Semple1  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  Taylor2  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 

0 

Hongkong 

12 

66 

0 

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    METHOD3 

Name  of 
Director 

Number  of 
Cases  of 
Paralysis 

Number  of 
Wounds 
Treated 

Percentage 

Jordan 
Cunningham 
Hodgson 
Taylor 

Morison 
Lorenzo 

0 
3 
0 
0 
0 
0 
0 

465 
84,844 
13,532 
5,125 
11,083 
11,000 

584 

0 
0.035  or  1/28,281 
0 
0 
0 
0 
0 

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.  Cornwall4  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 "yard  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 y2  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; 
1,310,1411/^  pounds  of  broken  out  eggs;  5,644,912  pounds  of  butter; 
7,207,979x/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; 
936,686x/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 

0 


Per  cent 

Treating 

Gonorrhea 

31.9 

100.0 

0.0 


Cases 

Treated 

117 

16 

0 


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;  4,540,3311/4  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 


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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,192,6271/2  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;  9,062,1831/2  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;  8,397,7261/2  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 


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43 

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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  7V2  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;  6,180,8763/4l  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,- 
2871/4  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;  14,817,4621/4  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;  17,866,20134  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 


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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  effective  in  controlling 
the  disease.  Certain  disadvantages  are  inherent  in  pneumothorax  ther- 
apy, not  the  least  of  which  is  the  great  length  of  time  which  it  requires. 
The  re-expansion  of  the  lung  at  the  termination  of  the  treatment  is  neces- 
sarily attended  by  the  danger  of  a  recrudescence  of  the  disease.  In  many 
instances  an  adequate  degree  of  collapse  cannot  be  attained  because  of  ad- 
hesions between  the  lung  and  the  chest  wall ;  again,  pneumothorax  may  be 
complicated  by  the  development  of  a  pleural  effusion  which  necessitates 
abandoning  this  form  of  treatment. 

When  pneumothorax  is  impossible  or  for  some  reason  is  contraindi- 
cated,  recourse  may  be  had  to  surgical  procedure.  It  must  not  be  thought, 
however,  that  the  two  methods  are  of  equal  value  or  that  one  can  be  sub- 
stituted for  the  other  in  every  case.  Experience  has  shown  that  there  are 
forms  of  pulmonary  tuberculosis  in  which  pneumothorax  is  to  be  pre- 
ferred to  thoracoplasty  while  in  other  cases  only  the  collapse  of  the  chest 
will  give  a  lasting  result. 

The  indications  for  embarking  upon  an  active  form  of  therapy  in  pul- 
monary tuberculosis,  whether  it  be  by  artificial  pneumothorax  or  surgical 
measures,  must  lie  primarily  in  a  failure  of  the  patient  to  respond  to  the 
more  conservative  measures.  Ideal  treatment  is  only  possible  when  the 
physician  is  so  experienced  in  the  clinical  course  of  the  disease,  that  he 
can  predict  with  some  degree  of  certainty  the  future  course  of  an  indi- 
vidual patient. 

Thoracoplasty 

By  and  large,  thoracoplasty  is  offered  to  the  "good  chronic,"  meaning 
thereby  the  patient  who  has  demonstrated  a  certain  degree  of  immunity 
to  the  disease  by  erecting  his  own  barriers  of  fibrous  tissue.  The  surgeon 
has  little  to  offer  the  patient  who  is  being  overwhelmed  by  the  acute  ex- 
udative form  of  the  disease.    These  patients  often  seek  the  surgeon  as  a 


final  court  of  appeal  for  a  steadily  progressing  infection.    Under  such  cir- 
cumstances an  operation  may  not  only  be  futile  but  actually  dangerous. 

In  order  to  be  favorable  for  operative  treatment  the  disease  should  be 
largely  confined  to  one  side.  Strictly  speaking,  pulmonary  tuberculosis  is 
rarely  unilateral,  and  most  of  the  patients  coming  to  operation  present 
some  signs  of  involvement  of  the  opposite  lung.  If  the  process  in  the  con- 
tralateral lung  is  not  extensive  and  especially  if  it  is  judged  to  be  inactive 
or  nonprogressive,  it  offers  no  contraindication  to  collapsing  the  chief 
focus  of  the  disease. 

The  general  condition  of  the  patient  must  be  such  as  to  enable  him  to 
stand  the  strain  of  the  operative  procedure.  The  operation  should  be  per- 
formed at  a  time  when  the  patient  fails  to  make  further  progress  under 
sanatorium  treatment,  but  not  postponed  until  he  is  beginning  to  go  down 
hill. 

Tuberculosis  of  the  intestines  or  kidneys  constitutes  a  contraindication, 
as  does  any  serious  constitutional  disorder.  The  most  favorable  ages  are 
from  20-35.  Operations  on  patients  over  45  should  be  approached  with 
caution. 

Brauer  of  Hamburg  was  the  first  to  design  an  operation  whereby  the 
removal  of  segments  of  ribs  produced  an  adequate  collapse  of  the  lung.  As 
might  be  expected,  the  early  attempts  were  attended  by  a  high  mortality, 
chiefly  because  too  long  segments  of  ribs  were  removed.  Sauerbruch,  also 
of  Germany,  modified  the  operation  by  removing  only  short  segments  of 
ribs  along  the  spine.  This  gives  almost  as  good  compression  as  the  ori- 
ginal operation  of  Brauer  because  the  collapse^of  the  chest  wall  is  largely 
brought  about  by  a  descent  and  rotation  of  the  ribs  likened  to  a  "bucket- 
handle  movement."  Sections  of  the  upper  ten  or  eleven  ribs  are  removed, 
always  including  a  short  section  from  the  first  rib.  The  "extrapleural 
paravertebral  thoracoplasty"  most  widely  used  today  is  in  the  length  of 
rib  resected,  midway  between  the  extensive  operation  first  proposed  by 
Brauer  and  the  more  limited  procedure  of  Sauerbruch.  The  operation  is 
usually  performed  in  two  or  more  stages  under  novocain  anesthesia  or 
novocain  supplemented  by  gas-oxygen.  Of  course  an  operation  of  this 
magnitude  is  a  strain  on  a  patient  already  invalided  by  long  standing  tu- 
berculosis. In  experienced  hands,  however,  the  immediate  mortality  is  as 
low  as  five  percent.  The  deaths  attributable  to  the  operation  have  largely 
been  due  to  pneumonia  or  sepsis  in  the  operative  wound. 

The  operation  is  often  feared  as  a  mutilating  procedure  which  results  in 
permanent  bodily  deformity.  As  a  matter  of  fact,  when  the  patient  is 
dressed  in  his  ordinary  clothes  it  is  usually  impossible  to  tell  with  any 
degree  of  certainty  which  side  has  been  collapsed.  This  is  true  even  with 
women  patients  wearing  light  blouses  and  is  due  to  the  fact  that  the  op- 
eration does  not  alter  the  contour  of  the  shoulder  as  it  leaves  the  clavicle 
and  scapula  in  their  normal  position. 

The  observation  of  even  one  patient  who  has  been  transformed  by  the 
operation  from  chronic  and  hopeless  invalidism  to  what  is  apparently  a 
normal  life  gives  adequate  evidence  of  its  great  value.  Fortunately,  how- 
ever, the  real  value  of  thoracoplasty  has  been  established  beyond  question 
by  statistics  of  several  carefully  studied  series  of  cases,  totalling  1159  in 
the  year  1925.  Broadly  speaking  the  percentage  results  of  these  and  other 
cases  show  one-third  apparently  cured,  one-third  improved  and  one-third 
either  unchanged,  worse  or  dead.  Thirteen  percent  died  from  causes  di- 
rectly or  indirectly  connected  with  the  operation. 

Almost  all  of  these  1159  patients  would  have  died  of  tuberculosis  if  op- 
eration had  not  been  undertaken  as  all  other  recognized  forms  of  treat- 
ment including  artificial  pneumothorax  had  been  exhausted.  Cases  that 
present  the  most  favorable  indications  for  operation  have  given  favorable 
results  in  as  high  as  91  per  cent. 

Following  the  operation  the  patient  should  remain  in  bed  for  six  months 
or  longer  depending  upon  individual  needs.  As  the  periosteum  is  not  re- 
moved with  the  ribs,  new  bone  forms  in  approximately  six  weeks.    During 


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this  period  the  patient  should  be  kept  in  bed  lying  on  the  affected  side  as 
much  as  possible  with  a  small  pillow  in  the  axilla.  When  on  his  back  a 
sand-bag  weighing  10  lbs.  is  placed  on  the  front  of  the  chest.  These  pro- 
cedures are  instituted  as  soon  as  the  immediate  post-operative  pain  sub- 
sides. 

Phrenicotomy 

A  diseased  lung  may  be  partially  put  at  rest  by  paralysis  of  the  dia- 
phragm on  the  corresponding  side.  This  may  be  accomplished  by  section- 
ing the  phrenic  nerve  in  the  neck,  a  relatively  minor  operation  which  is 
performed  under  novocain  anesthesia.  As  the  phrenic  nerve  is  apt  to  re- 
ceive an  accessory  branch  in  the  mediastinum  it  has  been  found  advisable 
after  sectioning  the  nerve  to  extract  the  lower  segment  in  order  to  inter- 
rupt these  communicating  fibers. 

The  indications  for  phrenic  nerve  section  have  not  as  yet  been  as  clearly 
established  as  those  for  thoracoplasty,  although  its  great  value  in  certain 
cases  has  been  dramatically  proven.  The  operation  is  in  no  way  a  substi- 
tute for  thoracoplasty  as  the  compression  it  brings  about  is  relatively 
slight.  Its  chief  effect  seems  to  be  attained  through  resting  and  relaxing 
the  lung.  That  this  relaxation  may  even  be  transmitted  to  the  apex  of  the 
lung  has  been  shown  by  the  disappearance  of  large  apical  cavities  follow- 
ing its  use. 

Paralysis  of  the  corresponding  leaf  of  the  diaphragm  serves  as  a  valu- 
able adjunct  to  thoracoplasty,  and  when  done  as  a  preliminary  operation 
seems  to  diminish  the  liability  to  pneumonia.  It  is  also  of  value  in  con- 
trolling hemorrhage. 

Pneumolysis 

In  certain  cases  in  which  a  regular  thoracoplasty  has  been  insufficient 
to  collapse  rigid  walled  cavities,  the  lung  may  be  further  compressed  by 
freeing  the  pleura  from  the  chest  wall  and  packing  the  space  with  fat, 
muscle,  or  even  paraffin.  Occasionally  this  procedure  is  used  alone  (api- 
colysis). 

Thoracoscopy 

Jacobaeus  (Stockholm)  devised  an  instrument  similar  to  a  cystoscope 
which  he  has  termed  a  thoracoscope.  With  this  instrument  he  is  able  to 
look  into  a  pneumothorax  cavity  by  making  a  small  incision  between  the 
ribs  under  novocain  anesthesia.  With  the  aid  of  a  cautery  it  is  possible 
to  sever  adhesions  which  may  be  interfering  with  the  proper  collapse  of 
the  lung.  This  operation  is  being  performed  successfully  in  an  increasing 
number  of  cases. 

SOCIAL  SERVICE  'IN  TUBERCULOSIS 

By  Eleanor  E.  Kelly, 
Supervisor  of  Social  Service,  Massachusetts  Department  of  Public  Health 

The  campaign  against  tuberculosis  is  one  of  the  most  challenging  of  all 
health  programs. 

The  death  rate  from  this  disease  is  decreasing  each  year  due  to  greater 
knowledge  regarding  control  of  tuberculosis,  and  increased  vigilance  on 
the  part  of  the  medical  and  nursing  professions  and  others  actively  en- 
gaged in  the  health  field.  This  vigilance  cannot  be  relaxed,  and  the  im- 
portance of  the  attack  upon  bad  social  conditions  which  may  be  predis- 
posing factors  must  also  be  repeatedly  emphasized. 

In  every  phase  of  social  service  the  problem  of  tuberculosis  appears 
either  directly  or  indirectly.  No  social  worker  is  free  from  the  respon- 
sibility of  contributing  towards  its  solution — whether  she  approaches  it 
directly  as  a  health  worker,  or  from  the  angle  of  child  welfare,  the  family, 
industry,  school  or  community. 

The  social  worker's  part  in  the  program  is  many-sided.  Obviously  the 
greatest  responsibility  rests  upon  the  worker  dealing  directly  with  health 


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problems,  but  she  must  have  the  cooperation  of  workers  in  all  other  fields. 
The  service  seems  to  fall  into  four  groups : 

Service  to  the  Sick  Patient 

The  social  worker  must  make  it  possible  for  him  to  have  the  essentials 
for  his  cure — rest,  nourishing  food,  plenty  of  fresh  air  and  sunshine.  In 
some  cases  he  must  have  sanitorium  care;  in  others  adjustments  are  to  be 
made  at  home  so  that  he  may  remain  there. 

Not  infrequently  the  adult  patient  must  be  restrained  from  hurrying 
West  or  South,  without  sufficient  funds  to  see  him  through,  trusting  to 
climate  alone  to  effect  a  cure,  sometimes  living  in  an  ill-ventilated,  cheer- 
less room  and  having  insufficient  nourishment.  Growing  lonely  and  dis- 
couraged, he  finally  returns  home  to  start  over  again  with  precious  time 
lost  and  money  spent.  Now  and  again,  through  the  cooperation  of  other 
agencies  or  relatives,  arrangements  can  be  made  for  adequate  care  and  a 
patient's  wish  to  go  West  gratified.  More  often,  however,  it  is  necessary 
to  persuade  him  to  accept  care  nearer  home. 

Then  on  the  other  hand,  there  is  the  patient  who  is  unwilling  to  leave 
home  although  in  need  of  sanitorium  care. 

The  utmost  patience  and  sympathy  are  necessary  in  dealing  with  the 
patient  who  has  just  been  diagnosed  tuberculous,  the  worker  realizing  that 
this  is  an  extremely  difficult  period  of  adjustment  for  him.  It  is  prob- 
ably much  easier  for  a  patient  to  accept  hospitalization  for  an  acute,  al- 
though severe,  illness,  than  to  consent  to  giving  up  all  activity  and  sub- 
mitting for  an  indefinite  period  of  time  to  a  rest  cure,  especially  if  he  does 
not  feel  very  ill  and  if  giving  up  will  mean  worry  about  his  business  or 
home.  This  is  the  point  at  which  the  social  worker  can  frequently  be  of 
greatest  service.  In  the  clinic  she  is  constantly  faced  by  such  problems 
and  can  usually  gain  the  confidence  of  the  patient,  assuring  him  that  help 
will  be  given  him  in  making  plans  to  carry  out  the  doctor's  recommenda- 
tion. 

But  she  must  help  him  to  help  himself — not  relieve  him  entirely  of  re- 
sponsibility, for  one  of  the  most  important  factors  in  a  patient's  recovery 
is  his  own  will  to  gain  health.  Many  a  patient  has  been  induced  to  make 
the  fight  by  the  knowledge  that  some  one  was  dependent  upon  him.  This 
incentive  must  not  be  entirely  removed,  but  when  the  responsibility  is 
overwhelming  he  should  be  helped  to  bear  it. 

The  patient  frequently  hears  with  dismay  the  doctor's  diagnosis.  He 
comes  from  the  clinic  discouraged  and  ill  and  wondering  what  is  to  become 
of  him  and  his  family.  His  mind  is  full  of  questions — Where  can  he  go 
for  care? — The  doctor  has  said  he  must  not  remain  at  home.  How  long 
will  he  have  to  be  out  of  work  ?  How  can  he  stretch  his  savings  to  cover 
the  family  expenses  and  his  own  care  until  he  returns  to  work?  Who  v/ill 
keep  an  eye  on  that  boy  who  needs  so  much  his  father's  firm  hand  just 
now?  Can  the  mother,  not  very  strong,  bear  up  under  added  responsibil- 
ities ?  The  social  worker  cannot  at  once  answer  all  his  questions  but  she 
can  give  encouragement  and  suggestions,  assuring  him  of  her  readiness 
to  help.  She  knows  from  experience  with  other  patients  how  bewildered 
he  is  and  frequently  he  goes  from  the  clinic  with  a  more,  hopeful  attitude 
because  he  knows — not  only  that  the  doctor  and  the  nurse  are  with  him  in 
his  fight,  but  that  the  social  worker  will  help  him  to  straighten  things  out 
at  home. 

Again  there  is  the  child  who  must  leave  school  and  have  care.  There  is 
a  waiting  list  at  the  only  sanitorium  to  which  she  would  be  eligible.  So 
far  as  housing  is  concerned,  the  child  could  probably  remain  at  home  quite 
satisfactorily  for  the  mother  lives  in  two  large,  sunny  rooms  in  a  suburb. 
There  is,  however,  no  one  to  care  for  the  patient.  The  mother,  a  widow, 
is  obliged  to  work  and  the  only  other  member  of  the  family  is  an  older 
girl,  who  attends  high  school.  This  girl  starts  the  younger  sister  off  to 
school  and  is  at  home  when  she  returns.    But,  if  the  child  is  not  to  go  to 


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school,  who  will  look  after  her  during  school  hours?     The  social  worker 
must  either  help  the  mother  to  make  some  home  arrangement  or  find  a 
temporary  home  for  the  child  until  she  can  be  admitted  to  the  sanitorium. 

Rest  is  one  of  the  fundamentals  in  sanitorium  care.  But  the  mother 
who  must  have  a  long  period  of  such  care  and  leaves  her  children  under 
inadequate  supervision  at  home  cannot  make  as  rapid  a  recovery  as  if  she 
had  no  home  worries  and  could  rest  mind  as  well  as  body. 

Social  service  must  find  ways  and  means  of  carrying  out  medical  advice. 
The  social  worker  knows  the  community  resources  and  utilizes  them  in 
making  a  constructive  plan — not  merely  tiding  the  patient  over  the  imme- 
diate need.  Naturally,  emergency  plans  are  often  made,  but  they  are  sel- 
dom final  solutions  of  a  problem  and  must  be  followed  by  an  effort  to  se- 
cure a  satisfactory  adjustment  of  the  patient  to  his  home  and  community. 

Sometimes  the  doctor  will  request  the  social  worker  to  report  on  home 
conditions  before  he  makes  his  recommendation;  and  this  kind  of  team 
work  makes  for  greater  efficiency  in  social  service. 

When  the  patient  has  reached  the  sanitorium,  the  social  worker  can  do 
much  to  keep  up  his  morale.  Small  friendly  services,  and  letters,  or  visits 
to  tell  how  the  family  is  getting  along,  often  help  greatly  in  keeping  the 
patient  cheerful.  Where  occupational  therapy  and  a  library  are  not  in- 
cluded in  the  sanitorium  or  hospital  facilities,  this  work  sometimes  de- 
volves upon  the  social  service  department. 

Contacts 

Just  as  important  as  planning  for  the  patient's  care  is  consideration  of 
protection  for  the  contacts  who  will  all  be  examined.  The  social  worker 
first  ascertains  the  attitude  of  the  patient  and  his  family  towards  his  con- 
dition. She  must  be  certain  that  living  conditions  are  such  that  it  will  be 
possible  for  the  family  to  take  necessary  precautions  and  that  they  are 
willing  to  do  so.  If  they  are  living  in  crowded  quarters'  and  the  patient  is 
to  remain  at  home,  it  may  be  necessary  to  place  the  childen  outside  the 
home  temporarily.  The  nurse  will  go  into  the  home  to  give  the  necessary 
instruction  and  the  social  worker  must  assure  herself  that  the  family  can 
follow  her  instructions.  Financial  aid  may  be  necessary  in  securing  ade- 
quate sleeping  accommodations  and  separate  utensils.  Transportation 
may  have  to  be  arranged  so  that  all  the  members  of  the  family  may  go  to 
the  doctor  or  clinic  for  examination. 

Follow-Up 

One  of  the  most  important  phases  of  the  work  is  the  follow-up  of  the 
patient  discharged  from  a  sanitorium  arrested  or  cured.  When  admission 
is  secured  for  the  patient,  the  social  worker's  responsibility  does  not  cease. 
She  must  know  that  he  will  later  return  to  satisfactory  home  conditions, 
and,  if  he  is  to  return  to  work  or  to  school  she  must  know  under  what  con- 
ditions. 

A  man  may  receive  excellent  care  in  a  sanitorium  and  be  discharged  in 
splendid  condition,  able  to  return  to  work.  If,  however,  the  disease  was 
contracted  at  work,  through  unhygienic  conditions  or  too  fatiguing  labors, 
it  is  wasted  effort  to  send  that  man  back  to  work  under  the  same  condi- 
tions. A  relapse  would  be  more  discouraging  to  him  than  his  first  illness 
and  months  of  time  and  effort  and  money  wasted.  The  social  worker 
learns  from  the  doctor  what  the  patient  is  physically  able  to  do,  and  at- 
tempts to  place  him  if  he  cannot  find  suitable  employment  for  himself.  On 
the  other  hand,  if  a  man  has  been  working  under  reasonably  satisfactory 
conditions,  return  to  his  former  occupation  will  be  far  less  of  a  strain 
than  new  work  under  somewhat  better  conditions. 

There  is  close  cooperation  between  the  social  worker  and  the  nurse 
throughout,  but  especially  in  the  follow-up  work.  The  nurse  reports  social 
needs  as  she  finds  them.  In  some  communities  the  nurse  herself  feels  that 
she  cannot  visit  all  of  the  patients  as  often  as  she  would  like,  and  here  the 


84 
social  worker  reports  to  the  nurse  when  there  seems  to  be  need  of  a  visit 
sooner  than  was  planned.    More  frequent  conferences  between  nurses  and 
social  workers  in  the  same  community  would  probably  be  helpful  to  both, 
especially  where  they  are  visiting  the  same  families. 

One  of  the  most  discouraging  features  of  the  work,  both  from  the  medi- 
cal and  from  the  social  viewpoint,  is  the  number  of  "repeaters"  in  the  san- 
itoria  and  hospitals.  But  what  chance  for  health  has  a  child  discharged 
to  a  crowded,  ill- ventilated,  sunless  tenement? 

Or  the  child  whose  parents,  through  ignorance  or  carelessness  fail  to 
insist  on  his  wearing  the  brace  ordered  for  him?  Social  Service  is  some- 
times called  upon  to  secure  a  brace  for  which  the  family  cannot  pay,  but 
very  often  it  requires  the  combined  efforts  of  the  doctor,  nurse  and  social 
worker  to  see  that  Johnny  wears  his  brace  when  "he  is  really  well  now". 

Preventive  Work 

More  and  more  the  necessity  for  preventive  work  in  tuberculosis  with 
both  children  and  adults  is  being  recognized  by  all  social  agencies.  Chil- 
dren who  are  underweight,  whether  contact  cases  or  not,  need  special  at- 
tention. Preventoria,  health  camps,  roof  classes,  are  doing  splendid  work 
in  this  field  and  the  social  worker  has  an  opportunity  to  help  by  steering 
suitable  cases. 

Parents  do  not  always  know  that  the  child  who  is  listless  or  irritable 
may  need  medical  attention  more  than  he  needs  punishment,  and  the  so- 
cial worker  can  often  aid  in  her  role  of  teacher. 

Child  welfare  work  plays  a  large  and  important  part  in  the  anti-tuber- 
culosis program,  for  the  child  who  is  taught  habits  of  right  living  is  much 
less  susceptible  to  disease  than  the  child  who  has  not  been  so  instructed 
and  he  will  carry  these  habits  into  adult  life.  So  much  disease  is  traced 
back  to  unwholesome  living  conditions  that  the  importance  of  giving  the 
child  his  chance  cannot  be  overstressed. 

Two  small  boys  had  been  discharged  from  a  sanitorium,  and  the  social 
worker  upon  visiting  found  that  they  were  running  wild,  not  having  suffi- 
cient rest  or  care.  Obviously  closer  supervision  of  the  children  was  neces- 
sary and  living  conditions  were  not  suitable.  But  another  problem  also 
was  presented — that  of  the  15-year-old  sister.  Three  years  previously  the 
mother  died  of  tuberculosis  at  which  time,  this  girl,  then  only  twelve  years 
of  age,  assumed  the  responsibility  of  the  entire  household,  cooking  and 
cleaning,  etc.  for  the  family  of  father,  and  six  children.  An  older  sister 
had  died  of  tuberculosis  and  a  younger  brother  was  now  in  a  sanitorium. 
Underweight,  overworked,  this  child  herself  seemed  a  potential  victim  of 
the  disease.  The  father  realized  the  danger  but  seemed  unable  to  make 
other  plans  for  his  children.  The  social  worker  with  his  approval  ar- 
ranged for  the  two  boys  to  have  care  in  foster  homes  where  they  could  be 
under  close  supervision  and  in  more  wholesome  surroundings.  The  girl  is 
to  return  to  school  and  the  responsibility  for  the  household  to  be  assumed 
by  a  housekeeper,  thus  giving  this  child  her  chance  for  health  and  edu- 
cation. 

Again  in  the  seasons  of  unemployment  there  is  the  temptation  for  the 
employment  worker  to  suggest,  and  for  the  applicant  to  accept,  work  which 
is  beyond  his  strength  and  which  is  carried  on  under  wholly  unsatisfac- 
tory conditions. 

The  social  worker  needs  always  to  be  looking  forward,  seeing  beyond 
the  need  of  the  individual  to  the  family  and  the  community.  She  is  an 
educator  as  well  as  counsellor  and  friend. 

The  aims  of  social  service  for  tuberculosis  might  be  summarized: 

1.  To  help  the  patient  to  help  himself  toward  cure  and  rehabilitation. 

2.  To  encourage  him  to  recognize  and  assume  his  responsibility  for 
protection  of  his  family  and  others  with  whom  he  comes  in  contact. 

3.  To  make  every  effort  towards  informing  the  people  in  the  community 
of  the  early  signs  of  tuberculosis,  and  of  the  danger  of  contact. 


85 

4.  To  encourage  health  examinations  and  to  cooperate  in  every  health 
project  in  the  community. 

5.  To  study  the  health  situation  and  problems  in  the  community  with 
a  view  to  contributing  and  interpreting  social  data  which  may  be  used  in 
research. 

6.  To  support  all  legislation  tending  to  promote  the  health  of  the  indi- 
vidual and  the  community. 

GRADUATION  ADDRESS 

at  the 

RUTLAND  STATE  SANATORIUM  TRAINING  SCHOOL 

June  24,  1929 

By  Alfred  Worcester,  M.D. 

Your  Superintendent  has  brought  back  vividly  to  my  mind  the  begin- 
ning of  this  institution,  and  suddenly  there  flashes  before  my  memory  my 
first  look  at  this  site.  The  woods  came  down  then  to  where  some  of  these 
buildings  are  and  a  swamp  somewhere  here  was  thickly  filled  with  high 
bush  blueberries.  It  seemed  a  shame  to  cut  them  down  merely  to  build  a 
hospital  and  I  never  quite  got  over  my  regret  that  those  blueberries  were 
not  saved.  But  that  was  a  long  time  ago.  I  believe  it  is  now  thirty  years 
since  I  was  last  upon  this  ground,  and  of  course  the  changes  are  tremen- 
dous. I  doubt  if  any  of  you  can  see  with  me  the  changes  that  have  taken 
place  within  the  last  30  years;  you  do  not  look  as  if  you  were  able  to  re- 
member half  so  far  back.  But  I  have  other  memories  that  I  think  should 
be  interesting  to  you  nurses. 

The  first  class  of  nurses  in  this  country  was  graduated  at  the  New 
England  Hospital  for  Women  and  Children.  In  that  class  of  three  was 
Linda  Richards  who  has  been  my  lifelong  friend.  I  remember  well  the 
almost  insurmountable  difficulties  the  founder  of  that  school,  Dr.  Susan 
Dimmock,  encountered.  She  was  a  beautiful  woman,  as  I  remember  her, 
young  and  ardent;  and  the  reason  I  have  for  remembering  her  so  well  is 
that  she  tried  to  persuade  my  mother  to  allow  a  sister  of  mine  to  enter 
that  first  class,  but  my  mother  was  obdurate,  believing  that  the  nursing 
profession  should  be  reserved  for — well,  old  maids!  However,  after  that 
class  had  graduated  mothers  believed  differently.  Linda  Richards  soon 
started  the  training  school  at  the  Massachusetts  General  Hospital.  That 
was  while  I  was  in  college  and  it  was  a  custom  then,  as  I  guess  it  is  now, 
for  those  who  intend  to  take  up  medicine  to  go  to  the  hospitals  to  see  op- 
erations, to  see  if  they  can  stand  the  smell  of  ether  and  the  sight  of  blood. 
One  day  it  was  noised  around  for  those  going  into  the  hospital  to  be  on 
the  lookout  for  some  young  nurses  that  were  well  worth  looking  at, — and 
so  they  were !  That  was  the  first  time  at  the  Massachusetts  General  Hos- 
pital that  any  nurse  was  in  uniform. 

Before  that  time  the  nursing  after  all  had  not  been  bad  at  the  Massa- 
chusetts General  Hospital.  In  Boston  there  had  never  been  bad  nursing 
and  the  old  nurses  in  New  England  are  entitled  to  the  greatest  amount  of 
credit.  In  New  York  the  conditions  were  more  like  what  they  had  been 
in  most  hospitals  abroad. 

Linda  Richards,  as  perhaps  you  know,  was  the  first  nurse  in  this  coun- 
try to  receive  a  diploma.  It  was  my  privilege  to  write  her  life,  or  rather 
to  edit  her  letters.  She  was  of  a  very  retiring  disposition  but  she  was  a 
good  letter  writer  and  she  fell  into  my  trap  by  answering  my  questions. 
Wherever  there  seemed  to  be  any  hiatus  in  the  story  I  would  write  ques- 
tions to  her  such  as  "When  you  were  in  this  or  that  difficulty  what  did  you 
do?"  and  she  would  answer,  and  so  when  I  put  her  letters  together  it  made 
quite  a  fairly  connected  history  of  her  life. 

But  J  will  go  back  of  Linda  Richards.  The  modern  profession  of  nurs- 
ing started  in  1834  at  Kaiserswerth  on  the  Rhine.  Everyone  agrees  to 
that.    The  art  of  nursing  is  much  older.    But  there  is  no  history  nor  any 


86 

mention  in  literature  of  such  service  previous  to  that  which  was  under- 
taken at  the  beginning  of  the  Christian  Era.  I  like  to  think  that  some  of 
the  women  who  followed  our  Lord  during  His  wanderings  in  Judea  and 
saw  His  way  of  dealing  with  the  sick  became  nurses,  for  very  soon  the 
custom  came  into  being.  The  first  reference  to  nurses  is  found  in  St. 
Paul's  letter  to  the  Romans  where  he  recounts  that  Sister  Phoebe  had 
"succored  many  and  also  myself."  A  better  translation  of  the  Greek 
words  would  be  "hath  stood  by".  Down  through  the  ages  there  are  plenty 
of  references  to  women  who  stood  by  the  sick  and  suffering,  but  it  was  not 
until  300  or  400  years  ago  that  the  large  orders  of  religious  nurses  came 
into  being.  I  once  found  in  Holland,  where  our  Pilgrim  Fathers  and 
Mothers  sojourned  before  coming  over  to  this  country,  an  account  of 
Mennonite  women  who  were  appointed  to  district  nursing  in  1584.  The 
reason  I  went  to  Holland  to  search  was  that  in  the  early  Pilgrim  records 
there  is  an  account  of  the  appointment  of  a  district  nurse  while  they  were 
in  Holland,  and  she  must  have  come  to  this  country  with  them.  I  believe 
she  was  the  mother  of  New  England  volunteer  nursing.  Night  or  day 
"watchers",  they  were  called. 

My  mother,  a  minister's  wife,  did  such  district  nursing  whenever  any 
one  in  the  neighborhood  was  sick;  and  later  when  I  began  my  practice  she 
often  helped  me.  There  was  no  trained  nursing  service  in  Waltham  then. 
I  well  remember  how  tender  and  efficient  was  her  care  of  the  newborn  and 
how  kind  she  was  to  all  the  sick  who  came  under  her  care.  I  asked  her 
once  how  many  newborn  babies  she  had  washed.  She  said,  "I  think  one 
hundred,  but  I  have  washed  and  laid  out  a  larger  number  of  the  dead." 
There  was  nothing  finer  than  the  neighbor  nursing  of  those  New  England 
women.    I  am  afraid  we  forget  that  in  our  pride  over  our  modern  schools. 

The  first  real  training  school,  as  I  have  said,  was  started  in  1834  in  a 
little  stone  house  in  Kaiserswerth  on  the  Rhine  by  Theodor  Fliedner.  It 
was  a  very  fortunate  thing  for  the  English  speaking  people  when  a  young 
English  girl  went  there  for  her  training.  That  was  Florence  Nightingale. 
She  had  had  some  training  in  a  hospital  at  Bruges.  When  Fliedner  saw 
the  delicate  girl  he  said,  "You  say  you  want  to  be  a  nurse,  why  you  cannot 
do  the  work  which  needs  to  be  done, — you  cannot  scrub  floors."  She  said, 
"I  can,"  and  she  did;  and  afterwards  she  told  me  it  was  a  very  dirty  floor, 
too. 

On  a  visit  to  Kaiserswerth  I  saw  an  old  nurse  counting  the  linen  as  it 
came  from  the  laundry,  and  behind  her  was  a  young  nurse,  also  checking 
it.  When  I  asked  the  young  nurse  what  she  was  doing  there  she  said,  "I 
am  counting  the  linen  too  because  she  can  no  longer  count  accurately  but 
she  is  not  aware  of  it."  That  was  a  beautiful  service,  and  at  80  years  of 
age  you  may  wish  it  were  being  done  for  you.  I  hope  the  young  nurse  in 
the  future  will  give  as  loving  care  as  that  old  nurse  received  whose  work 
was  nearly  done.  I  believe  that  suitable  occupation  should  be  found  for 
our  old  nurses,  for  I  believe  no  greater  blessing  can  be  bestowed  upon  all 
whose  ability  to  work  is  ebbing  away  than  by  giving  them  something  to 
do.  At  Bielefield  in  Germany  I  was  much  impressed  by  finding  that  every- 
one there  seemed  to  be  doing  something  for  some  one  else.  A  young  girl 
during  the  last  hours  of  her  life  was  holding  the  hand  of  a  little  helpless 
child  strapped  to  a  frame,  whose  querulous  complaints  no  other  hand  could 
still.  That  dying  girl  was  comforted  by  the  privilege  of  doing  something 
for  some  one  else. 

Well,  I  must  not  take  your  whole  evening.  I  warned  Doctor  Emerson 
if  he  once  let  me  stand  up  before  you  young  lovely  nurses  that  I  would 
never  stop  talking. 

However,  I  want  to  say  that  the  fine  quality  of  Florence  Nightingale's 
service,  of  Linda  Richard's  service  and  that  of  those  nurses  in  Kaisers- 
werth consisted  in  this,  that  in  addition  to  their  desire  to  serve  they 
added  technical  training  without  which  their  good  intentions  would  have 
been  of  far  less  value.  It  was  Ruskin  from  whom  I  first  learned  this 
splendid  truth,  that  an  art  requires  the  equal  exercise  of  the  head  and  the 


87 
hand  and  the  heart.  No  matter  how  much  a  nurse  knows,  no  matter  how 
well  she  has  stood  in  her  studies  and  examinations  she  is  not  good  for 
much  without  technical  training,  so  that  without  having  to  think  what  she 
is  doing  she  gives  the  right  touch  everytime.  But  the  Lord  preserve  us 
from  the  nurse  who  has  only  intelligence  and  technique!  The  old  fash- 
ioned nurse  who  knew  nothing,  and  whose  hands  dropped  everything  she 
touched,  would  be  far  better  for  any  of  us  in  extremity  than  the  highest 
trained  nurse  whose  training  has  been  one  of  the  head  and  hand  but  not 
of  the  heart.  It  has  been  charged  against  modern  nursing,  and  I  am 
afraid  with  some  justice,  that  modern  training  has  not  paid  sufficient  at- 
tention to  the  education  of  the  heart.  It  may  be  because  it  is  taken  for 
granted  that  any  woman  may  become  a  good  nurse,  inasmuch  as  she  has 
been  fitted  by  our  Creator  to  take  care  of  helpless  humanity,  and,  of  course, 
there  is  some  truth  in  that,  for  it  is  a  pretty  safe  venture  that  any  woman 
can  be  trained  to  give  loving  service.  But  sometimes  the  impulses  to  give 
loving  service  instead  of  being  followed  are  neglected  for  the  time  being 
as  there  is  so  much  to  do, — so  much  need  of  this  and  that  and  the  other, 
that  impulses  to  speak  lovingly,  to  look  lovingly,  to  touch  lovingly,  are  set 
aside  for  that  which,  for  the  time  being,  is  thought  to  be  of  more  impor- 
tance. Sometimes  the  young  nurse  hesitates  to  treat  her  patients  with  the 
loving  care  she  really  feels  from  the  mistaken  feeling  of  modesty  or  re- 
luctance to  let  her  feelings  be  seen.  Now  that  comes  from  the  common 
mistake  we  are  under  every  day  of  our  lives  of  thinking  that  our  love  is 
our  own.  God  is  love  is  a  common  expression.  It  is  just  as  true  to  say 
that  love  is  God,  streaming  down,  trying  to  find  expression  through  us; 
and  no  nurse  should  be  in  the  least  shy  or  reluctant  to  allow  the  love  of 
God  to  stream  through  her.  I  feel  that  you  must  realize  what  I  say  is 
true.  You  may  find  it  difficult  to  be  loving  to  a  patient  who  is  irritable 
and  repulsive,  but  suppose  you  try  the  experiment  of  treating  such  a  pa- 
tient lovingly  as  if  he  were  your  nearest  and  dearest.  Of  course,  it  re- 
quires the  exercise  of  your  will  to  do  this;  but  let  love  stream  through 
you  and  then  you  will  find  a  miracle  performed,  for  your  patient  will  be- 
come a  different  person.  Think  of  your  patient  and  give  the  care  you 
would  give  to  a  sister  or  brother,  for  we  are  all  children  of  the  same  lov- 
ing Father. 

ORGANIZING  A  TOXIN-ANTITOXIN  CAMPAIGN 

By  A.  A.  Robertson, 
Agent,  Health  Department,  Quincy,  Mass. 

During  a  diphtheria  prevention  campaign  commencing  April  22  and 
continuing  for  six  weeks,  the  three  toxin-antitoxin  immunization  treat- 
ments were  given  to  2725  children  at  clinics  conducted  by  the  Quincy 
Health  Department.    Of  this  number,  995  were  children  of  preschool  age. 

The  procedure  of  conducting  clinics  and  the  methods  adopted  in  selling 
the  idea  of  toxin-antitoxin  immunization  to  the  parents  of  Quincy  may 
be  of  interest. 

During  the  first  part  of  April  talks  on  diphtheria  prevention  were  given 
before  twenty-two  organizations,  mostly  women's  clubs.  Four  of  these 
talks  were  given  in  Italian  by  a  young  woman  who  volunteered  her  ser- 
vices. 

A  circular  explaining  toxin-antitoxin  was  prepared  and  mimeographed. 
Several  thousand  of  these  were  distributed  by  the  Metropolitan  and  John 
Hancock  agents,  by  the  visiting  nurses  of  the  Quincy  Women's  Club  and 
at  Health  Department  clinics.  To  this  circular  was  appended  a  request 
slip  and  several  hundred  parents  signed  these  and  returned  them  to  the 
department. 

Motion  pictures  furnished  by  the  Metropolitan  and  John  Hancock  were 
shown  at  every  performance  for  a  week  at  two  local  theatres.  There  was 
no  charge  for  these  showings. 


88 

Excellent  publicity  was  secured  through  the  two  local  newspapers,  in- 
cluding three  or  four  articles  a  week,  several  editorials  and  finally  an  ar- 
ticle of  about  three-quarters  of  a  page  on  the  Saturday  evening  before 
the  preschool  clinics  were  started.  During  the  campaign,  news  stories 
appeared  daily. 

A  list  of  names  of  all  Quincy  babies  born  between  January  1,  1925  and 
October  31,  1928  was  prepared,  each  name  being  entered  on  a  separate 
card.  To  these  children,  over  4700  of  them,  was  mailed  a  circular  mimeo- 
graphed letter  telling  the  story  of  T-A,  the  results  already  obtained  in 
Quincy  and  the  plans  of  the  Health  Department  for  the  campaign.  A  care- 
ful check  was  made  to  eliminate  the  names  of  those  who  had  died  or  who 
had  been  previously  immunized.  Past  experience  has  shown  us  that  bet- 
ter results  are  obtained  by  appealing  to  the  parents  through  the  child 
rather  than  directly  to  the  parent. 

Every  child  in  the  first  three  grades  of  the  public  schools  was  given  a 
mimeographed  letter  containing  information  about  the  school  clinics.  To 
this  letter  was  appended  a  request  slip,  which  slip  was  returned  directly 
to  the  school.  A  space  was  provided  for  a  notation  in  any  case  where  the 
child  had  been  previously  immunized.  Over  150  children,  of  whom  the 
Health  Department  had  no  record,  returned  their  slips  with  such  notations. 

The  squad  conducting  a  clinic  consisted  of  one  physician,  two  nurses 
and  sometimes  a  clerk.  One  of  the  nurses  painted  the  site  of  the  injection 
with  mercurochrome  and  the  other  assisted  the  physician  and  after  the 
injection  was  given,  swabbed  the  arm  with  a  70  per  cent  solution  of  al- 
cohol. 10  c.c.  Luer  syringes  and  platinum  needles  were  used,  the  needle 
being  flamed  in  an  alcohol  lamp  and  dipped  in  a  70  per  cent  solution  of 
alcohol  between  injections.  It  has  been  our  experience  that  the  use  of 
platinum  needles  is  safer,  speedier  and  more  economical  than  the  use  of 
steel  needles.-  A  23  gauge,  one  inch  needle  was  found  to  be  the  most  satis- 
factory. 

The  clinics  in  the  schools  were  started  on  April  22  and  continued  for 
three  weeks.  The  clinics  for  preschool  children  of  which  there  were  ten 
a  week,  were  started  two  weeks  later  on  May  6.  It  was  originally  planned 
to  conduct  these  clinics  for  a  period  of  three  weeks.  Because  so  many 
children  started  the  treatments  during  the  second  week  it  was  found  nec- 
essary to  extend  these  clinics  for  the  fourth  week.  Those  children  who 
started  but  did  not  complete  their  treatments  at  the  school  clinics  were 
given  the  opportunity  to  finish  at  the  preschool  clinics. 

Of  the  1067  preschool  children  who  started,  995  completed  the  course  of 
treatments.  Less  than  75  school  children  who  started  the  treatments 
failed  to  complete  them. 

The  cost  of  the  entire  campaign  was  $704.11  divided  as  follows: — Ser- 
vices for  physicians,  $480.00;  Mimeographing  and  mailing  $129.75;  Sup- 
plies $94.39. 

The  cost  of  immunizing  one  child  was  26  cents.  Previous  to  1927,  when 
diphtheria  immunization  work  was  first  begun  in  Quincy,  approximately 
thirty-five  cases  of  diphtheria  were  hospitalized  annually  at  an  average 
cost  per  case  of  $51.  On  this  basis,  sixty-eight  hundred  children  can  be 
protected  against  diphtheria  for  what  it  would  cost  for  diphtheria  hos- 
pitalization for  only  one  year.  This  is  a  striking  example  of  the  fact  that 
public  health  work  pays  in  dollars  and  cents  beyond  what  it  accomplishes 
in  the  saving  of  life  and  the  alleviation  of  suffering  which  cannot  be  meas- 
ured in  terms  of  money. 

At  the  present  time  we  have  records  of  5971  children  in  the  elementary 
grade  schools  who  have  been  immunized,  representing  54  per  cent  of  the 
population  of  that  group.  The  number  of  preschool  children  who  have  had 
the  toxin-antitoxin  treatments  and  of  which  we  have  records  is  1837. 
This  represents  30  per  cent  of  the  estimated  preschool  population. 

The  diptheria  morbidity  rate  has  been  steadily  dropping.  Last  year 
the  rate  was  2.8  per  10,000  population,  the  lowest  rate  in  the  history  of  the 
city.     The  rate  this  year  is  even  lower.     Only  five  cases  were  reported 


89 
during  the  first  seven  months  of  1929  as  compared  with  sixteen  cases  dur- 
ing the  corresponding  period  in  1928  and  median  endemic  index  of  forty- 
four. 

Since  June  24,  1928,  a  period  of  over  thirteen  months,  diphtheria  has 
not  claimed  the  life  of  a  Quincy  boy  or  girl.  Never  before  has  Quincy 
gone  for  an  entire  year  without  at  least  one,  and  usually  four  or  five, 
deaths  from  diphtheria. 

We  are  more  convinced  than  ever  that  diphtheria  can  be  banished.  Has 
not  the  time  arrived  when  every  case  of  diphtheria  in  any  community  will 
not  only  be  considered  an  indictment  against  the  intelligence  of  the  par- 
ents and  the  community  but  also  against  the  efficiency  of  the  health  de- 
partment ? 

DIPHTHERIA  STATISTICS  FOR  MASSACHUSETTS 

By  Edward  A.  Lane,  M.D., 
Assistant  Director,  Division  of  Communicable  Diseases 

The  following  tables  were  compiled  to  discover  how  the  diphtheria  mor- 
tality and  morbidity  have  been  distributed  over  the  State  by  divisions  or 
sections  and  among  the  larger  cities  during  recent  years. 

In  Table  I,  the  relatively  high  case  fatality  rates  in  the  Connecticut 
Valley  and  East  Central  (Worcester  County)  divisions  are  of  some  in- 
terest. 

Table  II  shows  the  relatively  wide  variation  in  diphtheria  mortality  and 
morbidity  experience  among  cities  of  25,000  population  and  over  for  the 
ten-year  period  1916-1925. 

Table  III  gives  the  diphtheria  mortality  rates  for  each  of  the  same 
group  of  cities  by  years  for  the  fifteen-year  interval,  1911-1925. 

It  was  thought  that  these  figures  might  be  of  some  general  interest 
especially  to  the  boards  of  health  of  the  given  cities. 


TABLE  1  — Diphtheria 
Massachusetts  —  by  Diiisions* 
1921-1925 


Fatality 

Division 

Population 

Deaths 

Death  Rate 

Cases 

Case  Rate 

Per 

Cases  per 

per  100,000 

per  100,000 

cent. 

Death 

Berkshire 1 

592,522 

51 

8.6 

839 

142 

6.1 

16 

Connecticut  Valley2  . 

2,204,761 

330 

15.0 

3,246 

148 

10.1 

10 

East  Central3    . 

2,375,707 

291 

12.3 

3,212 

135 

9.1 

11 

Northeasternf  4 

6,644,240 

845 

12.7 

12,970 

195 

6.5 

15 

Southeastern5    . 

3,870,136 

365 

9.2 

5,897 

152 

6.0 

17 

The  Cape6 

182,361 

13 

7.1 

224 

123 

5.8 

17 

State  (exclusive  of  Boston) 

15,869,727 

1,885 

11.9 

26,388 

166 

7.2 

14 

Boston 

3,845,507 

767 

19.9 

11,753 

303 

6.5 

15 

State  (entire) 

19,715,234 

2,652 

13.4 

38,141 

193 

6.9 

14 

*  The  divisions  consist  each  of  one  or  more  counties  as  follows: 

1  Berkshire — Berkshire  County. 

2  Connecticut  Valley — Franklin,  Hampden,  Hampshire  Counties. 

3  East  Central — Worcester  County. 

4  Northeastern — Essex,  Middlesex,  Suffolk  Counties. 

5  Southeastern — Norfolk,  Plymouth,  Bristol  Counties. 

6  The  Cape — Barnstable,  Nantucket,  Dukes  Counties. 
t  Exclusive  of  Boston. 


90 


TABLE  II  —  Diphtheria— 1916-1925 
Massachusetts  Cities  of  25,000  Population  and  Over  in  1920 


No. 

Fa 

TALITT 

Cities 

Cities 

Population 

Deaths 

Cases 

Death  Rate  Case  Rate 

Per 

Cases  per 

(by  Divisions) 

in  Div. 

per  100,000 

per  100,000 

cent 

Death 

Berkshire 

1 

431,531 

51 

678 

11.8 

157 

7.5 

13 

Pittsfield  . 

431,531 

51 

678 

11.8 

157 

7.5 

13 

Connecticut  Valley         3 

2,268,801 

455 

3,719 

20.0 

164 

12.2 

8 

Chicopee  . 

371,344 

91 

744 

24.5 

200 

12.2 

8 

Holyoke    . 

603,507 

113 

997 

18.7 

165 

11.3 

9 

Springfield 

1,293,950 

251 

1,978 

19.4 

153 

12.7 

8 

East  Central 

2 

2,223,345 

384 

4,593 

17.3 

206 

8.4 

12 

Fitchburg 

416,814 

99 

1,004 

23.8 

242 

9.9 

10 

Worcester 

1,806,531 

285 

3,589 

15.8 

199 

7.9 

13 

Northeastern 

17 

17,414,419 

3,324 

48,100 

19.1 

276 

6.9 

14 

Boston 

7,584,401 

1,775 

23,726 

23.4 

313 

7.5 

13 

Brookline* 

387,222 

11 

2,886 

2.8 

747 

0.38 

262 

Cambridge 

1,129,676 

101 

2,842 

8.9 

252 

3.5 

28 

Chelsea 

446,264 

46 

896 

10.3 

201 

5.1 

19 

Everett     . 

403,841 

56 

1,309 

13.9 

325 

4.3 

23 

Haverhill 

515,428 

97 

1,660 

18.8 

322 

5.8 

17 

Lawrence 

933,397 

203 

1,616 

21.8 

173 

12.5 

8 

Lowell 

1,111,109 

217 

2,292 

19.5 

206 

9.5 

11 

Lynn 

999,324 

170 

2,283 

17.0 

228 

7.5 

13 

Maiden 

499,900 

149 

1,461 

29.8 

293 

10.2 

10 

Medford 

439,716 

30 

649 

6.8 

148 

4.6 

22 

Newton 

479,416 

59 

711 

12.3 

149 

8.3 

12 

Quincy 

508,397 

32 

1,125 

6.3 

222 

2.8 

35 

Revere 

297,246 

25 

916 

8.4 

308 

2.7 

37 

Salem 

417,300 

99 

1,090 

23.7 

261 

9.1 

11 

Somerville 

940,778 

188 

1,929 

20.0 

205 

9.7 

10 

Waltham 

321,004 

66 

709 

20.5 

221 

9.3 

11 

Southeastern 

4 

3,457,779 

543 

5,714 

15.7 

165 

9.5 

11 

Brockton 

652,733 

54 

1,614 

8.3 

248 

3.3 

30 

Fall  River 

1,241,269 

278 

2,146 

22.4 

173 

13.0 

8 

New  Bedford 

1,186,798 

184 

1,665 

15.5 

140 

11.1 

9 

Taunton   . 

376,979 

27 

289 

7.2 

77 

9.3 

11 

Total 

27 

25,795,875 

4,757 

62,804 

18.5 

244 

7.6 

13 

*  Town. 


TABLE  III 

Mortality  from  Diphtheria,  Massachusetts  Cities,  1911-1926,  per  100,000 


Cities 

1911 

1912 

1918 

1914 

1915 

1916 

1917 

1918 

1919 

1920 

1921 

1922 

1923 

1924 

1925 

Boston  . 

.    17.0 

13.8 

22.2 

23.1 

29.1 

26.0 

37.8 

30.2 

21.0 

19.8 

20.1 

20.7 

23.2 

22.9 

12.9 

Brockton 

.      8.6 

8.4 

26.6 

22.8 

20.8 

9.5 

4.7 

3.1 

12.1 

10.6 

10.6 

9.1 

3.0 

12.2 

7.7 

Brookline  (Tc 

wn)    .      6.9 

3.3 

3.2 

3.1 

11.9 

0.0 

0.0 

5.5 

2.7 

2.6 

5.2 

10.0 

2.4 

0.0 

0.0 

Cambridge 

.    38.8 

23.4 

13.0 

14.8 

26.7 

13.7 

14.6 

10.9 

4.6 

5.4 

9.8 

7.9 

9.5 

7.6 

5.8 

Chelsea 

.    11.4 

8.0 

7.6 

14.4 

2.3 

13.9 

27.7 

9.3 

11.5 

9.2 

13.5 

4.4 

4.3 

6.4 

4.2 

Chicopee 

.    18.8 

14.5 

21.0 

81.5 

29.6 

34.7 

24.2 

32.0 

22.5 

21.0 

26.4 

26.2 

15.0 

24.4 

4.7 

Everett 

.    17.4 

0.0 

2.8 

21.6 

15.9 

5.2 

30.9 

5.1 

47.6 

24.8 

7.4 

7.3 

7.3 

2.4 

2.4 

Fall  River 

.    23.1 

27.0 

25.2 

21.8 

24.9 

16.1 

30.9 

22.1 

20.6 

32.1 

1S.7 

41.7 

16.6 

14.1 

11.6 

Fitchburg 

.   41.8 

12.9 

20.5 

25.4 

70.5 

52.5 

34.7 

14.8 

24.5 

12.1 

12.0 

18.9 

23.4 

18.5 

27.4 

Haverhill 

.    13.2 

17.2 

14.7 

2.2 

26.2 

29.6 

25.2 

17.1 

26.2 

18.7 

19.1 

15.5 

9.9 

20.0 

.  6.1 

Holyoke 

.    18.9 

18.6 

45.2 

33.2 

21.4 

16.5 

33.1 

9.9 

18.3 

10.0 

11.6 

34.9 

23.2 

14.9 

14.9 

Lawrence 

.    19.5 

12.5 

11.5 

39.1 

36.5 

26.3 

14.1 

19.3 

20.2 

23.4 

20.2 

17.0 

24.5 

33.1 

19.3 

Lowell  . 

.    15.9 

14.9 

32.6 

24.1 

23.0 

41.1 

25.6 

16.2 

22.2 

17.7 

32.1 

14.3 

14.4 

9.0 

3.6 

Lynn     . 

.    14.3 

15.2 

18.2 

25.3 

23.0 

20.7 

16.4 

8.2 

30.4 

28.1 

28.9 

12.9 

8.9 

7.8 

8.7 

Maiden 

.    17.5 

10.7 

38.0 

39.4 

47.0 

22.4 

45.0 

40.8 

18.3 

40.5 

30.1 

37.7 

25.6 

23.3 

15.4 

Medford 

.    24.0 

0.0 

10.7 

23.8 

3.3 

3.1 

11.6 

19.2 

7.9 

2.5 

12.0 

7.0 

4.5 

8.6 

0.0 

New  Bedford 

.    10.0 

20.5 

32.3 

20.4 

23.4 

9.8 

13.9 

17.0 

18.3 

27.3 

22.4 

19.1 

7.5 

11.7 

7.5 

Newton    . 

.     4.9 

2.4 

2.4 

9.4 

16.1 

2.3 

20.2 

26.6 

19.6 

12.8 

20.8 

6.1 

11.8 

3.8 

1.9 

Pittsfield 

.   20.6 

29.4 

15.2 

16.7 

5.0 

22.4 

17.2 

4.9 

4.8 

0.0 

6.9 

18.1 

31.0 

6.5 

6.4 

Quincy 

.    19.6 

8.1 

20.6 

17.3 

2.4 

2.4 

2.3 

13.1 

10.5 

8.2 

5.8 

1.9 

7.1 

10.3 

1.6 

Revere 

.      5.0 

9.4 

4.4 

12.4 

19.7 

0.0 

11.1 

10.8 

14.0 

13.7 

6.7 

6.5 

12.6 

6.1 

3.0 

Salem    . 

.    30.9 

4.9 

20.2 

7.9 

8.0 

5.2 

5.0 

9.8 

40.5 

28.2 

7.0 

35.1 

51.0 

18.7 

32.7 

Somerville"^ 

.    22.6 

18.4 

14.4 

29.3 

22.9 

26.0 

30.1 

26.3 

11.9 

23.5 

29.6 

19.8 

15.5 

15.3 

4.0 

Springfield 

.      9.7 

15.8 

16.3 

10.9 

9.6 

16.4 

54.5 

25.6 

19.7 

12.2 

17.3 

17.7 

14.5 

17.8 

4.2 

Taunton 

.    17.3 

11.4 

11.3 

5.6 

5.5 

22.0 

8.2 

2.7 

2.7 

10.7 

13.2 

7.9 

2.6 

0.0 

2.5 

Waltham 

.    10.6 

17.3 

23.8 

23.5 

26.5 

19.8 

16.4 

6.5 

12.9 

35.2 

31.2 

18.3 

35.9 

26.3 

2.9 

Worcester 

.    24.7 

20.8 

23.0 

11.2 

12.8 

14.3 

23.4 

12.0 

10.1 

7.7 

15.9 

15.7 

20.3 

22.2 

15.7 

91 


Editorial  Comment 


Early  Diagnosis  of  Tuberculosis.    It  has  been  said  that  by  the  time  there 

are  physical  signs  in  the  chest  the  tu- 
berculosis is  no  longer  early.  Other  physicians  have  claimed  that  this  is 
an  extreme  and  unnecessarily  discouraging  statement.  Both  sides  would 
agree,  however,  to  the  enormous  value  of  the  tuberculin  test,  particularly 
in  children  and  young  adults,  and  chest  X-ray  in  such  early  diagnosis. 
Thus  it  behooves  us  to  see  that  our  chest  clinic  resources  in  our  commu- 
nity are  adequate  and  are  being  used.  Also,  it  should  emphasize  to  par- 
ents the  importance  of  obtaining  these  examinations  for  their  children 
when  offered  through  the  state  clinics  (the  Chadwick  Clinics)  in  their 
schools.  Such  service  is  offered  to  their  children  at  an  age  when  treat- 
ment may  be  most  effective,  more  freely  in  Massachusetts  than  in  any 
other  state  in  the  Union.  Are  the  parents  of  Massachusetts  sufficiently  in- 
terested to  use  it? 

The  Chadwick  Clinics.  After  twenty  years  of  service  to  the  children  of 
Massachusetts  Dr.  Henry  D.  Chadwick  has  left 
us  for  service  in  Detroit.  He  built  up  the  excellent  institution  for  tuber- 
culosis in  children  at  Westfield.  Through  his  work  there  he  laid  the  foun- 
dation for  the  ten  year  childhood  tuberculosis  program  in  the  schools 
throughout  the  State,  which  is  now  beginning  its  sixth  year.  Nearly  one 
hundred  thousand  children  have  been  examined.  The  rest  of  the  world 
looks  on  at  this  most  progressive  of  all  large  scale  attacks  against  this 
disease.  As  a  tribute  to  his  genius  the  Public  Health  Council  has  voted 
that  henceforth  these  shall  be  known  as  the  "Chadwick  Clinics".  It  is  our 
privilege  to  see  that  they  shall  be  the  same  credit  to  their  founder  now  he 
has  left  us  that  they  were  under  his  inspiring  direction. 

Admission  of  Children  to  State  Sanatoria.    Any  child  under  sixteen  years 

of  age  in  the  Commonwealth 
is  eligible  to  admission  to  our  State  Sanatoria  on  filing  an  application  with 
the  Department  of  Public  Health,  Room  6,  State  House,  signed  by  a  li- 
censed physician.  North  Reading  and  Westfield  State  Sanatoria,  with 
some  five  hundred  beds,  are  reserved  for  children  with  pulmonary  and 
hilum  disease.  At  the  Lakeville  State  Sanatorium  excellent  service  is 
given  children  with  bone,  joint  and  other  forms  of  non-pulmonary  tuber- 
culosis. The  charge  to  either  the  family  or  the  town  for  this  service  is 
the  ridiculously  low  figure  of  seven  dollars  a  week.  For  this  service  the 
approval  of  the  local  board  of  health  is  not  necessary,  though  of  course  de- 
sirable. 

WHAT  THE  VON  PIRQUET  TEST  IS  NOT— AND  WHAT  IT  IS! 

The  Von  Pirquet  Test  is  NOT  a  Vaccination. 

In  applying  the  test  only  the  outer  layer  of  skin  (epidermis)  is  rubbed  off; 
there  is  no  bleeding;  nothing  goes  into  the  blood  vessels  as  we  do  not  go 
deep  enough  to  reach  the  small  blood  vessels  (capillaries).  There  is  no 
"sore"  produced  on  the  arm  (at  most  a  spot  like  a  mosquito  bite),  no  fever 
or  ache  or  pain.     The  test  has  no  influence  whatever  on  the  general  health. 

The  Von  Pirquet  Test  is  NOT  an  Inoculation. 

No  needle  is  used  and  nothing  is  injected  into  the  body.  (The  test  is 
applied  by  rubbing  off  the  epidermis  with  a  flat,  blunt  point.  We  use  some- 
thing very  much  like  a  jeweller's  screwdriver;  twirling  this  a  few  times  on 
the  skin  does  all  we  wish  and  "tickles  more  than  it  scratches.")  The  test 
has  not  the  slightest  power  to  cure  or  prevent  or  cause  tuberculosis. 


92 

The  Von  Pirquet  Test,  is  NOT  used  to  Cure  or  Prevent  Disease. 

It  is  used  solely  in  helping  to  make  a  diagnosis  and  has  no  use  at  all  as  a 
treatment  or  means  of  prevention  of  disease. 

A  Positive  Von  Pirquet  Reaction  Does  NOT  Mean  There  Necessarily  is  or  has 
been  a  Tubercular  Infection. 
As  soon  as  any  germ  capable  of  producing  disease  enters  the  body,  the 
defense  forces  of  the  body  rush  to  the  defense.  White  blood  cells,  the 
"fighting  cells,"  make  a  direct  attack  to  destroy  and  wall  in  the  germs,  and 
the  "chemical  division"  begins  to  make  antibodies  to  destroy  the  disease 
germs  and  prevent  further  or  future  infections.  This  is  true  when  tubercu- 
losis germs  enter  the  body;  an  anti-tubercular  serum  is  manufactured.  The 
germ  of  tuberculosis  has  a  wax  coat  so  that  the  serum  has  little  effect  in 
destroying  the  germ  itself.  This  germ  is  a  vegetable  and  grows  like  a  mold 
on  the  top  of  certain  broths  in  our  laboratory  bottles.  When  we  put  on  the 
arm  a  little  of  the  material  on  which  the  germ  of  tuberculosis  has  grown  and 
rub  off  the  top,  hard  skin  and  let  the  serum  of  the  body  come  up  in  contact 
with  this  "broth,"  if  an  anti- tubercular  material  has  been  made  by  the  body, 
it  is  rushed  to  the  point  where  the  test  is  made  and  shows  in  a  little  elevated 
spot  like  a  mosquito  bite. 

PLEASE  NOTE  CAREFULLY.— The  material  we  use  in  the  test  con- 
tains no  germs  living  or  dead;  all  have  been  filtered  out.  Not  only  is  the 
"broth"  filtered,  but  it  has  been  boiled  till  only  half  the  original  amount 
remains.     It  is  absolutely  clear  of  all  germs. 

What  IS  the  Test:   What  is  Its  Value? 

The  test  is  simply  an  "indicator";  it  tells  whether  enough  germs  of  tuber- 
culosis have  entered  the  body  to  produce  an  anti-tubercular  serum  in  the 
body.  That  means  germs  of  tuberculosis  have  some  time  or  other  entered 
the  system.  We  want  to  know  whether  there  are  any  now  making  trouble. 
The  early  central  fighting  ground  against  tuberculosis  is  in  the  glands  at  the 
root  of  the  lungs,  not  in  the  lungs.  We  X-ray  all  positive  tests  to  see  if 
these  glands  show  that  any  fight  is  now  going  on.  If  there  is  a  fight  now 
being  made,  the  X-ray  helps  us  to  find  this  out.  With  the  gland  fight  the 
trouble  is  still  within  the  defense  lines  of  the  body.  There  is  no  chance  of 
infecting  others.  The  family  doctor,  if  he  knows  conditions,  can  treat  and 
cure  this  Gland  Tuberculosis.  The  difficulty  is  not  to  cure  but  to  find  this 
early  infection.  If  we  can  only  find  all  the  gland  type  of  tuberculosis  (in 
10%  of  the  children)  we  can  cure  them  and  prevent  80%  of  the  Lung  Tuber- 
culosis which  would  develop  inside  of  twenty  years. 

The  Von  Pirquet  Test  and  X-ray  are  simply  used  to  find  these  early 
curable  cases. 

BOOK  REVIEW 

The  Nurse  in  Public  Health — By  Mary  Beard,  R.N.,  New  York:  Harper 
&  Brothers,  1929.    211  pp.  Price,  $3.50. 

Public  health  nurses  and  directors  of  nursing  organizations  will  find 
this  book  a  helpful  and  interesting  treatise  on  the  subject.  It  covers  the 
history  and  progress  of  public  health  nursing  from  the  beginning. 

In  the  first  chapter  the  author  brings  out  very  ably  the  change  of  em- 
phasis from  actual  bedside  nursing  to  the  present-day  idea  of  educating 
the  family  in  the  care  of  the  sick  in  the  home  and  in  health  habits  in  gen- 
eral. The  nurse's  responsibility  toward  each  individual  in  the  family  is 
stressed  and  Miss  Beard's  suggestion  that  the  nurse  time  her  visits  so 
that  each  individual  will  be  reached  is  a  good  one. 

In  the  chapter  on  the  rural  community  nurse  great  stress  is  laid  upon 
the  fact  that  the  rural  nurse  needs  thorough  preparation  in  the  public 
health  field,  to  cope  with  the  isolation  and  lack  of  facilities  to  be  found  in 
rural  communities.  Another  good  point  in  this  chapter  is  the  fact  that 
rural  nurses  gain  much  from  visiting  other  communities  to  see  how  they 
carry  on  their  work,  as  much  benefit  is  derived  from  the  experiences  of 
others  in  similar  fields. 


93 

Miss  Beard  emphasizes  the  fact  that  the  education  of  the  public  health 
nurse  is  of  vital  importance.  She  calls  attention  to  the  fact  that  training 
schools  for  nurses  up  to  the  present  time  have  not  included  in  their  cur- 
riculum the  type  of  education  that  fits  a  nurse  for  public  health  work, 
which  involves  the  consideration  of  the  whole  field  of  nursing  education. 

The  point  is  well  brought  out  in  the  chapter  on  public  health  nursing 
administration  that  it  is  realized  today  that  publicity  of  the  right  kind  is 
the  keynote  to  the  success  of  any  undertaking,  and  publicity  for  public 
health  nursing  should  begin  with  the  boards  of  directors  of  public  health 
nursing  organizations. 

While  the  author  points  out  the  value  of  antitoxin  in  the  treatment  of 
diphtheria,  a  splendid  opportunity  was  lost  for  bringing  to  the  fore,  in 
the  very  beginning  of  the  book,  the  necessity  for  early  immunization  of 
the  young  child  against  diphtheria. 

The  chapter  on  Public  Health  Nursing  in  Europe  is  of  interest. 

SEDGWICK  MEDAL  AWARD 

The  American  Public  Health  Association  announces  that  the  first  award 
of  the  Sedgwick  Memorial  Medal  will  be  considered  in  1929.  This  award 
was  established  in  honor  of  the  late  Professor  William  Thompson  Sedg- 
wick, a  former  President  of  the  American  Public  Health  Association. 
The  fund  which  provides  the  medal  was  raised  by  popular  subscription 
from  Professor  Sedgwick's  former  students  and  friends.  It  is  to  be 
awarded  for  distinguished  service  in  public  health. 

Except  for  the  fact  that  it  is  limited  to  the  recognition  of  service  in  the 
field  of  public  health  there  is  no  restriction  as  to  the  special  line  of  ser- 
vice that  will  be  considered.  Administration,  research,  education,  tech- 
nical service  and  all  other  specialties  in  the  public  health  profession  will 
receive  equal  consideration.  No  limitations  as  to  age,  sex  or  residence 
have  been  fixed,  though  only  candidates  who  are  nationals  of  the  countries 
in  the  American  Public  Health  Association, — at  present,  United  States, 
Canada,  Cuba  and  Mexico  are  eligible. 

The  Committee  of  the  Association  which  has  this  matter  in  charge  is 
composed  of: — 

Mr.  Homer  N.  Calver,  Secretary;  Dr.  Charles  V.  Chapin,  Dr.  Lee  K. 
Frankel,  Prof.  E.  0.  Jordan,  Dr.  George  W.  McCoy,  Dr.  M.  P.  Ravenel, 
Dr.  M.  J.  Rosenau,  Chairman;  Mr.  Robert  Spurr  Weston. 

The  committee  will  not  consider  direct  applications  from  candidates,  but 
asks  for  nominations,  giving  the  information  suggested  in  the  accompany- 
ing form.  Nominations  should  be  addressed  to  the  Secretary,  Homer  N. 
Calver,  370  Seventh  Avenue,  New  York,  N.  Y.,  and  should  include  the  fol- 
lowing : 

Name  of  the  proposed  candidate 
Residence  address 
Business  address 
Age 

Country  of  which  the  candidate  is  a  citizen 

Degrees  held,  date  received  and  institutions  from  which  received 
Principal  public  health  positions  held 

A  brief  description  of  the  distinguished  service  performed  because  of 
which  the  candidate  is  recommended  for  consideration.  This 
should  include  information  as  to  when  and  where  the  work  was 
done,  the  name  of  the  organization  or  institution,  if  any,  under 
whose  auspices  or  in  whose  service  the  candidate  worked,  an  esti- 
mation of  the  direct  or  indirect  effect  of  the  work  measured  in 
terms  of  life-saving  or  benefit  to  humanity.  Descriptive  articles, 
reports  or  similar  data  published  or  unpublished  will  be  helpful 
to  the  committee.  To  be  considered,  the  service  must  have  been 
actually  performed  and  not  be  merely  a  plan  or  suggestion. 
Anonymous  recommendations  will  not  be  considered  and  the  committee 
reserves  the  right  to  refrain  from  making  an  award  this  year. 


94 
NEWS  NOTE 

THE  FIRST  INTERNATIONAL  CONGRESS  ON  MENTAL  HY- 
GIENE is  to  be  held  at  Washington,  D.  C,  May  5-10,  1930.  This  Con- 
gress is  being  sponsored  by  mental  hygiene  and  related  organizations  in 
more  than  twenty-six  countries. 

The  officers  are  as  follows :  Honorary  President :  Herbert  Hoover.  Pres- 
ident: Dr.  William  A.  White,  Washington,  D.  C.  Secretary-General: 
Clifford  W.  Beers.  Address — Administrative  Secretary,  John  R.  Shillady, 
370  Seventh  Avenue,  New  York  City. 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  April,  May,  and  June,  1929,  samples  were  col- 
lected in  206  cities  and  towns. 

There  were  3,700  samples  of  milk  examined,  of  which  1,014  were  below 
standard;  from  30  samples  the  cream  had  been  in  part  removed,  and  40 
samples  contained  added  water. 

There  were  136  samples  of  food  examined,  of  which  31  were  adulter- 
ated. These  consisted  of  1  sample  of  butter  which  was  low  in  fat,  and  1 
sample  sold  as  butter  which  proved  to  be  oleomargarine;  1  sample  of 
cream  which  was  below  the  legal  standard  in  fat ;  2  samples  of  eggs  which 
were  sold  as  fresh  eggs  but  were  not  fresh;  4  samples  of  maple  sugar 
adulterated  with  cane  sugar  other  than  maple ;  10  samples  of  maple  syrup 
which  contained  cane  sugar ;  2  samples  of  sausage  which  contained  a  com- 
pound of  sulphur  dioxide  not  properly  labeled;  1  sample  of  liver  which 
was  decomposed;  4  samples  of  olive  oil,  2  samples  of  which  contained  for- 
eign oil,  and  2  samples  contained  cottonseed  oil;  1  sample  of  cider  which 
contained  a  compound  of  benzoic  acid  not  properly  labeled;  2  samples  of 
clams  which  contained  added  water;  1  sample  of  tea  which  was  moldy; 
and  1  sample  of  vinegar  which  was  low  in  acid. 

There  were  43  samples  of  drugs  examined,  of  which  5  were  adulterated. 
These  consisted  of  5  samples  of  spirit  of  nitrous  ether  which  were  defi- 
cient in  the  active  ingredient. 

During  April  and  May  the  police  departments  submitted  1,037  samples 
of  liquor  for  examination,  1,021  of  which  were  above  0.5%  in  alcohol. 
The  police  departments  also  submitted  40  samples  of  narcotics,  etc.,  for 
examination,  12  of  which  were  morphine,  6  opium,  2  cocaine,  2  strychnine, 
1  ergot,  1  lead  and  arsenic,  1  denatured  alcohol,  2  sulphuric  acid,  3  hair 
tonic,  and  10  samples  which  were  examined  for  poison  with  negative  re- 
sults. 

There  were  558  bacteriological  examinations  made  of  milk. 

There  were  94  bacteriological  examinations  of  soft  shell  clams  made,  36 
samples  in  the  shell,  34  of  which  were  unpolluted,  and  2  were  polluted,  and 
58  samples  of  shucked  clams,  all  of  which  were  unpolluted;  there  were  5 
bacteriological  examinations  made  of  hard  shell  clams,  in  the  shell,  all  of 
which  were  unpolluted ;  there  were  2  bacteriological  examinations  of  mus- 
sels made,  1  of  which  was  polluted,  and  1  unpolluted;  and  there  was  1 
bacteriological  examination  of  periwinkles  made,  which  was  unpolluted. 

There  were  91  hearings  held,  21  pertaining  to  violations  of  the  Food 
and  Drug  Laws,  46  pertaining  to  violations  of  the  Pasteurizing  Laws  and 
Regulations,  23  pertaining  to  violations  of  the  Milk  Laws,  and  1  pertain- 
ing to  violation  of  the  Slaughtering  Laws. 

There  were  63  cities  and  towns  visited  for  the  inspection  of  pasteuriz- 
ing plants,  and  183  plants  were  inspected. 

There  were  43  convictions  for  violations  of  the  law,  $1,195  in  fines  being 
imposed. 

John  Bailey  of  Dracut;  Octave  Boucher  of  Easthampton;  Lemuel 
Friend  of  Gloucester;  John  Paloian  of  Watertown;  James  Reid  of  Rayn- 
ham;  Edmond  F.  Belyea  and  Albert  Turcotte  of  Acushnet;  Biltmore  Cafe- 
teria, Incorporated,  Ernest  Belides,  and  Joseph  Lazotte  of  Taunton;  Wal- 
ter Bonalewsez  of  Rehoboth;  Sarkis  Chandoian  of  Methuen;  Dwight  D. 


95 

Chickering  of  Sterling;  Joseph  Kochuski  and  Earl  L.  Young  of  South 
Hadley;  Ellen  Russell  of  Danvers;  Cosmo  Dischini  of  Wellesley;  Michael 
Roumacker  of  Montague;  and  Nicholas  Moskos  of  Framingham,  were  all 
convicted  for  violations  of  the  milk  laws.  Lemuel  Friend  of  Gloucester; 
James  Reid  of  Raynham;  and  Joseph  Lazotte  of  Taunton,  all  appealed 
their  cases. 

Economy  Grocery  Stores  Corporation  of  Chelsea;  Chaney  Randall  of 
Revere ;  Victor  Wells  of  Winthrop ;  John  Koular is  and  Isaac  Widlanski  of 
Springfield;  Thomas  Haranas  of  Framingham;  The  Massachusetts  Mo- 
hican Company  of  Roxbury;  Ideal  Lunch  and  Restaurant  Company  of 
Newburyport;  Frank  Szpala  of  Easthampton;  and  Center  Lunch,  Incor- 
porated, of  West  Roxbury,  were  all  convicted  for  violations  of  the  food 
laws.  Victor  Wells  of  Winthrop,  and  Thomas  Haranas  of  Framingham, 
appealed  their  cases. 

The  Massachusetts  Mohican  Company  and  George  Paszko  of  Holyoke; 
and  H.  L.  Dakin  Company,  Incorporated,  of  Worcester,  were  convicted  for 
false  advertising.  H.  L.  Dakin  Company,  Incorporated,  of  Worcester  ap- 
pealed their  case. 

Audet  Bakery,  Incorporated,  and  Hathaway  Baking  Company  of  Salem; 
Morehouse  Baking  Company  of  Lawrence;  Ward  Baking  Company  of 
Cambridge;  General  Baking  Company  of  Charlestown;  and  Hathaway 
Bakeries,  Incorporated,  of  Springfield,  were  all  convicted  for  violations  of 
the  bakery  laws.    All  of  these  people  appealed  their  cases. 

Stephen  Wawrzyk  of  Wilbraham  was  convicted  for  violation  of  the 
slaughtering  laws. 

Max  Bookless  of  Pittsfield;  Edson  A.  Porter  of  Reading;  and  Producers 
Dairy  Company  of  Brockton,  were  all  convicted  for  violations  of  the  pas- 
teurizing laws. 

James  Reid  of  Raynham  was  convicted  for  obstruction  of  an  inspector. 
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  samples, 
by  Samuel  W.  Young  of  South  Hadley  Centre ;  2  samples  each,  by  Dwight 
D.  Chickering  of  Lancaster,  and  Joseph  Kockuski  of  South  Hadley  Centre. 

Milk  which  had  the  cream  removed  was  produced  as  follows :  2  samples, 
by  Sarkis  Chaudorian  of  Methuen;  and  1  sample  each,  by  Krikor  Daniel- 
ian  of  Methuen;  H.  P.  Goff  of  North  Dighton;  and  H.  S.  Weston  of  Deer- 
field. 

One  sample  of  cider  which  contained  a  compound  of  benzoic  acid  not 
properly  labeled  was  obtained  from  Uphams  Corner  Market  of  Dorchester. 

Eggs  which  were  sold  as  fresh  eggs  but  were  not  fresh  were  obtained 
as  follows: 

1  sample  each,  from  National  Cash  Market,  and  Mohican  Market,  both 
of  Holyoke. 

Maple  sugar  adulterated  with  cane  sugar  other  than  maple  was  obtained 
as  follows: 

1  sample  each,  from  Adamo  Avanucci  of  Holyoke,  and  Nicholas  Farnaro 
of  Fitchburg. 

Maple  syrup  which  contained  cane  sugar  was  obtained  as  follows:  2 
samples,  from  Imperial  Lunch  of  Mattapan;  and  1  sample  each,  from 
Jack  Melnick  of  Springfield;  Ernest  Halidas  of  Taunton;  George  Gregor 
of  Braintree;  Astoria  Cafeteria,  Incorporated,  of  Boston;  and  Beckmann 
of  Holyoke. 

One  sample  of  olive  oil  which  contained  foreign  oil  was  obtained  from 
Salim  Davis  of  Springfield. 

One  sample  of  tea  which  was  mouldy  was  obtained  from  Eagle  Grocery 
Company  of  North  Adams. 

There  were  ten  confiscations,  consisting  of  40  pounds  of  decomposed 
fowl;  74  pounds  of  sour  pork  livers;  100  pounds  of  decomposed  pork  loins; 


96 

7  pounds  of  decomposed  beef  livers ;  2  pounds  of  decomposed  calves'  livers ; 
30  pounds  of  decomposed  veal ;  49  pounds  of  decomposed  fillet  of  flounders ; 
300  pounds  of  decomposed  mackerel;  900  pounds  of  decomposed  mackerel; 
and  215  cans  of  decomposed  onions. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  March,  1929: — 327,120 
dozens  of  case  eggs;  504,665  pounds  of  broken  out  eggs;  306,685  pounds 
of  butter;  836,748%  pounds  of  poultry;  4,616,485  pounds  of  fresh  meat 
and  fresh  meat  products;  and  2,401,511%  pounds  of  fresh  food  fish. 

There  was  on  hand  April  1,  1929: — 218,640  dozens  of  case  eggs;  463,458 
pounds  of  broken  out  eggs;  760,422  pounds  of  butter,  5,602,988  pounds  of 
poultry;  18,204, 456%  pounds  of  fresh  meat  and  fresh  meat  products;  and 
6,089,070  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  April,  1929 : — 5,083,950  dozens 
of  case  eggs ;  892,909  pounds  of  broken  out  eggs ;  467,977  pounds  of  but- 
ter; 904,344  pounds  of  poultry;  3,499,800 %  pounds  of  fresh  meat  and 
fresh  meat  products;  and  3,127,072  pounds  of  fresh  food  fish. 

There  was  on  hand  May  1,  1929: — 5,185,020  dozens  of  case  eggs; 
769,429  pounds  of  broken  out  eggs;  328,843  pounds  of  butter;  4,602,057% 
pounds  of  poultry;  16,593, 281%  pounds  of  fresh  meat  and  fresh  meat 
products ;  and  6,492,829  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  May,  1929 : — 3,754,500  dozens 
of  case  eggs;  1,506,103  pounds  of  broken  out  eggs;  2,099,928  pounds  of 
butter;  908,880  pounds  of  poultry;  4,243,074%  pounds  of  fresh  meat  and 
fresh  meat  products;  and  5,915,321  pounds  of  fresh  food  fish. 

There  was  on  hand  June  1,  1929: — 8,482,620  dozens  of  case  eggs; 
1,763,428  pounds  of  broken  out  eggs;  1,785,486  pounds  of  butter;  3,852,- 
863%  pounds  of  poultry;  14,844,537*4  pounds  of  fresh  meat  and  fresh 
meat  products;  and  10,715,018  pounds  of  fresh  food  fish. 


97 


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 

Divison  of  Water  and  Sewage  Lab- 
oratories . 
Division  of  Biologic  Laboratories 

Divison  of  Food  and  Drugs 

Division  of  Child  Hygiene  . 
Divison  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  op  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
5M.     8-'29.     Order   6501. 


JON    8  10  t, 


«W  HOUSE,  BOSTON 
THE 

COMMONHEALTH 

Volume  16  ^*         Oct. -Nov. -Dec. 

No.  4  S^  1929 


Adult  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 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

What  is  Adult  Hygiene  and  Why?  by  George  H.  Bigelow,  M.D.      .  101 
The  Chronic  Disease  Problem  in  Massachusetts,  by  Herbert  L. 

Lombard,  M.D 103 

Health  Examinations,  by  Roger  I.  Lee,  M.D.         ....  108 

Chronic  Disease  and  the  Public  Welfare,  by  Richard  K.  Conant  111 
The  Cost  of  Preventable  Disease  in  Massachusetts,  by  Louis  I. 

Dublin,   Ph.D 115 

Health  Education  for  the  Adult,  by  Mary  R.  Lakeman,  M.D.  121 

Chronic  Disease  in  Industry,  by  Wade  Wright,  M.D.   .  125 

Nursing  the  Chronic  Patient,  by  Elizabeth  Ross,  R.N.  .  128 

The  Social  Worker  in  Adult  Hygiene,  by  Eleanor  E.  Kelly  .  129 

Proper  Use  of  Resources  for  the  Chronic  Sick,  by  Ida  M.  Cannon  133 
Cancer  Studies  in  Massachusetts,  No.  4. — Why  Do  People  Delay? 

by  Herbert  L.  Lombard,  M.D.  and  Mary  P.  Cronin  .  137 

Control  of  Diseases  of  Adult  Life,  by  W.  A.  Evans,  M.  D.       .  141 
What  the  Average  Adult  Should  Know  About  the  Prevention  of 

Arthritis,  by  Robert  B.  Osgood,  M.D 141 

The  Control  of  Cancer,  by  Robert  B.  Greenough,  M.D.  142 
What  the  Citizen  Should  Know  About  Asthma,  by  Francis  M. 

Rackemann,  M.D. 143 

Control  Measures  in  Diabetes,  by  Elliot  P.  Joslin,  M.D.  144 

Control  Measures  in  Heart  Disease,  by  William  H.  Robey,  M.D.    .  145 

Varicose  Veins,  by  John  Homans,  M.D.                  ....  146 

The  Business  Man,  by  Robert  W.  Buck,  M.D 147 

Exercise  as  a  Health  Agency,  by  Carl  R.  Schrader  147 
The  Health  of  the  Teacher,  by  Fredrika  Moore,  M.D.                       .148 

Work  as  an  Aid  to  Health,  by  Ida  S.  Harrington  149 

Food  for  the  Old,  by  Esther  V.  Erickson 150 

The  Dentist  and  Adult  Hygiene,  by  Eleanor  G.  McCarthy   .  150 

Hygiene  of  the  Industrial  Worker,  by  Derric  Parmenter,  M.D.     .  151 
Editorial  Comment: 

When  is  an  Adult?      .                    .                             ...  154 

The  Massachusetts  Cancer  Campaign  to  Date  154 

The  New  England  Health  Institute       .....  155 
The  Return  to  School  of  Children   (1)   After  Absence  with 

Communicable  Disease,  (2)  After  Absence  as  Contacts  .  155 
News: 

Reading  Matter  Available  for  Distribution  from  the  Massa- 
chusetts Department  of  Public  Health   ....  156 
First  International  Congress  on  Mental  Hygiene  .                    .  159 
Report  of  Division  of  Food  and  Drugs,  July,  August,  and  Septem- 
ber, 1929 ...  159 

Index                                       163 


101 
WHAT  IS  ADULT  HYGIENE  AND  WHY? 

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

Adult  Hygiene  is  quite  obviously  hygiene  of  the  adult.  We  are  all  fa- 
miliar with  maternal  and  infant,  preschool,  school,  college  and  industrial 
hygiene,  each  more  or  less  dealing  with  a  particular  age  group.  Then 
there  are  the  hygienes  dealing  with  particular  systems  of  the  body  such 
as  mental  and  dental  hygiene,  and  we  talk  of  hygiene  of  the  sputum  in 
tuberculosis,  hygiene  of  nutrition,  intestinal  hygiene,  the  hygiene  of  fresh 
air,  exercise,  work,  play,  rest  and  the  like,  which  are  included  under  the 
excellent  term  "health  habits."  Then  there  is  the  familiar  term  social 
hygiene  which  was  first  conjured  up  to  spare  our  delicate  feelings  and  in- 
cluded educational  work  directed  toward  the  control  of  gonorrhea  and 
syphilis.  This  has  expanded  to  include  education  toward  a  normal,  whole- 
some, honest  attitude  regarding  sex.  It  seems  to  me  a  thoroughly  illogical 
limitation  to  put  on  the  word  "social,"  and  in  some  places  this  is  being 
recognized.  But  anyway  it  is  clear  that  there  are  a  lot  of  hygienes,  and 
hygiene  is  the  fashion  of  the  day.  Dr.  Vincent  once  said  that  although  he 
had  not  read  the  afternoon  papers  the  last  time  he  counted  there  were  six- 
teen kinds  of  hygiene. 

In  creating  recently  within  the  State  Department  of  Public  Health  a 
Division  of  Adult  Hygiene  we  may  be  suspected  of  trying  to  make  two 
hygienes  grow  where  one  had  grown  before.  Previously  we  had  a  division 
of  Hygiene,  the  work  of  which  was  developed  and  grew  so  markedly  for 
ten  years  under  the  direction  of  Dr.  Champion.  About  a  year  ago  he  left 
us.  Dr.  Diez  took  his  place,  and  we  have  now  rechristened  her  division 
that  of  Child  Hygiene  which  for  ninety-nine  per  cent  of  its  activity  it  has 
been  all  these  years.  The  new  Division  of  Adult  Hygiene,  then,  means  not 
so  much  the  taking  over  of  activities  done  elsewhere  in  the  Department  as 
the  blazing  of  a  new  trail  of  activities  for  a  state  health  department. 

But  why  in  the  year  1929  this  new  division?  Are  there  not  enough 
things  already  inadequately  covered  by  existing  divisions  rather  than 
grasping  for  the  moon  with  a  new  one?  For  it  is  true  with  both  official 
and  unofficial  organizations  that  there  is  the  danger  of  expanding  the  ac- 
tivities say  twenty  per  cent  and  increasing  the  budget  only  five  per  cent. 
The  new  activity,  being  the  Cinderella,  usually  gets  all  it  reasonably  needs 
and  the  pinch  is  unevenly  spread  over  the  other  members  of  the  family. 
This  is  a  recognized  danger  that  we  must  guard  against. 

But  however  far  you  may  be  removed  from  the  fields  of  medicine,  pub- 
lic health,  nursing,  medical  social  work,  or  government,  you  must  have 
noticed  in  your  newspapers  and  in  talking  with  your  friends,  relatives  and 
acquaintances  that  the  problem  of  adult  chronic  disease  is  being  more  and 
more  brought  home  to  all  of  us.  That  is  because  in  those  parts  of  the 
country  that  have  been  settled  the  longest,  such  as  Massachusetts,  and  are 
therefore  furthest  removed  from  pioneer  conditions,  a  large  proportion  of 
our  population  is  in  the  age  group  which  is  subject  to  these  chronic 
diseases.  If  in  a  population  of  four  million  and  a  quarter  people  one  per- 
son dies  each  year  of  one  of  these  diseases  we  hear  nothing  of  it  unless  he 
happens  to  have  won  a  bunion  marathon  or  to  have  been  a  movie  star.  But 
if  one  hundred  thousand  people  should  die  of  the  same  disease  in  the  same 
year  it  would  bring  it  home  to  so  many  of  us  that  we  would  hear  of  nothing 
else.  So  with  the  average  age  of  our  population  pretty  old  now,  and  with 
it  growing  steadily  older  as  a  result  of  restriction  of  immigration,  falling 
birth  and  death  rates  and  the  like,  we  are  rapidly  getting  to,  if  we  have 
not  already  reached,  the  time  when  people  will  insist  on  talking  little  else 
than  chronic  adult  disease. 

Then  there  is  another  side  of  the  matter  which  is  quite  important. 
Disease  prevention  has  received  pretty  general  approval  and  the  keepers 
of  the  public  health  must  watch  out  lest  they  be  found  lacking  in  their 


102 
zeal  to  remove  this  scourge  of  public  disease.  The  successes  of  organized 
effort  against  typhoid  fever,  malaria,  hookworm,  yellow  fever  and  typhus 
fever  have  been  reiterated  in  every  key  that  the  ear  can  endure  and  a  few 
besides.  The  modern  miracles  of  insulin  in  diabetes  and  liver  in  pernicious 
anemia  have  not  only  granted  extension  of  life  and  surcease  from  pain  for 
the  sufferers  from  these  diseases,  but  have  also  quadrupled  the  cost  of  ani- 
mal abdominal  organs  which  must  give  dividends  to  somebody.  Thus  pre- 
vention is  demanded,  and  in  such  demands  the  public  does  not  make  fine 
distinctions.  The  mere  plea  of  ignorance  will  not  satisfy  it.  Death  from 
one  disease  has  been  controlled,  why  shouldn't  it  be  from  another?  And 
this  constitutes  precisely  one  of  the  most  exasperating  things  about  the 
public !  It  seems  much  more  interested  and  therefore  much  more  willing 
to  give  money  to  prevent  diseases  that  we  do  not  know  how  to  prevent 
than  it  does  to  prevent  those  that  we  do.  The  man  on  the  street  will  be 
likely  to  show  more  interest  in  talking  of  the  prevention  of  infantile  pa- 
ralysis than  of  smallpox,  diphtheria  or  syphilis,  though  we  have  many 
more  cases  of  each  of  the  latter  than  the  former.  So  lack  of  complete 
knowledge  as  to  the  prevention  of  chronic  adult  disease  will  act  as  no 
check  on  the  public  demand  for  such  prevention. 

This  was  all  well  illustrated  here  in  Massachusetts  by  our  experience 
with  cancer.  My  eminent  predecessor,  Dr.  Eugene  R.  Kelley,  spent  many 
years  in  hard  thinking  on  how  cancer,  and  for  that  matter  the  other 
chronic  diseases,  might  be  effectively  handled  by  a  state  health  depart- 
ment. In  cooperation  with  the  Harvard  Cancer  Commission  he  offered  to 
all  hospitals  and  physicians  in  the  State  expert  pathological  service.  He 
cooperated  in  an  effort  to  inform  the  medical  profession  of  the  best  diag- 
nostic and  therapeutic  opinion  as  to  cancer  in  its  many  catholic  manifes- 
tations. He  advised  the  legislature,  anxious  to  provide  beds  primarily  for 
the  dying,  that  a  study  of  the  whole  situation  should  be  made  and  Organ- 
ized for  such  a  study  when  his  life  ended.  The  acute  impatience  felt  by 
some  with  the  report  and  its  counsel  of  delay  because  of  ignorance,  the 
legislation  three  years  ago  directing  hospitalization,  clinics  and  further 
studies  by  the  Department  and  what  has  been  done  since  were  all  reported 
at  length  in  the  recent  cancer  number  of  the  Commonhealth.  From  all 
this  we  may  gather  what  will  be  demanded  of  us  in  regard  to  heart  disease, 
arthritis,  the  many  chronic  neurological  conditions  of  the  ageing  and  the 
like.  To  anticipate  this  and  to  start  what  can,  in  our  present  state  of 
knowledge,  be  done  to  prevent  and  alleviate  is  the  object  of  our  Division 
of  Adult  Hygiene. 

This  number  will  outline  what  we  now  know  about  some  of  the  out- 
standing diseases  in  this  group;  will  show  how  we  are  studying  the  ex- 
tent of  and  the  resources  for  these  diseases;  and  finally,  and  far  from 
satisfactorily,  it  will  show,  from  our  experience  with  cancer  and  from  best 
opinion  elsewhere,  what  steps  we  and  other  community  agencies,  and  most 
important  of  all  the  individual  adult,  can  take  to  stay  this  rising  tide  of 
death,  suffering  and  economic  loss.  From  the  contributors  to  this  number 
it  is  evident  that  we  can,  as  in  cancer,  command  aid,  advice  and  guidance 
of  the  most  qualified  and  thoughtful  persons  in  the  various  fields.  This  is 
well,  as  we  shall  certainly  need  them  to  save  us  from  discouraged  inactiv- 
ity on  the  one  hand  and  disrupting  false  steps  on  the  other.  For  I  doubt 
if  there  is  any  more  pressing  problem  in  the  whole  field  of  medicine,  soci- 
ology and  economics  today  than  that  of  chronic  disease,  and  who  knows 
but  what  an  unwise  solution  may  threaten  eventually  the  very  foundations 
on  which  government  in  this  country  is  based. 


103 
THE   CHRONIC   DISEASE   PROBLEM   IN   MASSACHUSETTS 

Introduction  to  the  Study 
1.    Increase  of  Chronic  Disease  in  Massachusetts 

By  Herbert  L.  Lombard,  M.D. 
Director,  Division  of  Adult  Hygiene 

The  outstanding  public  health  problem  of  the  present  day  is  the  control 
of  the  chronic  diseases  of  the  middle  aged.  The  campaign  for  infant  wel- 
fare has  seen  reductions  in  the  number  of  baby  deaths.  The  crusade 
against  tuberculosis  has  been  accompanied  by  a  great  lowering  of  the 
death  rate  from  this  disease.  There  has  been  a  decline  in  other  infectious 
diseases.  With  fewer  babies  and  children  dying,  more  individuals  will 
come  into  those  age  groups  where  the  diseases  of  middle  life  are  found. 

Three  years  ago  the  Massachusetts  Department  of  Public  Health  em- 
barked on  a  cancer  campaign  to  prolong  the  lives  and  reduce  the  sufferings 
of  individuals  afflicted  with  this  disease,  as  well  as  to  prevent  its  occur- 
rence in  others.  Hospitalization,  clinics,  education,  and  research  were 
employed. 

Early  in  the  program  the  Department  was  greatly  impressed  by  the 
large  number  of  individuals  who  sought  advice  at  the  cancer  clinics  for 
conditions  other  than  cancer.  In  many  of  the  clinics  diagnosis  was  lim- 
ited to  whether  or  not  the  individual  had  cancer.  In  a  few  clinics  a  com- 
plete diagnosis  was  made,  and  from  these  clinics  we  are  able  to  obtain 
some  idea  of  the  physical  conditions  affecting  the  non-cancerous  individ- 
uals who  desired  expert  advice. 

Table  I.  —  Per  Cent  of  Diagnoses  —  1928 

Cancer  cases 22 . 2 

Pre-cancerous  lesions    6.8 

Benign  tumors 8.4 

No  diseases 4.4 

Deferred  diagnoses    8.3 

Other  conditions  (no  further  diagnoses  made  in  clinics) 30 . 6 

Other  conditions  (with  diagnoses) : 

Diseases  of  female  genitals 3.9 

Warts,  wens,  moles,  cysts,  or  skin  diseases 3.8 

Mastitis 1.6 

Gastric  or  duodenal  ulcers     1.2 

Cholecystitis 1.2 

Hemorrhoids 9 

Hernia 7 

Chronic  appendicitis 6 

Neurasthenia 5 

Other  conditions    4.8  19 . 2 

Total 99 . 9 

Among  the  "other  conditions"  with  too  few  cases  upon  which  to  base 
rates  are:  heart  lesions,  glands,  non-cancerous  mouth  lesions,  neuritis  or 
neuralgia,  varicose  veins,  angioma,  adhesions,  goiters,  ulcers,  sacro-iliac 
strains,  hyperacidity,  abscesses,  chronic  constipation,  indigestion,  infec- 
tious diarrhea,  glossodynia,  scoliosis,  arteriosclerosis,  hypertension,  mus- 
cular strain,  visceroptosis,  diabetes,  painters'  colic,  obesity,  movable  kid- 
neys, and  arthritis. 

These  figures  indicate  that  a  considerable  part  of  our  middle-aged  pop- 
ulation is  suffering  with  some  form  of  chronic  disease,  as  over  half  the 
attendance  at  a  specialized  cancer  clinic  is  composed  of  individuals  sick 
with  other  chronic  diseases. 

Method  of  Approach: 

Studies  have  been  made  to  determine  the  various  factors  connected  with 
the  chronic  disease  problem.  House-to-house  surveys  have  been  made  in 
Brockton,  Greenfield,  and  several  small  towns  on  the  social,  economic,  and 
epidemiological  aspects  of  chronic  diseases.  General  morbidity  surveys 
previously  done  by  the  Department  in  Lawrence,  Winchester,  Wayland, 
and  Shelburne-Buckland  have  furnished  additional  information. 


104 

The  literature  has  been  comprehensively  reviewed  and  records  and  ques- 
tionnaires have  been  obtained  from  hospitals,  visiting  nurse  associations, 
convalescent  homes,  welfare  organizations,  and  the  practicing  physicians 
of  the  State. 

The  death  records  over  a  period  of  years  have  been  studied. 

From  these  sources  a  series  of  studies  of  the  chronic  sick  in  Massachu- 
setts will  be  made,  the  scope  of  which  will  cover  the  following  questions : 

1.  Is  chronic  disease  on  the  increase? 

2.  What  is  the  volume  of  chronic  disease  in  Massachusetts  ? 

3.  How  is  it  being  cared  for? 

4.  Is  there  a  need  for  more  resources,  and,  if  so,  what  type? 

5.  What  economic  problems  are  connected  with  chronic  disease? 

6.  What  is  the  duration  of  chronic  disease? 

7.  What  is  the  disability  caused  by  chronic  disease? 

8.  Is  chronic  disease  evenly  distributed  throughout  Massachusetts? 

9.  What  is  the  age,  sex  distribution  of  the  diseases? 

10.  What  factor  does  heredity  play? 

11.  What  factor  does  nativity  play? 

12.  What  factor  does  occupation  play? 

13.  What  are  the  rural,  urban  aspects  of  the  diseases? 

14.  What  possible  etiological  factors  can  be  proved? 

15.  What  are  the  secondary  causes  of  death? 

16.  How  can  social  service  help  in  the  problem? 

17.  How  can  visiting  nurse  service  help  in  the  problem? 

18.  How  can  education  help  in  the  problem? 

This  paper  will  deal  with  the  increase  of  chronic  disease  in  Massachusetts 
and  subsequent  papers  will  discuss  the  other  problems. 

The  Changing  Age  Distribution: 

During  the  past  fifty  years  the  population  of  Massachusetts  has  been 
gradually  growing  older.  The  average  age  has  increased  about  three 
years  during  this  period.  Between  1870  and  1920  the  per  cent  of  the  pop- 
ulation over  the  age  of  fifty  has  increased  from  15.0  to  17.9.  There  is 
every  reason  to  believe  that  the  population  is  now  ageing  at  a  greater  rate 
than  ever  before.  Immigration  is  restricting  the  number  of  young  adults 
entering  the  country.  The  Massachusetts  birth  rate  is  falling.  Public 
health  measures  are  prolonging  the  lives  of  young  individuals.  This  age- 
ing of  the  population  of  Massachusetts  should  be  taken  into  consideration 
in  all  long-time  programs  for  the  expansion  of  the  care  of  the  aged  and 
infirm.  In  1870,  for  every  individual  in  the  old  age  group  (over  sixty), 
there  were  seven  in  the  productive  age  group  (twenty  to  sixty) .  In  1920, 
the  ratio  had  decreased  to  6.5.  With  the  population  growing  older,  the 
ratio  of  individuals  over  sixty  to  those  twenty  to  sixty  will  probably 
further  decrease  and  the  financial  burden  on  the  productive  age  group  will 
increase. 

Table  II.  —  Peb  Cent  of  Population  over  Specified  Age 

Year                           Age  SO  Age  SO  Age  40  Age  50  Age  60  Age  70 

1850 57.7  36.3  21.9  12.2                      6  2  •>  5 

I860 61.1  38.3  23.4  13.2                      66  25 

1870 59.7  40.8  26.1  15.0                      7  5  29 

1880 61.9  42.6  27.8  16.3                      8  4  3~2 

1890 64.2  42.9  27.7  16.4                      84  3*3 

1900 64.1  43.8  27.4  15.8                      80  30 

1910 64.2  45.1  28.7  16.2                      80  3  1 

1920 64.0  46.9  31.0  17.9                      s!6  3.2 

The  Changing  Death  Rate: 

The  death  rate  from  all  causes  has  been  decreasing  over  this  fifty-year 
period  from  19.2  in  1870  to  14.3  in  1920.  A  large  part  of  the  decrease  has 
been  due  to  saving  the  lives  of  infants  and  children,  and  only  a  small  part 
applies  to  the  older  age  groups.  In  the  age  group  forty  to  fifty,  the  death 
rate  has  decreased  from  11.8  to  10.0,  while  in  the  fifty  to  sixty  group  it 


105 
has  increased  from  17.1  to  18.0,  in  the  sixty  to  seventy  group  from  31.7  to 
39.0,  and  in  the  over-seventy  group  from  91.3  to  107.2.     The  following 
table  emphasizes  the  fact  that  public  health  activities  have  done  little  to 
affect  the  death  rate  in  middle  life. 


Table  III.*  —  Total  Deaths 
Rate  per  1,000 

Year  All  Ages  40-50  50-60 

1870 19.2         11.8  17.1 

1880 19.4         11.9  17.4 

1890 17.3         12.9  20.0 

1900 17.2         11.7  20.3 

1910 15.6         10.8  19.8 

1920 14.3         10.0  18.0 

*  Rates  are  computed  using  a  ten-year  average  centering  on  the  census  year. 


60-70 

Over  70 

31.7 

91.3 

32.5 

94.6 

37.1 

99.8 

39.2 

106.2 

41.5 

106.5 

39.0 

107.2 

In  order  to  determine  the  changing  death  rates  in  individuals  over  fifty 
years  of  age,  rates  have  been  made  for  this  age  group  for  all  causes  of 
death.  The  rates  are  based  on  a  three-year  average  centering  on  the  cen- 
sus year  (Table  IV).  The  individual  diseases  have  been  grouped  accord- 
ing to  their  trends,  Group  A  having  all  diseases  with  a  constant  downward 
trend,  Group  B,  those  with  an  upward  trend,  and  Group  C,  the  others, 
which  have  an  initial  upward  trend  later  followed  by  a  downward  one. 

Table  IV.  —  Death  Rates  per  100,000  for  Individuals  over  Fifty 

Diseases  Having  a  Downward  Trend.     Group  A 

1850  1860  1870  1880  1890  1900  1910  1920 

Infections*    438  282  231  171  179  208  93  80 

Tuberculosis 768  677  549  425  306  231  174  118 

Old  age,  Ill-defined,  Unknown 1,315  1,083  1,061  787  631  429  141  38 

Epilepsy,  Convulsions,  Sudden  death 64  40  26  19  12  11  10  5 

Total  of  group 2,585      2,082      1,867      1,402      1,128         879         418         241 

Diseases  Hating  an  Upward  Trend.  Group  B. 

1850  1860  1870  1880  1890  1900  1910  1920 

Cancer 89  138  168  221  278  327  425  514 

Diabetes    4  9  9  13  26  44  73  78 

Heart 145  220  268  408  635  708  811  871 

Appendicitis   0  0  0  0  0  7  9  14 

Nephritis 1  5  33  104  165  267  388  388 

Leukemia,  Biliary  calculi,  Diseases  of  pros- 
tate, Benign  tumors  of  uterus,  Accidental 

gas 0  4  5  7  8  21  48  66 

Total  of  group 239         376         483         753      1,112      1,374      1,754      1,931 

Other  Diseases.     Group  C. 

1850       i860       1870  1880  1890  1900       1910  1920 

Apoplexy,  Paralysis 235         314         375  472  566  615         592  584 

Mental,  Nervous 49           64           75  104  115  137  •       86  34 

Pneumonia 149         224         291  408  446  470         473  304 

All  Others 455         559         600  761  874  909      1,027  734 

Total  of  group 888      1,161      1,341      1,745      2,001      2,131      2,178      1,656 

Total  Deaths   3,712      3,619      3,691      3,900      4,241      4,384      4,350      3,828 

*  Pneumonia  and  tuberculosis  are  not  included  in  "infections." 


"Total  deaths"  shows  no  increase  from  1850  to  1870 ;  a  marked  increase 
from  1870  to  1900;  and  a  decrease  from  1900  to  1920.  Group  A — infec- 
tions; tuberculosis;  old  age,  ill-defined,  and  unknown;  epilepsy,  convul- 
sions, and  sudden  death — has  a  constant  downward  trend.  Group  B — 
cancer;  diabetes;  heart;  appendicitis;  nephritis;  and  leukemia,  biliary 
calculi,  diseases  of  the  prostate,  benign  tumors  of  the  uterus,  and  acci- 
dental gas —  has  an  upward  trend.  Group  C,  comprising  the  remainder 
of  the  diseases,  has  a  steady  upward  trend  to  1910,  with  a  sharp  decline 
between  1910  and  1920. 


106 

DEATH  RATES  PER  100,000  FOR  INDIVIDUALS  OVER  FIFTY 

All  Causes  Divided  into  Three  Groups 


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Public  health  activities  will  account  probably  for  a  large  part  of  the  de- 
crease in  infections  and  tuberculosis.  It  is  extremely  probable  that  better 
diagnosis  and  certification  caused  the  decrease  in  old  age,  ill-defined,  and 
unknown,  and  deaths  which  were  formerly  classified  as  one  of  these  di- 
seases would  now  receive  a  more  adequate  diagnosis.    Probably  many  of 


107 
these  deaths  belonged  to  Group  B,  but  it  is  only  fair  to  assume  that  a 
portion  of  them  came  under  the  Group  C  classification. 

As  Group  C  is  rather  heterogeneous  in  composition,  and  as  the  individ- 
ual diseases  in  this  group  have  similar  trends,  it  seems  reasonable  to  be- 
lieve that  the  trend  of  this  group  depicts  changes  in  the  composition  of 
the  people  and  their  living  conditions. 

The  trend  of  Group  B  which  shows  a  greater  increase  than  Group  C  in 
the  early  decades  and  which  does  not  decline  following  1910  as  does  Group 
C,  points  toward  the  effect  of  other  valuables. 

If  we  assume  that  all  deaths  classified  as  old  age,  ill-defined,  and  un- 
known should  be  included  in  Group  B,  we  still  find  a  decided  upward  trend 
in  this  group.  (Group  D) 

Rate  per  100,000  for  Group  B  with  old  age,  ill-defined,  and  unknown 
deaths  included:  (Group  D) 

Year  1850       I860       1870       1880       1890       1900       1910       1920 

Group  D  1,554   1,459   1,544   1,540   1,743   1,803   1.895   1,969 

Probably  some  individuals  who  did  not  die  from  infections  or  tubercu- 
losis because  of  the  decrease  in  these  diseases,  died  of  Group  B  diseases. 
If  we  deduct  all  these  deaths  from  Group  D,  making  the  deaths  from  in- 
fections and  tuberculosis  constant,  we  have  a  trend  line  which  is  down- 
ward until  1880  and  practically  level  from  then  on. 

Rate  per  100,000  for  Group  B  with  old  age,  ill-defined,  and  unknown 

deaths,  removing  all  possible  increase  in  the  group  due  to  decreases 

in  infections  and  tuberculosis  (Group  E) 

Year  1850       1860       1870       1880       1890       1900       1910       1920 

Group  E  1,554   1,212   1,118    930   1,022   1,036    956    961 

It  is  most  unreasonable  to  assume  that  all  the  old  age,  ill-defined,  and 
unknown  deaths  rightfully  belong  to  Group  B  and  that  all  individuals  who 
did  not  die  of  tuberculosis  and  infections  died  of  Group  B  diseases.  It 
would  probably  be  nearer  the  truth  to  make  the  assumption  that  one-half 
of  the  ill-defined,  old  age,  and  unknown  belong  to  Group  B  and  one-half  of 
those  who  were  saved  from  dying  of  infections  and  tuberculosis  later  died 
of  Group  B  diseases.  Such  an  assumption  would  give  us  an  upward 
trend.  (Group  F) 

Rate  per  100,000  for  Group  B  with  one-half  the  deaths  of  old  age,  ill-de- 
fined, and  unknown  included,  and  one-half  of  those  dying  of  infections 
and  tuberculosis,  deducted.   (Group  F) 

Year 
Group  F    


1850 

1860 

1870 

1880 

1890 

1900 

1910 

1920 

896 

794 

800 

841 

1,066 

1,205 

1,355 

1,446 

Moreover,  following  1910,  the  fall  in  Group  C  does  not  occur  in  Groups 
B,  D,  E,  or  F.  This  reasoning  leads  us  to  believe  that  there  is  a  definite 
increase  in  the  Group  B  diseases  above  that  attributed  to  errors  in  diag- 
nosis and  certification,  changes  in  the  people  and  their  environments,  and 
public  health  activities. 

Age  specific  rates  have  been  made  for  heart  disease  and  cancer  from 
1910  to  1927  and  for  nephritis  from  1913  to  1927  for  the  age  groups  over 
forty.  (Table  V) — Heart  disease  is  practically  trendless  in  the  forty  to 
forty-nine,  fifty  to  fifty-nine,  and  sixty  to  sixty-nine  age  groups.  For  the 
seventy  to  seventy-nine  and  over  eighty  groups  there  are  decided  upward 
trends  for  both  sexes. ,  Cancer  shows  very  little  trend  in  the  forty  to  forty- 
nine  and  fifty  to  fifty-nine  age  groups,  but  an  upward  trend  for  the  other 
three.  Nephritis  has  an  upward  trend  in  the  older  age  groups  and  is 
nearly  trendless  in  the  lower  ones.  These  age  specific  rates  point  to  a  real 
increase  in  these  diseases. 


108 

Table  V.  —  Age  Specific    Death  Rates    for    Heart,    Cancer,    and    Nephritis 
Males.  Rate  per  1,000 


Heart 

Cancer 

Nephritis 

40-49  50-59 

60-69 

70-79 

80+ 

40-49  50-59  60-69  70-79 

80+ 

40-49  50-59  60-69  70-79 

80+ 

1910  . . 

...    1.5 

3.5 

9.7 

21.0 

38.0 

0.6 

1.6 

4.2 

6.6 

9.6 

1911  .. 

...    1.4 

3.4 

9.4 

19.2 

32.9 

0.6 

1.9 

4.7 

7.2 

9.1 

1912  .  . 

...    1.7 

4.4 

10.4 

22.5 

36.6 

0.6 

2.1 

3.6 

7.1 

8.1 

1913  . . 

...    1.6 

4.7 

10.8 

21.0 

40.7 

0.7 

2.2 

4.6 

7.2 

8.2 

0.9 

1.9 

4.7 

8.7 

12.2 

1914  .  . 

...    1.8 

4.6 

10.8 

23.4 

41.0 

0.6 

2.0 

4.5 

7.8 

10.0 

0.8 

2.2 

5.3 

8.5 

12.6 

1915  .  . 

...    1.5 

4.1 

9.9 

22.4 

37.6 

0.7 

2.2 

4.3 

7.6 

12.0 

0.9 

2.3 

4.5 

9.8 

15.2 

1916  .. 

...    1.8 

5.1 

12.1 

25.1 

47.0 

0.8 

2.3 

5.0 

8.1 

8.8 

0.8 

2.2 

t>.l 

9.9 

15.3 

1917  .  . 

...    1.8 

4.4 

12.6 

28.5 

55.1 

0.7 

2.0 

5.2 

8.8 

8.8 

0.9 

2.0 

4.7 

10.5 

18.0 

1918  .  . 

...    1.5 

3.7 

10.4 

24.6 

42.1 

0.9 

2.3 

4.6 

8.4 

11.1 

1.1 

2.2 

5.2 

11.4 

20.7 

1919  .. 

...    1.2 

3.0 

8.6 

21.9 

44.4 

0.7 

2.3 

4.8 

8.3 

10.6 

0.8 

1.8 

4.9 

10.0 

17.8 

1920  .  . 

...    1.1 

3.0 

9.0 

24.4 

49.3 

0.7 

2.4 

5.4 

9.4 

12.0 

0.7 

1.8 

4.2 

10.7 

20.5 

1921  .  . 

...    1.2 

3.4 

9.6 

22.6 

51.1 

0.7 

2.5 

5.5 

9.1 

11.1 

0.6 

1.5 

4.0 

8.8 

16.5 

1922  .  . 

...    1.4 

3.9 

10.1 

25.7 

57.8 

0.7 

2.4 

5.2 

9.8 

11.8 

0.6 

1.5 

3.7 

8.2 

16.2 

4.0 

11.7 

26.8 

54.5 

0.6 

2.3 

6.1 

9.1 

12.4 

0.6 

1.4 

3.7 

9.2 

17.9 

1924  .  . 

...    1.4 

3.9 

10.6 

26.2 

54.8 

0.8 

2.4 

6.2 

11.2 

12.5 

0.6 

1.5 

3.8 

8.4 

16.7 

4.2 

11.6 

28.8 

62.2 

0.7 

2.4 

6.2 

10.8 

14.4 

0.5 

1.2 

3.5 

8.0 

17.0 

1926  .  . 

...    1.6 

4.6 

12.9 

32.3 

64.8 

0.7 

2.5 

6.4 

11.6 

14.8 

0.6 

1.6 

4.3 

10.8 

17.8 

1927 

1.4 

4.2 

11.8 

30.1 

62.3 

0.7 

2.4 

6.3 

11.6 

12.9 

1.2 

1.6 

3.7 

9.3 

16.9 

Females. 

Rate 

per  1,000 

1910  . . . 

..    1.3 

2.7 

7.8 

16.2 

30.7 

1.6 

3.2 

5.6 

8.2 

8.6 

1911  ... 

..    1.3 

2.7 

7.7 

14.2 

30.2 

1.6 

3.4 

5.1 

8.5 

11.1 

1912... 

..    1.5 

3.5 

8.3 

17.4 

35.1 

1.7 

3.6 

5.8 

8.4 

10.9 

1913  ... 

..    1.5 

3.1 

10.3 

19.0 

36.4 

1.7 

3.4 

6.2 

8.1 

10.9 

0.8 

1.5 

3.3 

5.8 

10.2 

1914  .  .  . 

..    1.6 

3.7 

8.4 

18.9 

39.2 

1.7 

3.5 

6.0 

8.4 

11.5 

0.8 

1.5 

3.5 

5.8 

9.0 

1915  ... 

..    1.3 

3.2 

8.0 

17.1 

34.4 

1.7 

3.4 

6.2 

8.6 

12.5 

0.7 

1.8 

3.3 

6.7 

11.1 

1916  ... 

..    1.6 

3.6 

9.4 

21.5 

43.8 

1.8 

3.7 

6.2 

9.2 

12.9 

0.9 

1.4 

3.4 

6.7 

12.3 

1917  ... 

..    1.6 

3.6 

9.1 

21.5 

47.6 

1.7 

3.7 

6.6 

9.3 

11.5 

0.8 

1.6 

3.5 

6.9 

11.7 

1918  ... 

..    1.6 

3.4 

7.8 

18.3 

39.9 

1.7 

3.5 

6.3 

9.2 

12.5 

0.8 

1.7 

3.8 

8.0 

12.9 

1919  .  .  . 

..    1.1 

2.5 

7.4 

IS. 8 

39.1 

1.6 

3.6 

6.1 

8.8 

12.3 

0.8 

1.4 

3.6 

7.5 

13.7 

1920  .  .  . 

..    1.0 

2.7 

7.5 

20.1 

45.7 

1.7 

3.9 

6.3 

10.2 

12.8 

0.6 

1.4 

3.6 

7.6 

16.0 

1921  .  .  . 

..    1.2 

2.5 

7.8 

19.5 

43.0 

1.6 

3.7 

6.7 

10.1 

12.2 

0.6 

1.2 

3.3 

6.1 

11.5 

1922  .  .  . 

..    1.2 

2.9 

8.7 

22.3 

50.0 

1.7 

3.5 

6.3 

10.0 

13.7 

0.7 

1.2 

2.8 

6.7 

13.9 

1923  .  .  . 

..    1.2 

2.8 

8.9 

23.0 

49.6 

1.6 

3.6 

6.6 

10.4 

11.3 

0.7 

1.3 

3.2 

7.2 

13.6 

1924  .  .  . 

..    1.1 

2.8 

7.8 

21.2 

44.3 

1.6 

3.7 

6.3 

11.1 

12.1 

0.6 

1.3 

2.8 

6.0 

13.2 

1925  .  .  . 

..    1.2 

2.9 

8.6 

23.5 

52.0 

1.6 

3.7 

6.6 

11.8 

13.0 

0.5 

1.1 

3.0 

7.1 

10.6 

1926  .  .  . 

..    1.3 

3.2 

9.9 

26.5 

55.7 

1.6 

3.4 

6.9 

11.1 

11.9 

0.7 

1.6 

3  9 

8.2 

13.5 

1927 

1.1 

3.1 

8.6 

25.5 

52.1 

1.7 

3.5 

7.0 

11.3 

12.9 

0.6 

1.5 

3.2 

7.8 

15.4 

Conclusions : 

1.  The  population  of  Massachusetts  has  been  gradually  growing  older. 

2.  The  crude  death  rate  has  decreased,  but  for  age  groups  over  fifty 
there  has  been  an  increase. 

3.  Infections ;  tuberculosis ;  old  age,  ill-defined,  and  unknown ;  epilepsy, 
convulsions,  and  sudden  death  in  individuals  over  fifty  have  a  downward 
trend. 

4.  Cancer,  diabetes,  heart,  appendicitis,  nephritis,  and  a  group  com- 
posed of  leukemia,  biliary  calculi,  diseases  of  the  prostate,  benign  tumors 
of  the  uterus,  and  accidental  gas  have  an  upward  trend  which  apparently 
is  caused  by  factors  other  than  errors  in  diagnosis  and  certification,  pub- 
lic health  activities,  and  changes  in  the  people  and  their  environments. 

5.  All  other  diseases  show  an  initial  increase  followed  by  a  decrease. 
This  trend  gives  the  impression  that  it  is  caused  by  changes  in  the  com- 
position of  the  people  and  their  living  conditions. 

HEALTH  EXAMINATIONS 

By  Roger  I.  Lee,  M.D. 

Boston,  Mass. 

Of  course  you  are  all  familiar  with  the  various  platitudes  that  every- 
body says  about  health  examinations  such  as,  "You  should  take  account  of 
stock  once  a  year — you  do  that  with  your  business,  why  not  do  it  with 
your  body?"  "An  automobile  has  to  be  overhauled  every  so  often — why 
not  overhaul  the  human  machine?"    Too  often,  however,  the  enthusiastic 


109 

advocates  of  the  periodic  physical  examination  maintain  that  there  are 
advantages  in  these  examinations  which  experience  has  shown  do  not  ac- 
tually occur.  For  example,  some  people  expect  that  if  they  are  physically 
examined  on  January  first  of  one  year,  presumably  that  will  last  them  un- 
til January  first  of  the  next  year  and  nothing  ought  to  happen  to  them  in 
that  particular  time.  Of  course,  they  would  be  willing  to  say  that  they 
should  keep  out  of  the  way  of  automobiles,  etc.,  in  order  to  avoid  accidents. 
They  do  not  understand,  however,  that  many  of  our  diseases  like  cancer, 
for  instance,  or  even  heart  disease,  are  just  as  much , accidents  as  are  auto- 
mobile accidents.  Furthermore,  I  think  people  are  a  little  apt  to  think 
that  a  physical  examination  in  human  hands  may  do  superhuman  things. 

The  difficulty  as  we  see  it  in  actual  practice  is  to  find  a  point  at  which 
the  physical  examination  can  do  as  much  as  can  be  reasonably  expected 
within  certain  very  definite  limitations.  One  of  the  limitations,  of  course, 
is  the  limitation  of  money.  In  private  practice  there  are  few  patients  who 
can  have  a  physical  examination  such  as  is  sometimes  carried  on  in  which 
they  have  what  is  called  a  complete  X-ray  physical  examination  in  addi- 
tion to  the  ordinary  examination  by  the  physician.  Obviously  that  takes 
time  and  money.  Neither  is  it  necessary  that  a  person  should  be  physi- 
cally examined  by  a  large  group  of  specialists.  Some  people  who  are  phys- 
ically examined  like  to  feel  that  for  the  amount  of  money  which  they  give, 
or  which  is  allotted  to  their  examination,  they  should  see  an  eye  specialist, 
a  nerve  specialist,  an  ear  specialist,  a  heart  specialist,  and  what  not.  How- 
ever, experience  shows  that  it  is  perfectly  feasible  for  a  single  well-trained 
physician  to  carry  out  this  general  physical  examination,  with  the  under- 
standing that,  or  the  proviso  that,  he  may  want  to  recommend  special 
opinion  or  special  advice.  In  other  words,  the  physical  examiner  does  not 
have  to  be  able  to  treat  all  of  these  remote  specialties  but  he  has  to  know 
when  it  is  necessary  or  desirable  to  have  a  special  man  called  in  for  the 
purpose  of  definite  opinion  or  definite  advice  within  a  specialty. 

There  is  a  great  deal  of  discussion  as  to  how  much  time  should  be  al- 
lotted in  physical  examinations.  In  private  practice  in  the  office  with  an 
adult  patient,  an  hour  should  be  allowed  for  the  physical  examination.  Ob- 
viously that  is  impossible  in  group  or  mass  examinations.  Certainly  it  is 
impossible  in  the  examination  of  school  children.  As  a  matter  of  fact  it 
is  not  necessary  for  school  children  because  the  school  child  is  not  any- 
where near  as  complicated  as  the  grown  man  or  woman.  In  several  of  the 
universities  it  was  perfectly  feasible  to  examine  freshmen  in  a  relatively 
short  time  but  when  they  got  into  the  professional  schools  after  gradua- 
tion, more  time  was  needed  for  the  examination  because  they  were  older 
and  had  begun  to  have  problems  and  complications.  The  child  practically 
eats  only  what  is  put  in  front  of  him  and  often  times  such  things  as  the 
diet  of  the  child  are  not  of  particular  importance.  With  an  adult  man  or 
woman  there  are  such  problems  as  the  use  of  tobacco,  alcohol,  tea  or  cof- 
fee, etc.,  which  do  not  occur  at  least  very  commonly  amongst  school  chil- 
dren. 

The  physical  examination  will  disclose  certain  very  definite  things.  You 
can  count  on  fixed  percentages  of  certain  diseases  and  defects  depending 
upon  the  age  group  examined.  For  school  children  it  will  be  found  that 
2%  of  them  will  have  heart  disease.  In  the  examination  of  adults  that 
percentage  will  be  somewhat  higher.  In  the  examination  of  adults  of  over 
forty  years  of  age  certain  other  diseases  appear  in  a  perfectly  definite 
statistical  fashion. 

A  very  interesting  experiment  is  contemplated  where  we  are  going  to  have 
for  the  first  time  figures  on  a  certain  age  group,  namely,  what  is  known 
generally  as  the  high  school  group,  which  has  never  before  been  care- 
fully studied.  We  are  in  a  position  at  the  present  time  to  state,  on  account 
of  the  Ten-Year  Tuberculosis  Program  of  the  State  Department  of  Public 
Health,  what  the  incidence  of  tuberculosis  of  the  internal  glands  of  the 
chest  is  among  school  children  of  the  younger  age.  We  already  know, 
furthermore,  that  the  time  when  people  break  down  from  tuberculosis  is 


110 
some  time,  roughly,  in  the  twenties.  This  period  of  high  school  age  seems 
to  be  the  critical  age  concerning  tuberculosis.  Tuberculosis  is  the  impor- 
tant problem  in  that  particular  age  group.  Tuberculosis  is  diminishing 
and  no  longer  can  it  be  said  that  one  out  of  every  four  present  would  die 
of  tuberculosis.  More  recently  that  was  changed  to  one  out  of  ten.  Now 
it  is  much  less  than  that.  Some  of  us  who  are  gray-haired  have  gone  be- 
yond the  age  at  which  we  are  likely  to  come  down  with  tuberculosis.  One 
of  the  few  compensations  of  getting  old  is  that  you  are  not  likely  to  get 
tuberculosis,  you  don't  have  as  many  colds,  and  so  on.  The  Ten- Year 
Program  of  the  State  has  shown  that  there  is  a  certain  percentage  of 
school  children  who  are  infected  with  tuberculosis.  They  wait  until  they 
meet  the  stress  and  strain  of  life  in  the  twenties  or  thereabouts  before 
they  come  down  with  the  disease  and  before  they  die.  What  happens  to 
the  child  that  goes  from  the  earlier  school  days  to  high  school  ?  We  know 
that  a  certain  percentage  of  them  will  come  down  with  tuberculosis  in  the 
twenties,  happily  not  so  many  as  was  the  case  years  ago.  As  I  recall  my 
high  school  days,  none  of  my  companions  came  down  at  that  time  with 
tuberculosis.  I  recall  none  of  the  young  men  in  college  with  me  came  down 
with  it.  But  over  ten  per  cent  of  my  Medical  School  classmates  broke 
down  with  tuberculosis  before  they  were  thirty  and  a  considerable  per- 
centage died.  Fortunately,  as  I  have  said  before  those  cases  no  longer 
occur  in  that  proportion. 

I  have  taken  tuberculosis  as  one  illustration.  We  can  take  any  other 
disease  and  illustrate  physical  examinations  by  that.  I  have  taken  tuber- 
culosis because  that  seems  to  be  the  most  urgent  in  the  physical  examina- 
tion of  children  and  young  people.  The  important  thing  in  tuberculosis 
prevention  is  to  detect  those  cases  who  have  not  yet  the  disease  but  have 
the  infection.  The  problem  then  is  to  prevent  the  infection  from  develop- 
ing into  the  disease  that  we  call  consumption  and  at  this  stage  it  is  not 
difficult. 

If  I  may  digress  a  moment  I  will  say  that  our  emphasis  up  to  the  recent 
times  in  health  work  has  been  put  upon  public  health  measures.  For  ex- 
ample, years  ago  typhoid  fever  was  a  scandal.  The  public  authorities  took 
charge  of  the  situation,  purified  the  water  supplies,  looked  after  sewage, 
and  typhoid  has  largely  disappeared  off  the  face  of  the  earth.  Vaccina- 
tion universally  applied  eliminates  smallpox  and  few  people  even  in  the 
medical  profession  have  ever  seen  smallpox.  In  diphtheria  we  have  the 
diphtheria  antitoxin  as  treatment  and  the  prevention  with  the  toxin-anti- 
toxin mixtures,  so  that  diphtheria  has  been  much  reduced.  Unfortunately, 
in  diseases  like  influenza,  measles,  whooping  cough,  etc.,  where  we  have  no 
specific  remedy  or  preventive  measure,  we  have  not  been  particularly  suc- 
cessful in  the  control  of  these  diseases.  The  control  of  these  diseases  de- 
pends upon  the  personal  hygiene  of  the  individual. 

But  more  especially  in  those  deviations  from  full  health,  that  we  desig- 
nate as  "debility,"  "under  par,"  "lack  of  pep,"  does  personal  hygiene  play 
the  dominant  role.  We  all  like  to  feel  well,  with  an  abundance  of  vigor 
for  our  work  and  play.  If  we  do  not  feel  entirely  fit,  the  law  of  chances  is 
strong  that  a  health  examination  will  show  no  serious  disease  but  de- 
fects in  our  personal  hygiene.  However,  in  the  long  run  it  is  likely  that 
continued  abuse  of  the  human  machine  will  lead  to  trouble.  Certainly  the 
buyer  of  a  used  car  ordinarily  wants  to  know,  if  possible,  more  than  the 
age  of  the  car.  We  see  defects  in  personal  hygiene  in  children  who  show 
overweight,  underweight,  over-activity,  improper  diet,  lack  of  rest,  etc. 
We  see  particularly  in  adults  the  results  of  poor  personal  hygiene,  in  con- 
stipation, lack  of  sleep,  lack  of  exercise,  overeating,  improper  eating,  etc. 
In  any  series  of  physical  examination  we  find  that  the  greatest  number  of 
defects  are  due  mainly  to  poor  personal  hygiene.  By  physical  examina- 
tion a  large  number  of  little  defects  can  be  detected  and  corrected  that 
will  never  kill  but  can  add  to  the  wear  and  tear  of  life  and  in  the  end  pro- 
duce what  we  call  medically  a  wear  and  tear  disease,  namely  arterioscler- 
osis or  hardening  of  the  arteries.    In  the  physical  examination  of  the  em- 


Ill 

ployees  of  a  large  organization,  a  considerable  number  had  headaches.  On 
analysis  the  doctor  found  that  a  great  many  of  these  girls  worked  without 
breakfast,  some  perhaps  had  a  cup  of  coffee  after  they  got  to  work.  That 
is  poor  personal  hygiene.  The  correction  of  personal  habits  of  one  sort  or 
another  has  very  largely  eliminated  headaches  in  that  organization,  and 
increased  very  much  efficiency.  Now  these  were  not  diseases,  but  dis- 
orders that  seriously  interfered  with  efficiency,  and  with  health,  and  which 
if  persisted  in  would  add  to  the  wear  and  tear  of  the  human  machine  and 
which  well  might  make  the  individual  susceptible  to  various  diseases.  It 
is  at  this  point  that  the  emphasis  must  be  placed  in  these  health  examina- 
tions. 

In  private  practice  we  accomplish  more  in  two  lines  than  in  any  other. 
Often  it  is  not  so  much  the  detection  of  a  tubercular  infection  as  it  is  the 
question  of  reassuring  a  great  many  of  these  individuals  that  they  are 
sound.  It  is  bringing  to  them  a  certain  moral  comfort  which  helps  a  good 
deal.  That  is  a  very  important  feature  of  the  physical  examination.  The 
second  important  feature  of  the  physical  examination  is  the  correction  of 
disorders  and  teaching  of  personal  hygiene.  This  is  the  next  great  step  in 
the  public  health  program.  After  these  two  features  I  should  put  the  dis- 
covery of  these  important  diseases  like  diabetes,  tumors  and  things  of  that 
sort.  I  think  that  is  the  least  important  part  of  our  physical  examina- 
tions. 

In  conclusion  I  want  to  stress  again  that  in  physical  examinations  in 
health  one  should  bear  clearly  in  mind  what  the  important  features  are. 
One  should  not  expect  always  the  discovery  of  serious  disease; — that  is 
heart  disease,  a  tumor,  or  acute  appendicitis  to  be  operated  upon  five 
minutes  after  the  examiner  sees  him,  etc.  One  important  thing  is  to  re- 
lieve them  of  needless  worry.  A  second  very  important  thing  is  personal 
hygiene,  or  personal  habits,  and  the  correction  of  those. 

Finally,  we  want  to  get  everybody  in  this  Commonwealth  as  far  as  we 
can  living  in  a  hygienic  way,  so  hygienically  that  even  if  a  person  did  have 
an  incipient  tuberculosis  we  could  say  to  him  "You  are  living  properly  and 
it  makes  no  difference  if  you  have  a  little  tuberculosis,  you  can  take  care 
of  it  because  your  personal  hygiene  is  so  sound." 

I  repeat  again  that  this  is  an  era  of  a  new  public  health  measure,  per- 
sonal hygiene  as  opposed  to  public  hygiene,  and  that  one  of  the  important 
cogs  in  this  new  measure  is  the  routine  physical  examination.  One  of  the 
important  lessons  is  not  the  detection  of  organic  disease  after  it  is  once 
present,  but  the  detection  of  disorders  that  so  often  precede  organic  di- 
sease, and  by  the  correction  of  these  disorders,  in  a  large  measure,  the 
ravages  of  diseases  which  come  later  will  be  prevented. 

CHRONIC  DISEASE  AND  THE  PUBLIC  WELFARE 

By  Richard  K.  Conant 
State  Commissioner  of  Public  Welfare 

The  State  Department  of  Public  Welfare  is  fully  as  anxious  as  the  State 
Department  of  Public  Health  to  have  public  attention  centered  upon  the 
problem  of  chronic  illness.  We  hope  that  these  articles  about  Adult  Hy- 
giene will  be  widely  circulated,  and  that  the  campaign  of  public  informa- 
tion to  prevent  the  diseases  of  middle  age  will  become  as  effective  as  the 
Child  Health  campaign. 

When  we  deal  with  so  many  pitiful  and  so  many  hopeless  cases  of 
chronic  illness,  when  we  worry  over  the  problem  of  securing  adequate  hos- 
pital facilities  for  chronic  diseases,  and  when  we  struggle  to  make  life  pos- 
sible at  home  for  families  wholly  impoverished  by  the  diseases,  we  realize 
that  the  only  hope  for  the  future  is  in  prevention. 

Prevention  of  infant  mortality  is  succeeding,  prevention  of  epidemics 
of  children's  diseases  is  succeeding,  and  the  great  hope  for  the  better  eco- 
nomic security  and  the  better  family  life  of  the  nation  lies  in  the  preven- 


112 

tion  of  the  diseases  of  middle  age.  Much  progress  has  been  made  by  the 
State  Department  of  Public  Health  during  the  last  year  in  the  early  dis- 
covery and  treatment  of  cancer ;  the  Department  has  a  long  record  of  suc- 
cess in  the  prevention  of  tuberculosis;  all  success  to  it  with  your  help  in 
the  prevention  of  the  remaining  great  scourges  of  the  people — arthritis, 
heart  disease,  rheumatism,  paralysis,  diabetes,  arteriosclerosis,  and  the 
long  list  of  diseases  of  middle  age. 

In  the  household  budget  sickness  upsets  all  calculations.  The  family 
which  is  able  to  support  itself  is  forced  into  poverty  by  long  continued  ill- 
ness. The  State  Department  of  Public  Welfare  and  the  local  boards  of 
public  welfare  are  chiefly  concerned  with  two  large  problems — Child  Wel- 
fare, and  Family  Welfare.  Family  Welfare  is  more  permanently  and  seri- 
ously affected  by  chronic  illness  than  by  any  other  one  factor.  Unemploy- 
ment is  at  times  a  larger  immediate  factor  in  poverty,  but  it  is  more  tem- 
porary, and  in  the  long  run  the  greatest  single  cause  of  poverty  is  chronic 
illness.    A  conservative  estimate  of  this  factor  is  20  per  cent. 

The  following  table  shows  the  chief  factors  of  poverty  in  families  as- 
sisted by  the  State  Department  of  Public  Welfare  under  the  ordinary  re- 
lief laws.  The  factor  of  illness  appears  as  the  second  largest,  with  un- 
employment first.  Illness,  however,  is  a  more  permanent  factor  than  un- 
employment, because  almost  all  of  it  in  our  cases  is  chronic  illness. 

CAUSES  OF  POVERTY 

Factors  in  Cases  Aided  by  the  State  Because  Not  Legally  Settled  in  a  City 

or  Town 

1924  1925  1926  1927  1928 

Illness    1,026  1,149  1,093  1,153  1,082 

Desertion    364  348  316  364  300 

Widowhood 213  225  230  232  237 

Old  Age 77  81  100  81  105 

Unemployment    2,097  1,869  1,492  1,981  2,844 

Insufficient  income    343  392  382  486  522 

Husband  in  correctional  institution   228  217  199  190  206 

Orphans 11  11  14  15  17 

Insanity 24  26  15  26  23 

Blindness ! 17  14  13  12  13 

Non-support 54  73  65  73  95 

Miscellaneous 19  5  6  4  7 

Totals    4,473  4,410  3,925  4,617  5,451 

In  the  relief  of  the  families  listed  in  the  table,  the  State  spends  $750,000  a 
year. 

In  Mothers'  Aid,  for  which  there  is  an  expenditure  of  another  $900,000 
a  year  by  the  state,  which  is  more  than  doubled  if  you  add  the  expendi- 
tures of  the  cities  and  towns,  the  factor  of  chronic  illness  is  easily  20  per 
cent.  Of  the  659  new  families  aided  last  year,  444  were  aided  because  of 
the  death  of  the  father  and  94  because  of  the  chronic  illness  of  living 
fathers.  Many  of  the  deaths  were  the  result  of  chronic  diseases.  In  sup- 
port of  this  rough  estimate  of  at  least  20  per  cent,  the  Family  Welfare  So- 
ciety of  Boston  reports  that  sickness  was  a  factor  in  43  per  cent  of  the 
cases  of  families  and  individuals  helped  by  them  in  1927-28,  and  the  Bos- 
ton Provident  Association  reports  a  factor  of  38  per  cent  for  illness  for 
the  last  year. 

Cities  and  towns  spend  each  year  in  helping  needy  families  and  indi- 
viduals $7,500,000.  Applying  the  20  per  cent  estimate  to  this  figure  and 
to  the  $750,000  and  the  $900,000  given  above,  it  is  apparent  that  nearly 
$2,000,000  a  year  is  spent  by  the  public  agencies  in  assistance  at  home  be- 
cause of  chronic  disease.  The  amount  spent  by  private  relief  agencies 
and  by  individuals  in  gifts  to  assist  those  ill  with  chronic  diseases  would 
make  a  large  addition  to  this  sum. 

Largely  for  the  care  of  chronic  illness  the  State  Department  of  Public 
Welfare  maintains  a  State  Infirmary  at  Tewksbury  at  a  cost  of  nearly  a 
million  dollars  a  year,  and  a  Hospital  School  for  Crippled  Children  at  Can- 
ton at  a  cost  of  about  $200,000;  the  State  Department  of  Public  Health 


113 

maintains  a  cancer  hospital  at  a  cost  of  about  $200,000  a  year,  and  four 
state  sanatoria  for  tuberculosis  at  a  cost  of  about  a  million  dollars;  and 
the  cities  and  towns  maintain  one  hundred  twenty-three  local  infirmaries 
at  a  cost  of  about  $2,000,000  a  year.  In  addition  to  these  public  expendi- 
tures, five  large  charitable  hospitals  for  chronic  disease  in  or  near  Boston 
spend  $500,000  a  year.  In  the  general  hospitals,  studied  by  the  Boston 
Council  of  Social  Agencies  in  1927,  20  per  cent  of  all  the  patients  were 
found  to  be  chronically  ill.  The  incorporated  charitable  hospitals  in  the 
state  reported  their  expenditures  for  last  year  as  $19,000,000. 

In  spite  of  these  large  figures  of  the  expenditures  of  welfare  agencies, 
it  should  be  remembered  in  counting  the  cost  of  chronic  disease  that  by 
far  the  heaviest  cost  is  borne  by  the  families  themselves,  both  in  direct 
payments  for  care  and  treatment  and  in  loss  of  earnings.  This  cost,  of 
which  there  is  no  record,  must  be  enormous,  and  yet  the  cost  in  dollars  is 
far  exceeded  by  the  cost  in  physical  and  mental  suffering  and  by  the  loss  of 
useful  effort. 

In  public  welfare  progress,  in  the  field  of  care  and  treatment  of  chronic 
disease,  Massachusetts  has  maintained  its  leadership,  and  yet  it  has  ac- 
complished little  in  comparison  with  what  should  be  done.  It,  as  a  state, 
does  more  than  any  other  state  in  this  field.  In  its  State  Infirmary,  its 
Cancer  Hospital,  its  four  Tuberculosis  Sanatoria  and  in  its  Hospital 
School  it  provides  more  institutional  care  than  any  other  state.  It  is  the 
only  state  which  gives  aid  at  home  to  families  who  have  no  legal  settle- 
ment in  a  city  or  town,  and  it,  as  a  state  and  through  its  cities  and  towns, 
gives  more  adequate  aid  at  home  and  a  larger  amount  of  social  service 
than  most  states. 

Massachusetts  and  Rhode  Island  are  the  only  states  which  operate  State 
Infirmaries.  Our  excellent  institution  at  Tewksbury  is  unique  in  this 
country.  It  is  a  good  hospital  caring  for  twenty-five  hundred  patients, 
most  of  whom  are  ill  with  chronic  diseases. 

Unless  you  visit  the  State  Infirmary,  you  cannot  appreciate  it  as  it 
should  be  appreciated.  A  list  of  the  diseases  treated  is  published  in  its 
annual  report.  The  list  reminds  one  of  a  medical  dictionary.  Nearly 
every  known  disease  has  at  some  time  been  treated  there.  The  chronic 
diseases  are  the  most  numerous.  Last  year,  for  example,  there  were 
treated  in  the  hospital  wards  284  cases  of  heart  disease,  88  cases  of  cancer, 
635  cases  of  arteriosclerosis,  416  cases  of  tuberculosis,  230  cases  of  chronic 
rheumatism,  22  cases  of  diabetes,  13  cases  of  encephalitis,  and  585  other 
cases  of  diseases  of  the  nervous  system.  One  hundred  sixteen  different 
diseases  are  listed  for  the  4506  patients  who  were  treated  at  the  State  In- 
firmary last  year. 

To  visualize  the  institution  where  such  a  great  piece  of  humanitarian 
endeavor  is  carried  on,  imagine  a  group  of  college  campuses,  with  seventy 
buildings  in  the  various  groups,  a  small  town  in  itself,  with  all  the  neces- 
sary service  buildings,  such  as  a  power  plant,  a  laundry,  water  and  sew- 
age systems,  store  houses,  barns,  three  farms,  a  large  poultry  farm,  and 
even  a  community  store  and  canteen.  There  is  a  men's  hospital,  a  women's 
hospital,  a  children's  hospital,  and  two  separate  tuberculosis  hospitals;  the 
wards  are  well  classified,  and  immaculately  clean;  and  there  is  excellent 
medical  attention  by  the  staff  of  twelve  doctors  and  two  hundred  nurses 
and  attendants,  and  a  very  high  standard  of  care. 

In  one  of  the  wards  you  will  see,  sitting  up  in  bed,  making  surgical 
sponges,  such  a  sweet-faced  lady  of  middle  age,  so  smiling  and  cheerful 
that  you  wonder  if  she  can  really  be  ill.  She  suffers  from  frequent  attacks 
of  angina  pectoris.  When  she  feels  the  iron  hand  clutching  at  her  heart, 
she  holds  herself  up  tight  because  it  hurts  to  breathe;  and  as  she  suffers 
the  tortures  of  the  pain,  tears  come  and  she  holds  back  her  cries.  The 
attack  lasts  for  hours  and  she  bravely  keeps  her  head  until  it  becomes  easy 
again  for  her  to  live.  She  must  spend  most  of  her  days  sitting  up  in  bed, 
and  must  even  be  propped  up  with  pillows  when  she  sleeps  to  ease  the 
strain.    She  cannot  move  about  or  try  to  do  hard  work,  or  she  will  bring 


114 

the  attacks  on  faster.  But,  as  you  see  her  today,  the  pain  has  passed  and 
she  calls  cheerfully  to  you  as  you  move  down  the  aisle,  "Very  happy  here, 
Doctor.  Everything  is  fine."  She  cheers  the  other  patients  in  her  ward; 
she  is  a  striking  spirit  amongst  them  and  does  her  bit  as  well  or  a  little 
better  than  the  rest  of  us.  It  is  very  fortunate  that  the  state  maintains 
the  State  Infirmary  for  her  and  for  the  family  who  would  otherwise  be 
overburdened  with  her  care.  It  is  an  inspiration  to  know  that  people  who 
suffer  so  can  rise  above  their  physical  infirmities  and  lift  up  their  own 
and  help  to  lift  up  others'  souls. 

As  numerous  as  the  cases  of  heart  diseases  are  the  cases  of  arthritis. 
A  switchboard  operator  in  a  small  hospital  was  formerly  a  patient  at  the 
State  Infirmary.  She  went  there  at  the  age  of  twenty-four  with  a  bad 
case  of  infectious  arthritis.  Her  knee  joints  were  so  stiffened  with  the 
crippling,  lumpy  growths  that  she  had  to  lie  in  bed  for  two  years.  Baking 
and  massage,  an  operation  and  her  determined  effort  finally  got  her  up  on 
crutches.  A  hospital  which  understands  the  psychology  of  crippled  per- 
sons gave  her  a  chance  to  learn  to  operate  the  telephone  switchboard.  For 
a  year  she  worked  for  her  maintenance.  The  next  year  she  worked  in  the 
office  of  a  small  institution,  and  now  she  is  self-supporting  as  a  switch- 
board operator  in  a  hospital.  Many  failures,  hours  of  travelling  to  clinics, 
the  infinite  patience  of  employers,  and  most  important  the  indomitable  will 
of  the  patient  to  overcome  her  handicap  have  remade  her  body  and  given 
her  success. 

'  In  the  occupational  therapy  shop  at  the  State  Infirmary  you  might  have 
seen  a  year  ago  a  tall,  strong-shouldered,  young  man  with  a  self-reliant 
smile,  whose  hands  and  arms  were  so  twisted  as  the  result  of  a  motorcycle 
accident  that  he  could  not  reach  his  mouth  to  feed  himself  and  could  not 
dress  himself.  He  was  alert  of  mind  and  his  body  in  splendid  physical 
condition,  but  he  had  been  cut  off  from  all  normal  life.  Occupational  in- 
struction enabled  him  to  make  useful  and  beautiful  baskets,  and  at  the 
same  time  helped  the  strength  of  his  fingers  and  hands.  A  skillful  opera- 
tion enabled  him  to  use  his  hand  enough  to  feed  himself,  and  he  is  now 
making  strides  to  overcome  his  handicap. 

These  young  chronic  sick  patients  are  strongly  appealing,  not  only  from 
the  medical,  but  from  the  social  point  of  view.  It  is  necessary  to  do  what 
can  be  done  to  get  them  back  to  partial  health,  or  at  least  keep  their  minds 
active  and  interested.  For  such  patients  hospital  care  is  essential,  and 
there  are  too  few  facilities  for  it.  The  State  Infirmary  is  the  largest  hos- 
pital and  it  must  always  take  the  patient  for  whom  application  is  made. 
Private  charitable  hospitals  which  spend  much  more  per  capita  upon  food 
and  nursing  service  have  long  waiting  lists. 

Certain  patients  do  not  need  hospital  care,  and  if  they  are  sent  to  the 
State  Infirmary  the  social  service  workers  make  every  effort  to  find  a  way 
in  which  they  can  live  with  friends  or  relatives.  Two  maiden  ladies  who 
had  lived  in  a  lovely  old  house  in  a  small  New  England  town  had  spent 
their  lives  in  caring  for  their  aged  parents,  enjoying  at  times  opportuni- 
ties for  travel.  After  the  death  of  their  parents  the  sisters  made  poor  in- 
vestments and  in  a  few  years  lost  all  their  money  and  had  to  sell  their  old 
home.  They  were  proud  and  sensitive  and  left  town  to  try  to  earn  their 
living  by  securing  day  work  and  newspaper  writing,  but  it  was  a  meagre 
existence  full  of  hardships.  They  had  great  courage,  and  rather  than  ac- 
cept charity  they  almost  starved.  The  older  sister  was  taken  ill  with  can- 
cer and  both  ladies  went  to  the  State  Infirmary  where  they  were  given  a 
room  together.  Miss  Lucy,  frail  and  feeble,  suffering  with  rheumatism, 
waited  on  the  dying  sister,  who,  never  admitting  her  fatal  illness,  main- 
tained her  proud  self-reliance,  and  even  on  the  day  before  she  died  begged 
to  be  allowed  to  go  out  and  work  to  pay  her  way. 

After  the  sister's  death,  Miss  Lucy  wandered  from  one  ward  to  another, 
lonely  and  lost,  seeking  solace,  yet  shrinking  from  the  crude  kind  contacts 
of  strange  patients.  A  social  service  worker  found  in  Miss  Lucy's  home 
town  some  old  acquaintances  who  were  glad  to  go  to  see  her,  and  with 


115 

the  financial  assistance  of  the  state  she  was  found  board  with  a  girlhood 
friend  who  lived  very  near  her  old  home,  and  there  she  found  happiness. 

The  suffering  and  the  pathos  of  chronic  illness  is  enormous ;  the  cost  of 
the  care  and  treatment  is  enormous.  From  the  preventive  point  of  view, 
the  outstanding  fact  about  Chronic  disease  and  the  Public  Welfare  today 
in  Massachusetts,  as  in  every  other  state,  is  that  we  are  on  the  doorstep 
of  a  new  era  of  Adult  Hygiene.  We  are  slowly  accumulating  knowledge 
about  the  prevention  of  chronic  diseases  and  even  more  slowly  are  learn- 
ing how  to  apply  the  knowledge.  The  great  number  of  health  foods,  diets 
and  health  systems  are  evidences  of  the  first  stage  in  the  prevention  of 
chronic  disease,  when  nearly  every  one  tries  something  new  and  different. 
Most  of  the  experiments  are  an  improvement  over  the  old  systems  of  bad 
feeding  and  lack  of  exercise,  and  it  is  only  necessary  to  find  some  way  of 
supplying  the  necessary  guidance.  It  is  necessary  to  get  universal  health 
examinations,  more  general  attendance  at  clinics,  more  examination  and 
treatment  by  family  physicians,  somewhat  more  generalization  on  the  part 
of  specialists,  and  a  more  widespread  adoption  of  good  health  habits.  Pre- 
vention is  the  only  real  hope  in  the  situation. 

From  the  remedial  point  of  view,  the  outstanding  fact  about  Chronic 
Disease  and  the  Public  Welfare  today  in  Massachusetts,  as  in  every  other 
state,  is  the  need  for  additional  hospital  facilities.  Governor  Allen,  in  the 
progressive  and  comprehensive  public  welfare  program  which  he  proposed 
to  this  year's  legislature,  emphasizes  the  need  for  an  additional  unit  at 
some  state  hospital  for  the  care  of  persons  ill  with  chronic  diseases.  As 
Governor  Allen  said  in  that  message,  "The  end  of  government  is  the 
achievement  of  satisfaction  and  happiness  by  our  people.  No  group  can 
be  happy  in  the  presence  of  misery  or  suffering  or  poverty." 

THE  COST  OF  PREVENTABLE  DISEASE*   IN  MASSACHUSETTS 

By  Louis  I.  Dublin,  Ph.D., 

Statistician,  Metropolitan  Life  Insurance  Company,  New  York 

There  is  no  higher  obligation  of  the  modern  state  than  to  protect  the 
health  of  its  citizens.  For  health  is  basic  to  the  general  welfare.  I  can- 
not conceive  of  any  greater  service  which  you  can  render  to  the  Common- 
wealth than  to  help  banish  the  spectres  of  preventable  disease  and  of  pre- 
mature death.  We  are  altogether  too  prone  to  forget  these  truisms.  It  is 
only  when  an  epidemic  rages  that  we  are  stirred  up  from  our  lethargy  and 
we  see  on  all  sides  the  destructive  effects  of  sickness  and  of  death  on  indi- 
viduals, on  their  families,  and  on  the  community  in  general.  We  then  see 
sharply  and  in  exaggerated  form  what  we  overlook  daily  in  the  lesser  de- 
grees of  social  loss.  But  even  a  sizable  epidemic  usually  does  less  damage 
than  occurs  over  the  course  of  a  year  from  the  inobtrusive  effects  of  our 
continued  neglect. 

Little  do  we  ordinarily  appreciate  the  advantages  we  enjoy  as  the  result 
of  the  accomplishments  of  the  last  fifty  years  in  health  conservation.  We 
take  these  for  granted.  But  they  have  made  our  community  life  over,  and 
I  believe  they  are  in  large  measure  responsible  for  the  economic  prosperity 
and  the  higher  social  standards  which  prevail.  It  has  been  customary  to 
ascribe  our  current  financial  condition  to  the  interplay  of  economic  forces 
and  to  the  opening  up  of  our  natural  resources.  But  that  clearly  is  not  all. 
Most  of  us  do  not  realize  that  the  man  and  the  woman  of  today  live,  on  the 
average,  twenty  years  more  than  did  their  grandparents.  It  is  true,  of 
course,  that  this  accomplishment  is  largely  the  result  of  what  has  been 
achieved  in  preventing  the  ghastly  sacrifice  of  children  and  of  young  peo- 
ple. But  the  importance  of  this  must  not  be  taken  lightly.  Nor  have  the 
gains  been  limited  by  any  means  to  these  younger  ages.  Fifty  years  ago, 
a  baby  had  four  chances  in  five  of  surviving  its  first  year.  Today,  the 
chances  are  93  out  of  a  hundred.     In  other  words,  what  we  call  infant 


An  Address  on  Health  to  the  Statecraft  Institute,  Boston,  April  17,  1929. 


116 

mortality  has  been  reduced  from  about  200  per  thousand  births  to  only  65 
or  to  about  a  third.  Here  was  sheer  waste  of  human  life  which  we  have 
learned  to  prevent  through  the  application  of  common  sense  and  of  simple 
technical  means.  And  when  the  child  was  lucky  enough  to  survive  its  first 
year,  it  then  became  the  subject  of  a  host  of  infections  which  menaced  its 
life.  I  have  in  mind  such  conditions  as  diarrhea,  diphtheria,  smallpox 
and  typhoid  fever,  which  today  are  out  of  the  picture  altogether  or  are 
rapidly  becoming  so.  Our  knowledge  and  practice  of  how  to  care  for  the 
toddlers  and  the  children  in  the  schools  has  been  completely  revolutionized. 
As  a  result,  875  out  of  a  thousand  born  now  arrive  at  the  threshold  of 
manhood  and  of  womanhood  as  against  only  688  in  1880. 

A  child  that  is  saved  from  death  in  infancy  or  in  childhood  means  a  per- 
son saved  a  few  years  later  for  community  service.  Concretely,  we  see 
today  about  200  more  entering  the  age  of  self  dependence  out  of  every 
1,000  born  than  in  1880.  These  savings  not  only  prevent  the  emotional 
catastrophes  to  mothers,  but  make  available  to  the  communities  able- 
bodied  citizens  who  can  make  good  the  costs  which  have  been  involved  in 
bringing  them  into  the  world  and  in  rearing  them  to  manhood.  It  is  the 
nature  of  the  human  animal  in  a  civilized  community  that  he  can  produce 
more  than  he  costs.  Ordinarily,  we  give  more  than  we  get.  That  is  why 
we  are  valuable  creatures  even  in  the  grossest  sense  of  the  word.  We  are 
economic  assets  which  are  worth  conserving  and  when  there  has  been  a 
process  of  conservation  on  a  huge  scale  as  there  has  been  during  the  last 
fifty  years,  there  is  no  wonder  that  we  have  arrived  at  a  time  when  the 
great  masses  are  better  off,  can  earn  more,  can  save  more  and  can  live  al- 
together more  rational  and  creative  lives.  The  health  movement  which 
saw  so  much  of  its  initiative  and  development  in  this  Commonwealth  has 
arrived  at  a  point  when  its  effects  can  be  definitely  measured  in  terms  of 
a  happier  and  more  productive  life  for  all. 

I  should,  however,  be  doing  you  a  great  disservice  if  I  left  you  with  the 
impression  that  the  public  health  campaign  had  achieved  all  that  is  im- 
plied in  it.  There  is  very  much  yet  to  do  and  now  that  we  have  demon- 
strated the  principles  of  the  public  health  movement,  there  is  certainly  no 
excuse  for  not  doing  it.  We  can  add  ten  more  years  of  average  life-time 
to  the  twenty  we  have  already  added  and  thus  increase  still  further  the 
happiness  and  wellbeing  of  the  people.  I  know  of  no  simpler  and  more 
direct  route  of  establishing  a  happy  Commonwealth  than  by  reducing  di- 
sease and  preventing  premature  death  to  the  limit  of  our  knowledge  of 
sanitation  and  public  health  procedure.  Possibly  I  can  bring  this  home  to 
you  more  clearly  by  referring  to  such  activities  as  I  know  many  of  you 
are  engaged  in  in  your  local  social  service  work.  Many  of  you  are  inter- 
ested in  settlements  or  in  public  health  nursing  organizations,  in  child 
welfare  stations,  in  charity  organization  societies.  In  all  of  these,  you 
come  face  to  face  with  the  poor  and  the  under-privileged,  with  those  »who 
are  badly  adjusted,  and  those  who  in  general  need  community  help.  Is  it 
not  true  that  the  problems  with  which  you  are  concerned  in  these  organi- 
zations would  in  large  measure  disappear  if  disease  and  its  consequences 
could  be  checked?  That,  at  any  rate,  has  been  the  conviction  of  many 
leaders  in  social  work.  There  are  other  factors,  but  they  would  not  give 
us  much  concern  if  the  primary  ones  of  disability  and  premature  death 
could  in  some  way  be  brought  under  control.  What  would  it  mean  to  our 
Italian  or  to  our  negro  communities,  for  example,  if  they  could  know  what 
you  and  I  know  with  regard  to  personal  hygiene;  if  they  could  take  advan- 
tage of  the  modern  method  of  bringing  up  their  children  before  school  and 
during  school  years;  if  the  man  on  the  job  could  avoid  tuberculosis  and 
the  woman  could  go  through  her  maternal  duties  without  the  fears  and 
dangers  that  now  surround  them?  These  are  the  real  problems  in  the 
lives  of  these  people  and  if  we  could  only  lift  these  fears  in  some  big  com- 
munal way,  the  sun  would  come  in  and  brighten  their  lives.  At  one  swoop, 
we  could  eliminate  much  of  the  silly  stratification  and  painful  degradation 
into  which  sections  of  our  society  often  fall. 


117 

I  propose  to  discuss  with  you  the  approach  that  can  be  made  to  achieve 
the  health  results  which  I  have  in  mind.  Obviously,  this  is  a  big  subject 
and  I  can  only  touch  on  the  high  spots,  but  there  will  be  enough  to  exer- 
cise the  enthusiasm  and  ingenuity  of  all  of  us  if  we  really  mean  to  accom- 
plish some  of  these  results.  There  is  first  of  all  the  problem  of  infant 
mortality.  We  are  still  very  far  from  having  achieved  the  full  measure 
of  success  in  this  field  that  is  possible.  Your  very  latest  figures  show  that 
65,  out  of  every  thousand  babies  born,  die  before  they  are  a  year  old  and 
more  than  half  of  these  die  before  they  are  a  month  old.  There  is  no  ex- 
cuse whatever  for  continuing  this  slaughter  of  the  innocents.  There  are 
annually  well  over  5,000  children,  most  of  whom  are  still  sacrificed  to  ig- 
norance and  neglect.  The  great  majority  could,  with  a  measure  of  super- 
vision which  a  progressive  State  could  make  available  to  them,  survive  to 
the  point  of  being  productive  and  good  citizens.  This  will  mean,  of  course, 
that  more  mothers  will  need  care  and  instruction  during  pregnancy.  The 
value  of  prenatal  service  has  been  demonstrated  to  the  hilt.  This  will 
preserve  a  large  proportion  of  the  babies  that  are  now  born  either  pre- 
maturely or  who  die  of  congenital  debilities  and  malformations.  Of 
equally  great  importance  is  the  provision  of  adequate  care  of  the  mothers 
in  confinement.  But  this  takes  us  into  the  field  of  obstetrics.  There  is 
very  little  that  the  organized  community  can  do  until  more  physicians 
make  up  their  minds  to  do  this  work  with  greater  skill  and  a  better  con- 
science. Altogether  too  many  babies  are  victims  of  injuries  received  at 
birth  because  of  the  unpardonable  haste  of  the  doctor.  Then  there  are  the 
host  of  well  born  babies  that  die  because  their  mothers  do  not  know  how 
to  feed  them  or  perhaps  because  they  are  exposed  to  whooping  cough  or 
to  measles.  There  are  many  towns  and  cities  in  various  parts  of  the 
country  where  infant  mortality  rates  have  been  reduced  to  40  per  thou- 
sand and  even  to  30  per  thousand.  Chelsea,  Marlborough  and  Winthrop 
have  rates  between  30  and  35  and  there  is  no  reason  why  other  communi- 
ties of  Massachusetts  should  not  do  as  well.  That  would  save  2,600  infant 
lives  a  year  and  would  add  over  a  year  to  the  average  length  of  life  of  the 
whole  community. 

The  very  activities  which  I  have  just  enumerated  would  work  wonders 
also  in  the  lives  of  the  young  children  in  the  second  and  third  years,  in 
fact,  up  to  school  age.  You  are  all  aware  of  the  drive  that  has  been  made 
to  eradicate  diphtheria.  But  in  1927,  268  young  children  died  of  diph- 
theria in  Massachusetts.  Probably  fifteen  times  that  number,  we  do  not 
know  accurately  how  many,  suffered  from  this  disease  and  survived, 
thanks  to  the  beneficent  effect  of  the  early  administration  of  antitoxin. 
But  we  do  not  know  how  many  of  these  children  having  survived  diph- 
theria now  suffer  from  impaired  hearts  and  kidneys  which  will  shorten 
their  lives  in  later  years.  But  all  of  this  suffering  is  quite  unnecessary 
for  we  know  that  the  immunization  of  the  youngsters  with  toxin-antitoxin 
would  prevent  the  cases  as  well  as  the  deaths  from  diphtheria.  This,  too, 
has  been  amply  demonstrated.  A  child  that  is  fully  immunized  will  not 
get  diphtheria.  But  it  will  be  necessary  for  the  health  departments  and 
the  private  physicians  of  the  Commonwealth  to  bring  home  to  every 
mother  of  young  children  the  knowledge  of  this  remedy  and  to  make  avail- 
able facilities  for  immunization  either  at  State  expense  or  at  a  price  the 
average  mother  can  pay.  I  speak  of  diphtheria  only  as  an  illustration  for 
there  are  other  conditions  which  like  diphtheria  make  the  life  of  the  young 
child  hard.  There  is  poor  nutrition  and  the  attacks  of  scarlet  fever,  of 
measles  and  of  whooping  cough,  much  of  which  need  not  occur  and  would 
not  if  the  health  organizations  of  the  community  and  the  private  agencies 
engaged  in  public  welfare,  really  got  close  to  the  mothers  of  their  com- 
munities and  gave  the  service  which  controls  these  conditions. 

Then  there  is  the  problem  of  tuberculosis.  About  three  thousand  per- 
sons died  from  this  disease  in  1927  in  Massachusetts  and  possibly  25,000 
more  are  living  more  or  less  impaired  lives  because  of  a  heavy  infection 
of  this  disease  to  which  most  will  ultimately  succumb.   In  the  age  group 


118 
15  to  39,  this  disease  is  still  the  principal  cause  of  death.  Tuberculosis  is, 
however,  nothing  like  what  it  was  twenty-five  years  ago  when  Massachu- 
setts had  an  unenviable  place  in  the  list  of  States.  But  the  same  activi- 
ties which  have  brought  your  improvement  about  must  be  strengthened 
if  there  is  to  be  a  victory  over  this  quite  unnecessary  tax  on  vigor  and 
youth.  The  disease  is  on  the  wane  and  can  be  wiped  out  in  the  next 
twenty-five  or  thirty  years,  but  it  will  require  an  active  campaign.  It  will 
mean  that  children  must  be  well  fed,  that  they  must  be  protected  against 
infection  from  tuberculous  milk  coming  from  infected  herds  and  must 
know  how  to  keep  their  bodies  in  good  physical  condition.  I  heartily  favor 
the  ten  year  program  begun  by  Dr.  Kelley  and  continued  by  Dr.  Bigelow 
by  which  a  wholesale  effort  is  being  made  to  discover,  by  state-wide  exami- 
nation, the  children  who  already  show  signs  of  infection  and  who  need 
special  care  to  prevent  further  damage  from  tuberculosis.  Extraordinary 
results  have  already  followed  from  the  operation  of  this  plan,  for  you  now 
know  where  the  positive  reactors  are.  You  know  also  that  they  have  been 
reduced  by  23  per  cent  in  a  relatively  short  period  of  time.  This  disease 
begins  in  most  cases  in  childhood  and  if  it  can  be  discovered  and  treated 
adequately,  the  outlook  in  most  of  those  cases  is  entirely  favorable.  Out 
of  this  effort  will  probably  come  very  valuable  by-products  and,  of  these, 
I  consider  most  important  the  popularization  of  the  annual  physical  exam- 
ination. More  and  more,  there  must  be  set  up  facilities  for  such  examina- 
tions in  all  good-sized  communities  of  the  Commonwealth  equipped  with 
the  necessary  facilities  of  good  diagnostic  clinics,  so  that  not  only  tubercu- 
losis may  be  discovered  in  incipient  stages,  but  other  serious  conditions 
as  well.  What  was  so  clearly  demonstrated  as  possible  in  Framingham, 
can  be  achieved  throughout  Massachusetts.  By  this  means,  it  will  be  pos- 
sible to  prolong  the  lives  of  1,500  people  each  year,  many  of  whom  are 
fathers  and  mothers  with  young  children.  It  is  difficult  adequately  to 
measure  the  savings  to  the  community  resulting  from  this  effort. 

Another  very  desirable  public  health  activity  is  an  attack  on  the  diseases 
which  affect  the  great  mass  of  the  population  in  middle  life.  To  quote 
your  Health  Commissioner,  "The  chronic  diseases  are  the  most  important 
medico-social  problems  facing  us."  I  believe  he  is  entirely  right.  The 
infections  are  gradually  coming  under  control.  But  that  only  results  in 
more  people  arriving  at  40  and  50,  many  of  whom  suffer  from  one  or 
another  of  the  chronic  conditions.  We  have  accomplished  only  a  very  lim- 
ited saving  if  we  stop  without  attacking  the  correlated  problem  of  the 
chronic  diseases.  We  have  learned  that  they,  too,  are  largely  preventable. 
I  have  in  mind  the  impairments  of  the  heart,  blood  vessels  and  kidneys, 
and  the  worst  blight  of  all,  cancer,  which  affect  a  great  many  persons  in 
middle  life  when  they  ought  to  be  at  the  very  height  of  their  usefulness. 
You  must  not  think  that  the  chronic  diseases  are  limited  to  old  people.  No 
one  pretends  that  these  conditions  will  submit  to  control  as  easily  as  have 
diphtheria  and  tuberculosis  and  as  we  hope  pneumonia  will  in  the  next 
five  or  ten  years.  But  we  believe  that  in  many  cases  the  effects  of  these 
chronic  diseases  can  be  staved  off  to  give  these  people  a  longer  lease  on  ac- 
tive and  happy  life.  Again  we  must  have  community  organization  which 
means  facilities  for  the  examination  of  people  by  competent  medical  ex- 
aminers who  will  discover  the  presence  of  these  conditions  early  when 
something  can  be  done  about  it;  when  a  word  of  advice  as  to  habits  may 
result  in  staying  the  impairment  of  function  of  the  vital  organs,  or  when 
a  minor  operation  will  stop  the  development  of  a  malignant  growth. 

This  program  is  especially  important  in  Massachusetts.  You  have  a 
larger  proportion  of  middle-aged  and  old  people  than  in  most  other  States 
and  this  condition  will  probably  get  worse  in  view  of  the  declining  birth 
rate  and  the  continued  reduction  in  mortality  at  the  younger  ages.  Unless 
an  attempt  is  made  to  control  the  degenerative  diseases  in  middle  life  you 
are  likely  to  find  yourselves  spending  a  great  deal  of  money  each  year  to 
provide  increased  hospitalization  for  the  chronic  sick  in  State  institutions. 
This  is  a  very  expensive  venture  as  you  are  already  discovering  in  relation 


119 

to  the  care  of  cancer  cases.  It  would  probably  prove  much  more  satisfac- 
tory to  you  to  encourage  the  set  up  of  annual  medical  examinations,  the 
extension  of  district  nursing  service  to  the  sick  in  their  homes  and  in 
other  ways,  to  care  for  these  people  while  there  is  still  hope  for  them. 

How  may  all  this  be  accomplished?  My  answer  is  primarily  through 
the  operations  of  the  official  health  departments.  They  are  empowered 
with  these  functions  partially  in  the  towns  and  cities  and  partially  in  the 
State  Department.  But  you  will  say  that  there  are  now  such  health  de- 
partments actively  functioning.  What  more  is  there  to  do?  It  is  true 
that  Massachusetts  has  for  many  years  led  and  still  leads  in  the  complete- 
ness of  its  public  health  service.  But  it  is  equally  true  that  even  in  this 
Commonwealth  there  is  an  immense  task  for  completion.  Only  in  the 
larger  cities  of  the  Commonwealth  is  the  health  work  in  the  hands  of  full- 
time  officers.  In  the  smaller  communities,  the  health  officer  is  usually  a 
part-time  employee  practicing  medicine  on  the  side  and  with  his  main  in- 
terest in  his  practice.  The  whole  set-up  for  a  large  proportion  of  the  pop- 
ulation is  still  an  impossible  one  for  the  efficient  accomplishment  of  the 
tasks  I  have  outlined. 

Massachusetts  is  essentially  an  urban  State  and  yet  about  20  per  cent 
of  the  people  live  in  rural  areas,  that  is,  in  communities  with  populations 
under  10,000.  As  I  have  intimated,  it  is  in  these  villages  and  in  the 
smaller  towns  that  the  problem  of  the  public  health  is  particularly  acute. 
You  would  be  rendering  your  Commonwealth  an  enormous  service  if  you 
would  concentrate  your  effort  on  the  situation  in  them.  In  a  certain  sense, 
the  difficulty  is  of  an  economic  nature.  It  is  obviously  impossible  for  each 
small  community  to  obtain  modern  health  service  for  it  could  scarcely 
afford  to  pay  for  the  full  time  of  a  health  officer  and  all  that  goes  with  it 
in  terms  of  laboratory  and  clinical  facilities  necessary  for  the  conduct  of 
a  modern  health  program.  You  must  seek  a  larger  unit  than  the  small 
community.  In  many  cases,  the  county  is  the  logical  health  unit.  You 
have  yourselves  pioneered  in  this  direction  by  organizing  the  health  work 
of  the  rural  county  of  Barnstable,  which,  by  all  accounts,  has  proved  a 
very  successful  experiment.  The  same  might  be  done  in  several  other 
counties.  But  for  the  most  part,  the  county  is  too  large  and  clumsy  as  an 
administrative  unit.  I  understand  that  permissive  legislation  has  been 
passed  this  year  allowing  towns  to  unite  in  union  health  districts  in  a 
manner  similar  to  the  superintendency  districts  for  education  which  have 
been  in  force  for  some  time.  For  the  community  under  10,000  and  for 
some  communities  above  this  figure,  this  is  the  only  solution.  You  must 
concentrate  on  a  coordinated  effort  to  get  adjacent  communities  to  agree 
on  the  establishment  of  unified  health  service  under  competent  full-time 
supervision,  adequately  financed.  If  those  of  you  who  live  in  the  smaller 
communities  would  concentrate  on  this  effort  for  the  next  few  years  and 
make  it  a  special  point  to  accomplish  this,  you  would  work  a  revolution  in 
the  health  conditions,  not  only  of  your  localities,  but  of  your  Common- 
wealth. 

The  larger  towns  and  cities  already  have  public  health  departments  and 
as  I  have  said  they  compare  very  favorably  with  the  best  in  the  country. 
This  is  very  generally  acknowledged.  But  there  is  still  much  to  do,  and 
I  take  it  that  you  want  me  to  tell  you  frankly  what  that  is.  A  Committee 
of  the  American  Public  Health  Association  composed  of  experts  on  health 
department  organization,  has  studied  this  problem  of  health  organization 
for  a  period  of  ten  years.  They  have  spread  their  efforts  over  a  great 
many  of  the  States  and  have  studied  especially  the  cities  of  Massachusetts. 
Their  first  insistence  is  on  the  appointment  of  a  full-time,  well-trained 
medical  officer  of  health.  The  time  when  any  medical  practitioner  or  a 
layman  might  step  into  a  health  department  and  hope  to  accomplish  good 
results  is  over.  Health  service  is  a  specialized  task  requiring  very  definite 
training.  Such  a  health  officer  must  enjoy  permanence  of  tenure,  subject, 
of  course,  to  good  conduct  and  efficiency.  His  position  must  be  free,  in 
any  case,  from  political  pressure.    There  must  be  a  Board  of  Health  with 


120 

specific  duties  sharing  in  the  responsibility  and,  finally,  there  must  be  a 
definite  program,  budgeting  the  total  expenditures  in  a  number  of  definite 
ways;  so  much  for  administration;  so  much  for  laboratory  service;  for 
communicable  disease  prevention  and  supervision;  for  public  health  edu- 
cation ;  for  public  health  nursing ;  for  child  welfare ;  and  so  much  for  vital 
statistics  registration.  In  other  words,  we  have  now  achieved  a  very  defi- 
nite conception  of  an  organization  which  fits,  with  slight  modification, 
most  communities.  This  conception,  moreover,  is  the  best  judgment  of 
the  health  officers  themselves  arrived  at  after  much  study,  trial  and  effort 
in  a  large  number  of  communities  under  different  conditions.  Such  well- 
balanced  service  will  cost,  they  say,  about  $2.50  per  capita  per  annum.  In 
a  community  of  10,000,  this  will  mean  $25,000  a  year  for  public  health 
service  and  in  a  community  of  100,000,  a  budget  of  $250,000.  In  Massa- 
chusetts, your  cities  are  actually  spending  much  less.  Only  one  city,  Fall 
River,  seems  to  have  an  adequate  budget,  namely,  $2.58  per  capita. 
Brookline  and  New  Bedford  come  next  with  $2.11  per  capita.  The  rest 
show  much  less  for  their  actual  expenditures  and  a  number  spend  only  be- 
tween sixty  and  seventy  cents  per  capita.  There  is  no  way  of  doing  the 
necessary  work  with  insufficient  funds.  One  service  or  another  will  suf- 
fer; either  the  child  health  work  or  the  tuberculosis  work  or  the  hospital- 
ization of  the  communicable  diseases  or  the  public  health  nursing ;  or  you 
will  waste  the  greater  part  of  the  appropriations  you  have  made  by  going 
through  the  motions  with  a  half -trained  health  officer  whom  you  are  pay- 
ing a  meagre  salary.  This  is  the  crux  of  the  whole  situation,  and  I  should 
feel  that  I  had  missed  an  opportunity  if  I  did  not  stress  above  all  things 
else  this  matter  of  the  adequate  financing  of  your  local  health  departments 
in  order  that  you  may  obtain  the  services  of  trained,  full-time  men.  They 
will  take  care  of  the  rest. 

There  is  still  another  and  very  important  phase  of  the  problem  and  this 
concerns  the  State  health  organization.  You  have  been  for  many  years 
and  are  still  very  fortunate  in  your  choice  of  Health  Commissioners  and 
in  the  character  of  the  service  they  are  rendering.  That  is  everywhere 
acknowledged.  But  here,  too,  there  is  much  to  be  done.  The  State  De- 
partment has  very  important  functions.  It  oversees  and  coordinates  the 
local  services,  stimulates  effort,  and  points  out  the  opportunities  for  im- 
provement in  health  work  here  and  there.  It  conducts  the  State  Labora- 
tory and  supplies  the  biological  products  for  the  Commonwealth.  It  is  an 
organization  for  study  and  investigation.  More  recently,  it  has  inter- 
ested itself  in  such  problems  as  tuberculosis  and  cancer  control.  I  have 
already  told  you  of  its  most  important  contribution  to  the  solution  of  the 
problem  of  tuberculosis.  In  the  cancer  field,  the  Legislature  has  in  recent 
years  placed  in  the  department  the  responsibility  for  the  care  of  cancer 
cases,  I  suppose  on  the  theory  that  the  smaller  communities  could  not  pos- 
sibly take  care  of  these  patients  adequately.  The  total  budget  of  the  State 
Health  Department  is  now  approximately  $2,700,000,  of  which  $1,700,000 
or  close  to  two-thirds,  goes  to  the  four  State  sanatoria  and  the  cancer  hos- 
pital. In  addition,  a  quarter  of  a  million  is  paid  out  to  cities  and  towns 
as  subsidy  for  hospitalizing  their  tuberculous  sick.  This  leaves  three- 
quarters  of  a  million  for  direct  public  health  work,  which  is  equivalent  to 
seventeen  cents  per  capita.  This  amount,  I  believe,  is  too  small  for  what 
your  Health  Commissioner  tries  to  accomplish.  I  know  that  he  would 
much  rather  emphasize  the  education  of  the  public  along  health  lines 
throughout  the  State,  investigate,  direct  and  encourage  the  local  services 
than  engage  in  the  care  of  chronic  diseases  in  institutions.  His  concep- 
tion of  his  department  is  perfectly  right,  namely,  of  a  coordinating  and  a 
directing  agency.  But  to  do  that  right  costs  money  and  seventeen  cents 
per  capita  is  not  enough.  At  least  twice  that  amount  would  seem  to  me  to 
be  called  for  as  a  supplement  to  the  amounts  which  I  have  already  indi- 
cated as  adequate  for  the  local  health  departments. 

To  summarize  then,  it  will  require  that  the  citizens  of  Massachusetts 
will  have  to  tax  themselves  to  an  amount  of  $3.50  per  capita  to  cover  the 


121    • 

local  services,  the  State  services,  and  the  cost  of  the  voluntary  health  or- 
ganizations that  are  so  essential  in  cooperating  with  the  official  agencies. 
In  the  Commonwealth  of  Massachusetts,  that  will  mean  actually  an  expen- 
diture of  between  fifteen  and  sixteen  million  dollars  a  year,  as  against  the 
present  expenditure  of  about  ten  million  dollars.  You  may  well  ask 
whether  the  additional  six  million  dollars  are  justified.  This  is  certainly 
no  time  for  playing  fast  and  loose  with  public  funds.  There  is  a  strong 
movement  on  foot  for  retrenchment  and  for  efficiency  in  public  service. 
My  answer  is  that  the  added  expenditure  is  called  for  as  a  measure  of 
economy.  It  is  the  one  sure  way  to  get  the  full  value  out  of  the  dollars 
you  are  now  spending.  There  is,  however,  another  aspect  of  the  subject 
which  must  be  stressed.  Most  people  do  not  realize  the  great  stakes  that 
are  involved  in  the  conservation  of  life.  We  do  not  like  to  think  in  eco- 
nomic terms  when  we  talk  of  men,  women  and  children.  But  they  have 
economic  value  and  in  the  aggregate  their  economic  values  transcend  all 
others.  I  have  estimated  that  our  human  capital  is  worth  five  times  all 
other  capital  including  real  property,  live  stock,  machinery,  agricultural 
and  mining  products,  and  manufactured  goods  of  all  sorts.  It  costs  much 
money  to  bring  children  into  the  world.  It  costs  more  money  to  raise 
them  and  that  is  true,  not  only  of  your  children  and  my  children,  but  of 
children  in  the  families  of  the  great  masses  of  workers.  That  is  why  it  is 
a  dreadful  waste  of  capital  to  allow  babies  to  be  born  prematurely  and  to 
die  prematurely  and  to  have  young  men  and  women  at  the  very  threshold 
of  life  sicken  and  die  of  tuberculosis  and  later  of  heart  disease  when  they 
still  have  before  them  years  of  valuable  activity  in  which  they  may  make 
good  the  cost  of  bringing  them  into  the  world  and  of  rearing  them.  When 
a  wage  earner  at  30  is  cut  down,  his  family  suffers  a  loss  of  $30,000.  Is  it 
worth  a  few  dollars  per  capita  to  supply  the  facilities  necessary  to  make 
that  sort  of  loss  less  likely?  I  think  it  is.  I  have  estimated  that  in  the 
United  States  each  year  we  lose  a  total  of  six  billions  of  dollars  in  the 
value  of  the  lives  lost  from  preventable  causes.  In  addition,  sickness  costs 
directly  in  lost  wages,  in  reduced  production,  as  well  as  in  the  necessary 
medical  and  hospital  care  a  total  in  excess  of  two  billions  of  dollars  a  year. 
The  total  bill,  in  other  words,  rises  to  the  staggering  figure  of  eight  bil- 
lions of  dollars  a  year.  There  is  no  reason  why  conditions  in  Massachu- 
setts are  not  very  much  the  same  as  in  other  States  and  I  would,  there- 
fore, estimate  that  your  total  tax  on  the  score  of  preventable  death  and 
disease  is  not  far  from  three  hundred  millions  a  year.  It,  therefore,  re- 
solves itself  to  this  proposition:  Are  you  prepared  to  recommend  the  ex- 
penditure of  a  few  more  millions  of  dollars,  in  all  not  more  than  six,  in 
order  to  save  three  hundred  millions  and  at  the  same  time  increase  in  un- 
measured terms  the  happiness  and  prosperity  of  your  people.  That  is  the 
crux  of  the  problem.  There  is  no  greater  investment  available  to  any  or- 
ganized community  than  an  investment  in  good,  well-balanced  and  exe- 
cuted public  health  service. 

HEALTH  EDUCATION  FOR  THE  ADULT 

By  Mary  R.  Lakeman,  M.D., 
Epidemiologist,  Division  of  Adult  Hygiene 

Most  of  us  become  interested  in  health  only  as  we  feel  it  slipping  from 
our  grasp. 

The  task  in  health  education,  it  seems  then,  is  to  make  the  subject  of 
health  so  live,  so  full  of  vital  interest  that  it  will  attract  and  hold  the  at- 
tention by  its  dramatic  possibilities  just  as  have  the  newer  discoveries  of 
modern  science  in  other  and  more  obviously  practical  fields — such  as  the 
radio,  electrical  developments,  etc. 

There  are  stories  in  physiology,  for  instance,  the  striking  effects  of  the 
release  of  adrenalin  under  strong  emotion,  the  fascinating  serial  story  of 
digestion,  the  prize-fighter's  training  and  where  he  gets  his  endurance — ■ 


122 
which  carry  all  the  inherent  interest  of  the  front-page  story  of  the  avi- 
ators' endurance  test  or  the  speed  reached  in  the  last  automobile  race.    It 
remains  for  us  to  find  the  kernel  of  true  interest  and  to  give  it  a  congenial 
soil  properly  prepared  for  the  planting  of  the  seed. 

When  our  people  once  comprehend  the  enormous  possibilities  for  health 
improvement  which  are  being  opened  up  through  the  continuous  outflow 
of  knowledge  pouring  in  upon  us  from  field  and  laboratory,  an  irresistible 
demand  will  be  created,  to  put  that  knowledge  into  effect.  This  is  the 
challenge  which  faces  us  today. 

Education  of  the  Adult 

That  the  mature  human  being  is  susceptible  to  educational  measures, 
notwithstanding  many  freely-expressed  opinions  to  the  contrary,  is  clearly 
brought  out  in  the  studies  recently  made  by  E.  L.  Thorndike  of  Columbia 
University.  Mr.  Thorndike  says : — "Nobody  under  forty-five  should  re- 
strain himself  from  trying  to  learn  anything  because  of  a  belief  that  he  is 
too  old  to  be  able  to  learn  it.  .  .  .  "If  he  fails  in  learning  it,  inability  due 
directly  to  age  will  very  rarely,  if  ever,  be  the  reason." 

The  studies  on  which  Mr.  Thorndike  bases  these  statements  show  the 
adult  of  forty  or  forty-five  to  be  capable  of  learning  as  much  as  the  ado- 
lescent, but  requiring  more  time  in  which  to  do  it.  Watson  calls  attention 
to  the  fact  that  this  is  largely  compensated  for  by  the  scope  the  mature 
mind  has  achieved  through  wide  backgrounds  of  general  experience  which 
the  adolescent  lacks.  The  adult,  too,  demands  a  reason  for  what  he  is 
asked  to  do,  and  furthermore,  he  wants  a  specific  worthwhile  job  with  a 
definite  purpose  to  work  for.  Perhaps  this  is  one  of  the  reasons  for  the 
great  popularity  of  the  fad  for  weight-reduction.  We  can  measure  our 
gain  and  loss  in  familiar  pounds  and  ounces,  and  discuss  the  calories  we 
consume  the  while  we  consume  them. 

Interest 

If,  as  there  seems  to  be  little  reason  to  doubt,  interest  is  the  first  word 
in  education,  then  apparently  the  first  step  in  health  education  for  the 
adult  is  to  create  interest  in  health  among  the  people.  But,  who  are  the 
people?  And  what  are  they  now  interested  in?  Our  school  is  a  large  one 
and  our  classes  ungraded.  It  includes  alike  the  student  at  his  books  and 
the  day -laborer  at  pick  and  shovel;  the  mother,  with  twenty  small  hands 
to  get  into  mischief  and  as  many  small  feet  to  run  away  on,  and  the  lan- 
guid lady  who  never  walks  if  she  can  ride,  never  stands  if  she  can  sit,  and 
never  sits  if  she  can  lie  down.  Then  there  is  the  slender  school  or  business 
girl  courting  a  boyish  figure,  and  the  overweight  matron ;  the  hard-pressed 
business  man  and  the  street-corner  loafer.  How  enlist  the  interest  of 
each  one — and  of  all  the  others? 

Until  we,  who  assume  that  we  have  something  to  teach,  find  common 
ground  with  those  we  assume  have  need  of  our  teaching,  we  shall  not  get 
far  ahead. 

From  the  Known  to  the  Unknown 

Again  comes  an  echo  of  the  words  of  wisdom  of  our  friends,  the  edu- 
cators, "Education  should  progress  from  the  known  to  the  unknown." 
Hence,  we  must  build  upon  the  zeal  for  a  boyish  figure,  or  the  longing  of 
the  mother  to  hold  out  for  her  children's  sake — for  each  a  separate  plan 
whose  foundation  will  rest  upon  the  controlling  interest  of  each  individual 
or  each  small  group.  To  the  mechanic,  the  threadbare  but  still  serviceable 
analogy  of  the  engine  duly  inspected  and  kept  in  repair,  may  drive  home 
the  similar  need  of  his  physical  engine  for  inspection  and  repair. 

To  the  all-too-devoted  mother  no  appeal  is  so  strong  as  the  well-being  of 
her  children.  We  may  be  able  to  win  her  confidence  by  convincing  her 
that,  without  care  for  her  own  physical  being  she  cannot  create  an  at- 
mosphere of  happiness  and  vigor  for  her  children. 

The  young  girl  who  longs  for  the  fair,  smooth  skin  of  her  favorite  movie 


123 

star  may,  by  way  of  that  longing,  be  led  to  cultivate  habits  of  eating  and 
living  that  will  bring  their  own  reward. 

The  Students 

In  our  ungraded  school  of  health,  too,  we  are  going  to  find  all  types  of 
mind.  A  few  alert,  quick  to  absorb  every  new  idea  and  asking  the  reason 
for  everything.  There  will  be  more  who  are  passive,  uninterested,  unac- 
customed to  doing  their  own  thinking,  responsive  only  when  they  receive 
an  emotional  jolt,  and  lapsing  into  a  state  of  inaction  immediately  there- 
after. 

One  successful  teacher  of  health  declares  her  pupils  to  be  of  three  types : 
1.  The  one  who  needs  to  be  shown  once,  and  once  only.  2.  The  one  who 
needs  to  be  shown  many  times,  but  who  finally  gets  the  point  and  carries 
on.  3.  The  one  who  must  be  shown  each  single  step  over  and  over  again, 
then  watched  as  he  performs  the  task  until  at  last  habit  comes  to  the 
rescue. 

We  shall  meet  the  readers  and  the  non-readers,  the  eye-minded,  the  ear- 
minded,  those  who  in  the  words  of  the  darkey,  "sit  'n  think,"  and  others 
who  "jes'  sit." 

The  Single  Idea 

We  may  well  keep  in  mind  the  wisdom  of  presenting  to  most  folks  a 
single  thought  or  idea  at  one  time.  Few  of  us  grasp  more,  and  we  must 
remember  that  we  are  expecting  grown  folks,  who  have  dropped  the  learn- 
ing habit,  to  comprehend  in  a  few  minutes  ideas  which  we  have  been  ab- 
sorbing for  years.  Better,  too,  that  our  language  be  unnecessarily  simple 
for  some  than  unintelligible  to  any. 

Where  to  Begin 

While  we  are  trying  to  discover  just  what  is  the  task  of  adult  education 
in  health,  we  may  with  profit  turn  our  attention  to  certain  groups  which 
have  been  definitely  shown  to  be  in  need  of  help.  There  is,  for  instance, 
the  young  girl  who  cuts  down  her  midday  meal  in  what  she  considers  the 
interests  of  her  figure,  and  incidentally  perhaps,  of  her  pocketbook.  Too 
often  she  is  encouraged  by  an  over-stout  but  not  over-wise  mother  who  is 
reducing  her  calories  by  Mme.  So-and-So's  method  and  who  thinks  that 
which  is  sauce  for  the  goose  must  be  sauce  for  the  gander.  Meantime,  the 
life-tables  tell  us  clearly  of  the  inroads  tuberculosis  is  still  making  among 
young  girls  in  spite  of  a  rapidly-declining  death-rate  in  other  age  groups. 

In  certain  isolated  instances  we  have  seen  marked  success  attend  efforts 
to  entice  these  youngsters  into  sound  habits  of  eating  and  sleeping.  Let 
us  learn  from  them  how  these  results  may  be  extended. 

Then  there  is  the  tired  mother  who,  like  the  poor,  is  always  with  us. 
Some  of  the  city  settlements,  a  few  clinics,  and  the  home  extension  work- 
ers are  helping  her  to  conserve  her  energies  and  to  feed  herself  as  well  as 
she  does  her  children.  Let  us  learn  from  them  and  carry  on  the  good  work 
with  them. 

The  man,  who  for  years  has  been  a  prisoner  at  his  desk  or  counter  may 
yet  yield  to  the  fascination  of  an  old  hobby  if  someone  will  take  the  pains 
to  go  with  him  or  tell  him  where  he  can  play  the  old  games  that  call  for 
the  use  of  the  big  muscles.  Are  such  resources  available  in  all  our  com- 
munities— and  does  the  man  who  might  make  good  use  of  them  always 
know  about  them — and  is  the  cost  within  his  means  ?  If  not,  what  can  we 
do  about  it? 

The  Health  Examination 

Time  and  energy  given  without  stint  will  be  well  spent  in  an  endeavor 
to  convince  our  people  that  the  periodic  health  examination  is  capable  of 
bringing  large  returns. 

Neither  the  public  nor  the  medical  profession  is  yet  fully  persuaded 
that  the  health  examination  is  a  life-saving  and  health-giving  measure  of 
the  first  importance.    It  is  doubtful  whether  any  public  health  measure  is 


124 
more  fundamental  in  the  prevention  of  unnecessary  illness,  or  in  the  pro- 
longation of  the  span  of  life — or  better  yet,  the  span  of  health,  after  the 
age  of  forty  or  forty-five  than  is  the  periodic  examination  followed  by 
sound  advice  from  a  qualified  physician.  Advice  must  be  given  in  so  con- 
vincing a  manner  that  the  "patient"  may  be  induced  to  reverse  certain 
habits  of  living  if  necessary,  sometimes  at  a  considerable  sacrifice.  This 
responsibility  falls  squarely  upon  the  shoulders  of  the  examining  physi- 
cian. In  fact,  the  degree  to  which  he  succeeds  in  having  his  advice  carried 
out  will  be  the  measure  of  the  efficiency  of  the  periodic  examination  as  a 
means  of  raising  the  level  of  health  through  middle  age. 

Ways  must  be  found  to  make  such  service  available  to  all  at  a  cost 
within  their  means.  It  may  be  that  as  the  demand  increases  more  physi- 
cians will  become  interested  in  this  means  of  health  conservation.  At 
present  there  appear  to  be  but  few.  The  Life  Extension  Institute  and  a 
number  of  clinics  in  the  larger  cities  offer  a  satisfactory  examination. 
The  custom  is  extending  slowly  and  is  almost  certain  to  be  accepted  by  the 
people  at  large  before  many  years.  As  the  demand  increases,  service  will 
become  available. 

Disease  Prevention 

Much  will  undoubtedly  be  done  in  the  future  in  the  prevention  of  cer- 
tain disease  conditions  appearing  commonly  in  middle  life.  Already  it  is 
known  that  through  the  spread  of  information  of  the  causes  of  diabetes, 
heart  disease,  arthritis  and  others  of  the  so-called  "silent"  diseases,  much 
can  be  done  to  avert  some  of  the  disastrous  results  occurring  at  present 
from  these  diseases.  It  will  take  time  and  thought  to  determine  what  is 
to  be  done  in  these  directions.    But  that  is  another  story. 

An  organized  program  looking  toward  the  control  of  cancer  is  already 
under  way  and  the  experience  gained  through  the  working  out  of  this  pro- 
gram will  be  of  great  value  in  pointing  the  way  in  the  wider  field  of  adult 
hygiene. 

A  Broader  Program 

In  considering  a  program  of  education  in  this  new  field  the  Department 
is  naturally  looking  to  those  who  are  already  working  along  each  particu- 
lar line,  and  to  the  health  workers  in  each  community.  In  the  cancer  pro- 
gram the  medical  profession,  the  hospitals,  the  public  health  nurses,  and 
the  social  workers  have  been  heavily  drawn  upon  for  advice  and  for  ser- 
vice. Groups  of  citizens  are  also  giving  generously  of  their  time  in  build- 
ing public  opinion,  and  in  keeping  the  people  informed  of  the  growing  re- 
sources and  instructed  in  the  early  signs  of  the  disease. 

Similarly  in  other  directions  the  same  sort  of  support  will  be  looked  for 
by  the  Department  and  we  have  faith  that  it  will  not  be  in  vain.  We  shall 
look  to  the  educators,  especially  those  who  are  dealing  with  students  above 
high  school  age,  and  those  who  have  already  paved  the  way  in  physical  ed- 
ucation, in  nutrition,  in  home  economics,  in  mental  hygiene.  We  shall 
look  for  help  from  the  public  libraries,  in  fact  from  all  those  who  have 
been  leading  the  way  on  the  road  we  now  are  bidden  to  travel  with  them 
toward  the  common  goal  of  health  and  a  lengthened  span  of  health. 

Adult  Education 

Our  path  seems  to  lie  especially  close  to  that  of  our  friends  who  are  ac- 
tive in  the  old-new  movement  for  adult  education,  a  movement  as  old  as 
public  education  itself,  for  the  first  efforts  to  bring  about  public  education 
were  directed  to  the  adult — yet  new  through  the  renewed  impetus  given 
to  adult  education  by  the  success  of  the  Danish  Folk  Schools,  University 
Extension  and  similar  movements  which  are  making  it  possible  for  the 
older  student  to  carry  on  his  intellectual  development.  It  is  gratifying  to 
learn  that  subjects  related  to  health  have  been  offered  in  many  such 
courses.  Much  more  can  be  done  than  has  been  done  to  make  these  sub- 
jects attractive  and  to  show  their  relationship  to  every-day  living  and  to 
success  in  life. 


125 
The  Printed  Word 

As  we  learn  that  the  average  adult  spends  approximately  ninety  minutes 
a  day  in  reading  we  see  one  great  avenue  open  before  us  by  which  infor- 
mation in  matters  of  health  may  be  brought  to  the  mature  mind. 

The  magazines  have  been  quick  to  seize  upon  this  opportunity,  and  in 
many  instances  are  doing  amazingly  good  public  health  work. 

If  further  evidence  were  needed  of  the  value  of  the  printed  word,  we 
should  find  it  in  the  results  of  a  study  of  314  adults  among  whom  it  was 
learned  that  fifty-three  per  cent  read  books,  seventy-six  per  cent  read  mag- 
azines and  ninety-seven  per  cent  read  newspapers.  In  age,  it  appears,  that 
the  largest  number  of  readers  are  between  seventeen  and  thirty. 

Health  and  the  Emotions 

Though  we  realize  that  action  springs  almost  solely  from  the  arousing 
of  some  emotion  and  that  the  emotional  appeal  of  health  is  not  a  powerful 
one,  we  yet  have  confidence  that  our  people  will  sooner  or  later  grasp  the 
significance  of  health  as  an  asset  no  less  tangible  than  the  gold  which  lured 
the  "forty-niners"  into  the  West.  It  may  be  "easier  to  weep  than  to 
think,"  but  it  is  not  in  the  nature  of  New  England  folk  to  sit  down  and 
weep  to  no  purpose.  We  have  to  be  shown,  and  we  like  to  think  it  over,  to 
be  sure,  but  we  are  a  people  who  in  the  end  act — and  act  usually  with 
wisdom. 

The  Secret  of  Success 

Frankly  facing,  then,  all  of  these  known  difficulties  and  many  not  yet 
known,  we  believe  success  will  attend  our  efforts  just  insofar  as  these  are 
directed  toward  meeting  the  specific  need  of  an  individual  or  group,  and 
as  they  fall  in  line  with  activities  of  proven  worth  which  are  already  being 
carried  on  in  each  community. 

CHRONIC  DISEASE  IN  INDUSTRY 

By  Wade  Wright,  M.D., 
Assistant  Medical  Director,  Metropolitan  Life  Insurance  Company 

The  admonition  to  "keep  well,"  frequently  uttered  by  those  solicitous 
of  the  public  health,  is,  without  quibble,  a  counsel  of  perfection.  Even 
quite  casual  searching  of  the  souls  and  bodies  of  any  group  beyond  the  age 
of  childhood  reveals  in  practically  all  individuals  very  definite  physical  or 
mental  impairment,  though  they  may  be  in  many  instances  minor  ones. 
The  task  of  "keeping  well"  is  essentially  that  of  not  becoming  any  sicker. 

The  true  incidence  of  chronic  disease  in  any  sizeable  adult  group,  such 
as  that  represented  by  industrial  workers,  has  never  been  determined,  but 
there  exist  some  data  which  indicate  the  prevalence  and  character  of  such 
disease. 

Most  of  the  sickness  commonly  recognized  among  industrial  workers  is 
that  which  is  of  such  severity  as  to  result  in  loss  of  working  time.  This 
sickness  absenteeism  undoubtedly  reflects  fairly  accurately  the  incidence 
and  severity  of  the  more  quickly  incapacitating  forms  of  acute  illness,  but 
it  is  most  inadequate  as  an  index  of  the  incidence  and  severity  of  chronic 
diseases.  The  latter  may  exist  in  mild  form  without  occasioning  sick  ab- 
sences. This  sickness  on  the  job,  the  remaining  at  their  tasks  of  men  and 
women  who  are  far  from  being  fully  physically  competent,  presents  one  of 
the  greatest  problems  as  well  as  the  greatest  opportunity  of  industrial 
medicine. 

If  there  is  to  be  obtained  a  truly  comprehensive  picture  of  the  effects  of 
chronic  disease  in  industry,  there  must  be  considered  not  only  deaths  from 
such  causes,  but  sickness  on  the  job,  and  particularly  the  casting  on  the 
industrial  scrap  heap  of  lives  prematurely  wrecked  by  chronic  disease. 

Only  in  very  recent  years  have  there  been  collected  in  this  country  rea- 
sonably trustworthy  data  concerning  morbidity.  Our  mortality  tables 
leave  much  to  be  desired  but  they  are  models  of  precision  and  complete- 


126 

ness  beside  our  morbidity  statistics.  Despite  the  fact  that  the  primary 
job  of  health  agencies  is  the  prevention  and  alleviation  of  illness,  a  great 
part  of  the  agencies  join  with  the  morticians  in  a  primary  interest  in 
mortality.  If  mortality  tables  reflected  very  precisely  the  causes  of  ill- 
ness this  common  disregard  of  morbidity  might  be  excused.  Mortality 
tables  show  little,  however,  beyond  the  terminal  causes  of  death  and  offer 
but  a  fragmentary  picture  of  disease  in  the  communities  to  which  they 
relate.  Both  types  of  data  are  needed  for  they  supplement  each  other.  It 
is,  thus,  worth  knowing  that  in  a  certain  group  20  per  cent  of  the  deaths 
are  attributable  to  heart  disease,  but  only  about  2  per  cent  of  the  illnesses. 

Out  of  the  several  thousand  ailments  enlisted  in  the  battalion  of  death, 
it  is  not  a  wholly  simple  task  to  select  those  causing  chronic  disease.  For 
present  purposes,  however,  there  may  be  included  practically  all  of  the 
"general  diseases,". such  as  rheumatism,  anemia,  tumors,  and  tuberculo- 
sis; most  of  the  nervous  diseases  including  insanity;  diseases  of  the  cir- 
culatory system;  pleurisy;  certain  of  the  diseases  of  the  digestive  system, 
including  peptic  ulcer,  indigestion,  and  gall  stones;  a  large  part  of  the 
diseases  of  the  genito-urinary  system  including  nephritis,  prostatitis,  and 
cystitis,  and  a  few  additional  causes.  Data  from  industrial  sources  re- 
garding certain  diseases,  as  for  example  the  venereal  diseases  and  mental 
disease,  are  unquestionably  fragmentary. 

It  would  perhaps  be  difficult  to  find  in  this  country  more  reliable  mor- 
tality data  relating  to  a  large  aggregation  of  industrial  workers  than  those 
presented  in  the  group  mortality  experience  of  several  of  the  larger  in- 
surance companies  issuing  "group  insurance."  It  should  be  kept  in  mind 
that  this  insurance  is  issued  to  active  workers  on  payroll  and  that  there 
are  thus  excluded  individuals  too  ill  to  be  eligible  for  industrial  employ- 
ment. 

An  experience  of  several  years'  duration,  embracing  almost  15,000,000 
life  years  of  exposure,  indicates  that  almost  two  thirds  of  the  deaths  oc- 
curred from  conditions  which  are  fairly  designated  as  chronic  disease. 

CAUSE  PERCENT 

Disease  of  the  heart  and  circulatory  system  .  .20 


Disease  of  the  brain  and  nervous  system 
Cancer  and  other  malignant  tumors 
Tuberculosis  .  . 

Genito  urinary  and  prostate  disease 
Disease  of  the  digestive  system 
Diabetes         ..... 


10 
9 
8 
7 
6 
1 


It  is  of  interest  that  there  is  no  discernible  relation  existing  between 
occupation  and  the  death  rate  from  cardiac  disease. 

In  addition  to  these  losses  there  were  admitted  claims  for  total  and  per- 
manent disability  which  numbered  about  12  per  cent  of  the  total  number 
of  deaths.  Of  these  claims  the  overwhelming  majority  are  attributable  to 
chronic  disease.  Precise  data  regarding  the  distribution  by  cause  of  these 
total  and  permanent  disabilities  are  not  at  present  available.  Studies  of 
very  similar  claims,  however  (under  "ordinary"  rather  than  "group"  in- 
surance), have  shown  about  40  per  cent  due  to  pulmonary  tuberculosis,  15 
per  cent  to  various  forms  of  mental  disorder,  5  per  cent  to  cancer,  5  per 
cent  to  heart  disease,  3  per  cent  to  rheumatism,  and  the  balance  quite 
widely  scattered. 

From  the  medical  records  of  a  few  progressive  industrial  or  mercantile 
establishments  and  from  the  statistical  data  relating  to  group  health  in- 
surance there  may  be  obtained  quite  significant  figures  concerning  inca- 
pacitating sickness  due  to  chronic  diseases. 

The  valuable  studies  of  the  United  States  Public  Health  Service  of  the 
morbidity  experience  of  the  Edison  Electric  Illuminating  Company  of 
Boston  show  that  of  all  days  lost  from  illness  during  a  ten-year  period 
including  absences  of  one  day  and  longer,  about  30  per  cent  were  lost  from 


127 

diseases  of  the  chronic  type,  among  both  males  and  females.  If  the  ill- 
nesses of  very  short  duration  were  excluded  the  portion  of  loss  due  to 
chronic  disease  would  of  course  be  much  greater.  Among  males  the  great- 
est loss  was  due  to  rheumatism  (the  term  used  broadly),  followed  by 
"neuresthenia,"  gastric  disease,  pulmonary  tuberculosis  and  diseases  of 
the  circulatory  system.  The  greatest  loss  among  females  was  due  to 
"neuresthenia,"  with  gastric  disease,  pulmonary  tuberculosis,  disease  of 
the  circulatory  system  and  rheumatism  following  in  the  order  named. 

In  an  extensive  experience  under  group  health  insurance  policies  issued 
by  the  Metropolitan  Life  Insurance  Company,  in  this  instance  employing 
data  relating  to  claims  payable  on  the  eighth  day  of  illness  for  a  maximum 
period  of  26  weeks,  the  losses  from  chronic  illness  constitute  between  40 
and  50  per  cent  of  all  losses.  Among  males  the  five  ranking  causes  are  the 
same  as  those  presented  in  the  Boston  Edison  data  though  the  order  of 
magnitude  is  slightly  different;  rheumatism,  diseases  of  the  circulatory 
system,  neuresthenia,  gastric  disease,  and  pulmonary  tuberculosis. 
Among  females,  neuresthenia  leads  as  a  cause  of  incapacity  with  diseases 
of  the  circulatory  system,  rheumatism,  genito-urinary  disease,  anemia 
and  tuberculosis  following. 

The  great  advances  in  "public  health  work"  in  this  country  have  been, 
in  large  part,  related  to  the  prevention  or  control  of  the  communicable 
diseases  of  childhood.  In  the  flushed  enthusiasm  of  joy  over  the  curtail- 
ment of  infant  mortality,  public  health  workers,  the  medical  profession  in 
general,  and  certainly  the  public  at  large  have  apparently  neglected  to  note 
that  in  recent  years  the  expectation  of  life  at  nearly  all  ages  beyond  in- 
fancy has  been  declining.  From  mid-life  onward  the  mortality  rates  are 
distinctly  less  favorable  than  they  were  about  ten  years  ago. 

There  is  no  occasion  to  advocate  the  abandonment  of  interest  and  effort 
in  the  control  of  infant  mortality,  but  there  are  good  reasons  indicating 
need  for  the  development  of  better  mechanism  than  now  exists  for  the 
control  of  disease  and  the  reduction  of  mortality  among  those  persons  who 
are  vouchsafed  the  celebration  of  their  first  birthdays. 

The  farce  of  medical  certification  of  children  applying  for  permits  to 
work,  the  physical  condition  of  youthful  applicants  for  industrial  employ- 
ment bespeak  something  better  than  the  tawdry  medical  politics  and  po- 
litical medicine  which  characterize  school  medical  work  in  many,  if  in- 
deed not  most,  communities. 

There  may  be  question  of  the  merits  or  demerits  of  periodic  physical 
examinations  and  of  diagnostic  centers,  favor  or  criticism  of  hospital  out- 
patient services  and  sighs  for  the  old-time  family  doctor,  whiskers,  high 
hat  and  all,  but  the  fact  remains  that  a  great  part  of  the  medical  profes- 
sion's job  is  going  undone.  The  fact  remains  that  the  job  is  not  even  well 
defined  in  the  minds  of  most  physicians  except  that  portion  of  the  job 
which  presents  itself  in  office  or  in  clinic.  The  lack  of  health  agencies  can 
at  present,  perhaps  be  best  defined  through  the  careful  study  of  such  sick- 
ness and  mortality  data  as  those  relating  to  groups  in  school  or  industry 
and  objectives  there  be  localized. 

The  outstanding  causes  of  death  and  disability  among  industrial  work- 
ers apart  from  accidents  and  acute  respiratory  disease,  are  heart  disease, 
cancer,  tuberculosis,  gastric  disease,  genito-urinary  tract  disease,  rheu- 
matism and  "neuresthenia,"  a  vague  diagnostic  term  reflecting  often  the 
mental  state  of  the  diagnostician  rather  than  that  of  the  patient.  There 
may  be  debated  the  degree  to  which  these  conditions  are  preventable  or 
remediable.  There  can  be  no  question,  however,  that  we  are  not  now  ap- 
plying in  season  even  an  important  fraction  of  the  knowledge  and  skill  at 
hand  for  the  relief  of  these  few  outstanding  forms  of  disease  to  the  end 
that  there  may  be  mitigated  the  present  tragic  loss  of  health,  happiness, 
social  utility,  and  life. 

The  doctors  are  practicing,  the  patients  are  doctoring.  Between  them 
they  can  find  better  ways  than  now  commonly  exist,  the  one  to  serve,  the 
other  to  be  served. 


128 
NURSING  THE  CHRONIC  PATIENT 

By  Elizabeth  Ross,  R.N., 
Director,  Health  Center,  Brookline  Friendly  Society 

The  so-called  chronic  patient  is  one  of  the  greatest  problems  of  the  med- 
ical and  nursing  professions.  While  a  few  of  this  group  of  patients  re- 
ceive much  more  care  than  is  their  just  share,  the  great  majority  of 
chronic  patients  do  not  have  the  care  that  they  need.  Especially  are  they 
neglected  when  we  consider  their  need  of  what  we  may  classify  as  scien- 
tific medical  supervision,  which  means  the  rehabilitation  of  the  patient  to 
normal  health  or  as  near  to  normal  as  is  possible  for  the  individual  to 
attain. 

In  civilized  countries  such  as  our  own  a  person  who  is  acutely  ill  is  well 
taken  care  of.  There  is  always  a  way  to  obtain  adequate  care  and  treat- 
ment for  the  patient  in  a  critical  stage  of  sickness,  providing  the  individ- 
ual or  those  responsible  are  willing  to  put  themselves  into  the  hands  of 
medical  or  social  workers.  The  chronic  patient  is  not  as  fortunate.  The 
large  majority  of  these  patients  are  in  their  own  or  boarding  homes  and 
receive  very  little  of  either  medical  or  nursing  care,  and  what  attention 
they  do  receive  is  usually  palliative  and  given  with  the  idea  of  carrying 
the  patient  through  to  the  end  as  easily  as  possible  at  the  minimum  of 
expense. 

As  is  usual  in  situations  of  such  magnitude,  the  causes  are  so  many  that 
to  rectify  them  we  would  have  to  rebuild  the  whole  social  structure  of 
modern  living,  but  after  all  that  is  what  we  are  really  doing  day  by  day 
and  even  though  the  situation  viewed  as  a  whole  seems  unsurmountable, 
taken  as  individual  cases  there  is  much  that  could  be  done  to  improve  the 
present  state  of  things  if  physicians,  nurses  and  social  workers  would  be 
willing  to  lead  the  way. 

One  of  the  first  great  needs  is  for  classification.  At  present  we  list  as 
chronic  everything  from  encephalitis  to  senility.  The  patients  are  of  any 
age  from  infancy  to  one  hundred  plus.  The  types  of  diseases  include 
mental,  communicable,  digestive,  circulatory,  cardiorenal  and  respiratory, 
in  fact,  every  disease  that  flesh  is  heir  to. 

The  definition  of  "chronic"  is  often  confused  with  "incurable,"  with  a 
disastrous  effect  on  the  patient  and  the  family.  Consequently,  many  peo- 
ple became  incurable  because  they  are  not  expected  to  recover  and  drag 
on  through  years  of  unnecessary  misery,  a  burden  to  themselves  and 
others. 

Another  great  stumbling  block  in  the  care  of  the  chronic  patient  is  the 
ever-present  question  of  cost  of  medical  and  nursing  care.  How  can  the 
individual  or  families  meet  this  cost  if  they  belong  to  the  wage-earning 
or  small-salaried  group;  even  the  comparatively  well-to-do  cannot  afford 
long  continued  sickness.  If  the  family  cannot  meet  the  cost,  on  whom 
should  the  burden  fall?  Should  it  be  the  local  community,  the  state,  or 
private  philanthropy?  Or  is  it  possible  to  work  out  a  system  of  health 
insurance  that  would  provide  adequate  medical  and  nursing  care  at  a  price 
that  the  ordinary  family  could  pay?  This  problem  of  costs  will  have  to 
be  answered  before  we  can  possibly  hope  to  bring  the  needed  nursing  and 
medical  care  to  the  many  chronic  patients  who  are  now  neglected. 

Perhaps  the  nation-wide  study  of  the  cost  of  sickness  that  is  now  being 
carried  on  may  throw  some  light  upon  this  vexatious  problem.  In  the 
meanwhile,  the  graduate  nurses,  whether  they  are  working  in  hospitals, 
in  the  homes  as  private  nurses,  or  as  public  health  nurses,  have  an  oppor- 
tunity to  help  thousands  of  chronic  patients  and  those  responsible  for 
their  care.  The  nurse  must  first  of  all  accept  the  task  as  her  responsibil- 
ity and  recognize  that  she,  more  than  any  other,  can  change  the  attitude 
of  mind  that  has  developed  in  regard  to  the  care  of  the  chronic  patient. 

The  private  duty  nurse  can  make  it  her  objective  to  bring  to  the  chronic 
patients  what  she  knows  for  the  stimulation  and   information  that  is 


129 

needed  to  build  up  a  self-control  and  self-knowledge  that  makes  it  possible 
for  even  the  person  who  has  a  physical  handicap  to  get  the  most  out  of  life. 

The  public  health  nurse  who  goes  from  home  to  home  has  an  even  wider 
opportunity  to  help  in  this  way,  for  she  reaches  many  families,  and  if  she 
is  a  real  public  health  nurse,  the  family,  as  well  as  the  patients,  will  turn 
to  her  for  advice  and  help.  She  can  teach  the  difference  between  the 
chronic  illness  that  can  be  cured  or  helped  and  diseases  that  are  really  in- 
curable. Whether  it  is  chronic  or  incurable,  the  family  needs  to  know 
that  the  patient's  greatest  need  is  to  be  helped  to  understand,  not  only  the 
cause  of  the  illness  and  what  is  the  treatment  necessary,  but  the  great 
need  of  helping  the  patient  to  live,  not  as  a  dependent  invalid,  but  as  one 
who  has  a  place  in  the  world  of  affairs.  Sometimes  she  will  have  the  nurs- 
ing care  of  the  chronic  patient  and  it  will  give  her  an  opportunity  to  make 
the  family  understand  what  it  is  that  the  patient  needs  beyond  the  need 
of  having  baths  and  having  her  bed  made.  It  may  be  that  the  patient 
should  get  up  and  try  her  strength,  but  has  not  the  will  power  to  make  her 
own  decisions,  or  perhaps  it  is  a  problem  of  an  over-indulged  person  who 
needs  most  of  all  to  be  taught  self  control.  Perhaps  the  other  members  of 
the  family  are  being  sacrificed  to  a  selfish  neurotic  who  could,  if  she 
would,  do  much  for  herself  but  prefers  to  depend  upon  others.  Such  a  pa- 
tient needs  to  be  placed  under  the  guidance  of  a  mental  hygiene  worker 
who  can  break  down  the  inhibitions  that  have  been  built  up  through  years 
of  selfishness. 

The  partially  handicapped  always  need  occupation — something  to  do 
that  will  give  an  interest  in  life  and  make  them  useful  and  happy. 

All  of  these  things  are  true  of  the  chronic  patients  who  are  living  in 
institutions  or  private  hospitals  and  the  nurses  who  are  constantly  with 
them  can  best  guide  and  help  them  to  escape  the  bondage  that  sickness  has 
created. 

There  are  two  great  tasks  before  us  in  the  care  of  the  chronic  patient. 
The  first  one  is  to  make  it  possible  for  them  to  have  the  type  of  medical 
and  nursing  care  that  will  give  every  chance  of  recovery,  complete  or  par- 
tial, as  the  case  may  be.  The  other  task  is  to  bring  to  those  who  need  it 
so  much  the  kind  of  service  that  will  be  required  for  the  special  needs  of 
each  individual  chronic  patient,  a  service  that  will  help  them  not  only  to 
recover  their  physical  health,  but  will  be  always  mindful  of  the  greater 
needs  of  life. 

We  must  not  close  on  a  note  that  considers  sickness  of  any  kind  as  some- 
thing inevitable.  Many,  we  might  almost  say  most,  of  our  chronic  pa- 
tients are  sick  because  of  unhealthful  living,  and  this  brings  us  to  the 
great  objective  that  should  be  foremost  in  the  mind  of  every  health 
worker.  If  we  can  teach  the  art  of  keeping  well,  we  will  be  able  to  abolish 
chronic  sickness  and  establish  chronic  health  in  its  stead. 

THE  SOCIAL  WORKER  IN  ADULT  HYGIENE 

By  Eleanor  E.  Kelly, 
Supervisor  of  Social  Service,  State  Department  of  Public  Health 

What  place  has  social  service  in  a  program  of  adult  hygiene?  Can  the 
social  worker  afford  to  spend  time  on  individuals  who  are  not  ill  physically 
or  mentally  and  who  present  no  obvious  social  problem? 

Perhaps  not — perhaps  she  ought  to  assume  no  responsibility  for  this 
group.  The  social  worker  has  problems  enough  with  the  poor,  the  sick, 
the  delinquent  and  neglected.  She  has  been  accorded  a  definite  place  in 
child  hygiene  but  possibly  there  is  no  need  for  her  to  consider  service  to 
adults  who  are  well. 

She  must,  however,  meet  problems  arising  from  neglect  of  hygiene  and 
ignorance  of  the  laws  of  health,  and  she  learns  to  see  in  present  ills,  evi- 
dence of  past  mistakes.  Has  she  not  then  some  responsibility  for  helping 
to  prevent  these  mistakes? 


130 

Modern  medical  science  emphasized  the  preventive  aspect  of  medicine 
recognizing  the  wisdom  and  economy  of  conserving  health  and  strength 
rather  than  trying  to  seek  them  when  they  are  lost.  The  patient  is  urged 
to  find  out  how  to  keep  well  rather  than  wait  to  learn  why  he  is  ill.  With 
present  knowledge  and  facilities,  the  pursuit  of  such  a  policy  is  made  much 
more  profitable  to  him  than  ever  before.  Slight  disabilities  may  be  ex- 
plained and  the  cause  removed  before  they  actually  assume  alarming  pro- 
portions. The  X-ray,  metabolism  apparatus  and  other  resources  of  mod- 
ern medicine  bring  to  light  defects  which  formerly  were  sometimes  ob- 
scure and  difficult  to  diagnose.  Frequently  these  defects  can  be  cured 
merely  by  attention  to  the  fundamental  laws  of  hygiene.  People  must  still 
be  educated,  however,  to  the  acceptance  of  sane  rules  for  living.  There 
will  always  exist  the  individual  who  feels  that  he  has  thrown  his  money 
away  on  a  doctor  who  orders  more  exercise  or  more  sleep  instead  of  pre- 
scribing some  magic  potion  which  will  enable  him  to  continue  wearing  out 
his  machinery  with  no  attempt  to  reinforce  the  weak  spots.  Men  and 
women  so  often  fail  to  accept  the  doctor  as  adviser  as  well  as  healer.  And 
not  only  is  he  counsellor  and  healer,  but  also  student,  constantly  acquiring 
through  experience  with  each  individual  case,  a  better  insight  into  the 
causation  of  disease. 

Similarly,  social  service,  in  the  minds  of  many,  still  means  palliation 
only — tiding  over  the  individual  or  family  when  in  distress.  This  must 
always  be  an  important  element  in  social  service;  existing  social  ailments 
must  be  cured  or  relieved  and  temporary  relief  of  one  form  or  another  may 
be  indicated.  The  social  worker,  however,  should  never  be  so  absorbed  in 
the  treatment  of  the  disorders  that  she  cannot  seek  to  know  the  cause  and 
to  use  this  knowledge  toward  prevention  of  the  same  disease  in  others. 

Social  service  aims  are  constructive,  not  merely  palliative.  The  build- 
ing material  must  be  carefully  chosen  and  all  the  intricate  parts  of  the  so- 
cial fabric  so  woven  together  that  a  well  defined  and  durable  pattern  is 
formed.  Frequently,  however,  the  social  worker  is  called  in  when  the  ma- 
terials are  so  worn  down  that  rebuilding  is  exceedingly  difficult.  She  is 
summoned,  for  example,  when  finances  are  exhausted,  whereas  she  might 
have  been  called  in  to  help  conserve  resources.  She  is  asked  to  provide  for 
a  family  of  children  when  the  mother  breaks  down  from  overwork;  help 
with  the  mother's  problem  months  before  might  have  prevented  the  break- 
down. 

Individual  problems  such  as  these  quite  properly  belong  to  the  field  of 
social  service;  the  scope  of  this  field,  however,  is  not  limited  to  individual 
case  work — important  and  absorbing  as  this  is. 

Recognition  of  the  place  of  social  workers  in  a  broader  field  comes  as  we 
show  readiness  to  accept  the  responsibility.  We  must  demonstrate  our  in- 
terest in  the  common  problems  of  humanity,  and  ability  to  contribute 
towards  their  solution,  at  the  same  time  carrying  out  a  thorough  and  effec- 
tive plan  for  each  individual  case  problem. 

One  of  the  most  important  considerations  for  a  social  service  program 
is  health — the  health  of  the  group  and  of  each  individual  member  of  the 
group.  Hygiene,  the  technique  of  healthful  living,  thus  becomes  of 
primary  importance  in  the  field  of  social  service.  Child  hygiene  and  men- 
tal hygiene  are  quite  generally  recognized  as  legitimate  fields  of  action  for 
specialized  social  service;  but  what  of  adult  hygiene  per  se? 

A  program  of  social  service  for  adult  hygiene  must  necessarily  be 
largely  a  matter  of  cooperation  with  health  agencies.  Social  service,  how- 
ever, has  a  definite  part  to  play  in  this  organized  effort,  and  a  serious  re- 
sponsibility. 

Such  a  program  will  include : 

First — a  study  of  the  resources  for  the  conservation  of  health,  and  for 
the  care  of  the  sick,  and  the  dissemination  of  this  information. 

Social  service,  because  of  its  very  personal  concern  with  the  lives  of 
many  individuals  offers  an  unusual  opportunity  for  influencing  these 
people  to  take  steps  toward  improving  or  regaining  health. 


131 

Here  is  the  father  of  a  large  family  who  realizes  the  importance  of 
keeping  fit  in  order  that  his  earning  capacity  shall  not  be  lowered.  He 
tires  easily  and  would  like  to  know  why  he  is  not  quite  up  to  par,  but  he 
feels  that  he  cannot  pay  the  doctor's  fees  for  a  physical  examination,  and 
cannot  afford  the  necessary  time  from  work  to  attend  a  health  clinic.  The 
social  worker  will  arrange  a  clinic  appointment  after  working  hours;  or 
she  may  assist  in  some  wise  adjustment  of  the  family  budget  which  will 
enable  them  to  include  an  allowance  for  a  periodic  check-up  on  health. 
This  should  be  possible  not  only  for  the  wage  earner,  but  for  the  entire 
family. 

The  young  woman  who  is  straining  her  eyes  at  work,  not  knowing  just 
where  to  go  for  competent  advice,  postpones  seeking  it,  or  perhaps  satis- 
fies herself  with  a  pair  of  cheap  glasses  which  "fit  any  eyes  and  cure  any 
visual  defect."  Advice  as  to  a  good  oculist,  or  possibly  assistance  in  find- 
ing a  new  job  where  there  is  less  eye  strain  may  mean  prevention  of  a  seri- 
ous eye  defect  later.  The  social  worker  may  perchance  have  learned  of  the 
need  while  visiting  the  family  for  quite  a  different  purpose,  but  she  must 
be  alert  to  recognize  the  chance  for  service.  In  the  knowledge  and  use  of 
existing  resources  lies  her  opportunity. 

Regular  health  examinations  frequently  seem  to  the  individual  to  do  no 
more  than  deplete  funds;  just  as  frequently,  however,  they  reveal  condi- 
tions which  are  not  minor  defects  but  which,  if  neglected,  may  develop 
into  more  serious  conditions.  A  warning  in  time,  and  recognition  of  dan- 
ger signals  may  mean  the  saving  of  an  individual  from  years  of  invalidism 
or  suffering.  There  is  greater  interest  now  than  ever  before  in  the  health 
of  the  individual  and  every  social  worker  should  inform  herself  as  to  the 
essentials  for  maintaining  health  standards  and  urge  upon  those  whom 
she  is  helping — the  acceptance  of  these  standards. 

It  would  be  well  for  the  social  worker,  too,  to  look  to  her  own  personal 
problem  of  healthful  living.  Many  of  us  who  are  in  the  field  quite  fre- 
quently break  the  most  fundamental  rules  of  health — irregular  or  hurried 
meals,  lunchless  days,  the  occasional  long  hours  of  overtime  without  rest 
intervals,  which  seem  inevitable  but  which  are  usually  the  result  of  poor 
management.  These  workers  are  not  the  most  convincing  advocates  of 
healthful  living.  Nor  are  those  of  us  who  carry  around  our  own  petty 
worries — our  own  mental  outlook  undoubtedly  reacts  upon  those  whom 
we  are  trying  to  help. 

Second — the  care  of  the  chronic  sick  is  a  problem  which  weighs  heavily 
on  the  social  worker  for  it  is  she  who  must  often  make  necessary  plans 
and  adjustments  for  hospital  or  home  care.  Adequate  care  must  be  as- 
sured for  the  patient  and  his  own  wishes  carried  out  as  far  as  possible. 
On  the  other  hand,  the  burden  upon  the  family  of  the  home  care  of  a 
chronically  sick  patient  is  sometimes  such  that  other  members  break  un- 
der the  strain  and  suffer  physically  or  mentally.  Social  workers  have  here 
a  responsibility  also  to  the  well  members  of  the  family — to  prevent  them 
from  assuming  an  overwhelming  burden.  There  is  a  nice  distinction  to  be 
made  between  an  "overwhelming  burden"  and  a  "legitimate  responsibil- 
ity." 

The  social  worker  is  in  a  position  to  interpret  social  conditions  in  terms 
of  human  reactions.  She  knows  from  experience  in  her  families  what  it 
means  to  the  health  of  the  mother  of  a  large  family  to  try  to  stretch  a 
meagre  income  to  cover  the  added  expense  sometimes  entailed  by  the  care 
of  an  invalid — or  in  her  busy  day,  to  add  time  for  the  extra  care.  She 
knows  too  how  anxious  this  same  mother  is  to  assume  the  added  burden 
regardless  of  her  own  limited  strength. 

For  the  third  part  of  the  program,  let  us  glance  at  some  of  the  stum- 
bling blocks  in  the  way  of  hygienic  living.  How  many  of  them  perhaps, 
are  social  factors? 

Neglect  is  probably  responsible  for  a  greater  share  of  ill  health  than 
we  are  ready  to  believe.  In  this  country  a  large  majority  of  persons  seem 
never  to  have  time  enough  to  rest,  to  do  things  in  a  leisurely  way.    Many 


132 

can  find  no  time  to  seek  exercise  and  recreation,  are  inefficient  in  handling 
their  own  time  and  energy,  or  are  unwilling  to  make  the  exertion.  Ele- 
vators and  automobiles  relieve  us  of  the  necessity  of  walking  and  develop 
a  "lazy  streak."  Weary  pleasure  seekers  could  not  give  up  a  few  evenings 
of  parties  and  theaters  just  to  rest;  and  wholesome  meals  might  spoil  the 
figure ! 

The  duty  of  warning  these  miscreants  devolves  upon  health  educators, 
but  there  are  times  when  social  workers  must  also  be  health  educators. 
Where  friendly  contacts  have  been  made  and  the  confidence  of  a  family 
secured  by  a  social  worker,  the  opportunity  for  her  to  offer  such  advice  is 
readily  found  and  may  be  received.  Failure  to  care  for  teeth,  to  wear  suf- 
ficient clothing,  or  to  live  hygienically  in  other  ways  may  be  due  to  lack  of 
funds  or  merely  neglect.    The  social  worker  must  determine  which. 

Ignorance  may  be  due  to  indifference,  mental  inability,  language  dif- 
ficulty, or  lack  of  educational  opportunities.  A  certain  type  of  ignorance 
breeds  superstition  and  creates  resentment  of  any  attempt  at  enlighten- 
ment. Sometimes  these  people  learn  only  by  experience,  and  some  never 
learn.  Inability  to  understand  English  is  a  difficulty  which  can  be  over- 
come by  patient  explanations  through  an  interpreter.  Frequently,  how- 
ever, it  is  necessary  to  understand  and  interpret  certain  racial  prejudices 
or  religious  customs. 

Poverty.  No  amount  of  health  instruction  in  regard  to  hygienic  liv- 
ing will  avail  in  homes  where  there  is  absolute  lack  of  means  with  which 
to  buy  the  essentials.  If  a  family  can  barely  secure  the  minimum  food 
allowance  from  day  to  day,  how  can  25  per  cent  be  added  to  the  cost  for 
additional  nourishment  for  the  pregnant  woman,  or  50  per  cent  for  the 
nursing  mother?  How  can  that  family  protect  a  tuberculosis  contact  who 
should  have  plenty  of  wholesome  food?  It  is  useless  to  urge  the  family 
to  make  better  provision  for  these  needs,  unless  help  is  given  them.  Is  it 
not  better  economy  to  supply  extra  milk  for  a  few  months  in  a  tuberculous 
family  than  later  to  pay  the  sanatorium  board  of  a  patient  who  has  not 
had  strength  to  resist  the  disease  ?  This  type  of  help  is  necessary  in  cer- 
tain individual  cases,  but  the  problem  will  reappear  in  another  family  and 
still  another,  and  must  eventually  be  met  by  more  effective  measures. 

So  many  ills  are  laid  to  the  door  of  poverty,  and  poverty  itself  is  fre- 
quently the  result  of  continued  ill  health,  unemployment  or  other  misfor- 
tunes. Everywhere  organizations  and  thinking  individuals  are  attempt- 
ing to  find  the  answer  to  the  need  for  a  living  wage  for  every  individual 
and  adequate  protection  for  him  in  time  of  misfortune.  Savings,  insur- 
ance, old  age  pensions,  all  have  a  direct  bearing  on  the  problem.  The  so- 
cial worker  can  supply  valuable  data  as  to  the  prevalence  of  certain  unde- 
sirable social  conditions.  She  sees  at  first  hand  the  devastating  effect  on 
the  family  and  individual  of  poverty,  crime,  and  disease,  and  her  interpre- 
tation of  the  social  factors  involved  should  form  an  important  contribu- 
tion towards  an  analysis  of  the  situation. 

Poor  housing  conditions  play  an  important  part  in  the  consideration 
of  hygiene.  We  believe  that  sanitary  housing,  sunlight,  fresh  air,  and 
personal  cleanliness  are  essential  to  health.  And  yet  how  many  people  are 
there  housed  under  conditions  which  almost  preclude  the  possibility  of  se- 
curing even  one  of  these  essentials  ?  Our  laws  protect  tenement  dwellers 
against  the  worst  housing  evils,  but  there  are  many  homes  into  which 
fresh  air  seldom  enters,  and  sunlight  never.  Social  workers  are  obliged 
sometimes  to  advise  removal  of  families  for  one  reason  or  another,  and 
they  have  always  to  consider  many  factors,  such  as  the  rent,  proximity  to 
work,  and  to  school,  as  well  as  the  condition  of  the  house.  It  is  seldom 
possible  to  secure  a  tenement  which  meets  with  all  requirements,  but  if 
something  must  be  sacrificed,  let  it  not  be  conditions  which  make  for 
healthful  living,  for  in  the  end  payment  will  be  exacted  through  lowered 
power  of  resistance  or  actual  disease.  Everyone  wants  to  keep  his  health 
but  the  poor  man  and  his  family  must  keep  it,  for  they  cannot  afford  to 
be  ill.     Overcrowding  must  be  guarded  against  and  adequate  provision 


133 
made  for  any  member  of  the  family  who  is  ill  or  from  whom  the  others  in 
the  family  need  protection.  Where  housing  conditions  warrant  inter- 
ference, they  should  be  reported  to  the  Board  of  Health.  Social  workers, 
however,  sometimes  make  the  mistake  of  reporting  homes  which,  while 
distressingly  untidy,  nevertheless  cause  no  menace  to  health.  An  ex- 
tremely untidy  home  must  certainly  be  upsetting  to  the  mental  state  of 
the  family,  but  it  does  not  breed  disease.  The  visiting  housekeeper's  as- 
sistance will  sometimes  prove  effective  in  these  cases. 

Unsatisfactory  working  conditions  are  a  menace  to  the  health  of  the 
worker  for  at  least  half  of  his  waking  hours  are  spent  at  his  job.  This  re- 
sponsibility rests  on  industry,  but  the  social  worker  should  assure  herself 
that  helpful  conditions  exist  in  the  factory  or  shop  in  which  she  secures 
employment  for  a  client.  The  employment  manager  will,  as  a  rule,  reject 
an  applicant  for  whom  he  considers  the  work  would  be  too  great  a  physical 
effort.  The  zealous  social  worker  will  frequently  attempt  to  overrule  his 
judgment,  especially  if  the  applicant  is  anxious  to  work,  and  in  need  of 
funds.  When  employment  is  scarce,  it  is  a  temptation  for  the  applicant  to 
accept  whatever  is  offered,  even  though  he  knows  it  to  be  beyond  his 
strength.  If  he  breaks  down  in  the  end,  it  may  have  been  a  costly  experi- 
ence. Such  considerations  as  noises  and  odors  can  usually  be  ignored  as 
the  worker  will  become  accustomed  to  them,  but  occasionally  an  individ- 
ual's reactions  to  these  disturbing  features  may  be  such  that  it  would  be 
unwise  for  him  to  be  subjected  to  them. 

The  fourth  part  of  the  program  involves  constructive  aids  to  health. 
These  are  merely  instruments  with  which  to  remove  the  stumbling  blocks. 

The  social  worker  has  always  the  opportunity  and  the  responsibility  for 
health  education  with  the  individual  and  the  group  which  is  her  immediate 
concern.  She  has  innumerable  opportunities  to  guide  and  assist  in  the 
selection  of  homes  and  jobs  which  meet  with  health  requirements,  in  plan- 
ning with  the  individual  families  to  include  in  the  budget  suitable  food 
and  clothing,  and  other  necessities. 

Her  responsibility,  however,  does  not  end  here,  for  from  the  very  fact 
that  she  has  acquired  this  experience,  arises  the  obligation  to  contribute 
not  only  facts,  but  interpretation  of  the  social  significance  of  those  facts, 
which  may  help  towards  bringing  the  possibility  of  health  nearer  to  all 
the  people. 

Hereupon  she  assumes  her  share  of  the  responsibility  toward  well  people 
in  an  effort  to  help  them  to  keep  well.  She  works  for  the  development  and 
use  of  facilities  for  wholesome  recreation  and  healthful  exercise. 

She  gives  her  support  to  organizations  doing  constructive  health  work; 
she  works  for  legislation  in  the  interests  of  health.  Social  service  in  hy- 
giene thus  resolves  itself  into  preventive  medical  social  service,  emphasiz- 
ing on  the  one  hand,  the  prevention  of  disease,  and  on  the  other,  the  pro- 
motion of  health. 

PROPER  USE   OF  RESOURCES   FOR  THE   CHRONIC  SICK 

By  Ida  M.  Cannon 

Chief  of  Social  Service,  Massachusetts  General  Hospital 

Does  this  title  immediately  suggest  institutions  where  patients  should 
go  during  prolonged  illness?  Undoubtedly  we  do  need  more  and  better 
equipped  hospitals  for  the  study  and  care  of  those  with  chronic  disease, 
but  it  is  not  our  first,  nor  do  I  believe  our  greatest,  need.  I  wish  to  urge 
the  greater  importance  of  an  increased  resourcefulness  on  the  part  of 
doctors,  public  health  nurses,  social  workers  and  families  and  friends  of 
those  who  are  facing  the  necessity  of  making  plans  for  care  of  patients 
who  must  face  months  and  possibly  years  of  continuous  ill  health.  That 
resourcefulness  should  recognize  that  in  spite  of  the  fact  that  large  num- 
bers of  people  are  chronically  ill,  they  must  not  be  considered  en  masse.  If 
ever  individualization  is  necessary,  it  is  in  the  interest  of  those  who  see 


134 
before  themselves  the  probability  of  months  and  years  of  illness  and  in- 
capacity to  fulfill  life's  normal  activities. 

The  first  step  in  intelligent  planning  for  care  of  the  patient  is  to  secure 
from  competent  medical  authority  a  comprehensive  judgment  of  the  treat- 
ment plan  that  should  be  followed  and  some  information  as  to  the  probable 
prognosis.  Second,  how  can  this  be  secured  so  that  the  patient  can  get  the 
greatest  satisfaction  and  peace  of  mind  ?  I  have  known  instances  in  which 
this  order  has  been  reversed  and  wisely  so,  it  seemed  to  me.  What  can  it 
profit  a  man,  woman  or  child,  if  he  has  excellent  doctors  and  nurses  at 
hand,  under  the  best  of  hygienic  conditions,  but  is  so  utterly  unhappy  that 
his  well  prepared  food  cannot  be  digested. 

Fortunately  people  generally  are  less  fearful  of  going  to  hospitals  than 
in  years  past,  a  tribute  to  the  service  and  spirit  of  our  modern  medical  in- 
stitutions. It  is  not  conducive  to  human  well  being  however,  to  live  to- 
gether in  large  numbers.  It  is  good  occasionally  when  in  good  health  and 
high  spirits  we  are  moved  by  a  common  interest  or  purpose  to  feel  our- 
selves part  of  the  crowd.  A  football  game  or  political  rally  may  bring  the 
thrill  that  can  come  from  giving  free  expression  to  our  gregarious  in- 
stinct, but  when  we  are  sick  that  instinct  is  surely  in  abeyance  and  we  feel 
very  particularly  unique.  Few  people  get  satisfaction  in  being  with  large 
numbers  of  other  sick  people.  It  is  not  impossible  that  we  may  resort  to 
hospitals  too  readily  taking  from  the  home  some  of  the  vital  human  ex- 
periences of  sickness,  birth  and  death  which  have  much  to  give  in  enrich- 
ment of  human  relationships. 

There  are,  however,  other  considerations.  Medical  care  is  costly. 
Equipment,  necessary  to  modern  medicine,  medical  skill  in  its  great  diver- 
sity, nursing,  occupational  and  physiotherapy  can  be  given  more  economi- 
cally in  an  institution  than  in  the  home.  The  justification  for  institu- 
tional care  for  patients  must  take  into  consideration  these  facts  as  well  as 
the  natural  human  desire  to  be  at  home  with  family  and  friends.  Through 
the  generosity  of  one  of  its  citizens,  Boston  has  one  of  the  best,  if  not  the 
best,  hospital  for  the  care  of  chronic  disease  in  this  country.  But  the 
Robert  Breck  Brigham  hospital  has  only  seventy-four  beds  and  is  re- 
stricted to  use  of  Boston  residents.  It  might  lose  some  of  its  quality  if  it 
were  a  large  institution.  But  it  would  be  fortunate  for  the  citizens  of 
Massachusetts  if  such  units  could  be  duplicated  in  other  cities. 

Before  we  can  adequately  discuss  this  question  of  resources  for  the 
chronic  sick  we  should  know  the  extent  of  the  problem  more  accurately 
than  we  now  do.  And  this  is  a  question  of  local  concern  particularly  since 
any  solution  must  come  largely  through  local  resources.  Those  with  pro- 
longed illness  should  be  kept  as  near  to  family  and  friends  as  possible. 

Boston  is  the  only  city  of  Massachusetts  that  has  attempted  to  get  a 
comprehensive  picture  of  the  chronic  disease  problem.  The  study  made  in 
1927-28  by  the  Boston  Council  of  Social  Agencies  gave  a  partial  compre- 
hension of  the  problem  Boston  has  in  hand.  This  study  gives  an  analysis 
of  4,316  patients,  exclusive  of  those  with  tuberculosis  and  mental  disease, 
under  care  during  the  period  of  the  study.  3,508  were  residents  of  Boston, 
808  coming  to  Boston  for  care  from  other  cities.  This  report  should  be 
carefully  read  by  any  one  interested  in  the  subject.  The  information  there 
gathered  is  significant  to  a  discussion  of  resources.  The  figures  on  ages 
are  surprising  to  any  who  may  think  of  this  question  as  primarily  one  of 
old  age.  17.7  per  cent  (761)  were  children  under  15  years  of  age.  41  per 
cent  (1,807)  were  sixty  years  and  over.  41.3  per  cent  (1748)  were  scat- 
tered in  the  ages  15  to  59  years.  So  in  seeing  the  problem  as  a  whole,  we 
must  think  of  children  beginning  life  handicapped  by  continued  illness, 
instead  of  in  health  and  high  hopes,  old  people  ending  life  in  infirmity  and 
those  facing  middle  life  who  are  carrying  the  larger  burdens  of  responsi- 
bilities, whose  hopes  and  plans  and  capacities  for  work  have  been  rudely 
disrupted  by  sickness.  For  our  present  purpose  we  are  concerned  prima- 
rily with  the  two  older  groups.  Children  are  better  provided  for  in  Mas- 
sachusetts than  are  adults. 


135 

Each  community  in  Massachusetts  should  ask  itself  whether  there  are 
in  its  boundaries  people  who  are  sick  and  unprovided  for.  It  sometimes 
appears  that  it  is  only  the  quack  and  unscrupulous  medical  practitioner 
who  has  initiative  to  reach  out  to  the  chronic  sufferer.  Assurances  of 
speedy  recovery  are  successful  in  depleting  the  bank  account  and  post- 
poning adequate  treatment  for  many  patients.  But  until  we  get  into  the 
minds  of  our  fellow  citizens  the  importance  of  early  treatment  by  com- 
petent physicians,  and  the  assurance  that  facilities  are  available  for  car- 
rying out  the  prescribed  treatment,  we  must  expect  to  have  many  turn  to 
those  who  give  them  false  hopes.  A  community  that  wishes  to  answer  in 
the  affirmative  the  question,  have  you  adequate  facilities  for  the  care  of 
the  chronic  sick,  might  put  to  itself  some  such  questions  as  these : 

Are  there  physicians  of  proper  professional  standing  accessible  to  those 
who  are  ill?  (Unhappily  there  are  places  in  Massachusetts  where  this  is 
not  so.) 

Is  it  possible  to  secure  trained  nurses,  or  attendant  nurses  for  those  who 
can  pay  for  their  services  in  the  homes? 

Are  there  visiting  nurses  who,  under  suitable  medical  advice,  can  give 
the  necessary  bedside  care  and  instruction  to  the  family  of  the  patient  for 
what  the  family  is  able  to  pay? 

Is  there  available  a  well  equipped  hospital  where  patients  can  go  tem- 
porarily for  study  and  for  periods  of  skillful  treatment  and  be  sent  home 
with  a  well  laid  plan  for  carrying  out  the  treatment  at  home? 

Are  there  available  well  managed  nursing  homes  for  patients  who  can- 
not be  cared  for  at  home  and  need  nursing  care,  but  not  continuous  medi- 
cal attendance. 

Finally,  are  there  hospital  facilities  for  the  treatment  and  care  of  those 
who  cannot  be  cared  for  at  home  and  for  whom  institutional  care  is  neces- 
sary? 

Massachusetts  has  about  400  hospitals  with  bed  capacity  of  approxi- 
mately 26,000,  exclusive  of  the  institutions  set  aside  for  mental  disease. 
About  800  of  these,  aside  from  the  State  Infirmary,  are  for  the  avowed 
purpose  of  taking  care  of  the  chronic  sick.  The  Holy  Ghost  Hospital  for 
Incurables  in  Cambridge  with  its  210  beds  is  one  of  these  taking  patients 
without  regard  to  residence,  race,  sex,  or  creed.  The  House  of  the  Good 
Samaritan  is  given  over  to  the  care  of  heart  disease  in  women  and  children 
and  cancer  in  women.  And  there  are  others  like  the  Boston  Home  for  In- 
curables, St.  Vincent's  Hospital  of  Worcester,  and  Palmer  Memorial,  where 
the  former  idea  of  nursing  care  for  those  hopelessly  incurable  has  given 
way  to  more  active  treatment  for  the  comfort  and  benefit  of  the  patients. 
The  Boston  Council  of  Social  Agencies  report  on  chronic  disease  gives 
these  and  other  resources  in  the  vicinity  of  Boston,  although  admission  is 
necessarily  restricted  to  the  residents  of  Boston.  The  list  of  incorporated 
institutions  published  by  the  State  Department  of  Public  Welfare  is  more 
inclusive. 

Massachusetts  has  shown  a  generous  solicitude  toward  old  age  in  the 
establishment  of  some  80  endowed  homes  for  aged  men  and  women  dis- 
tributed pretty  generally  across  the  state.  Most  of  these  have  legal  re- 
strictions for  admission,  32  are  exlusively  for  women,  8  exclusively  for 
men.  But  when  once  admitted  these  old  people  can  spend  their  days  there 
through  the  infirmities  of  old  age.  There  are  those  who  appreciate  the 
fact  that  security  during  old  age  and  especially  when  illness  and  infirmi- 
ties come  is  one  of  the  pressing  social  problems  of  our  state.  For  many 
people,  the  possibility  of  remaining  at  home,  with  one's  family,  or  even  in 
a  room  with  familiar  surroundings,  is  more  to  be  desired  than  the  best  of 
hygiene  and  good  care  in  a  home.  Tenement  and  apartment  houses  may 
make  home  arrangements  for  care  impossible.  And  the  intimate  contact 
of  daily  living  may  bring  intolerable  unhappiness.  We  must  know  our  pa- 
tients and  our  families  well  enough  to  be  able  to  recognize  such  facts  when 
they  exist. 

That  an  institution,  however  big  and  overpowering  in  its  aspect,  can 


136 

still  give  individual  consideration  of  its  patients,  is  exemplified  many 
times  at  the  State  Infirmary  at  Tewksbury.  In  spite  of  its  2,500  beds, 
there  are  many  patients  who,  through  the  nurses  and  the  social  service 
department,  have  been  made  to  feel  that  their  personality  is  understood 
and  their  individual  interests  considered.  The  City  or  State  Infirmary  is 
the  last  resort  for  the  chronic  sick  and  properly  so,  but  when  necessity 
presses  it  is  often  a  surprise  to  the  patient  to  find  how  far  from  their  ex- 
pectations is  the  friendly  interest  and  care  they  find  there.  This  is  par- 
ticularly true  in  many  of  our  local  city  infirmaries  as  Mr.  Francis  Bard- 
well  has  so  beautifully  shown  in  his  "Adventures  of  Old  Age." 

Nursing  homes  or  private  homes  turned  into  small  convalescent  homes 
where  patients  may  be  accepted  for  care  have  increased  very  rapidly  in 
Eastern  Massachusetts  during  the  past  few  years.  Such  nursing  and 
boarding  homes,  numbering  315,  were  reported  as  known  to  physicians 
and  hospital  social  workers  in  the  report  of  the  Boston  Council  of  Social 
Agencies  previously  referred  to.  There  is  no  licensing  or  public  super- 
vision of  nursing  homes  as  such.  The  experience  of  some  of  the  medical 
social  workers  would  suggest  that  such  supervision  is  urgently  needed.  A 
new  law  (Chapter  305  of  the  Acts  of  1929)  requires  that  anyone  boarding 
three  or  more  persons  over  60  years  of  age,  not  members  of  the  immediate 
family,  must  secure  from  the  State  Department  of  Public  Welfare  a  li- 
cense for  two  years.  The  provisions  of  this  act  will  cover  licensing  of 
many  of  these  nursing  homes  since  many  of  them  are  at  present  boarding 
chronic  patients  over  60  years  of  age.  Further  supervision  is,  however, 
sorely  needed,  for  two  reasons.  Some  of  these  private  homes  are  totally 
unsuited  for  the  care  of  chronic  invalids  because  of  poor  management  or 
inadequate  equipment  and  fire  risks.  Also  many  competent  women,  some 
of  them  trained  nurses,  who  wish  to  remain  at  home,  have  gone  to  consid- 
erable expense  to  remodel  and  equip  their  homes  expecting  to  find  a  great 
demand  for  their  services.  They  have  to  charge  rates  (the  majority  are 
$15  to  $75  a  week)  that  will  make  it  possible  for  them  to  maintain  the 
home  and  give  some  margin  to  cover  services.  The  higher  priced  rooms 
help  to  balance  the  cheaper  ones.  So  rapid  has  been  the  increase  in  the 
number  of  these  nursing  and  boarding  homes  that  few  of  them  are  filled 
to  capacity  at  any  time  and  a  large  number  of  them  have  had  to  be  closed 
at  a  great  loss  to  the  proprietress.  They  need  to  be  safeguarded  against 
unwarranted  establishment  of  such  homes  where  many  already  exist  and 
the  patients  should  be  safeguarded  against  resorting  to  nursing  homes  in- 
adequately managed.  But  at  present  there  is  no  one  place  where  one 
could  find  out  where  these  homes  are,  to  get  information  about  their 
charges  and  quality  of  service,  nor  is  there  any  supervision  of  them.  Nor 
can  a  prospective  matron  of  such  a  home  consult  any  central  authority  con- 
cerning the  need  for  establishment  of  such  a  home.  A  considerable  num- 
ber of  these  nursing  homes  around  Boston  are  well  known  and  frequently 
patronized  by  hospital  social  workers,  but  they  find  that  the  best  of  the 
matrons  wish  counsel  and  advice  on  many  questions  that  a  state  super- 
visor might  render.  This  question  should  be  seriously  considered  and  in 
the  interests  of  many  chronically  ill  patients  some  remedy  for  the  present 
situation  should  be  found. 

Massachusetts  is  fortunate  in  the  widespread  prevalence  of  local  vis- 
iting nursing  associations  prepared  to  give  a  fine  quality  of  bedside 
nursing  in  the  homes  of  patients.  Every  community  should  have  such 
service,  not  only  for  the  poor,  but  for  those  who  can  pay  for  hourly 
nursing  service.  For  the  chronic  sick,  the  attendant  nurse  under  super- 
vision may  be  very  satisfactory. 

Occupation  during  the  long  hours  of  general  physical  inactivity  is 
one  of  the  needs  of  our  patients  that  is  sometimes  overlooked  in  the  ur- 
gency of  the  necessity  for  medical  and  nursing  care.  Some  patients 
are  very  resourceful.  Reading,  knitting,  sewing,  rug  making  and  bas- 
ketry have  helped  to  while  away  hours  otherwise  weary  and  unprofit- 
able.    The  extension  of  occupational  therapy  from  our  hospital  wards 


137 

into  the  patients'  homes,  such  as  we  find  carried  on  under  the  Christo- 
pher Shop  in  Boston,  is  in  the  right  direction.  It  is  an  essential  in  the 
institution.  We  need  more  thought  and  ingenuity  in  answering  this 
question  of  how  to  fill  the  hours  more  satisfactorily  for  these  patients. 
It  should  be  not  merely  occupation.  It  should  be  occupation  with  the 
satisfaction  of  creation  or  return  of  some  kind  for  the  effort  expended. 

One  sometimes  hears  comments  on  the  "psychology  of  the  chronic 
patients".  It  has  been  the  experience  of  many  hospital  social  workers 
that  there  is  nothing  typically  characteristic  of  patients  with  chronic 
disease.  There  is  no  typical  attitude  of  patients  with  heart  disease 
nor  those  with  tuberculosis.  But  there  is  probably  nothing  that  Life 
can  bring  to  us  that  is  a  more  severe  test  of  our  character.  Most  of  us 
can  behave  nobly  (and  be  thankful  for  it)  or  pettishly  (and  regret  it) 
during  an  acute  illness  or  an  emergency.  But  the  tedium  of  chronic 
ill  health  brings  a  test  that  is  often  revealing  of  the  underlying 
character  of  the  patient.  I  remember  vividly  a  patient  who  over  a 
a  period  of  15  years  of  almost  constant  suffering  from  Reynaud's  disease 
was  admitted  to  the  wards  of  a  general  hospital  eight  times  for  partial 
amputation  of  her  legs  as  the  disease  progressed.  Each  admission  was  an 
occasion  for  demonstration  of  her  triumphant  personality  and  her  cheer- 
ing and  challenging  influence  over  all  the  patients  in  the  ward.  We  must 
not  look  for  "typical  characteristics,"  but  rather  for  characteristics  of  the 
particular  patient  with  whom  we  are  concerned.  We  must  appreciate  the 
severe  tests  to  which  the  patient  will  be  subjected  and  try  to  meet  the 
psychological  situation  as  well  as  the  physical  and  social  one.  I  have  seen 
patients  who  from  a  feeling  of  inadequacy  to  meet  life's  obligations — 
which  attitude  may  have  been  in  part  due  to  the  physical  condition — have 
rested  with  some  content  in  the  verdict  of  permanent  disability  and  the 
protection  of  institutional  life.  But  this  is  not  a  common  reaction.  We 
must  defend  ourselves  against  that  sterile  and  inhuman  attitude  which 
tends  to  classification  of  people  just  because  they  have  the  one  common 
experience  of  prolonged  illness. 

First  and  last,  then,  we,  who  are  concerned  with  this  problem  of  care 
for  patients  with  chronic  disease,  must  recognize  the  fact  that  the  psy- 
chological factor  is  a  dominant  one.  It  is  effected  primarily  by  the  char- 
acter of  the  patient,  but  can  be  effected  to  a  large  extent  by  the  confidence 
that  may  be  won  by  skilled  and  kindly  medical  care  received  and  the  satis- 
factions which  remain  after  life  has  been  robbed  of  many  normal  interests 
and  occupations.  Medical  science  is  giving  us  new  hope  for  effective 
treatment  and  for  cure  of  chronic  diseases  that  formerly  had  been  con- 
sidered incurable.  It  should  be  our  aim  to  make  possible  to  every  chronic 
patient  the  skilled  medical  service  that  he  needs  as  early  as  possible  in  the 
course  of  the  disease. 

The  plans  for  care  of  the  patient  should  be  individualized  and  the  home, 
with  readjustments,  the  visiting  nurse,  the  nursing  home  or  hospital 
should  be  sought  only  as  a  result  of  a  carefully  thought  out  medical-social 
plan. 

Suggested  Reading: 

Report  on  Chronic  Disease  in  Boston.  A  survey  made  by  the  Boston 
Council  of  Social  Agencies. 

The  Adventures  of  Old  Age  by  Francis  Bardwell.  Published  by  Hough- 
ton Mifflin. 

CANCER  STUDIES  IN  MASSACHUSETTS 

4.    Why  Do  People  Delay 

By  Herbert  L.  Lombard,  M.D.,  Director,  and  Mary  P.  Cronin,  Secretary, 
Division  of  Adult  Hygiene 

In  the  Special  Report  of  the  Departments  of  Public  Health  and  Public 
Welfare   (House  Document  1200)   it  was  found  that  cancer  patients  in 


138 
Massachusetts  averaged  an  eight  months'  delay  between  first  symptom 
and  first  consultation  with  a  physician. 

At  the  suggestion  of  Dr.  Walter  B.  Cannon,  a  study  has  been  made  to 
ascertain  the  reasons  for  this  delay.  The  records  obtained  in  the  cancer 
clinics  have  been  used  and  the  clinic  social  workers  have  collected  special 
information  regarding  221  cancer  patients  who  had  either  attended  one  of 
the  State-aided  cancer  clinics  or  the  Pondville  Hospital.  In  the  investi- 
gation both  the  reasons  for  the  delay  before  consulting  the  physician  and 
the  reasons  for  the  delay  before  beginning  treatment  were  ascertained. 
For  convenience,  this  group  of  221  cancer  cases  will  be  designated  "Study 
Group." 

During  the  thirty-three  months  ending  August  31,  1929,  1,252  individ- 
uals with  cancer  and  4,083  individuals  without  cancer  attended  the  State- 
aided  cancer  clinics.  The  median  interval  of  delay  between  first  symptom 
and  first  consultation  with  a  physician  for  the  cancer  patients  was  6.5 
months  and  for  individuals  without  cancer,  6.3  months.  The  percentage 
of  the  cancer  cases  who  came  within  eight  weeks  of  first  symptom  was 
34.1  and  of  the  non^-cancer  cases,  35.9.  When  these  groups  were  sub- 
divided into  sex  the  median  interval  for  the  non-cancer  patients  for  males 
was  6.5  months  and  for  females,  6.3  months.  The  percentage  of  the  non- 
cancerous individuals  who  consulted  a  physician  within  eight  weeks  after 
first  symptom  was  35.6  for  males  and  35.9  for  females.  This  difference, 
0.3±1.7,  is  not  statistically  significant.  In  the  cancer  group  the  median 
interval  for  males  was  8.2  months  and  females,  5.4  months.  The  percent- 
age of  males  who  came  within  eight  weeks  is  30.8  and  of  females,  37.6. 
This  difference,  6.8±2.7,  is  statistically  significant,  and  indicates  that  fe- 
males with  cancer  consult  physicians  at  an  earlier  period  than  males,  in 
part  probably  because  of  location. 

When  the  cancers  are  sub-divided  by  location,  females  are  shown  to  de- 
lay less  than  males  in  all  groups  with  the  exception  of  skin  (Table  I). 

Table  I.  —  Median  Delay  by  Type 

Male.  Female.  Total. 

Buccal  and  esophagus 5.3  2.7  4.7 

Uterus 1.9  1.9 

Skin 13.6  14.3  13.7 

Breast    *  4.2  3.9 

All  Others 4.0  3.6  3.8 

*  Too  few  cases  to  compute  a  median. 

When  the  cancer  patients  for  1928  and  1929  are  subdivided  by  the  na- 
tivity of  their  parents,  we  find  that  those  whose  parents  were  both  born 
in  the  United  States,  29.1  per  cent  of  the  males  and  32.3  per  cent  of  the 
females  went  to  a  doctor  within  eight  weeks.  This  difference,  3.2zt5.0,  is 
not  significant.  The  percentage  of  males  with  both  parents  born  abroad 
who  consulted  a  physician  within  eight  weeks  is  32.7  and  for  females, 
37.7.  This  difference,  5.0±4.0  is  not  significant.  The  differences  between 
the  foreign  males  and  the  native  males,  3.6±4.4,  and  between  the  foreign 
and  native  females,  5.4±4.6,  are  not  significant. 

The  Study  Group  resembles  the  Total  Clinic  Group  in  the  age  of  the  pa- 
tients, the  median  age  of  the  males  in  both  groups  being  sixty-three  and 
the  females,  fifty-seven.    The  types  of  cancer  differ  somewhat  (Table  II). 

Table  II.  —  Per  Cent  of  Cancers  by  Type 

Total 

Study  Group  Clinic  Group 

(221  Cancers)  (1,252  Cancers) 

Buccal  and  esophagus 16.8  21.9 

Uterus 17.6  9.5 

Skin 28.0  34.9 

Breast    23 . 0  16.9 

All  Others 14.6  16.7 

The  median  delay  in  the  Study  Group  for  males  was  8.4  months,  com- 
pared with  8.2  in  the  Total  Clinic  Group ;  for  females  of  the  Study  Group, 
7.2,  and  of  the  Total  Clinic  Group,  5.4.    While  there  is  a  considerable  dif- 


139 

ference  in  the  median  delay  for  females  between  the  two  groups,  this  dif- 
ference is  not  apparent  if  the  last  year  only  of  the  clinic  records  are  used. 
There  has  been  a  slight  increase  in  the  median  delay  during  the  three 
years  experience  of  the  cancer  clinics.  In  1927  the  delay  was  6.0  months, 
in  1928  it  was  6.6  months,  and  for  the  first  eight  months  of  1929,  7.2 
months.  This  increase  can  be  explained  in  part  by  the  change  in  the  type 
of  cancers  which  are  coming  to  the  State-aided  clinics.  Table  III  shows 
that  the  percentage  of  skin  cancers,  which  have  a  long  period  of  delay  are 
increasing,  while  breast,  buccal-esophagus,  and  all  other  cancers  with 
short  periods  of  delay  are  decreasing.  Cancers  of  the  uterus  are  increas- 
ing, but  the  short  delay  of  this  group  does  not  compensate  for  the  others. 
Moreover,  the  skin  cancers  show  an  increase  in  the  period  of  delay  from 
eleven  months  in  1927  to  twenty-four  months  in  1929. 

Table  III.  —  Percentage  Distribution  of  Cancers  by  Location 

Total 

1927  1928  1929* 

Buccal  and  esophagus 23 . 8  21.9  21.5 

Uterus   8.2  8.9  11.8 

Skin   '. 29 . 8  36 . 1  36 . 8 

Breast 21.0  15.7  15.5 

All  Others 17.2  17.3  14.3 

*  Eight  months. 

Delay  Before  Consulting  a  Physician 

The  greatest  single  cause  for  delay  was  among  those  individuals  who 
considered  their  condition  a  minor  illness.  Warts,  moles,  indigestion,  and 
other  maladies  were  thought  to  be  the  trouble.  (Table  IV)  Forty-eight 
per  cent  of  the  individuals  attributed  their  conditions  to  these  minor 
causes.  Ten  per  cent  delayed  on  account  of  negligence ;  9  per  cent  because 
the  symptom  was  not  severe;  12  per  cent  felt  the  delay  was  too  short  to 
be  considered;  and  the  remaining  21  per  cent  attributed  their  delay  to 
either  fear,  economics,  opposition  to  doctors,  ignorance,  the  use  of  home 
remedies,  bad  advice,  or  a  few  miscellaneous  reasons. 

There  are  significant  differences  between  the  sexes  in  their  relation  to 
fear  and  thinking  their  condition  to  be  a  minor  malady.  There  are  border- 
line significances  between  the  sexes  in  their  opposition  to  doctors  and  ac- 
cepting poor  advice.  Males  were  more  apt  to  delay  than  females  because 
they  thought  their  condition  was  a  minor  malady;  whereas,  fear,  opposi- 
tion to  doctors,  and  poor  advice  were  found  to  a  greater  extent  among  the 
females. 

Table  IV.  —  Reason  for  Delay  between  First  Symptom  and  First  Visit  to  Physician 

total  male                          female  difference 

No.  Per  Cent  No.  Per  Cent  No.       Per  Cent 

Thought  it  other  conditions 106       48 . 2  54  59 . 4  ±4 . 8  52  40 . 0  ±4 . 3  19 . 4  ±6 . 4 

Felt  delay  short 26       11.6              8  8.8=1=3.0  18  13.9±3.0  5.1±4.2 

Negligence    23       10.4             9  9.9=b3.1  14  10.8±2.6  0.9=1=4.0 

Symptoms  not  severe 19         8.6              7  7.7=b2.8  12  9.2±2.5  1.5±3.8 

Ignorance 12         5.4              6  6.6±2.6  6  4.6=bl.8  2.0±3.3 

Fear 10         4.5             0  O.OiO.O  10  7.7±2.3  7.7=fc2.3 

Economics 6         2.7              2  2.2±1.5  4  3.1±1.5  0.9±2.1 

Used  home  remedies 6         2.7              4  4.4=1=2.1  2  1.5=1=1.1  2.9±2.4 

Miscellaneous 5         2.4              1  1.1=1=1.1  4  3.1±1.5  2. Oil. 9 

Bad  advice 4          1.8              0  O.OiO.O  4  3.1=1=1.5  3.1±1.5 

Opposed  to  doctors 4          1.8              0  O.OiO.O  4  3.1=bl.5  3.1=1=1.5 

Delay  Before  Treatment 

About  two-fifths  of  the  patients  received  treatment  within  one  week  of 
consultation  with  physician.  (Table  V)  About  one-eighth  of  the  patients 
had  a  median  delay  of  two  weeks  while  making  the  necessary  arrange- 
ments. Eight  per  cent  of  the  group  have  received  no  treatment  up  to  the 
present  time.  The  median  delay  of  the  remainder  was  eight  months  for 
males,  five  months  for  females,  and  six  months  for  totals. 

Almost  12  per  cent  of  the  221  patients  (26  per  cent  of  those  who  de- 
layed) delayed  treatment  because  of  poor  advice  given  by  physicians;  6 
per  cent  on  account  of  fear ;  and  5  per  cent  on  account  of  negligence.    Six 


140 

per  cent  refused  treatment  and  16  per  cent  delayed  because  of  economics, 
poor  family  cooperation,  no  faith  in  doctors,  no  reason,  or  for  miscellane- 
ous reasons.  There  were  no  significant  differences  between  the  sexes  in 
regard  to  the  delay  between  consultation  with  physician  and  treatment. 

Table  V.  —  Reason  fob  Delay  between  Physician  and  Treatment 

TOTAL  MALE  FEMALE'  DIFFERENCE 

No.  Per  Cent  No.  Per  Cent  No.  Per  Cent 

No  delay  (within  one  week)     ...  92  41.7  38  41.S±5.2  54  41.6±4.3  0.2±6.7 

Waiting  for  arrangements    30  13.6  13  14.3±3.7  17  13.1±3.0  1.2±4.7 

Poor  advice  given  by  doctors    ..  26  11.8  9         9.9=h3.1  17  13.1±3.0  3.2±4.3 

Fear               13  5.9  5         5.5±2.4  8         6.2±2.1  0.7±3.2 

Refused  immediate  treatment  . .  13  5.9  4         4.4±2.1  9         6.9±2.2  2.5±3.0 

Negligence    12  5.4  7         7.7±2.8  5         3.8=1=1. 7'  3.9±3.3 

Miscellaneous 11  5.0  4         4.4±2.1  7         5.4±2.0  1.0±2.9 

Noreason 11  5.0  3         3.3±1.9  8         6.2=1=2.1  2.9=b2.8 

Economics    5  2.3  4         4.4=b2.1  1         0.8±.2  3.6±2.2 

Poor  family  co-operation 4  1.8  3         3.3=1=1.9  1         0.8±    .2  2.5=1=2.0 

No  faith  in  doctors 4  1.8  1         I.lil.l  3         2.3±1.3  1.2±1.7 

The  reasons  given  for  delay  between  first  symptom  and  first  visit  to 
physician  point  toward  the  need  of  greater  educational  activities.  Indi- 
viduals who  feel  that  their  condition  is  some  minor  malady  and  those  who 
fail  to  see  a  physician  through  ignorance  should  be  taught  the  danger 
signs  of  cancer.  Those  who  delay  on  account  of  fear  should  know  that  can- 
cer is  not  a  hopeless  disease.  For  those  who  do  not  consult  a  physician 
because  of  economic  conditions  a  knowledge  that  State-aided  clinics  fur- 
nish free  diagnosis  should  be  given.  Those  using  home  remedies,  receiv- 
ing advice  from  quacks,  and  opposed  to  doctors  should  know  that  surgery 
and  radiation  are  the  only  proven  methods  for  the  cure  of  cancer.  Those 
who  delay  because  the  symptom  is  not  severe  should  realize  that  pain  is 
not  usually  an  early  symptom  of  cancer.  To  the  negligent,  the  knowledge 
that  in  some  forms  of  cancer  the  chance  for  cure  decreases  4  per  cent  a 
week  should  be  known. 

The  reasons  given  for  delay  between  first  visit  to  physician  and  first 
treatment  point  toward  a  better  knowledge  of  cancer  on  the  part  of  some 
physicians  and  greater  activity  on  the  part  of  the  social  worker.  The 
physicians  in  the  State  who  are  somewhat  backward  in  their  methods  of 
diagnosis  and  treatment  should  avail  themselves  of  such  educational  re- 
sources as  the  Graduate  Courses  in  Cancer  offered  by  the  medical  society, 
the  various  cancer  clinics  held  widely  over  the  State,  and  the  like.  The 
figure  of  12  per  cent  in  the  Study  Group  who  received  poor  advice  is  some- 
what better  than  the  14  per  cent  figure  reported  by  Simmons  and  Daland, 
but  there  is  still  evidently  need  for  further  education.  The  social  worker 
should  endeavor  to  allay  fear,  improve  family  cooperation,  arouse  the  neg- 
ligent, and  point  out  the  resources  of  the  State  available  to  everybody. 

Conclusions 

1.  The  median  delay  between  first  symptom  and  first  consultation  with 
a  physician  for  individuals  with  cancer  coming  to  the  State-aided  cancer 
clinics  in  Massachusetts  is  6.5  months. 

2.  Males  delay  longer  than  females  except  for  skin  cancers. 

3.  The  greatest  delay  is  in  cases  of  cancer  of  the  skin  and  the  shortest 
delay  is  among  those  patients  having  cancer  of  the  uterus. 

4.  Thinking  the  condition  was  a  minor  malady  is  the  largest  single 
cause  of  delay.  Among  the  males,  this  reason  is  considerably  greater 
than  among  the  females. 

5.  The  greatest  single  cause  of  delay  between  consultation  with  physi- 
cian and  treatment  was  because  of  poor  advice  on  the  part  of  the  attending 
physician. 

6.  Forty-five  per  cent  of  the  cancer  patients  had  a  median  delay  of  six 
months  after  consulting  a  physician  while  55  per  cent  received  treatment 
within  a  short  time  following  diagnosis. 

7.  The  median  interval  of  delay  is  increasing  each  year  since  our  first 
figures  in  1927.    This  is  profoundly  disappointing  in  view  of  the  intensive 


141 

medical  and  lay  education  carried  on.  Possibly  it  is  in  part  due  to  the 
fact  that  the  percentage  of  individuals  with  skin  cancers  attending  the 
clinics  has  increased,  as  this  group  delays  much  longer  than  any  other. 
Our  current  figures,  however,  indicate  that  the  delay  in  skin  cancers  is 
increasing,  while  other  types  remain  about  the  same. 

CONTROL  OF  DISEASES  OF  ADULT  LIFE 

By  W.  A.  Evans,  M.D., 

Professor  of  Public  Health,  Northwestern  University 

A  division  of  adult  hygiene  pioneering  in  a  hitherto  almost  unoccupied 
field  must  go  forward  by  trial  and  error.  Other  departments  of  health 
will  watch  with  interest  not  only  the  experiment  as  it  is  begun,  but  will 
also  be  interested  in  developments  as  they  are  undertaken.  It  is  certain 
they  will  follow  the  lead  of  the  Massachusetts  Department. 

The  fact  that  this  division  is  built  around  the  cancer  bureau,  in  success- 
ful operation  for  over  two  years,  and  under  the  observation  of  every  health 
department  in  the  country,  assures  the  Division  of  Adult  Hygiene  the  at- 
tention of  departments  of  health.  Of  greater  moment  is  the  interest  of 
the  people  served. 

In  so  far  as  we  can  judge  by  death  rates,  the  health  of  babies  and  older 
children  is  being  well  cared  for,  while  that  of  adults  is  being  neglected. 
A  few  decades  ago  the  evidence  was  convincing  that  we  did  not  know  how 
to  care  for  children  or  else  the  knowledge  was  not  applied.  Something  was 
wrong  with  mothercraft.  A  determined  effort  was  made  to  change  this. 
Among  other  things  that  were  done  every  health  department  organized  a 
division  of  child  hygiene.  Out  of  all  of  this  a  great  reduction  in  infant 
mortality  has  come.  The  improvement  in  this  group  is  almost  altogether 
responsible  for  the  improvement  in  the  general  death  rate. 

Meanwhile,  the  average  age  of  the  population  is  increasing.  Those 
whose  lives  were  saved  in  childhood  are  now  grown  up  men  and  women. 
The  great  adult  group  yearly  becomes  numerically  greater.  There  fol- 
lows increasing  importance  of  cancer,  apoplexy,  Bright's  disease,  heart 
disease,  arteriosclerosis,  diabetes,  adult  pneumonias  and  other  diseases 
which  levy  heavy  toll  on  persons  in  adult  life.  Some  of  these  are  the  result 
of  infections  against  which  measures  of  defense  can  be  found  and  applied. 
Others  are  in  whole  or  in  great  part  due  to  errors  in  habits.  These  can  be 
pointed  out  and  adults  can  be  helped  to  so  live  as  to  avoid  them. 

Guidance  in  habits  and  customs  should  be  a  function  of  a  health  depart- 
ment. There  are  many  degenerative  disorders  which,  while  they  cripple 
organs,  have  slight  tendency  to  destroy  life.  One  function  of  a  division  of 
adult  hygiene  might  be  termed  a  "how-to-live-with"  activity  charged  with 
the  duty  of  showing  men  with  crippled  organs  how  to  live  efficiently  and 
comfortably.  Among  the  disorders  where  life  can  be  maintained  on  a  pro- 
ductive and  comfortable  basis  for  a  long  time,  if  the  law  is  lived,  are: 
chronic  Bright's  disease,  heart  disease  with  compensation,  diabetes,  ar- 
teriosclerosis, many  of  the  disorders  of  senescence,  epilepsy  and  various 
other  mental  disorders. 

The  people  can  expect  results  from  a  division  of  adult  hygiene.  It  will 
help  the  cancer  situation,  it  will  reduce  the  death  rate  of  the  higher  age 
periods  and  it  will  promote  healthful  living. 

WHAT  THE  AVERAGE  ADULT  SHOULD  KNOW  ABOUT  THE 
PREVENTION  OF  ARTHRITIS 

By  Robert  B.  Osgood,  M.D., 

Boston,  Mass. 

He  should  realize  that  anything  which  tends  to  weaken  the  normal  de- 
fense mechanisms  of  the  body  and  which  lowers  his  resistance  to  influ- 
ences unfavorable  to  health,  predisposes  the  individual  to  arthritis.    These 


142 
predisposing  causes  are  very  important.  Lowered  resistance  allows  chem- 
ical poisons  produced  within  the  body  to  affect  the  joints.  These  poisons 
may  contain  no  germs  and  may  not  even  be  produced  by  germs.  They 
may,  however,  be  manufactured  by  bacteria  and  sometimes  the  germs 
themselves  may  invade  the  joint  tissues  and  damage  them  beyond  repair. 
What  induces  this  condition  of  the  body  which  makes  a  man,  woman  or 
child  "threatened"  with  arthritis? 

1.  Continued  fatigue  of  mind  and  body.  If  we  are  tired,  we  do  not 
digest  our  food  properly.  If  the  marvelous  chemical  machine  of  our  intes- 
tines does  not  give  the  blood  the  exact  amount  and  kind  of  nourishing 
matter  which  the  different  tissues  of  the  body  must  have  in  order  to  be 
healthy,  the  tissues  become  weak  and  finally  they  become  diseased.  Rheu- 
matism is  said  to  run  in  certain  families,  and  if  a  person  has  this  ten- 
dency, the  joint  tissues  may  feel  this  lack  of  proper  nourishment  first.  If 
we  do  not  use  our  bodies  correctly,  we  tire  much  more  easily. 

2.  Improper  food  and  imperfect  regular  evacuation  of  the  bowels.  Too 
little  drinking  water.  Too  much  heavy,  starchy  food.  Too  much  sweets. 
Too  much  meat.  Too  little  of  the  vitamines  such  as  are  contained  in  the 
citrus  fruits,  fresh  green  vegetables,  whole  wheat  bread,  yeast  and  cod 
liver  oil. 

3.  Too  little  exercise  and  fresh  air  and  sunlight. 

4.  Sickness,  especially  that  caused  by  germs,  such  as  rheumatic  fever, 
grippe,  common  colds,  pneumonia,  typhoid  fever,  dysentery,  and  diseases 
of  the  generative  organs. 

After  the  diseases,  although  most  of  the  body  may  succeed  in  over- 
coming the  invading  host  of  bacteria,  small  colonies  in  the  intestines,  in 
the  tonsils  and  teeth  and  sinuses  may  intrench  themselves  and  send  out 
occasional  marauding  parties  into  the  joints. 

If  you  would  avoid  being  "threatened"  with  arthritis, 

1.  Avoid  over-fatigue  of  mind  and  body. 

2.  Be  sure  that  you  get  the  proper  kind  of  food  in  proper  amounts  to 
keep  you  at  a  normal  weight  and  bring  about  a  normal  regular  evacuation 
of  the  bowels. 

3.  Take  regular  (but  not  necessarily  strenuous)  exercise  and  get  all  the 
fresh  air  and  sunlight  you  can.  Learn  how  to  stand  and  sit  correctly  and 
to  use  the  body  with  least  mechanical  strain. 

4.  Have  a  general  examination  by  your  own  physician  or  at  a  hospital 
clinic  at  least  once  a  year.  This  is  especially  important  after  you  have 
recovered  from  any  sickness  caused  by  germs,  in  order  to  be  sure  that  no 
harmful  small  foci  of  infection  remain  hidden  but  still  active,  in  the  body. 
Arthritis  can  be  prevented  and  many  forms  can  be  cured. 

THE  CONTROL  OF  CANCER 

By  Robert  B.  Greenough,  M.D., 

President,  Massachusetts  Medical  Society 

In  spite  of  world-wide  investigation,  we  have  at  the  present  time  no  ade- 
quate knowledge  in  regard  to  the  cause  or  the  specific  treatment  of  cancer, 
and  the  control  of  the  disease  therefor  resolves  itself  into  two  measures, 
(1)  the  prevention  of  the  disease,  and  (2)  its  treatment  by  methods  which 
have  been  proved  to  be  of  value. 

Prevention  of  cancer,  in  spite  of  our  lack  of  knowledge  of  the  precise 
causes  of  the  disease,  can  be  accomplished  in  certain  locations  at  least  be- 
cause of  the  well-established  relation  which  has  been  found  to  exist  be- 
tween "pre-cancerous  conditions,"  themselves  of  a  non-malignant  nature, 
and  cancer.  These  conditions  as  a  rule  present  themselves  as  chronic  in- 
flammatory diseases  of  the  surface  tissues,  and  they  are  especially  signifi- 
cant on  the  external  skin,  in  the  mouth,  and  in  the  genito-urinary  tract. 
Their  significance  depends  upon  the  fact  that  cancer  is  prone  to  develop 
in  any  situation  where  long  standing  chronic  inflammatory  disease  calls 


143 

forth  excessive  efforts  at  repair.  Perhaps  the  most  conspicuous  example 
of  this  nature  is  the  development  of  cancer  of  the  cervix  of  the  uterus  at 
the  site  of  erosions  and  lacerations  consequent  upon  childbirth.  Many  of 
these  pre-cancerous  conditions  can  be  effectively  treated  by  surgical  meas- 
ures and  by  radiation  in  such  a  way  as  to  remove  the  danger  of  cancer  de- 
veloping in  this  position.  Leukoplakia  of  the  mucous  membranes ;  chronic 
ulcerations  of  the  mouth,  attributable  to  irregular  teeth  or  ill-fitting  tooth 
plates;  the  papillary  and  keratotic  changes  of  exposed  parts  of  the  skin, 
especially  in  aged  persons,  pigmented  moles,  and  other  benign  tumors  of 
the  skin  and  of  organs,  such  as  the  uterus,  ovary,  breast,  colon,  and  rec- 
tum, are  further  examples  of  "pre-cancerous"  conditions  in  which  the  de- 
velopment of  cancer  may  be  prevented  by  adequate  treatment. 

For  the  cure  of  actual  cancer  the  chief  reliance  is  placed  today  upon  sur- 
gical measures,  including  electric  and  other  cauterization,  and  radiation. 
Both  surgery  and  radiation  have  proved  their  effectiveness  in  curing  can- 
cer in  most  of  its  common  situations.  For  their  successful  employment, 
however,  the  disease  must  be  recognized  in  its  incipient  local  condition  be- 
fore the  wide-spread  extension  of  the  disease  has  occurred  which  is  char- 
acteristic of  its  later  stages.  It  is  for  this  reason  that  the  early  recogni- 
tion of  the  disease  is  of  such  great  importance  and  it  is  to  aid  in  this  early 
recognition  of  the  disease  that  campaigns  for  the  education  of  the  public 
and  of  the  medical  profession  have  been  so  widely  carried  on.  The  early 
symptoms  of  cancer  are  in  no  way  distinctive  and  diagnostic  and  it  fre- 
quently happens  that  the  most  expert  clinician  may  require  an  exploratory 
operation  to  settle  the  diagnosis  in  a  doubtful  case.  It  is  for  this  reason 
that  the  Department  of  Public  Health  has  organized  a  group  of  special 
cancer  clinics  distributed  throughout  the  State  and  affiliated  with  the  State 
Cancer  Hospital  at  Pondville,  to  the  end  that  expert  diagnostic  service  may 
be  made  available  without  undue  expense  to  every  citizen  and  to  every 
physician  in  Massachusetts.  The  recognition  of  a  case  of  cancer  in  its 
early  and  curable  stage  and  the  prompt  provision  of  adequate  treatment 
whether  by  surgery  or  radiation  is  the  most  effective  measure  known  to  us 
at  present,  for  the  control  of  this  disease. 

WHAT  THE   CITIZEN  SHOULD  KNOW  ABOUT  ASTHMA 

By  Francis  M.  Rackemann,  M.D., 
Massachusetts  General  Hospital 

Asthma  is  a  disease  with  many  causes  which  excite  the  attack  in  those 
individuals  who  have  an  asthmatic  background,  called  "allergy."  Allergy 
is  inherited  through  the  male  and  the  female  alike.  Its  manifestations 
include,  beside  asthma,  chiefly  hay  fever  and  eczema.  That  is  why  these 
several  diseases  are  so  frequently  associated  together,  not  only  in  the  in- 
dividual patient,  but  in  his  family.  For  example:  the  grandfather  has 
asthma,  the  father  has  hay  fever  and  the  small  son,  who  had  eczema  in  in- 
fancy, now  wheezes  with  his  colds. 

In  half  the  cases  with  asthma  the  patient  is  hypersensitive  to  some  par- 
ticular substance  in  his  environment.  In  children  we  suspect  a  particular 
food  and  may  find  eggs,  wheat  or  milk  as  a  causative  factor.  In  adults  we 
suspect  some  dust,  perhaps  the  pollen  of  some  plant,  perhaps  some  animal, 
like  a  dog  or  cat,  perhaps  some  dust  in  the  home  or  perhaps  some  dust  con- 
nected with  the  occupation. 

In  the  other  half  of  the  cases  the  cause  of  asthma  is  inside  the  patient's 
body  in  the  form  either  of  some  chronic  infection,  like  bad  tonsils  or  bad 
teeth,  or  infected  nasal  sinuses  with  polyps  in  the  nose.  Recurrent  colds, 
which  are  followed  by  bronchitis,  may  be  later  accompanied  by  wheezing 
which  is  asthma.  In  other  cases  this  bronchitis  becomes  more  severe  and 
the  excessive  cough  and  shortness  of  breath  result  in  stretching  (emphy- 
sema) of  the  lungs  which  makes  a  bad  matter  worse.  This  stretching  ag- 
gravates the  infection;  the  infection  and  continued  cough  aggravate  the 


144 

stretching.  It  is  these  cases  which  are  so  difficult  to  treat.  In  the  early 
stages  and  before  emphysema  has  developed,  the  chance  of  success  with 
appropriate  treatment  is  good.  This  treatment  may  sometimes  be  simply 
the  elimination  of  feather  pillows ;  or  it  may  be  such  measures  to  improve 
the  general  health  as  a  change  in  diet,  a  rest  after  dinner ;  or  possibly  an 
operation  to  remove  the  gall-bladder  or  other  cause  of  chronic  disease;  or 
finally,  treatment  may  be  with  vaccines  which  aim  to  increase  the  general 
resistance. 

We  have  recently  found,  at  the  Massachusetts  General  Hospital,  that 
among  a  total  of  1074  patients  with  asthma,  213  of  them  (one  out  of  five) 
were  entirely  freed  of  their  trouble  for  at  least  two  years  following  the 
last  visit.  Apparently  they  have  been  "cured."  In  addition,  many  others 
are  greatly  improved.  All  this  means  that  sufferers  from  asthma  should 
consult  a  doctor  who  can  find  its  cause  and  give  proper  treatment.  Fur- 
thermore, if  this  treatment  is  given  earlier,  the  chance  of  success  is 
greater.  About  half  the  children  with  asthma  "outgrow"  it,  but  the  other 
half  do  not. 

Patent  medicines,  which  relieve  many  patients,  do  not  reach  the  funda- 
mental cause  of  the  disease  and,  therefore,  should  not  be  relied  upon. 

CONTROL  MEASURES  IN  DIABETES 

By  Elliot  P.  Joslin,  M.D., 
Boston,  Mass. 

If  a  disease  is  to  be  controlled  one  must  know  its  extent.  During  1928 
in  Massachusetts  statistically  there  were  930  deaths  from  diabetes,  but  in 
reality  the  word  "diabetes"  occurred  upon  1,040  death  certificates.  This 
is  explained  by  cancer,  tuberculosis,  typhoid  and  similar  conditions  rank- 
ing as  major  causes  and  thus  displacing  diabetes  as  a  primary  cause  of 
death.  In  a  way  this  is  unfortunate,  because  the  patient  whose  resistance 
is  lowered  by  diabetes  becomes  a  prey  to  infections,  notably  to  tuberculosis 
in  former  years,  and  such  cases  should  be  charged  to  diabetes.  It  would 
be  a  help,  therefore,  in  controlling  diabetes  if  all  death  certificates  were 
made  out  in  detail  so  that  the  diabetic  background  would  show. 

The  first  year  following  the  onset  of  diabetes  is  the  diabetic-coma- 
danger-zone  and  is  far  more  productive  of  coma  than  any  other  year. 
Naturally  it  should  be  the  least  productive  of  coma,  and  perhaps  if  the 
case  histories  were  more  accurate,  it  would  show  this  to  be  true.  Coma 
cases  are  often  seen  by  a  physician  unacquainted  with  the  patient's  past. 

During  1928,  36  per  cent  of  the  diabetic  deaths  of  the  State  occurred  in 
hospitals.  In  the  hospitals  the  mortality  from  coma  was  approximately  11 
per  cent  and  the  total  coma  mortality  in  the  State  was  approximately  9.2 
per  cent.  Possibly  these  figures  are  too  low  and  diabetic  coma  should  ap- 
pear more  often  on  the  death  certificate  and  take  the  place  of  the  word 
"diabetes"  which  frequently  stands  alone.  Although  diabetic  coma  is  far 
less  common  in  Massachusetts  than  formerly,  we  may  not  have  advanced 
as  much  as  the  statistics  indicate.  The  average  age  of  death  of  the  cases 
of  coma  was  52  years  in  contrast  to  the  non-coma  cases  in  which  it  was 
62  years. 

Cardio-renal  and  vascular  conditions  caused  43  per  cent  of  the  diabetic 
deaths,  infections  22  per  cent,  tuberculosis  3.4  per  cent,  cancer  4.0  per 
cent,  but  there  were  21  per  cent  of  the  total  deaths  in  which  diabetes  was 
the  only  word  on  the  death  certificate. 

Patients  practically  never  die  of  uncomplicated  diabetes,  and,  therefore, 
the  contributory  cause  should  be  recorded.  It  would  also  be  a  help  in  any 
plan  for  the  control  of  diabetes  if  the  words  "with"  or  "without  coma" 
were  also  included. 


145 
CONTROL  MEASURES  IN  HEART  DISEASE 

By  William  H.  Robey,  M.D., 

Clinical  Professor  of  Medicine  in  Harvard  University,  President  of  the 
American  Heart  Association 

The  Causes  of  Heart  Failure 

The  normal  heart  and  circulation  are  so  adjusted  that  the  work  of  the 
heart  is  facilitated,  but  a  disturbance  in  any  part  of  the  heart  or  other 
organs  increases  the  work  of  maintaining  the  circulation  and  eventually 
leads  to  overwork  and  failure  of  the  heart  muscle.  So  long  as  the  heart 
can  overcome  the  effects  of  disease  and  maintain  the  circulation  efficiently 
no  symptoms  are  produced  but  when  too  great  a  strain  is  put  upon  it  signs 
of  exhaustion  and  failure  appear. 

The  conditions  which  produce  structural  changes  in  the  heart  valves, 
muscle,  blood  vessels  or  other  organs  which  lead  eventually  to  heart  failure 
are,  in  order  of  their  frequency,  arteriosclerosis,  rheumatic  fever,  scarlet 
fever,  syphilis  and  diphtheria. 

History  and  Observation. 

A  very  complete  history  should  be  taken  in  every  case.  Observation  of 
the  person  at  rest  and  at  work  helps  greatly.  Etiology  must  be  determined 
in  each  patient  if  we  are  to  attack  the  cause  of  his  cardiac  disturbance. 

Rheumatic  Fever  and  Syphilis. 

Rheumatic  fever  and  syphilis  are  the  two  great  causes  of  heart  disease 
in  the  youth  and  young  adult.  Space  does  not  permit  a  discussion  of  the 
focal  infection  as  a  cause  of  rheumatic  heart  disease  but  it  is  the  writer's 
belief  that  such  foci  as  diseased  tonsils  and  teeth  are  mighty  factors  in  its 
production.  The  argument  that  tonsillectomy  does  not  prevent  rheumatic 
fever  may  be  met  with  the  statement  that  the  operation  is  often  deferred 
until  other  foci  of  infection  have  been  established,  the  joints  for  example, 
from  which  the  attack  of  rheumatism  is  renewed  during  a  period  of  low- 
ered resistance.  The  history  of  mild  sore  throats  as  much  as  definite  at- 
tacks of  tonsilitis  should  be  considered  as  indications  for  tonsillectomy. 

A  more  frequent  use  of  the  Wassermann  reaction  should  be  made.  The 
discovery  of  an  unsuspected  or  forgotten  syphilitic  infection  may  save  the 
patient  from  cardiac  involvement  a  few  years  later.  Aortic  regurgitation 
and  aneurysm  are  the  two  common  syphilitic  lesions.  Salvarsan  or  its 
allies  should  be  used  with  great  caution  in  syphilitic  aortitis. 

Irregularities  of  Heart  Action. 

The  physician  of  today  who  is  to  intelligently  interpret  cardiac  abnor- 
malities must  understand  the  meaning  of  the  various  types  of  arhythmia. 
Likewise  he  must  be  able  to  differentiate  between  functional  and  organic 
murmurs. 

Rest  and  Work. 

Children  who  have  shown  a  cardiac  involvement  during  or  following  an 
acute  infection  should  be  given  a  complete  rest  in  bed  for  several  months. 
Rest  will  do  more  to  restore  cardiac  compensation  than  any  other  thera- 
peutic measure. 

In  all  cardiac  lesions  coming  to  us  for  treatment  the  balance  between 
rest  and  work  must  be  judiciously  estimated.  Rest  the  heart  first  and  then 
carefully  study  the  amount  of  work  which  it  can  do.  Often  the  occupation 
of  the  individual  must  be  modified  or  changed.  Do  not  hesitate  to  see  the 
patient  frequently  to  establish  the  right  habits  of  rest,  work  and  play.  The 
symptoms  of  cardiac  exhaustion  are  undue  fatigue,  breathlessness  and 
pain. 


146 
VARICOSE  VEINS 

By  John  Homans,  M.D., 
Surgeon,  Peter  Bent  Brigham  Hospital 

The  usual  cause  of  varicose  veins  among  men  is  hard  work,  in  the  sense 
of  heavy  lifting  and  long  hours  of  standing,  and  among  women,  childbirth. 
In  either  case,  the  superficial  veins  of  the  legs  become  dilated  from  at- 
tempting to  carry  blood  up-hill  against  too  great  resistance.  Such  causes 
cannot  be  prevented ;  men  must  work  and  women  must  bear  children,  and 
work  as  well,  so  that  it  is  the  secondary  effects  of  varicose  veins  against 
which  people  must  protect  themselves. 

Varicose  veins  first  show  themselves  below  the  knee  on  the  inner  side 
of  the  calf.  But  this  is  not  actually  where  they  begin,  for  they  are  always 
present  in  the  thigh  (though  well  concealed  in  the  fat)  before  they  appear 
below.  They  are  raised  above  the  skin,  bluish  as  a  rule  and  usually  take 
rather  a  snaky  course.  A  good  sized  varicose  vein  may  be  from  one  quar- 
ter to  one  half  an  inch  in  width.  Many  persons  having  veins  of  this  sort 
will  testify  that  they  have  no  unpleasant  symptoms  whatever.  Others  suf- 
fer from  a  heavy  feeling,  from  itching  of  the  skin,  and  from  the  sort  of 
tingling  discomfort  which  everyone  experiences  when  obliged  to  stand  per- 
fectly still  for  a  long  period.  But  in  any  case  there  is  in  varicose  veins  a 
stagnation  of  impure  blood  which  the  deeper  veins  must  carry  away. 

Persons  possessing  varicose  veins  are  subject  to  three  sorts  of  compli- 
cations of  which  two,  that  is  ulcer  and  phlebitis,  are  very  troublesome. 
The  third,  rupture  of  a  vein,  rarely  occurs  but  is  a  rather  terrifying  acci- 
dent, for  bleeding  continues  from  the  opening  so  long  as  the  leg  is  left  de- 
pendent. However,  once  the  leg  is  elevated  and  pressure  applied  to  the 
bleeding  point,  hemorrhage  stops  at  once.  As  a  rule,  when  this  accident 
has  occurred  the  veins  should  be  removed  or  destroyed,  for  a  recurrence  is 
probable. 

Varicose  ulcer  is  very  common.  It  may  develop  insidiously  or  suddenly. 
In  the  first  case  it  usually  follows  the  appearance  of  a  brownish  or  reddish 
area  not  far  above  the  ankle  in  the  course  of  a  large  vein.  In  the  second, 
it  follows  a  scratch  or  blow  upon  the  skin  which,  in  the  presence  of  the 
stagnant  superficial  circulation,  fails  to  heal  and  becomes  infected.  Very 
extensive  deep,  painful  ulcers  only  become  established  after  many  years 
and  after  a  small  ulcer  has  broken  open  and  healed  several  times.  There- 
fore, persons  who  have  varicose  veins  should  be  careful  to  keep  their  legs 
clean,  with  soap  and  water,  for  it  is  infection  which  causes  the  early  ulcer 
to  spread  and  deepen.  Those  who  are  exposed  to  injury  should  protect 
themselves  against  blows  and  scratches,  by  bandages  as  a  rule.  Very  good 
semi-elastic  cotton  bandages  are  now  available  and  are  not  difficult  to  put 
on.  But  once  a  sore,  however  small,  has  appeared,  it  is  a  warning  that  the 
varicose  veins  should  be  removed  or  destroyed,  for  thereafter  an  ulcer  is 
always  threatened. 

Phlebitis  is  actually  a  clotting  of  blood  in  a  varicose  vein.  There  is 
sometimes  considerable  inflammation  and  pain ;  at  other  times  hardly  any. 
Generally  a  sore  lump  appears  in  an  especially  dilated  part  of  a  vein  and 
from  this  point  the  process  spreads  up  and  down.  If  the  victim  goes  to 
bed,  the  process  clears  up  in  the  course  of  several  weeks.  If  he  keeps 
about,  even  with  a  well  applied  bandage,  the  clot  is  very  slow  to  disappear. 
The  vein  is  never  destroyed  by  phlebitis  but  becomes  subject  to  recurrence 
of  the  trouble. 

There  is  no  way  of  preventing  phlebitis,  save  by  removing  or  destroying 
the  veins,  but  once  it  has  occurred,  some  sort  of  operation  should  almost 
certainly  be  performed.  It  is  difficult  to  say  how  much  of  a  risk  a  person 
is  subject  to  who  suffers  from  phlebitis.  There  is  a  theoretical  danger 
that  a  thrombus  may  be  detached,  carried  to  the  lungs  and  cause  death — 
but  this  danger  is  very  remote  indeed  unless  the  clotted  vein  is  massaged 
or  injured. 


147 

As  for  the  operative  treatment  of  varicose  veins  and  their  complications, 
there  is  no  doubt  that  radical  operations,  as  generally  performed,  are  dis- 
liked and  distrusted  by  many.  To  be  successful  they  must  be  carried  out 
with  a  degree  of  pains  and  skill  which  most  surgeons  cannot  or  will  not 
give  them.  Yet  they  offer  the  most  lasting  and  satisfactory  cure,  espe- 
cially when  varicose  ulcers  are  present  or  threatened,  and  they  are  essen- 
tial to  the  prevention  of  attacks  of  phlebitis. 

Varicose  veins  are,  however,  destroyed  by  certain  chemicals  which  can 
be  injected  into  them  with  comparatively  little  difficulty.  Such  injections 
can  only  be  made,  as  a  rule,  in  the  calf,  so  that  the  veins  which  are  left  in 
the  thigh  must  in  the  end  distend  a  new  set  of  veins  below,  but  to  offset 
this  disadvantage,  the  treatment  can  be  given  with  little  interruption  of 
the  patient's  occupation  and  is  by  far  the  best  ambulatory  treatment  for 
varicose  ulcer  which  has  ever  been  devised. 

There  are,  then,  appropriate  curative  remedies  for  those  whose  occupa- 
tion and  way  of  life  expose  them  to  the  disabling  effects  of  varicose  veins. 
For  those  who  can  afford  to  lead  a  life  of  little  exertion,  bandaging  and 
elevation  of  the  legs,  when  opportunity  offers,  bring  sufficient  relief  and 
forestall  the  disabling  complications. 

THE  BUSINESS  MAN 

By  Robert  W.  Buck,  M.D., 

Chief  of  the  Health  Clinic,  Boston  Dispensary 

Physiologically  speaking,  the  business  man  differs  from  other  men  only 
in  an  economic  way.  The  principles  of  efficient  maintenance  are  similar 
for  a  Rolls  Royce  and  an  old  Ford,  but  the  increased  cost  of  breakdowns 
and  repairs  makes  it  incumbent  upon  the  economically  more  valuable  unit 
to  take  the  best  possible  care  of  himself. 

The  analogy  between  automobiles  and  men  can  be  carried  further.  Both 
are  complicated  mechanisms  deriving  their  power  from  fuel  which  re- 
quires oxygen  to  be  properly  consumed,  and  leaves  a  residue  of  carbon  and 
waste  products.  A  man  does  not  run  about  emitting  smoke  and  carbon 
monoxide  from  his  exhaust,  but  he  exhales  a  chemically  related  product, 
carbon  dioxide,  with  every  breath. 

The  waste  products  of  man's  internal  combustion  engine  are  excreted 
through  four  channels;  lungs,  skin,  kidneys  and  intestinal  tract;  each  as 
essential  as  the  leg  of  a  table  or  the  wheel  of  a  car.  The  ape  man  living  an 
arboreal  life  and  eating  fruit  and  nuts  did  not  need  to  consider  his  elimi- 
native  functions.    We  sedentaries  do. 

We  need  to  exercise  our  lungs  by  deep  breathing,  our  skin  by  a  morning 
bath  with  a  stiff  brush,  followed  by  a  rubdown,  our  kidneys  by  drinking  a 
proper  amount  of  water  and  our  intestinal  tract  by  eating  green  vege- 
tables and  fruits  in  abundance. 

But  we  also  need  recreation,  which  a  machine  does  not.  One  who  regu- 
larly inquires  into  the  business  man's  hobbies  rarely  finds  much  beyond 
golf,  which  is  good,  but  a  bit  limited  in  its  possibilities. 

Your  up-to-date  doctor  or  health  clinics  will  check  up  on  your  system  of 
health  maintenance.    They  should  be  consulted  annually  for  this  purpose. 

Let  wealth  and  wisdom  unite  in  the  maintenance  of  health. 

EXERCISE  AS  A  HEALTH  AGENCY 

By  Carl  R.  Schrader 

Supervisor  of  Physical  Education,  Massachusetts  Department  of  Education 

The  need  for  definite  exercise  in  this  age  of  civilization  is  theoretically 
accepted,  but  is  far  from  being  met  in  practice.  The  purpose  of  it  in  the 
health  sense  is  a  two-fold  one.  On  the  one  hand,  it  aims  towards  physical 
health  in  abundance;  on  the  other,  toward  a  balanced  and  happy  frame  of 
mind.    The  three  steps  that  are  necessary  to  approach  that  abundant  state 


148 
of  health  are :  first,  the  recognition  of  the  need  and  the  will  to  do ;  second, 
to  determine  the  type  of  recreation  to  pursue ;  and  third,  to  engage  in  that 
recreation  in  a  sane  way. 

The  need  we  discover  either  by  our  annual  physical  examination,  or 
through  our  own  honest  intelligence.  The  choice  of  recreation  is  more  dif- 
ficult, inasmuch  as  type  of  vocation,  age,  early  training,  and  present  physi- 
cal condition  must  be  determining  factors.  Those  engaged  in  confined 
mental  work  need  a  type  of  exercise  that  means  relief  from  mental  alert- 
ness. Golf,  bowling,  rowing,  dancing,  quoits,  hiking,  mountain  climbing, 
etc.,  are  of  that  character.  Those  on  the  other  hand,  whose  work  is  more 
routine  and  monotonous,  should  seek  activities  that  engage  the  whole  of 
man,  involving  body  and  soul.  The  team  type  of  exercise  is  to  be  pre- 
ferred— tennis,  volley  ball,  tenikoit,  fist  ball,  soccer,  etc.  In  these  games, 
in  order  to  be  safe,  it  is  important  that  one  seek  playmates  and  opponents 
of  similar  speed  in  order  to  insure  a  fair  margin  of  success  and  satisfac- 
tion, as  well  as  avoid  over-exertion,  in  other  words,  play  sanely.  Not  to 
be  despised,  although  mentioned  last,  are  the  calisthenic  type  of  exercises. 
They  are  most  effective  when  performed  with  others  in  class,  because  of 
the  social  factor.  But  even  when  they  are  taken  alone  at  home,  coming 
over  the  radio,  they  serve  a  yaluable  purpose.  They  may,  when  all  other 
means  for  exercise  seem  impossible,  serve  as  a  good  substitute,  but  even 
when  other  recreation  is  followed,  they  serve  as  a  most  effective  supple- 
ment, and  make  the  body  an  obedient  servant. 

Many  a  back  yard  will  furnish  facilities  for  vigorous  play,  and  the 
neighborhood  playground  possibilities  have  only  been  scratched  for  and  by 
the  adult.  Make  a  courageous  start.  One  is  never  too  old  to  play,  but  old 
rather  because  one  does  not  play. 

THE  HEALTH  OF  THE  TEACHER 

By  Fredrika  Moore,  M.D., 
Pediatrician,  State  Department  of  Public  Health 

True  economy  frequently  consists  in  spending  money.  Nowhere  is  this 
more  true  than  in  the  schools  and  no  factor  in  the  school  situation  will 
yield  greater  returns  for  money  invested  than  the  teacher. 

Big  business  realizes,  as  necessary  for  efficiency,  not  only  properly 
equipped  plants,  but  a  personnel  which  is  in  good  condition  physically, 
mentally  and  emotionally.  A  personnel  of  this  kind  means  on  one  hand 
the  expenditure  of  money,  but  on  the  other  hand  saving  through  decreased 
absence,  lessened  turnover,  increased  output  and  greater  general  effi- 
ciency. _  If  good  physical,  mental  and  emotional  health  has  increased  effi- 
ciency in  the  business  world,  how  much  more  are  these  assets  needed  in  a 
world  where  the  workers  are  handling  human  material. 

If  modern  education  consists  in  teaching  the  child  to  adapt  himself  to 
life  and  to  live  in  such  a  way  that  he  gets  the  most  out  of  it  and  puts  all  of 
himself  into  it,  how  impossible  it  is  for  this  type  of  education  to  be  carried 
on  by  a  teacher  who  is  herself  unadjusted.  The  teacher  who  is  under  par 
physically  and  unsatisfied  emotionally,  means  a  loss  to  the  school  commit- 
tee due  to  absences,  frequent  change  of  personnel  and  loss  to  the  children 
of  the  influence  of  the  highest  type  of  womanhood. 

From  the  teacher's  point  of  view,  health  is  one  of  her  greatest  assets,  as 
she  will  realize  if  she  answers  honestly  the  following  questions : 

1.  Upon  what  days  do  I  do  the  best  work,  those  days  when  I  am  feeling 
fit  physically,  or  when  I  am  below  par  or  worried  and  anxious  over 
something? 

2.  Which  teacher  gets  the  most  out  of  life,  the  one  who  is  vigorous  or 
the  one  who  is  sickly? 

3.  Which  teacher  is  more  likely  to  get  promotions,  the  one  who  is  ail- 
ing or  the  one  who  has  enough  vitality  to  work  and  play  and  still 
have  a  reserve  for  emergency? 


149 

4.  Which  teacher  has  the  greater  influence  upon  those  under  her,  the 
one  who  can  meet  the  high  spirits  of  her  boys  and  girls  or  the  one 
who  feels  teaching  a  burden? 

Though  school  committees  and  teachers  both  may  realize,  theoretically, 
the  value  of  good  health,  they  may  be  unwilling  to  pay  the  price,  for  it 
exacts  a  price  just  like  any  other  worthwhile  thing.  For  school  commit- 
tees this  price  is  the  outlay  of  some  money ;  for  the  teacher  it  is  the  self- 
denial  and  self-control  demanded  by  laws  of  healthful  living.  But  school 
committees  will  find  their  money  returned  increased  many  fold  in  better 
trained  school  children,  fewer  absences  and  lessened  turnover.  For  the 
teachers  they  will  find  their  reward  in  greater  joy  in  living  and  the  enjoy- 
ment which  comes  from  work  well  done. 

From  the  point  of  view  of  the  school  committee,  these  are  the  points  to 
be  considered  in  engaging  teachers : 

1.  Has  she  graduated  from  a  normal  school  where  she  has  been  given  a 
health  consciousness  and  the  knowledge  of  the  laws  of  right  living? 

2.  She  should  present  before  employment  a  certificate  of  physical  fit- 
ness. 

3.  Proper  living  conditions  should  be  made  available  for  her. 

4.  Her  salary  should  be  adequate  so  that  she  may  live  comfortably,  be 
able  to  put  by  something  for  her  later  years  and  yet  have  something 
to  spend  on  professional  advancement. 

5.  Provision  of  sanitary  working  surroundings. 

6.  Hygienically  arranged  program. 

7.  Constructive  supervision. 

For  teachers  the  following  are  considerations : 

1.  The  knowledge  of  the  laws  of  right  living  mentally,  physically  and 
emotionally. 

2.  The  willingness  to  observe  these  laws. 

3.  Willingness  to  seek  help  when  anything  goes  wrong  mentally,  physi- 
cally or  emotionally. 

4.  An  annual  physical  examination. 

5.  An  adequate  social  life. 

6.  Living  as  a  part  of  the  community. 

7.  Budgeting  of  her  time. 

WORK  AS  AN  AID  TO  HEALTH 

By  Ida  S.  Harrington, 
Executive  Director,  American  Homemakers,  Inc.,  Rhode  Island  Center 

Ideally  the  health  teaching  of  the  schools  should  result  in  permanently 
healthful  living.  But  health  habits,  like  grammar,  often  deteriorate  when 
expert  supervision  is  withdrawn. 

A  common  excuse  for  neglect  of  the  human  machine  is:  "What  does  it 
matter  how  I  do  my  work,  as  long  as  I  get  it  done?"  It  matters  vitally. 
Spending  more  strength  than  a  task  requires  is  like  paying  more  money 
than  a  purchase  justifies. 

The  daily  routine  should  be  the  best  daily  dozen.  Failure  to  use  it  as 
practice  in  physical  training  counteracts  the  training  itself.  Standing 
and  walking,  in  the  kitchen  or  on  the  street,  offers  practice  in  maintaining 
poise,  a  springy  step  and  the  art  of  pursuing  a  direct  route  to  one's  desti- 
nation,— as  contrasted  with  a  labored  progress  of  hunched  shoulders  and 
rigid  feet. 

Stair  climbing,  practiced  in  easy  erect  posture  with  natural  breathing, 
putting  the  bulk  of  the  work  on  legs  and  feet,  instead  of  on  back,  arm  and 
banister,  makes  practical  application  of  knee-lifting  exercises. 

Low  cupboards  and  ovens  offer  practice  in  raising  and  lowering  the  body 
without  letting  it  crumple  into  a  sorry  heap.  A  quick  bend  to  pick  a  pin 
or  raveling  from  the  floor  duplicates  the  "jack-knife  dive,"  so  familiar  in 
systems  of  exercise. 


150 

Reaching  and  lifting  should  become  a  beneficial  exercise,  not  a  martyr- 
dom. 

In  short,  all  daily  tasks,  from  beating  eggs  to  writing  letters,  offer  prac- 
tice in  overcoming  such  wrong  methods  of  work  as  are  evidenced  by  a  set 
jaw,  scowling  face  and  cramped  muscles.  Timely  rest  periods  bring  fur- 
ther opportunity  for  practicing  relaxation. 

Only  intelligent  care  and  use  can  give  the  body  the  ideal  of  health — un- 
consciousness of  itself.  This  ideal  cannot  be  achieved  by  intermittent 
methods.  Health  habits  must  be  in  daily  use.  Chief  among  them  must  be 
the  daily  practice  in  making  the  day's  tasks  an  aid  to  physical  fitness. 

FOOD  FOR  THE  OLD 

By  Esther  V.  Erickson, 
Consultant  in  Nutrition,  State  Department  of  Public  Health 

The  hygiene  of  the  adult,  as  well  as  that  of  any  age  group  includes 
among  other  factors  that  of  diet.  Food  certainly  concerns  each  one  in  the 
family,  from  the  newly  born  infant  to  the  grandmother  or  great  grand- 
mother. We  realize  that  the  infant  does  not  eat  as  the  preschool  child,  nor 
the  preschool  child  as  the  adolescent,  and  so  on.  How  should  grandmother 
or  grandfather  plan  to  get  the  greatest  pleasure  from  their  food?  Much 
publicity  is  given  the  nonagenarian  who  may  proclaim  that  he  always  had 
and  still  has  pies  and  pastries  daily.  Is  this  to  be  recommended  as  the  diet 
for  the  old  or  is  it  rather  an  exception? 

During  the  rapidly  growing  period,  youth,  with  an  abundance  of  spirit, 
expends  much  energy  both  in  conscious  activity  and  in  the  natural  func- 
tion of  growth.  Appetite  is  ravenous !  The  adolescent  wonders,  or  rather 
the  parents  wonder  "how  the  child  can  get  enough."  With  increasing 
years  growth  ceases,  thereby  reducing  the  amount  of  food  necessary  for 
that  purpose.  In  old  age  the  physiological  functions  slow  down;  the 
amount  of  voluntary  activity  also  is  lessened.  Since  the  amount  of  food 
we  need  depends  on  our  activity,  it  is  evident  that  in  old  age  we  need  less 
food.  Van  Norden  suggests  that  to  modify  the  food  requirements  of  the 
adult  of  the  middle  life  the  following  reductions  should  be  made  in  the 
diet  of  the  normal  adult ;  60-70  years,  reduction  is  10  % ;  70-80  years, 
20% ;  80-90  years,  30%.  In  fact,  in  quantity,  the  person  over  seventy  re- 
quires but  little  more  food  than  the  child  who  is  entering  school.  In  other 
respects,  too,  the  diet  of  the  aged  resembles  that  of  the  preschool  child, 
i.e.,  in  quality.  Grandmother,  with  a  digestive  function  that  is  slowing 
down,  chooses  those  foods  easily  digested  as  milk,  fruits,  vegetables,  well- 
cooked  cereals,  eggs;  avoiding  pies,  pastries  and  fried  foods  of  all  kinds. 
Coffee  and  tea,  not  allowed  in  the  diet  of  preschool  Betty  may,  with  judg- 
ment, be  included  in  grandmother's  diet.  Also  the  latter  often  feels  better 
with  three  meals  which  are  not  as  hearty,  then  a  "wee  bite"  of  something, 
as  milk  and  a  cracker,  between  meals  or  before  going  to  bed.  Eating  reg- 
ularly and  sleeping  regularly  with  plenty  of  fresh  air  still  determines  the 
conditions  of  the  body  which  is  to  receive  food. 

Remember  that  the  ravenous  appetite  of  youth  and  activity  which  may 
have  brought  about  the  habit  of  hearty  eating  needs  no  longer  to  be  met. 
Such  a  quantity  might  overtax  the  heart,  kidneys,  liver  and  digestive  sys- 
tem. A  simple,  nourishing,  wholesome  diet  reduced  in  amount  will  meet 
the  needs  for  the  aged. 

THE  DENTIST  AND  ADULT  HYGIENE 

By  Eleanor  G.  McCarthy, 

Consultant  in  Dental  Hygiene,  State  Department  of  Public  Health 

The  general  health  of  any  adult  may  be  seriously  affected  by  an  unclean 
mouth  and  broken-down  dental  machine.  As  sound  teeth  do  much  to  pro- 
duce positive,   radiant  health  and  prevent  general  systematic   infection 


151 
they  should  receive  considerable  attention  at  the  annual  physical  examina- 
tion. Most  adults  have  many  dental  troubles — weak,  flabby  gums,  teeth 
missing,  malocclusion,  "dead  teeth"  that  may  be  abscessing — these  are  the 
most  common.  This  picture  is  not  exaggerated.  Preventive  dentistry,  as 
we  now  conceive  it,  will  not  be  reflected  in  the  mouths  of  adults  for  several 
generations,  and  even  with  the  best  care  that  was  available  the  adult  of 
today  often  finds  himself  faced  with  serious  problems  because  of  accidents, 
poor  mechanical  work  done  in  years  previous,  or  even  an  inherited  ten- 
dency toward  narrow  arches  and  abnormal  dentitions. 

The  most  important  preventive  service  that  the  dentist  can  offer — X- 
rays  to  determine  impacted  teeth,  abscesses,  weakened  bone  structure 
(first  indication  of  pyorrhea)  and  mechanical  restorations  to  preserve  a 
normal  occlusion — is  beyond  the  means  of  the  average  American.  Educa- 
tion concerning  the  necessity  for  this  type  of  dental  service  will  not  solve 
the  problem  as  it  is  basically  an  economic  one.  Until  the  nutritional  hab- 
its of  the  people  are  changed,  until  dentistry  begins  with  the  first  teeth, 
until  the  people  realize  the  value  of  early  regular  dental  care,  the  dentist 
will  find  the  average  adult  with  a  "badly  crippled  chewing  machine." 

Even  for  that  proportion  of  the  public  which  has  been  able  to  have  reg- 
ular dental  care  during  childhood  there  are  many  points  concerning  the 
care  of  the  teeth  that  they  must  consider.  To  avoid  trouble  they  must  be 
ever  vigilant  in  the  home  care  of  their  teeth — flabby  gums  need  careful 
massage,  they  must  consider  their  teeth  as  a  chewing  machine,  not  as  a 
series  of  single  organs.  They  will  realize  the  necessity  of  replacing  lost 
teeth  with  artificial  substitutes,  they  will  realize  that  often  the  more  ex- 
pensive bridge  or  plate  will  be  the  less  expensive  in  the  end.  They  must 
be  interested  in  knowing  how  their  teeth  bite  together  if  they  are  to  pre- 
vent pyorrhea.  They  must  know  that  only  with  an  X-ray  can  the  dentist 
get  a  complete  picture  of  the  condition  of  their  teeth.  Only  then  will  they 
be  able  to  safeguard  their  teeth  and  prevent  the  typical  dental  troubles  of 
middle  age. 

HYGIENE  OF  THE  INDUSTRIAL  WORKER 

By  Derric  Parmenter,  M.D., 
Industrial  Consultant,  State  Department  of  Public  Health 

Anyone  who  has  no  independent  income,  as  we  all  know,  must  work  for 
a  living  or  become  a  State  charge.  Every  worker  then,  in  the  industrial 
field,  whatever  his  or  her  skill,  must  have  one  asset  or  capital,  namely, 
good  health.  On  the  worker's  health  depends  his  production  and  efficiency, 
and  also  in  the  last  analysis,  his  ability  to  support  himself  and  his  family. 
It  is  the  most  important  thing  in  the  lives  of  all  industrial  workers  and 
should  be  the  first  care  of  every  employer  in  industry.  Without  it  very 
little  can  be  done. 

This  is  as  important  for  the  employer  of  labor  as  it  is  for  the  workman 
himself.  Illness  means  not  only  loss  of  wages  but  also  an  economic  loss  to 
the  man  who  pays  those  wages.  If  we  stop  to  think  a  minute,  the  wage  of 
$1200  a  year  capitalized  would  mean  around  $20,000.  Perhaps  such  a 
wage  would  not  produce  that  much.  It  does  serve  to  show,  however,  what 
industry  loses  when  such  a  wage  earner  drops  out  or  is  ill.  It  takes  time 
to  train  new  people  and  that  is  a  loss.  Somebody  has  to  pay  for  medicines 
and  doctors'  bills. 

Statistics  gathered  over  a  number  of  years  have  shown  that,  in  what  we 
may  call  the  working  age  group — from  18-45  or  50  years — the  mortality 
rate  is  higher  than  it  is  in  the  same  age  group  of  the  general  population. 
This  mortality  is  increasing  rather  than  decreasing  in  comparison  with 
the  mortality  rate  for  the  general  population. 

The  question  arises  as  to  what  this  may  be  due.  There  have  even  been 
suggestions  that  the  State  should  go  into  the  practice  of  medicine,  if  in- 
dustry Would  not  take  care  of  its  own  people.  This  was  some  time  ago. 
Today,  with  the  establishment  of  medical  departments,  in  many  stores  and 


152 

factories,  industry  has  shown,  particularly  in  Massachusetts,  that  it  in- 
tends taking  care  of  its  human  machinery. 

In  exercising  this  care,  it  has  found  certain  definite  problems  to  cope 
with  and  has  employed  very  definite  methods.  One  of  its  most  difficult 
problems  has  been  that  of  chronic  disease.  You  have  read,  and  will  read 
from  other  writers,  the  various  other  aspects  of  chronic  disease,  but  in  in- 
dustry it  represents  a  very  definite  problem.  With  the  increased  speed  of 
living,  mass  production,  and  the  general  noise  and  confusion  of  a  mechan- 
ical age,  the  so-called  chronic  diseases  of  the  heart,  lungs,  kidneys,  and 
nervous  system,  have  increased  tremendously. 

A  man  of  middle  age  with  a  chronic  disease  might,  in  the  old  days,  have 
been  able  to  work  in  safety  on  a  farm  or  at  some  similar  occupation.  It  is 
another  thing  for  him  to  operate  a  highly  complicated  and  expensive  bit  of 
machinery  which  may  hurt  somebody  if  he  is  not  always  alert.  There  is 
more  need  for  him  to  take  good  care  of  himself  so  that  he  will  last  longer 
and  not  endanger  the  lives  of  others  as  well  as  his  own.  You  may  say  that 
we  cannot  prevent  to  any  great  extent  a  thing  like  heart  disease.  This  is, 
perhaps,  true,  but  we  can  certainly  care  for  it  in  such  a  way  that  a  longer 
and  useful  life  is  secured  to  the  sufferer. 

How  can  this  be  done  ?  That  is  a  second  problem  that  industry  has  had 
to  meet.  Medicine  has  enabled  us  to  reduce  infant  and  child  mortality.  It 
has  helped  us  to  decrease  the  amount  of  illness  from  typhoid,  malaria,  and 
diphtheria,  and  a  number  of  other  diseases.  It  has,  however,  so  far,  made 
very  little  progress  in  the  actual  prevention  of  chronic  disease. 

We  have  heard  a  good  deal  of  late  about  preventive  medicine  and  a  good 
deal  of  hygiene  and  it  is  by  the  practice  of  this  type  of  medicine  and  by 
constant  education  in  matters  of  hygiene  that  industry  has  been  able  to 
conserve  to  some  extent  the  health  of  the  industrial  worker.  Much  of  this 
has  to  be  done  by  the  worker  himself.  He  is  not  sure  what  is  meant  by 
hygiene.  He  knows  that  proper  hygiene  is  necessary  for  good  health,  but, 
after  all,  hygiene  means  nothing  more  than  good  living  habits  and  good 
thinking  habits.  Make  no  mistake  about  the  importance  of  the  latter. 
Freedom  from  worry,  a  job  a  man  likes,  lack  of  friction  with  his  fellow 
workers,  all  these  things  are  as  useful  in  keeping  him  healthy  as  the 
proper  amount  of  food  and  proper  amount  of  sleep. 

Everyone  who  works  has  two  houses  in  which  to  live.  One  is  home 
where  he  is  16  hours  a  day,  the  other  his  factory  or  his  office,  where  he  is 
the  rest  of  the  time.  It  is  just  as  important  that  he  observe  good  hygienic 
principles  of  living  in  one  place  as  it  is  in  the  other.  At  home,  he  is  under 
his  own  control.  In  the  shop,  or  office  his  employer  is  responsible  for  a 
number  of  things  which  may  affect  his  health  over  which  he  has  no  control. 

We  have  heard  a  good  deal  of  late  about  industrial  poisons  and  indus- 
trial hazards.  We  have  organizations  which  are  ever  devising  new  ways 
of  safe-guarding  machinery  to  prevent,  as  far  as  possible,  the  occurrence 
of  accidents.  The  State  maintains  an  organization  for  this  purpose  and 
we  have  numerous  outside  organizations  such  as  the  National  Safety  Coun- 
cil, and  others.  The  modern  factory  has  its  own  safety  committee  which 
performs  these  same  functions  a  little  more  in  detail.  The  need  for  safety 
as  far  as  accidents  are  concerned  is  one  to  which  industry  is  thoroughly 
awake.    It  is  concrete  and  easy  to  understand. 

The  need  for  the  worker  to  care  for  his  health  is  not  quite  so  clear. 
Both  he  and  industry  have  been  slow  to  realize  the  importance  of  good 
habits  and  even  slower  the  importance  of  proper  mental  adjustment  of  the 
worker  to  his  job  and  his  daily  life.  Industry  has  met  this  by  the  estab- 
lishment of  medical  departments  where  nurses  are  at  hand  and  doctors  on 
call,  not  to  study  the  more  serious  diseases,  but  as  far  as  possible  to  treat 
the  minor  ailments  and  keep  them  from  becoming  worse.  The  medical  de- 
partment should  see  that  a  man  has  the  proper  light  to  work  with,  that  he 
has  the  proper  kind  of  chair,  if  he  uses  one,  that  small  cuts  and  wounds 
are  treated  promptly  to  prevent  infection,  that  coughs  and  colds  and  diges- 
tive upsets  are  taken  care  of,  before  they  become  incapacitating. 


153 

It  is  to  the  interest  of  both  employer  and  employee  to  do  this.  Early 
treatment  will  keep  a  man  on  the  job  and  save  him,  in  turn,  from  losing 
wages.  At  the  same  time  a  medical  department  can  give  him  advice  which 
may  be  useful  at  home.  It  can  urge  him  to  be  careful  about  his  diet,  sleep, 
the  amount  of  water  he  drinks,  the  shoes  he  wears,  in  fact,  all  sorts  of  per- 
sonal details.  This  may  sound  to  some  extent  like  paternalism  but  it  really 
is  not.  It  is  health  education  and  furthermore  it  provides  the  needed  con- 
tact without  which  incipient  disease  could  hardly  be  discovered  in  time. 
We  have  then,  in  the  midst  of  industry  itself,  a  medium  for  combating  the 
problem  of  chronic  disease. 

But  the  worker  must  do  his  part.  After  all,  in  his  own  home — his  other 
house — how  he  lives  is  strictly  up  to  him.  It  often  happens  that  a  man 
will  work  hard  for  eight  hours  in  the  day  and  then  go  home  and  not  get 
sufficient  sleep,  play  too  hard,  eat  unwisely,  and  come  back  to  work  tired 
before  he  begins  the  day.  This,  of  course,  ought  not  to  be,  but  preventing 
such  conditions  is  a  slow  process. 

Let  us  look  for  a  minute  at  the  things  which  a  man  may  do  for  himself. 
Some  of  these  have  been  mentioned.  If  he  has  to  be  on  his  feet  all  day, 
not  only  is  it  important  that  he  has  properly  fitting  shoes,  but  also  that 
these  same  shoes  have  a  sufficiently  thick  sole.  This  seems  like  a  simple 
detail  and  yet  personal  experience  has  demonstrated  to  me  that  very  few 
men  who  have  to  work  on  their  feet  give  very  much  thought  to  these  im- 
portant items.  Exercise  is  a  thing  which,  nowadays,  we  seldom  do  enough. 
In  the  shop,  the  work  itself  is  frequently  all  the  exercise  that  is  necessary. 
With  the  office  and  desk  worker  it  is  a  different  matter.  It  becomes  an  in- 
dividual problem.  We  are  paying  a  good  deal  of  attention  to  diet  these 
days.  Careful  attention  to  this  is  as  necessary  as  it  is  to  get  sufficient 
sleep. 

The  problem  of  the  industrial  worker  is  different  from  that  of  the  rest 
of  the  population.  Other  people,  to  a  large  extent,  can,  if  they  do  not  feel 
well  for  any  particular  reason,  let  up  and  do  the  work  the  next  day  or  rest 
for  awhile.  The  industrial  worker  cannot  do  this.  He  must  be  efficient  to 
keep  his  job.  If  he  is  not  in  good  health  he  has  lost  his  chief  asset.  All 
the  trained  skill  in  the  world  is  of  no  use  unless  it  is  backed  by  good 
health.  Even  if  he  has  some  chronic  disease,  with  careful  living,  he  may 
be  able  to  work  10  or  15  years  longer  than  he  would  without  any  care. 

From  the  point  of  view  of  industry,  and,  after  all,  our  industrial  popu- 
lation is  perhaps  the  most  important  unit  in  the  general  population — the 
hygiene — the  living  habits  and  the  thinking  habits  of  the  worker — is  a 
most  important  thing.  This  is  to  a  large  extent  an  industrial  State  and 
the  health  of  its  workers  is  one  of  its  most  important  assets.  Industry  is 
doing  more  and  more  to  conserve  this  asset  but  each  individual  must  do 
his  part.  We  have  not  done  nearly  enough  yet  to  really  cut  down  the 
amount  of  chronic  disease  in  industry.  Much  remains  to  be  done  and  this 
undoubtedly  is  the  job  of  the  industries  in  this  State. 


154 


Editorial   Comment 


When  is  an  Adult?  Legally  an  individual  becomes  an  adult  at  the  age  of 
twenty-one;  physiologically  the  thing  happens  at  pu- 
berty ;  while  mentally,  according  to  our  psychological  friends,  frequently  it 
never  happens  at  all.  This  vagueness,  of  course,  does  not  help  us  in  de- 
fining our  field  of  activity  for  adult  hygiene.  As  usual,  the  law  gives  the 
most  concrete  and  the  least  workable  answer.  We  want  to  direct  our  en- 
deavors toward  those  age  periods  when  the  deleterious  factors  are  at  work 
which  later  show  up  grossly  in  some  one  of  the  chronic  adult  diseases.  In 
other  words,  we  aim  feebly  to  prevent  the  factors  which  bring  about  de- 
generation of  one  or  the  other  organs. 

The  optimist  says,  we  believe,  that  the  average  human  animal  is  at  his 
height  of  physiological  effectiveness  around  the  second  or  third  year. 
After  this  degeneration  sets  in.  This  would  suggest  that  all  money  for 
prevention  should  be  spent  only  on  the  very  young.  But  few  adults  desire 
personally  to  be  classified  with  the  preventively  hopeless.  But  there  are 
others  who  claim  degeneration  begins  prenatally,  and  even  back  a  few  gen- 
erations. However  this  may  be,  it  is  evident  that  we  must  look  to  the 
Child  Hygiene  workers  to  continue  to  attack  degeneration  as  they  have 
been  doing  noisily,  and  in  some  instances,  effectively. 

The  new  Division  should  take  up  the  cudgel  in  earliest  adult  life,  say 
around  fifteen  to  eighteen.  Administratively  we  can  say  this  Division 
should  begin  with  the  college  group.  For  obvious  reasons  the  normal 
school  groups  can  most  effectively  be  reached  through  the  Child  Hygiene 
Division,  probably,  while  the  industrial  groups  should  be  the  especial  re- 
sponsibility of  the  Adult  Hygiene  workers  as  they  have  been  in  cancer. 
The  average  out-patient  department  finds  difficulty  often  in  allocating 
those  in  the  fourteen  to  sixteen  age  groups  between  the  departments  of 
pediatrics  and  medicine.  We  shall  have  the  same  difficulty  and  anomalous 
situations  will  arise.  However,  we  are  constantly  urging  cooperation  on 
local  boards  of  health  and  although  we  are  occasionally  accused  of  having 
but  little  of  it  ourselves,  we  shall  try  to  develop  it  and  thus  avoid  any 
"blind"  ages  where  neither  the  Division  of  Adult  Hygiene  or  Child  Hy- 
giene feel  responsible  for  a  preventive  medical  program. 

The  Massachusetts  Cancer  Campaign  to  Date.    In  the  past  three  years  the 

Massachusetts  Cancer  Pro- 
gram has  emerged  from  a  nebulous  beginning  to  an  established  status.  It 
comprises  hospitalization,  clinics,  education  and  statistical  research. 

A  hospital  with  provisions  for  eighty-five  patients  is  running  to  capac- 
ity. Cancer,  in  all  stages  of  the  disease,  is  being  admitted.  From  June 
21,  1927,  to  August  1,  1929,  there  have  been  1,246  admissions,  846  dis- 
charges, and  320  deaths.  The  Out-Patient  Department  holds  a  weekly 
clinic  and  averages  twenty-five  patients.  New  construction,  now  under 
way,  will  furnish  better  accommodations  for  this  department  and  some 
twenty  additional  beds  for  the  hospital. 

There  are  now  twelve  clinics  functioning  in  seventeen  cities  and  towns. 
Two  or  three  additional  clinics  will  probably  be  established.  Between  De- 
cember 17,  1926,  and  August  1,  1929,  5,066  patients  have  attended  these 
clinics,  27.7  per  cent  of  whom  have  had  cancer,  with  approximately  one- 
half  of  these  in  the  operable  stage  with  a  chance  for  cure. 

Educational  activities  have  continued  throughout  the  period.  Most  of 
the  work  in  the  clinic  centers  is  being  done  by  the  local  educational  sub- 
committees of  the  clinics,  while  in  the  non-clinic  communities  the  work  has 
largely  been  done  by  the  personnel  of  the  Department  of  Public  Health. 

A  number  of  statistical  studies  have  been  conducted.  Some  of  the  most 
outstanding  findings  are  as  follows: 

1.    Massachusetts  has  the  highest  cancer  death  rate  of  any  state  in  the 


155 

Union.    This  is  largely  due  to  the  large  number  of  foreign  extraction 
groups  in  the  state. 

2.  There  are  approximately,  at  any  one  period,  10,000  cancer  patients 
in  Massachusetts. 

3.  The  foreign  born  and  the  children  of  foreign  born  have  a  high  death 
rate  from  cancer  of  the  gastro-intestinal  tract. 

4.  The  median  duration  between  the  first  symptoms  and  consultation 
with  a  physician  is  a  little  over  six  months. 

5.  Probably  30  per  cent  of  all  cancer  patients  can  be  cured  if  proper 
treatment  is  instituted  early  in  the  disease,  and  the  present  delay  re- 
sults in  nearly  1,000  needless  deaths  yearly. 

6.  For  every  patient  attending  a  state-aided  clinic,  twenty-two  go  to 
the  office  of  the  private  physician. 

7.  Nearly  half  the  patients  attending  the  clinics  do  so  because  of  news- 
paper publicity. 

The  New  England  Health  Institute.     It  happens  quite  appropriately  that 

the  New  England  Health  Institute, 
in  the  order  of  rotation  which  has  become  customary  among  the  six  New 
England  states,  comes  to  Massachusetts  in  Boston's  tercentenary  year — 
1930. 

The  Institute  will  meet  in  Boston,  therefore,  from  April  14  to  18,  with 
headquarters  at  Hotel  Statler. 

It  is  the  purpose  of  the  Committee  in  charge  of  the  Institute,  under  the 
leadership  of  Dr.  George  H.  Bigelow,  Commissioner  of  Public  Health,  to 
add  several  new  courses,  or  sections,  to  those  which  have  previously  repre- 
sented the  various  interests  of  those  attending  the  Institute. 

There  will  be  a  new  section  on  Preventive  Medicine,  with  clinics  in  the 
morning,  bearing  on  various  aspects  of  disease  control,  and  an  academic 
session  each  afternoon  which  will  afford  opportunity  for  hearing  speakers 
of  national  reputation. 

There  will  be  a  Nursing  Section,  distinct  from,  though  closely  cooper- 
ating with,  the  customary  Public  Health  Nursing  section.  By  means  of 
the  new  section  an  effort  will  be  made  to  interest  all  nurses  in  the  nursing 
aspects  of  preventive  medicine. 

A  section  on  Social  Work  will  also  be  introduced  for  the  first  time. 
Many  of  the  newly-faced  problems  in  public  health  deal  intimately  with 
questions  of  vital  interest  to  social  workers.  It  has,  therefore,  been 
deemed  advisable  to  bring  some  of  these  problems  up  for  discussion  by  so- 
cial workers  and  others. 

Dentists,  too,  will  participate  in  next  year's  Institute,  arranging  a  pro- 
gram of  public  health  subjects  of  especial  interest  to  the  dental  profession. 
The  Graduate  Course  in  Cancer,  which  was  offered  last  Spring  by  the 
Massachusetts  Medical  Society  to  dentists,  as  well  as  to  physicians, 
brought  clearly  to  view  some  problems  in  preventive  medicine  which  are 
the  common  concern  of  both  professions.  Cancer  is  not  the  only  problem 
in  which  the.  relationship  is  extremely  close. 

On  Tuesday,  April  15,  the  main  banquet  will  be  held  in  the  Ballroom  of 
the  Statler.  The  Committee  takes  especial  pleasure  in  being  able  to  an- 
nounce that  Dr.  Livingston  Farrand  will  be  the  chief  speaker  on  this  oc- 
casion. Among  other  notable  speakers  who  will  be  heard  during  the  In- 
stitute are,  Miss  Elizabeth  Fox,  Dr.  Joseph  C.  Bloodgood,  Dr.  Haven  Em- 
erson and  Dr.  Kendall  Emerson,  Dr.  Gladys  Dick  and  others  with  whom 
arrangements  have  not  yet  been  completed. 


In  order  to  avoid  the  possibilities  of  misunderstanding  of  the  editorial 
appearing  in  the  April-May-June,  1929  School  Hygiene  number  of  The 
Commonhealth  under  the  heading  "The  Return  to  School  after  Absence 
with  Communicable  Disease,"  we  are  printing  this  fuller  statement  con- 
cerning re-admission. 


156 

THE  RETURN  TO  SCHOOL  OF  CHILDREN  (1)  AFTER  ABSENCE 

WITH  COMMUNICABLE  DISEASE,   (2)  AFTER  ABSENCE 

AS  CONTACTS 

1.1  The  law  states  that  those  children  who  have  been  absent  with 
communicable  disease  may  be  re-admitted  only  through  certificate  of 
the  local  board  of  health  or  the  school  physician.  However,  if  the  cer- 
tificate from  the  school  physician  is  at  variance  with  the  rules  and 
regulations  of  the  local  board  of  health  governing  the  release  of  cases 
from  isolation,  obviously  the  board  of  health  regulations  take  prece- 
dence over  the  certificate  of  the  school  physician.  On  the  other  hand, 
the  school  physician  has  authority  to  exclude  from  the  school  children 
who  may  have  been  released  from  isolation,  without  restriction  by  the 
local  board  of  health. 

2.2  While  the  law  states  that  a  child  exposed  to  or  a  contact  with  a 

case  of  communicable  disease  shall  not  attend  school  until  the  teacher 
has  been  furnished  with  a  certificate  from  the  local  board  of  health 
or  from  the  attending  physician,  stating  that  danger  of  conveying 
such  disease  by  such  a  child  has  passed,  unless  the  certificate  from  the 
family  physician  conforms  with  the  rules  and  regulations  of  the  local 
board  of  health  having  to  do  with  contacts  in  the  specific  disease  un- 
der consideration,  such  a  certificate  is  not  valid.  In  this  situation 
also  the  school  physician  still  has  authority  to  exclude  the  child  from 
school,  in  spite  of  the  fact  that  the  local  board  of  health  has  released 
the  child  from  quarantine  with  restrictions. 

1  Section  31,  Chapter  111,  General  Laws. 
Sections  55  and  56,  Chapter  71,  General  Laws. 

2  Section  15,  Chapter  76.  General  Laws. 


News 


READING  MATTER  AVAILABLE  FOR  DISTRIBUTION  BY  THE 
MASSACHUSETTS   DEPARTMENT   OF  PUBLIC  HEALTH 

FOR  LAY  DISTRIBUTION 

Adult  Hygiene  Division 
Arteriosclerosis 

Arteriosclerosis 

Communicable  Disease  Division 
Anterior  Poliomyelitis 

Acute  Anterior  Poliomyelitis 

Infantile  Paralysis — Helpful  Suggestions  (Met.  Life  Ins.  Co.) 

Adult  Hygiene  Division 
Cancer 

Preventive  Medicine  From  Your  Family  Physician 

Help  Fight  Cancer 

Your  Nurse  Says 

Whats  and  Whys 

What  Every  Woman  Should  Do  About  Cancer 

Cancer — (John  Hancock  Life  Insurance  Company) 

Cancer  Cures 

Danger  Signals — (various  languages) 

Destroy  the  Weed 

Fear  and  Cancer 

Food  After  Forty 

Go  to  Your  Doctor 

Growth  of  an  Idea 

Health  Departments  and  the  Medical  Profession 


157 
How  the  Dentist  Can  Help 
How  the  Nurse  Can  Help 
A  Message  of  Hope  About  Cancer 
The  New  Idea  of  Cancer 
What  the  Public  Health  Nurse  Should  Do 

Child  Hygiene  Division 
Child  Hygiene 

Aids  to  Bowel  Movement 

Attention!    Stand  Tall 

Away  with  Colds 

Baby  and  You,  The 

Breast  Feeding 

Brownie  Health  Rules 

Building  Baby's  Teeth 

Care  of  the  Child  in  Hot  Weather 

Care  of  the  Child  in  Cold  Weather 

Cooking  for  Health 

Diet  for  the  Prospective  Mother 

Diet  for  Children  from  Birth  to  2  Years 

A  Baby  Primer  (Prudential  Ins.  Co.) 

Care  of  the  Baby  "  "       " 

What  to  Eat  "  "       " 

Eating  for  Teeth 

Feeding  the  Adolescent 

Feeding  the  School  Child 

Feeding  the  Pre-School  Child 

Food  Ways  to  Health 

Health  Creed,  A 

Is  This  Your  Child?    Fussy,  Finicky 

Keeping  Well 

Milk 

Minerals 

Save  Those  Baby  Teeth 

Suggestions  for  Care  During  Pregnancy 

Supplies  Necessary  at  Time  of  Confinement 

Ten  Rules  for  Healthful  Living 

Vitamins 

Your  Teeth 

Sensible  Sun  Baths 

Suggestions  of  Safety — (Children's  SOS) 

Prenatal  and  Postnatal  Letter  Registry 

Communicable  Disease  Division 
Diphtheria 

Prevent  Diphtheria 

Preventing  Diphtheria  (John  Hancock  Mut.  Life  Ins.  Co.) 

The  Prize  Winner  (Metropolitan  Life  Ins.  Co.) 

Adult  Hygiene  Division 
Heart  Disease 

Heart  Disease  and  its  Prevention 
Rheumatic  Heart 

Communicable  Disease  Division 
Influenza 

Prevent  Influenza  (John  Hancock  Mut.  Life  Ins.  Co.) 

Insects 

House  Ants  (Kinds  and  Methods  of  Control) 
The  Bed  Bug 


158 
Cockroaches 

Fleas  and  Their  Control 
The  House  Fly  and  How  to  Suppress  It 
The  Stable  Fly 

Fly  Traps  and  Their  Operation 
Malaria — Some  Facts  About  Malaria 
Mosquito  Remedies  and  Preventives 
The  Yellow  Fever  Mosquito 
How  to  Get  Rid  of  Rats 
Screw  Worms  and  Other  Maggots  Affecting  Animals 

Measles 

Measles  Bulletin  No.  14 

Child  Hygiene  Division 
Mental  Hygiene 

Being  a  Parent  is  the  Biggest  Job  on  Earth  (Nat.  Com.  Mental  Hy- 
giene) 
Enuresis — (Nat.  Com.  Mental  Hygiene) 
Protecting  the  Mind  of  Childhood — Richards,  Reprint 
Salvaging  Sam — (Mass.  Society  for  Mental  Hygiene) 
Twenty  Aids  to  Mental  Health — (Mass.  Society  for  Mental  Hygiene) 

Communicable  Disease  Division 
Milk 

Milk  Bulletin  No.  16 
What  is  Pasteurized  Milk? 

Rabies 

A  Community  Problem — Bigelow  and  Webber,  Reprint 

Smallpox 

Arguments  for  Compulsory  Vaccination  of  all  School  Children — 
Woodward,  Reprint 

Arguments  in  Favor  of  Extending  Legal  Requirements  for  Vaccina- 
tion— Woodward,  Reprint 

Information  Relative  to  the  Importance  of  Vaccination  against  Small- 
pox— Woodward,  Reprint 

Smallpox  is  Preventable   (American  Society  for  Medical  Progress) 

Biologic  Laboratories 

Smallpox  and  Vaccination — White,  Reprint 

Vaccination  against  Smallpox — Its  Technic  and  Interpretation — 
White,  Reprint 

Tuberculosis  Division 
Tuberculosis 

Laws  and  Regulations  concerning  State  Subsidy 

Directions  for  Home  Treatment  in  Tuberculosis  (Mass.  Tuberculosis 

League) 
Sleeping  and  Sitting  in  the  Open  Air  (Nat'l  Tuberculosis  Asso.) 
Tuberculosis  Directory  (not  up-to-date) 
Becoming  Acquainted  with  the  Enemy,  Tuberculosis 
Proposed  Tuberculosis  Prevention  Program — Kelley,  Reprint 
"IF"  (used  on  clinics) 

Communicable  Disease  Division 
Typhoid  Fever 

Suggestions  as  to  Instruction  of  those  caring  for  persons  ill  with 
typhoid. 


159 
Venereal  Disease 

I  Didn't  Know — Deland,  Reprint 
A  Few  Facts  About  Gonorrhea 
A  Few  Facts  About  Syphilis 
U.  S.  Public  Health  Service 

Ivy  and  Sumac  Poisoning 

Note: — A  limited  amount  of  material  of  interest  to  professional  groups  is 
available  for  distribution  upon  request  to  the  Department  of  Public  Health, 
546  State  House,  Boston,  Mass. 

FIRST  INTERNATIONAL  CONGRESS  ON  MENTAL  HYGIENE 
(To  be  held  in  Washington,  D.  C.,  May  5-10,  1930) 

Progress  is  being  made  in  the  organization  of  the  First  International 
Congress  on  Mental  Hygiene,  to  be  held  in  Washington,  D.  C,  May  5-10, 
1930.  Educators,  psychiatrists,  other  physicians,  public  officials,  social 
workers,  industrialists  and  many  others  from  all  over  the  world  are  ex- 
pected to  be  present  when  the  Congress  convenes. 

Herbert  C.  Hoover  has  honored  the  Congress  by  accepting  the  position 
of  honorary  president.  Already  twenty-six  countries  are  represented  on 
the  Committee  on  Organization,  of  which  Dr.  Arthur  H.  Ruggles,  of  Prov- 
idence, R.  I.,  is  chairman.  Dr.  William  A.  White,  of  Washington,  D.  C, 
is  president  of  the  Congress,  and  Clifford  W.  Beers  is  Secretary-General. 
The  Congress  is  being  sponsored  by  mental  hygiene  and  related  organiza- 
tions in  many  countries. 

Questions  to  be  discussed  at  the  Congress  will  include  the  relations  of 
mental  hygiene  to  law,  to  hospitals,  to  education,  industry,  social  work,  de- 
linquency, parenthood  and  community  problems.  A  world-wide  view  of 
mental  hygiene  progress  will  be  given.  The  subject  will  be  discussed  also 
in  specific  application  to  the  maladjustment  problems  of  individuals,  spe- 
cial attention  being  probably  given  to  childhood,  adolescence  and  later 
youth.  It  is  the  contention  of  those  promoting  the  Congress  that  mental 
hygiene  has  to  do  with  the  conservation  of  mental  health  in  general,  not 
merely  with  nervous  and  mental  diseases.  The  point  of  view  of  clinical 
diagnosis  and  treatment  will  be  considered,  as  well  as  that  of  administra- 
tion of  institutions  and  agencies. 

Basic  expenses  of  the  Congress  are  being  underwritten  by  the  recently 
organized  American  Foundation  for  Mental  Hygiene.  Opportunity  will  be 
afforded  for  acquaintance  among  delegates  of  the  various  countries,  and 
translations,  together  with  other  conveniences,  will  facilitate  comprehen- 
sion of  all  that  may  be  said  in  unfamiliar  languages.  Administrative 
headquarters  have  been  opened  at  370  Seventh  Ave.,  New  York  City, 
where  John  R.  Shillady,  Administrative  Secretary,  is  in  charge.  A  mem- 
bership fee  of  $5  (including  the  Proceedings)  has  been  fixed. 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  July,  August,  and  September,  1929,  samples  were 
collected  in  226  cities  and  towns. 

There  were  2,456  samples  of  milk  examined,  of  which  975  were  below 
standard;  from  62  samples  the  cream  had  been  in  part  removed,  and  32 
samples  contained  added  water. 

There  were  233  samples  of  food  examined,  of  which  44  were  adulterated. 
These  consisted  of  1  sample  of  oleomargarine  intended  for  use  on  pop  corn 
to  be  sold  as  buttered  pop  corn ;  1  sample  of  buttered  pop  corn  which  con- 
tained oleomargarine;  2  samples  of  butter  which  were  rancid;  11  samples 
of  eggs,  9  samples  of  which  were  sold  as  fresh  eggs  but  were  not  fresh, 
and  2  samples  were  decomposed ;  1  sample  of  maple  sugar  adulterated  with 
cane  sugar  other  than  maple;  5  samples  of  maple  syrup  which  contained 
cane  sugar;  2  samples  of  olive  oil  which  contained  cottonseed  oil;  5  sam- 
ples of  vinegar  which  were  low  in  acid;  1  sample  of  ham  which  was  de- 
composed ;  5  samples  of  sausage,  4  of  which  contained  a  compound  of  sul- 
phur dioxide  not  properly  labeled,  and  1  sample  contained  coloring  matter ; 


160 
1  sample  of  dried  apricots  which  contained  sulphur  dioxide  not  properly 
labeled;  1  sample  of  ammonia  not  bearing  the  poison  label  as  required  by 
law;  and  8  samples  of  metal  polish,  used  in  hotels  and  restaurants,  which 
contained  cyanide. 

There  were  74  samples  of  drugs  examined,  of  which  6  were  adulterated. 
These  consisted  of  1  sample  of  spirit  of  nitrous  ether,  4  samples  of  lime 
water,  all  of  which  were  deficient  in  the  active  ingredient;  and  1  sample 
of  ether  for  anaesthesia  which  did  not  conform  to  the  standard  of  purity 
of  the  U.  S.  Pharmacopoeia,  containing  aldehyde  and  peroxide. 

The  police  departments  submitted  1,896  samples  of  liquor  for  examina- 
tion, 1,868  of  which  were  above  0.5%  in  alcohol.  The  police  departments 
also  submitted  20  samples  of  narcotics,  etc.,  for  examination,  10  of  which 
were  morphine,  1  cocaine,  2  hydrochloric  acid,  3  hair  restorer,  1  sample  of 
fish  oil  containing  valerianic  acid,  1  sample  of  cloth  containing  sulphuric 
acid,  1  prescription  which  was  found  to  be  correctly  compounded,  and  a 
mixture  of  sulphuric,  oxalic,  and  boric  acids,  containing  also  small 
amounts  of  lead,  zinc,  iron  and  phosphorous,  which  was  submitted  in  a 
lead  bottle,  and  1  sample  of  medicine  examined  for  poison  with  negative 
results. 

There  were  152  bacteriological  examinations  made  of  milk. 

There  were  35  bacteriological  examinations  of  soft  shell  clams  made,  30 
samples  in  the  shell,  29  of  which  were  unpolluted,  and  1  was  polluted,  and 
5  samples  of  shucked  clams,  4  of  which  were  unpolluted,  and  1  was  pol- 
luted ;  there  were  2  bacteriological  examinations  made  of  hard  shell  clams, 
in  the  shell,  both  of  which  were  unpolluted. 

There  were  124  hearings  held,  23  pertaining  to  violations  of  the  Food 
and  Drug  Laws,  12  pertaining  to  violations  of  the  Pasteurizing  Laws  and 
Regulations,  87  pertaining  to  violations  of  the  Milk  Laws,  and  2  pertain- 
ing to  violation  of  the  Slaughtering  Laws. 

There  were  43  cities  and  towns  visited  for  the  inspection  of  pasteurizing 
plants,  and  160  plants  were  inspected. 

There  were  68  convictions  for  violations  of  the  law,  $1,305  in  fines  being 
imposed. 

Ayoub  Baklini  of  Salem;  Paul  Rapplas  of  Cambridge;  Dana  H.  Elkins, 
3  cases,  and  Harold  Hynes  of  Wayland;  Nicholas  Georjantas,  John  Bak- 
sanski,  Joseph  Tefts,  and  Joseph  Bryla,  all  of  Westfield;  Hugh  Hanlon, 
Charles  E.  O'Connell,  and  James  Matzouranis,  all  of  Chelsea;  Raymond 
F.  Stevens  of  Winchendon;  Napoleon  Adam  of  New  Bedford;  James  By- 
ron, Chris  Christopholous,  Fred  W.  Carter,  John  J.  Pippin,  and  Mary  Mc- 
Dermott,  all  of  Buzzards  Bay;  Chris  Eckhoff  of  North  Bernardston;  An- 
thony Rodzen  of  Hadley  Centre;  Leon  Chandler  of  South  Yarmouth; 
Whiting  Milk  Companies,  4  cases,  and  Abe  Lahage  of  Hull;  Benjamin  E. 
Chapman  of  Middleboro;  Helen  Doyle  and  Charles  Lysell  of  Wareham; 
James  J.  Feeney  of  Andover;  Elnathan  Kelley  and  Joseph  Robicheau  of 
Harwich;  Charles  W.  Garland  and  George  W.  Melzard  of  East  Sandwich; 
Samuel  J.  Hamel  of  Orleans;  Ruth  M.  Horn  of  Osterville;  James  Jarvis 
of  Reading ;  Walter  Kay  and  Vasilio  Velimesis  of  Falmouth ;  Frank  Page 
of  West  Harwich;  Louis  Laravire  of  Hyannis;  Peter  Liopes  and  Sotel 
Masho  of  Lynn ;  David  Lipshitz  of  Lanesboro ;  Maud  W.  Sotes  and  Nicho- 
las Sotes  of  Onset;  and  Eben  True  of  Amesbury,  were  all  convicted  for 
violations  of  the  milk  laws.  James  J.  Feeney  of  Andover  appealed  his  case. 

Rene  Paul  Bergeron  of  Chicopee;  and  Peter  Mandrakos  of  Dorchester, 
were  both  convicted  for  violations  of  the  food  laws. 

Anthony  Pappadopulos  of  Westfield;  Day  and  Night  Lunch,  Incorpo- 
rated, of  Springfield;  Harvey  H.  Daigneau  and  Julius  Young  of  Lynn; 
Economy  Grocery  Stores  Company,  Incorporated,  of  Boston;  and  Rena  L. 
Angus  of  South  Yarmouth,  were  convicted  for  false  advertising. 

John  Boria  of  Millbury;  A.  R.  Parker  Company  of  East  Bridgewater1; 
and  Hyalmar  Soderholm  of  West  Bridgewater,1  were  convicted  for  viola- 
tions of  the  pasteurizing  laws. 

1  Plea  of  nolo  contendere.     Case  placed  on  file. 


161 

Charles  F.  Post  and  William  Milligan  of  Alford;  Clarence  Havens  and 
Lester  W.  Knight  of  New  Braintree;  George  McNally  of  Brockton;  and 
Herman  Penn  of  Greenfield,  were  all  convicted  for  violations  of  the  slaugh- 
tering laws.    Herman  Penn  of  Greenfield  appealed  his  case. 

Abraham  Shatzman  of  Chelsea;  and  David  Rothchild,  on  2  counts,  of 
Roxbury,  were  convicted  for  violations  of  the  mattress  law.  David  Roth- 
child, on  2  counts,  of  Roxbury,  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  samples, 
by  John  Dmytryck  of  Millis;  2  samples  each,  by  Joseph  Tefts  and  John 
Baksanski,  both  of  Westfield ;  and  Paulina  Bigis  of  Chicopee  Falls ;  and 
1  sample,  by  Henry  Weltanen  of  Westminster. 

Milk  which  had  the  cream  removed  was  produced  as  follows :  2  samples, 
by  Linus  Adler  of  Ashby;  and  1  sample  each,  by  Edward  A.  Mclntire  of 
Fitchburg,  and  Joseph  Brigea  of  Westfield. 

Two  samples  of  oleomargarine  intended  for  use  on  pop  corn  to  be  sold 
as  "buttered  pop  corn"  were  obtained  from  Anthony  Pappadopulos  of 
Westfield. 

One  sample  of  dried  apricots  which  contained  sulphur  dioxide  and  was 
not  properly  labeled  was  obtained  from  Warren  S.  Hixon  &  Company  of 
Lynn. 

One  sample  of  maple  sugar  adulterated  with  cane  sugar  other  than  ma- 
ple was  obtained  from  Adamo  Avanucci  of  Holyoke. 

Maple  syrup  which  contained  cane  sugar  was  obtained  as  follows:  1 
sample  each,  from  Alfonso  Wedge  of  Greenfield;  Day  &  Night  Cafeteria 
of  Springfield;  Pine  Cone  Lunch  of  Yarmouth;  Rena  L.  Angus  of  Bass 
River;  and  Mary  E.  Brydges  of  Dennisport. 

Sausage  which  contained  a  compound  of  sulphur  dioxide  and  was  not 
properly  labeled  was  obtained  as  follows:  2  samples,  from  Ganem's  Mar- 
ket of  Lawrence ;  and  1  sample  each,  from  George  Corey  and  Wadie  Mallof , 
both  of  Lawrence. 

One  sample  of  sausage  which  contained  coloring  matter  was  obtained 
from  the  Sirloin  Store  of  Lynn. 

One  sample  of  ham  which  was  decomposed  was  obtained  from  Waldorf 
System,  Incorporated,  of  Boston. 

Vinegar  which  was  low  in  acid  was  obtained  as  follows :  2  samples  each, 
from  A.  Dupius  of  Fall  River;  and  Charles  F.  Cushman  of  Rock. 

There  were  four  confiscations,  consisting  of  109  pounds  of  decomposed 
turkeys ;  30  pounds  of  dried  out  deer ;  27,000  pounds  of  decomposed  squid ; 
and  5,570  pounds  of  miscellaneous  dried  out  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  June,  1929 :— 2,315,520  dozens 
of  case  eggs;  586,815  pounds  of  broken  out  eggs;  6,673,002  pounds  of  but- 
ter; 1,416,703  pounds  of  poultry;  5,694,489y2  pounds  of  fresh  meat  and 
fresh  meat  products ;  and  9,325,407  pounds  of  fresh  food  fish. 

There  was  on  hand  July  1,  1929: — 10,315,710  dozens  of  case  eggs; 
1,807,886  pounds  of  broken  out  eggs;  7,738,785  pounds  of  butter;  3,943,- 
492%  pounds  of  poultry;  16,809,921%  pounds  of  fresh  meat  and  fresh 
meat  products ;  and  17,591,358  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  July,  1929 : — 1,427,190  dozens 
of  case  eggs;  768,164  pounds  of  broken  out  eggs;  7,314,261  pounds  of 
butter;  931,990  pounds  of  poultry;  5,738,482  pounds  of  fresh  meat  and 
fresh  meat  products;  and  8,784,968  pounds  of  fresh  food  fish. 

There  was  on  hand  August  1,  1929: — 10,866,120  dozens  of  case  eggs; 
1,921,074  pounds  of  broken  out  eggs;  13,774,023  pounds  of  butter;  3,445,- 
276y2  pounds  of  poultry;  16,187,814%  pounds  of  fresh  meat  and  fresh 
meat  products ;  and  23,425,398  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 


162 
food  placed  in  storage  during  the  month  of  August,   1929: — 1,125,090 
dozens  of  case  eggs ;  708,407  pounds  of  broken  out  eggs ;  3,600,794  pounds 
of  butter;  998,588%  pounds  of  poultry;  4,053,844 y2  pounds  of  fresh  meat 
and  fresh  meat  products;  and  4,567,206  pounds  of  fresh  food  fish. 

There  was  on  hand  September  1,  1929 : — 10,435,650  dozens  of  case  eggs ; 
1,911,177  pounds  of  broken  out  eggs;  15,285,605  pounds  of  butter;  3,822,- 
988%  pounds  of  poultry;  14,018,0541/4  pounds  of  fresh  meat  and  fresh 
meat  products;  and  44,861,774%  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  Commujiicable  Diseases 

Division  of  Water  and  Sewage  Lab- 
oratories   ..... 
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. 

Charles  B.  Mack,  M.D.,  Boston. 

Wilson  W.  Knowlton,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Leland  M.  French,  M.D.,  Pitts- 
field. 


Publication  op  this  Documbnt  aitkoved  by  the  Commission  on  Administration  and  Finance 
10M.     ll-'29.     Order  C281. 


16S 

INDEX 

PAGE 

Admission  of  Children  to  State  Sanatoria   .  .91 

Adult,  Health  Education  for  the,  by  Mary  R.  Lakeman,  M.D.  121 

Adult,  When  is  an    .  .....      154 

Adult  Hygiene,  Social  Worker  in,  by  Eleanor  E.  Kelly  .  .      129 

Adult  Hygiene,  The  Dentist  and,  by  Eleanor  G.  McCarthy  150 

Adult  Hygiene,  What  it  is  and  Why,  by  George  H.  Bigelow,  M.D.  .      101 
Adult  Life,  Control  of  Diseases  of,  by  W.  A.  Evans,  M.D.  141 

Alley,  Leon  T.,  M.D.,  Sanatorium  Treatment  of  Extra-Pulmonary 

Tuberculosis  ....... 

Asthma,  What  the  Citizen  Should  Know  About,  by  Francis  M 

Rackemann,  M.D.  ...... 

Bigelow,  George  H.,  M.D.,  Milk  Legislation 

Bigelow,  George  H.,  M.D.,  Tuberculosis  Control  in  Massachusetts 

Bigelow,  George  H.,  M.D.,  What  is  Adult  Hygiene  and  Why? 

Bigelow,  George  H.,  M.D.,  What  Milk  in  the  Schools?  . 

Bovine  Tuberculosis,  Eradication  in  Massachusetts,  by  Evan  I 

Richardson  ....... 

Brief  History  of  Milk-Borne  Disease  in  Massachusetts,  by  Filip 

C.  Forsbeck,  M.D 

Broadening  Field  of  Cancer  Education  .    '      . 

Buck,  Robert  W.,  M.D.,  The  Business  Man  ..... 

Business  Man,  by  Robert  W.  Buck,  M.D. 

Cancer,  Control  of,  by  Robert  B.  Greenough,  M.D. 

Cancer  Campaign  to  Date  ..... 

Cancer  Education,  The  Broadening  Field  of 

Cancer  Studies  in  Massachusetts,  No.  4. — Why  Do  People  Delay 

by  Herbert  L.  Lombard,  M.D.  and  Mary  P.  Cronin  . 
Cannon,  Ida  M.,  Proper  Use  of  Resources  for  the  Chronic  Sick 
Chadwick,  M.D.,  Ten  Year  Program  for  Children — Progress  and 

Plans  ........ 

Chadwick  Clinic,  The  How  and  Why  of  the,  by  Paul  Wakefield 

M.D 

Chadwick  Clinics        ........ 

Champion,  Merrill  E.,  Resignation  of  ... 

Chronic  Disease  and  the  Public  Welfare,  by  Richard  K.  Conant 
Chronic  Disease  in  Industry,  by  Wade  Wright,  M.D.   . 
Chronic  Disease  Problem  in  Massachusetts,  by  Herbert  L.  Lom 

bard,  M.D 

Chronic  Patient,  Nursing  the,  by  Elizabeth  Ross,  R.N. 
Chronic  Sick,  Proper  Use  of  Resources  for  the,  by  Ida  M.  Cannon 
Clinics  (Habit)  and  Their  Purpose,  by  Olive  A.  Cooper,  M.D. 
Clinics    (Psychiatric   School)    for   the   Examination   of   Retarded 

Children,  by  Neil  A.   Dayton,  M.D. 
Clinics,  Reorganization  of  the  School 

Communicable  Disease,  The  Return  to  School  After  Absence  With 
Communicable  Disease,  Return  to  School  of  Children   (a)   After 

Absence  with  communicable  disease,   (b)  After  Absence 

as  contacts  ........ 

Communicable  Diseases  in  the  School,  Controlling,  by  Edward  A. 

Lane,  M.D 

Conant,  Richard  K.,  Chronic  Disease  and  the  Public  Welfare 

Control  Measures  in  Diabetes,  by  Elliot  P.  Joslin 

Control  Measures  in  Heart  Disease,  by  William  H.  Robey,  M.D. 

Control  of  Cancer  by  Robert  B.  Greenough,  M.D. 

Control  of  Diseases  of  Adult  Life,  by  W.  A.  Evans,  M.D. 

Controlling  Communicable  Diseases  in  the  School,  by  Edward  A 

Lane,  M.D 


PAGE 
47 

21 

5 

115 

137 


164 

Cooper,  Olive  A.,  M.D.,  Habit  Clinics  and  Their  Purpose   . 
Correcting  Defects  in  School  Children        ..... 
Cort,  Joseph  C,  Milk  Production         .... 
Cost  of  Preventable  Disease  in  Massachusetts,  by  Louis  I.  Dublin 
Cronin,  Mary  P.  and  Herbert  L.  Lombard,  M.D.,  Cancer  Studies 

in  Massachusetts,  No.  4 — Why  Do  People  Delay?   . 
Dayton,  Neil  A.,  M.D.,  Psychiatric  School  Clinics  for  the  Exam- 
ination of  Retarded  Children 
Defects  in  School  Children,  Correcting 
Demonstration,  Franklin  County  Five  Year 
Dental  Hygiene,  Report  of  the  Consultant  in,  1928 
Dental  Hygiene,  Ten  Years'  Progress  in,  1919-1929 
Dentist  and  Adult  Hygiene,  by  Eleanor  G.  McCarthy 
Diabetes,  Control  Measures  in,  by  Elliot  P.  Joslin,  M.D 
Diez,  M.  Luise,  M.D.,  Appointment  of  .  . 

Diphtheria  Statistics  for  Massachusetts,  by  Edward  A.  Lane,  M.D 
Diseases  of  Adult  Life,  Control  of,  by  W.  A.  Evans,  M.D 
Dublin,  Louis  I.,  The  Cost  of  Preventable  Disease  in  Massachu 

setts  ..... 

Ear  and  Eye  Testing  in  the  Schools  . 
Editorial  Comment: 

Admission  of  Children  to  State  Sanatoria 

Bishop   Lawrence's   Lecture 

Broadening  Field  of  Cancer  Education 

Chadwick  Clinics  .... 

Correcting  Defects  in  School  Children 

Early  Diagnosis  of  Tuberculosis 

Eye  and  Ear  Testing  in  the  Schools 

Franklin  County  Five  Year  Demonstration 

Gorgas  Memorial  Essay  Contest  . 

Health  Education  Material 

Massachusetts  Cancer  Campaign  to  Date 

May  Day  and  the  Summer  Round  Up  . 

New  England  Health  Institute     .  .  22, 

Reorganization  of  the  School  Clinics   . 

Return  to  School   After  Absence  with   Communicable 

Disease  ........        56,  155 

School  Health  Survey  Service       ......       59 

School  Lunch      .........       59 

Should  Health  Officers  Recommend  Milk?     ....       20 

Smallpox  and  Vaccination   .......       55 

Summer  Round  Up      ........       21 

Ten  Years'  Progress  in  Dental  Hygiene  1919-1929  57 

What  the  Von  Pirquet  Test  is  Not — and  What  it  is !  .91 

When  is  an  Adult? 154 

Why  School  Hygiene?  ...  ...       55 

Educating  the  Handicapped  Child,  by  Arthur  B.  Lord  ...       43 

Erickson,  Esther  V.,  Food  for  the  Old 150 

Erickson,  Esther  V.,  Milk  as  a  Food  ......         7 

Evans,  W.  A.,  M.D.,  Control  of  Diseases  of  Adult  Life  .  141 

Exercise  as  a  Health  Agency,  by  Carl  R.  Schrader  .  .      147 

Eye  and  Ear  Testing  in  the  Schools   ......       59 

First  International  Congress  on  Mental  Hygiene  94,  159 

Food  and  Drugs,  Report  of  Division  of 

October,  November,  December  1928 

January,  February,  March  1929   . 

April,  May,  June  1929 

July,   August,    September   1929 
Food  for  the  Old,  by  Esther  V.  Erickson   . 
Food,  Milk  as  a,  by  Esther  V.  Erickson 


i65 

PAGE 

Forsbeck,  Filip  C,  M.D.,  A  brief  History  of  Milk-Borne  Disease 

in  Massachusetts  .....  .10 

Franklin  County  Five  Year  Demonstration  .  .60 

Gorgas  Memorial  Essay  Contest           ......  23 

Growth  of  Our  Children    .           .  61 

Habit  Clinics  and  Their  Purpose,  by  Olive  A.  Cooper,  M.D.  .          .  47 

Handicapped  Child,  Educating  the,  by  Arthur  B.  Lord  43 

Harrington,  Ida  S.,  Work  as  an  Aid  to  Health                 .""*'.  149 

Health  Education  for  the  Adult,  by  Mary  R.  Lakeman,  M.D.             .  121 
Health  Education  in  Junior  and  Senior  High  Schools,  The  Need 

for,  by  Jean  0.  Latimer       ......  41 

Health   Education   Material        ......  58 

Health  Examinations,  by  Roger  I.   Lee,   M.D.    ....  108 

Health  Program  in  the  Schools,  by  Elizabeth  H.  Sampson   .  37 
Health  Program  in  the  Schools,  The  Value  and  Results  of  a,  by 

William  H.  Slayton                           39 

Health  of  the  Teacher,  by  Fredrika  Moore,  M.D.  148 

Heart  Disease,  Control  Measures  in,  by  William  H.  Robey,  M.D.  .  145 

Homans,  John,  M.D.,  Varicose  Veins  .                    ...  146 

How  and  Why  of  the  Chadwick  Clinic,  by  Paul  Wakefield,  M.D.  .  72 

Hygiene  of  The  Industrial  Worker,  by  Derric  Parmenter,  M.D.         .  151 

Industrial  Worker,  Hygiene  of  the,  by  Derric  Parmenter,  M.D.  151 

Industry,  Chronic  Disease  in,  by  Wade  Wright,  M.D.  .                    .  125 

Joslin,  Elliot  P.,  M.D.,  Control  Measures  in  Diabetes  .  144 

Kelly,  Eleanor  E.,  Social  Service  in  Tuberculosis           ...  81 

Kelly,  Eleanor  E.,  Social  Worker  in  Adult  Hygiene    .  129 

Lakeman,  Mary  R.,  M.D.,  Health  Education  for  the  Adult  .  121 
Lane,  Edward  A.,  M.D.,  Controlling  Communicable  Diseases  in  the 

School 31 

Lane,  Edward  A.,  M.D.,  Diphtheria  Statistics  for  Massachusetts  .  89 
Latimer,  Jean  0.,  The  Need  for  Health  Education  in  the  Junior 

and  Senior  High  Schools       ......  41 

Lawrence's   (Bishop)   Lecture      .......  20 

Lawrence,  Bishop,  Social  Infection  and  The  Community  14 

Lee,  Roger  L,  M.D.,  Health  Examinations             ....  108 

Lombard,  Herbert  L.,  M.D.,  and  Mary  P.  Cronin,  Cancer  Studies 

in  Massachusetts,  No.  4. — Why  Do  People  Delay?   .          .  137 
Lombard,  Herbert  L.,  M.D.,  Chronic  Disease  Problem  in  Massa- 
chusetts        .........  103 

Lord,  Arthur  B.,  Educating  the  Handicapped  Child    ...  43 
Man,  The  Business,  by  Robert  W.  Buck,  M.D.                                     .147 

Massachusetts  Cancer  Campaign  to  Date   .....  154 

May  Day  &  Summer  Round  Up  .......  60 

McCarthy,  Eleanor  G.,  The  Dentist  and  Adult  Hygiene  150 

Memoriam  to  Fred  B.  Forbes    .......  24 

Mental  Hygiene,  First  International  Congress  on                 .        94,  159 

Milk  as  a  Food,  by  Esther  V.  Erickson         .....  7 

Milk-Borne  Disease  in  Massachusetts,  Brief  History  of,  by  Filip 

C.  Forsbeck,  M.D 10 

Milk  in  the  Schools,  by  George  H.  Bigelow,  M.D.           ...  34 

Milk  Legislation,  by  George  H.  Bigelow,  M.D.     ....  3 

Milk  Production,  by  Joseph  C.  Cort   ......  5 

Milk,  Should  Health  Officers  Recommend   .....  20 

Milk,  What  is  Pasteurized           .......  12 

Moore,  Fredrika,  M.D.,  Health  of  the  Teacher   .  .148 

Need  for  Health  Education  in  Junior  and  Senior  High  Schools,  by 

Jean   O.   Latimer  ......  .41 

New  England  Health  Institute 22,  155 

Nurse  in  Public  Health,  by  Mary  Beard,  R.N.  (book  review)  92 

Nursing  the  Chronic  Patient,  by  Elizabeth  Ross,  R.N.  .          .          .  128 


166 

PAGE 

Organizing  a  Toxin — Antitoxin  Campaign,  by  A.  A.  Robertson  87 

Parmenter,  Derric,  M.D.,  Hygiene  of  the  Industrial  Worker  .  151 

Pasteurized  Milk,  What  is  .......        12 

Physical  Education  in  the  School,  by  Carl  Schrader  ...  35 
Preventable  Disease  in  Massachusetts,  The  Cost  of,  by  Louis  I. 

Dublin 115 

Proper  Use  of  Resources  for  the  Chronic  Sick,  by  Ida  M.  Cannon  .      133 
Psychiatric  School  Clinics  for  the  Examination  of  Retarded  Chil- 
dren, by  Neil  A.  Dayton,  M.D.  .46 
Public  Welfare,  Chronic  Disease  and  the,  by  Richard  K.  Conant  .      Ill 
Publications  of  the  Department                     .                                       61,  156 
Rackemann,   Francis  M.,   M.D.,  What  the   Citizen   Should  Know 

About  Asthma  .  143 

Reorganization  of  the  School  Clinics  ......       56 

Report  of  the  Consultant  in  Dental  Hygiene,  1928       ...       49 
Resources  for  the  Chronic  Sick,  Proper  use  of,  by  Ida  M.  Cannon  .      133 
Retarded  Children,  Psychiatric  School  Clinics  for  the  Examina- 
tion of,  by  Neil  A.  Dayton,  M.D.     .  .46 
Return  to  School  After  Absence  with  Communicable  Diseases    .       56 
Return  to  School  of  Children   (a)  After  Absence  with  Commun- 
icable Disease  (b)  After  Absence  as  Contacts  .      155 
Richardson,  Evan  H.,  Bovine  Tuberculosis  Eradiction  in  Massa- 
chusetts        .                                        .                    .  .4 

Robertson,  A.  A.,  Organizing  a  Toxin-Antitoxin  Campaign  .  .       87 

Robey,  William  H.,  M.D.,  Control  Measures  in  Heart  Disease  145 

Ross,  Elizabeth,  R.N.,  Nursing  the  Chronic  Patient  128 

Rutland  State  Sanatorium,  Graduation  Address  at  the  Training 

School,  by  Alfred  Worcester,  M.D.  .....        85 

Salmon   (Thomas  William)   Memorial  .....        61 

Sanatoria,  Admission  of  Children  to   .  .91 

Sanatorium  Treatment  of  Extra-Pulmonary  Tuberculosis,  by  Leon 

T.   Alley,   M.D. 74 

School,  The  Return  to,  After  Absence  with  Communicable 

Disease  ........         56,  155 

School  Clinics,  Reorganization  of  .  .56 

School  Health  Survey  Service    .......        59 

School    Hygiene,    Why  .  .55 

School  Lunch  .  .  .59 

Schools,  A  Health  Program  in  the,  by  Elizabeth  H.  Sampson  .       37 

Schools,  Eye  and  Ear  Testing  in  the  ......       59 

Schools,  Physical  Education  in  the,  by  Carl  Schrader  ...  35 
Schools,  The  Need  for  Health  Education  in  Junior  and   Senior 

High  Schools,  by  Jean  O.  Latimer  .41 

Schools,  The  Value  and  Results  of  a  Health  Program  in  the,  by 

William  H.  Slayton 39 

Schrader,  Carl  R.,  Exercise  as  a  Health  Agency  ....  147 
Schrader,  Carl  R.,  Physical  Education  in  the  Schools  ...  35 
Sedgwick,  Medal  Award     ........       93 

Should  Health  Officers  Recommend  Milk? 20 

Slayton,  William  H.,  The  Value  and  Results  of  a  Health  Program 

in  the  Schools       ........       39 

Smallpox  and  Vaccination  .......       55 

Social  Infection  and  the  Community,  by  Bishop  Lawrence   .  14 

Social  Service  in  Tuberculosis,  by  Eleanor  E.  Kelly       ...        81 
Social  Worker  in  Adult  Hygiene,  by  Eleanor  E.  Kelly  .  .  .129 

Summer  Round  Up    .  .......       21 

Summer  Round  Up  and  May  Day        ......        60 

Surgical  Treatment  of  Pulmonary  Tuberculosis,  by  Edward   D. 

Churchill,  M.D .78 

Survey  Service,  School  Health    .......       59 


167 

PAGE 

Teacher,  Health  of  the,  by  Fredrika  Moore,  M.D.  148 

Ten  Year  Program  for  Children — Progress  and  Plans,  by  Henry 

D.  Chadwick,  M.D.  ...  .70 

Ten  Years'  Progress  in  Dental  Hygiene  1919-1929  57 

Thomas  William  Salmon  Memorial        ......       61 

Toxin-Antitoxin  Campaign,  Organizing  a,  by  A.  A.  Robertson  87 

Tuberculosis  (Bovine)  Eradication  in  Massachusetts,  by  Evan  H„ 

Richardson  ........         4 

Tuberculosis  Control  in  Massachusetts,  by  George  H.  Bigelow, 

M.D.  ...  .69 

Tuberculosis,  Early  Diagnosis  of    .  .91 

Tuberculosis,  Sanatorium  Treatment  of  Extra-Pulmonary,  by  Leon 

T.  Alley,  M.D 74 

Tuberculosis,  Social  Service  in,  by  Eleanor  E.  Kelly  ...  81 
Tuberculosis,  Surgical  Treatment  of  Pulmonary,  by  Edward  D. 

Churchill,  M.D.  78 

Tuberculosis,  Ten  Year  Program  for  Children  —  Progress   and 

Plans,  by  H.  D.  Chadwick,  M.D. 70 

Vaccination  and  Smallpox  .55 

Value  and  Results  of  a  Health  Program  in  the  Schools,  by  William 

H.  Slayton  .....       39 

Varicose  Veins,  by  John  Homans,  M.D.       .....     146 

Von  Pirquet  Test,  What  it  is  not — and  What  it  is         .  91 

Wakefield,  Paul,  M.D.,  The  How  and  Why  of  the  Chadwick  Clinic  .  72 
What  is  Adult  Hygiene  and  Why?,  by  George  H.  Bigelow,  M.D.,  .  101 
What  is  Pasteurized  Milk?  .12 

What  Milk  in  the  Schools,  by  George  H.  Bigelow,  M.D.  34 

What  the  Citizen  Should  Know  About  Asthma,  by  Francis  M. 

Rackemann,  M.D.  143 

When  is  an  Adult?    .  ...  154 

Why  Do  People  Delay? — Cancer  Studies  in  Massachusetts,  No. 

4. — by  Herbert  L.  Lombard,  M.D.  and  Mary  P.  Cronin  137 

Why  School  Hygiene?         ......  .55 

Worcester,  Alfred,  M.D.,  Graduation  Address  at  the  Rutland  State 

Sanatorium  Training  School  .....       85 

Work  as  an  Aid  to  Health,  by  Ida  S.  Harrington  ....  149 
Wright,  Wade.  M.D.,  Chronic  Disease  in  Industry  .     125 


APR    5 


THE 
COMMONHEALTH 


Volume  17 
No.   1"/ 


Jan.-Feb.-Mar. 
1930 


Child  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 

Entered  as  second' class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


page 
CONTENTS 

The  Child's  Bill  of  Rights 3 

Child  Hygiene,  by  M.  Luise  Diez,  M.D.  .  .  .4 

How  to  Make  a  Prenatal  Visit,  by  Mary  P.  Billmeyer,  R.N.     .  7 

Standards  in  Obstetrics,  by  Robert  L.  DeNormandie,  M.D.       .  10 

Maternity  as  a  Public  Health  Problem,  by  Matthias  Nicoll,  Jr.,  M.D.     12 

Maternal  Nursing,  by  E.  P.  Ruggles,  M.D 17 

Certain  Communicable  Diseases:  Their  Relation  to  the  Prospective 
Mother,  the  Infant  and  the  Pre-school  Child,  by  Clarence 

L.  Scamman,  M.D. 22 

Dental  Hygiene,  by  E.  Melville  Quinby,  M.R.C.S.,  L.R.C.P.,  M.D.       .     24 
Standards  of  Pre-school  Hygiene,  by  Susan  M.  Coffin,  M.D.  28 

The  Value  of  Child  Hygiene   in  the  Public   Health   Program,   by 

Charles  F.  Wilinsky,  M.D 30 

Home  Visit  by  Infant  Hygiene  Nurse,  by  M.  Gertrude  Martin,  R.N.     33 
A  Pre-school  Child  Visit,  by  Anna  K.  Donovan,  R.N.       .                    .37 
The   Importance  of   Habit   Training   for  the   Infant  and   the   Pre- 
school Child,  by  Sybil  Foster 38 

Judging  Nutrition,  by  Eli  C.  Romberg,  M.D.  .  .  .  .41 

Interstitial  Keratitis,  by  Joseph  J.  Skirball,  M.D.   .  .45 

Organization  of  a  Community  Health  Committee,  by  Helen  M.  Hack- 

ett,  R.N.  and  Albertine  P.  McKellar  .46 

The  Value  of  Child  Hygiene  Publicity,  by  Florence  L.  McKay,  M.D.     48 
Linking  up  the  Pre-school  Child  and  the  School  Child,  by  Fredrika 

Moore,  M.D. 49 

Path-Finding  in  Adult  Hygiene,  by  Mary  R.  Lakeman,  M.D.   .  50 

Address  Given  by  Mrs.  Charles  Sumner  Bird  at  a  Meeting  of  the 

Committee  or?  Governor  Allen's  Public  Welfare  Program   .      52 
The  Eighth  New  England  Health  Institute,  by  George  H.  Bigelow, 

M.D 54 

Editorial  Comment: 

Child  Health  Day  and  Summer  Round-up — 1930       .  .56 

Well  Child  Conferences  in  1929 .56 

News  Notes;. '11 

How  to  Attend  the  New  England  Health  Institute   .  .  .57 

Summer  School  of  School  Nursing  and  Dental  Hygiene       .  .      58 

Summer  Courses  in  Public  Health  and  Biology         .  .  .59 

Maternal   Deaths  .  .  .....      59 

First  International  Congress  on  Mental  Hygiene — Preliminary 

Announcement  .60 

Massachusetts  Department  of  Mental  Diseases  Quarterly  Bulletin     61 
Book  Notes: 

From  Boston  to  Boston  (Book  Review)    .  .  .  .  .62 

Children  Well  and  Happy   .  .  .....      62 

The  Public  Health  Nurse — March  Number                                     .62 
Heport  of  Division  of  Food  and  Drugs,  October,  November  and  De- 
cember, 1929 63 


The  Child's  Bill  of  Rights 

THE  ideal  to  which  we  should  strive  is  that  there  shall  be  no  child  in 
America : 

That  has  not  been  born  under  proper  conditions 

That  does  not  live  in  hygienic  surroundings 

That  ever  suffers  from  undernourishment 

That  does  not  have  prompt  and  efficient  medical  attention  and  in- 
spection 

That  does  not  receive  primary  instruction  in  the  elements  of  hy- 
giene and  good  health 

That  has  not  the  complete  birthright  of  a  sound  mind  in  a  sound 
body 

That  has  not  the  encouragement  to  express  in  fullest  measure 
the  spirit  within  which  is  the  final  endowment  of  every 
human  being. 

Herbert  Hoover 


CHILD  HYGIENE 

M.  Luise  Diez,  M.D. 

Director,  Division  of  Child  Hygiene 
Massachusetts  Department  of  Public  Health 

It  is  a  little  difficult  to  know  where  to  start  when  speaking  of  Child  Hy- 
giene. One  naturally  thinks  it  begins  with  the  infant  when  it  is  born  but 
that  is  only  an  important  episode  and  we  must  begin  before  this  period. 
We  start  with  the  child — but  with  the  child  that  is  old  enough  to  be  taught 
his  or  her  responsibility  as  a  member  of  the  family  and  a  member  of  the 
community — the  parent  of  the  future  in  fact. 

I  do  not  believe  it  is  too  early  to  begin  this  teaching  in  the  upper  class 
of  the  grade  schools,  for  so  many  children  do  not  go  beyond  these  schools 
and  there  is  no  further  opportunity  to  give  the  necessary  training.  Begin 
by  teaching  the  child  personal  hygiene  in  all  its  phases  with  its  relation  to 
the  community  at  large — the  prevention  of  diseases,  the  establishment  of 
good  morals  and  good  behavior  with  their  bearing  upon  the  future  of  the 
race  and  nation.  Teach  them  what  is  meant  by  the  family  and  the  part 
the  child  is  supposed  to  play  in  this  institution.  This  can  be  done  with 
simple  understandable  language  and  comparisons.  The  machinery  you 
have  is  the  Parent-Teacher  Association,  health  workers,  public  health 
nurses  and  members  of  the  various  professions  that  bear  on  these  subjects. 

Carry  the  work  through  the  higher  schools,  through  the  adolescent  and 
young  adult  stages.  Then  you  will  have  laid  the  foundation  for  healthy 
prospective  fathers  and  mothers  and  for  future  citizens. 

The  home  must  be  created  in  a  proper  and  suitable  environment  as  this 
is  the  dominating  factor  of  human  development  and  in  order  to  attain  this 
the  economic  condition  of  the  people  should  be  such  as  to  enable  them  to 
provide  good  living  conditions  and  a  good  dietary  thus  lowering  the  mor- 
tality and  morbidity  rates. 

Now  we  have  the  setting  for  the  advent  of  the  child.  We  are  presup- 
posing healthy  parents,  but  in  order  to  have  a  strong  and  well  baby  at 
birth  with  continued  vigor  to  carry  it  beyond  its  first  year  of  life  the 
mother  must  have  proper  supervision  and  care  and  instruction  during  the 
entire  period  of  pregnancy,  expert  care  at  the  time  of  delivery  and  after, 
and  also  receive  careful  instruction  in  infant  care  and  hygiene. 

In  order  to  attain  this  there  must  be  a  willingness  on  the  part  of  the 
prospective  mother  to  cooperate,  an  obligation  on  the  part  of  the  prospec- 
tive father  to  see  that  she  gets  this  service,  and  a  greater  obligation  on 
the  part  of  the  community  to  provide  such  service;  and  the  community 
must  be  willing  to  pay  the  cost,  for  it  is  a  safe  investment  from  a  soci- 
ologic  and  economic  standpoint. 

How  can  this  be  done  by  the  community?  By  surveys  to  ascertain 
causes  of  maternal  and  infant  deaths,  closer  inspection  of  institutions 
which  care  for  mothers  and  babies  and  training  of  obstetric  attendants, 
higher  standards  in  prenatal,  natal  and  postnatal  service  as  well  as  in  in- 
fant and  pre-school. 

All  this  is  expensive  and  means  expert  service,  training  for  which  is 
time  and  money  consuming,  so  the  members  of  a  community  must  be 
taught  to  place  a  proper  valuation  on  this  service.  Obstetrics  should  oc- 
cupy the  same  major  position  in  the  practice  of  medicine  as  surgery  at  the 
present  time  with  the  same  training  and  commensurate  fees. 

The  United  States  occupies  twentieth  position  in  puerperal  mortality 
rates  among  the  nations  of  the  world  and  yet  we  know  by  proper  prenatal 
care,  mortality  and  morbidity  of  mother  and  child  can  be  cut  down  from 
one-half  to  one-third. 

In  Massachusetts  in  1928,  456  mothers  and  5,118  infants  under  the  age 
of  one  year,  died.  There  were  also  2,821  stillbirths.  Of  deaths  under  15 
years  of  age  there  were  2,126  due  to  diseases  of  early  infancy,  which  in- 
clude 177  from  congenital  debility,  133  prematures,  394  from  injury  at 


5 

birth,  222  from  other  causes  of  early  infancy  and  from  lack  of  care;  1,710 
from  diseases  of  the  respiratory  system,  1,122  from  epidemic  and  endemic 
infections,  282  from  tuberculosis,  930  from  diseases  of  the  digestive  sys- 
tem and  2,277  all  other  diseases.  What  a  fearful  waste  of  life  when  we 
know  that  the  majority  of  these  deaths  could  and  should  be  prevented ! 

The  death  of  a  mother  must  be  considered  from  an  economic  standpoint. 
There  is  greater  mortality  and  morbidity  among  motherless  children,  es- 
pecially in  the  earlier  years.  There  is  an  increased  cost  to  the  community 
as  many  of  these  children  are  supported  by  town  funds.  There  is  also 
more  delinquency  to  be  found  among  these  families. 

Congenital  defectiveness  and  poor  heredity  are  important  factors  in 
many  of  the  so-called  malnourished  children  and  children  with  the  ina- 
bility to  assimilate  food,  giving  rise  to  the  cause  of  death  from  prevent- 
able diseases  in  the  digestive  tract. 

The  same  causes  that  kill  infants,  make  them  sick,  maim  or  cripple  them 
for  life  and  incapacitate  them  physically,  mentally  and  morally.  Again 
the  same  causes  that  prevent  and  control  mortality  and  morbidity  reflect 
themselves  in  an  improved  health,  vitality  and  prolonged  life  in  the  later 
age  groups. 

The  increase  in  national  vigor  that  would  result  from  universal  educa- 
tion in  maternity  and  infant  hygiene  and  from  proper  prenatal,  infant  and 
postnatal  care  can  hardly  be  overestimated. 

President  Hoover  has  said,  "Our  goal  is  the  normal  child,  the  child 
whose  organs  function  efficiently,  whose  growth  is  progressing  unimpeded, 
whose  senses  are  developing  unhampered  and  whose  potentialities  are 
being  realized  mentally,  physically  and  morally." 

Those  of  us  who  are  engaged  in  child  health  promotion  even  to  the 
smallest  degree  have  a  stupendous  work  before  us  to  attain  that  goal. 

This  needs  properly  organized  and  conducted  child  hygiene  work  in 
every  community,  rural  as  well  as  urban,  of  every  state. 

Although  the  ultimate  goal  is  the  same  in  large  cities,  small  towns  and 
rural  districts,  the  greater  difficulties  are  found  in  the  rural  district.  The 
needs  are  different,  especially  in  carrying  out  the  corrective  measures. 
The  approach  is  different,  the  organization  methods  are  different  and  must 
be  adapted  to  the  geographic,  as  well  as  economic  conditions. 

In  rural  communities  the  problems  are  distance,  mode  of  travel,  weather, 
occupation,  amount  of  money  available  to  carry  on  the  work  and  the  type 
of  service  to  be  given. 

The  machinery  necessary  is  an  interested,  receptive,  cooperative  com- 
munity where  interest  is  not  only  as  a  collective  body  but  as  individuals 
and  as  individual  members  of  various  organizations.  There  must  be  suf- 
ficient local  funds  or  funds  supplied  by  organizations.  The  State  Depart- 
ment of  Public  Health  will  give  every  assistance  in  its  power  in  the  way 
of  service  that  may  be  available.  There  should  be  an  interested,  enthusi- 
astic, well  paid  and  not  overworked  public  health  nurse  who  is  free  to 
carry  on  an  educational  program.  Her  efforts  must  not  be  hampered  by 
too  many  other  types  of  work.  Bedside  nursing  is  an  essential  service 
both  for  the  laity  and  for  the  doctor,  not  only  in  hastening  recovery  from 
illness,  but  is  an  economic  factor  in  relation  to  the  community.  The  fewer 
sick  days  charged  up  against  the  members  of  a  community  means  more 
money  possessed  by  that  community.  Bedside  nursing,  especially  if  it  in- 
cludes delivery  service  is  a  very  essential  service  in  a  community.  It  is 
difficult  to  solve  this  problem  except  by  having  enough  nurses  to  divide  the 
work  or  if  there  is  a  generalized  nursing  plan  instituted,  have  the  com- 
munity properly  zoned  with  a  sufficient  number  of  nurses  so  there  is  only 
one  nursing  contact  with  a  family  for  all  nursing  service. 

Instruction  in  taking  care  of  the  chronic  sick  can  be  given  to  members 
of  the  families  or  willing  neighbors  or  there  could  be  trained  lay  workers 
in  the  community  who  could  give  this  care  under  supervision. 

Proper  means  of  transportation  and  communication  is  very  necessary  in 
carrying  on  this  work.    There  should  be  a  car  where  the  nurse  has  long 


6 

distances  to  cover  and  there  should  be  suitable  quarters  where  people  can 
come  to  consult  the  nurse  and  attend  the  various  health  clinics  maintained 
— a  great  saving  of  time,  effort  and  money  on  the  part  of  the  worker,  with 
more  people  served. 

Also  enlist  the  interest  of  the  press  as  publicity  plays  a  large  part  in 
putting  over  health  education  but  remember  daily  and  weekly  papers  print 
only  news,  so  present  your  material  in  the  form  of  a  news  paragraph. 

Where  needed  the  community  nurse  should  get  in  touch  with  the  new 
infant  as  soon  after  birth  as  possible  in  order  to  assist  physician  and 
mother  in  establishing  breast  feeding.  The  first  two  or  three  weeks  often 
determines  whether  the  baby  will  be  naturally  or  artificially  fed  and  we 
all  know  the  benefits  and  value  of  breast  feeding.  The  mother  needs  help 
and  encouragement  for  this  is  a  new  profession  for  her  and  she  has  prob- 
ably had  little  or  no  training  in  it. 

Every  child  should  be  under  medical  supervision  from  the  time  of  its 
birth.  The  physician  should  see  the  baby  once  a  week  for  the  first  month, 
once  a  month  for  the  first  three  months  and  every  three  months  for  the 
first  year  and  every  six  months  to  a  year  thereafter.  This  is  for  the  pre- 
sumably well  child — a  well  child  service.  It  is  only  in  this  way  that  minor 
defects,  which  later  become  serious,  may  be  detected  and  corrected. 

The  pre-school  child  is  now  coming  into  its  own.  They  were  rather 
neglected;  therefore,  when  school  age  was  reached  they  were  frequently 
found  to  be  mentally  and  physically  handicapped.  Defects  more  commonly 
found  during  this  period  are  dental  with  60  %  or  70  %  having  dental  caries 
in  varying  degree,  then  we  have  the  postural  defects,  45%  to  50%,  and 
then  malnutrition  20%  to  25%.  That  seems  so  unnecessary  but  we  must 
consider  the  underlying  causes  and  they  are  ignorance,  lack  of  money,  lack 
of  interest  and  a  lack  of  facilities  for  correction  of  defects. 

In  large  cities  there  are  innumerable  facilities  but  in  the  rural  districts 
and  smaller  towns  there  are  none  except  for  the  overworked  and  often  un- 
derpaid doctor.  What  the  solution  is  of  this  difficulty  is  a  problem  for  us 
all.  Seek  financial  aid  from  those  who  can  give,  and  do  not  hesitate  to  ask 
for  it  and  keep  on  asking.  Though  this  is  a  form  of  charity  it  is  educa- 
tional in  its  results  and  will  pay  interest  on  investment.  Another  possible 
solution  may  be  the  establishment  of  a  public  health  community  center  in 
districts  where  all  ages  could  be  brought  for  care  which  otherwise  could 
not  be  given.  There  is  another  phase  of  child  hygiene  to  which  we  must 
pay  more  attention  and  that  is  the  mental  hygiene  of  the  younger  child. 
As  President  Hoover  says  "Equally  important  and  interrelated  with  the 
physical  needs  are  the  emotional  needs  of  childhood,  such  as  the  need  for 
wise  love  and  understanding,  for  protection  against  such  psychic  blights 
as  fear  and  the  abuse  of  primitive  emotions  such  as  anger."  This  is  most 
important  as  well  during  the  adolescent  stage  and  for  the  young  adult. 
Today  there  are  so  many  boys  and  girls,  men  and  women  handicapped  for 
their  race  of  life  because  of  this  lack  of  understanding  and  guidance. 
Much  can  be  done  with  the  school  child  who  is  a  difficult  or  problem  child 
by  training  the  teachers  in  child  guidance  and  by  having  properly  trained 
school  councillors  or  visiting  teachers.  Children  are  extremely  plastic  in 
body  and  equally  so  in  mental  qualities.  They  are  in  our  hands  and  ours 
the  privilege  to  carry  them  to  normalcy  or  as  far  on  the  way  as  their  han- 
dicaps permit.  Ruskin  says  "There  is  no  true  potency  but  that  of  help — 
nor  true  ambition  but  the  ambition  to  serve." 


HOW  TO  MAKE  A  PRENATAL  VISIT 

Mary  P.  Billmeyer,  R.N. 
Department  Consultant  in  Public  Health  Nursing 
Massachusetts  Department  of  Public  Health 
Since  the  real  nature  of  and  need  for  complete  prenatal  and  maternity 
care  is  not  understood  by  most  patients,  it  is  of  utmost  importance  that  a 
nurse's  approach  be  most  tactful  and  friendly — winning  the  complete  con- 
fidence of  the  patient.  This  may  be  done  in  a  few  minutes  on  the  first 
visit,  or  it  may  take  several  visits  and  a  longer  time.  Unless  the  patient 
meets  you  more  than  half  way,  never  attempt  a  full  nursing  visit  the  first 
time  you  see  her.  Ask  what  arrangement  she  has  made  for  care  at  the 
time  of  delivery.  If  she  has  registered  with  a  clinic  or  hospital,  make  note 
of  that ;  if  she  has  engaged  a  physician  be  sure  to  communicate  with  him 
explaining  your  work  and  the  policies  of  your  organization  in  cooperation 
with  doctors.  Permission  should  be  obtained  from  him  before  giving  defi- 
nite advice,  taking  blood  pressure,  fetal  heart  rate  or  simple  urinalysis. 
Be  sure  that  all  physicians  understand  clearly  that  nursing  supervision  in 
no  way  aims  to  take  the  place  of  medical  care,  but  rather  makes  it  more 
effective  by  teaching  the  mother  to  follow  instructions. 

The  prenatal  visit  should  always  be  conducted  in  an  orderly,  business- 
like manner,  which  impresses  the  mother  with  its  importance. 

After  greeting  the  patient,  select  a  place  for  the  interview,  remember- 
ing the  advantage  of  privacy.  See  that  she  is  comfortably  seated,  then 
select  a  table,  chair  or  machine  top  to  use  for  the  nursing  bag  and  its  con- 
tents. Protect  the  piece  of  furniture  to  be  used  as  the  working  table  by 
covering  it  with  newspaper.  Good  bag  technique  is  very  important,  and 
since  there  is  always  a  possibility  of  encountering  a  communicable  disease 
or  an  infection,  a  valuable  lesson  in  individual  precautions  may  be  taught 
the  patient,  and  by  this  demonstration  of  protection  to  her  even  greater 
confidence  in  the  nurse  may  be  established. 

While  preparing  for  nursing  care,  ask  the  patient  about  her  general 
health,  giving  her  a  chance  to  talk  about  any  aches,  pains,  or  troubles. 
Direct  the  conversation,  covering  especially  such  points  as  headache,  vis- 
ual disturbance,  dyspnoea,  nausea  and  vomiting,  constipation,  vaginal  dis- 
charge, etc.,  in  such  a  way  that  any  abnormal  condition  may  be  discovered. 
In  order  to  make  a  full  prenatal  visit,  the  following  articles  are  neces- 
sary. 

1  butcher  apron 

1  mouth  thermometer 

1  rectal  thermometer 

1  stethoscope 

1  blood  pressure  apparatus 

1  paper  arm  band  enclosed  in  cotton  bag 

1  bottle  green  soap 

1  orange  wood  stick 

absorbent  cotton  in  envelope 

1  tongue  depressor 

2  paper  napkins 

3  paper  towels 

Urinalysis  outfit:  (unless  specimens  are  taken  to  station) 
1  specimen  bottle 
1  aluminum  cup 
1  paper  cup 
1  test  tube 
1  test  tube  holder 
1  urinometer  and  holder 

1  bottle  of  50%  acetic  acid  with  rubber  stopper 
1  medicine  dropper 
1  box  of  matches 
1  Sterno 
1  instrument  basin 


8 

Since  detailed  instructions  as  to  technique  and  procedure  are  so  excel- 
lently outlined  in  the  Handbook  of  Standard  Methods  of  the  Division  of 
Maternity,  Infancy  and  Child  Hygiene,  State  Department  of  Health,  New- 
York,  will  quote  at  intervals. 

"Roll  sleeves  well  back  above  elbows,  open  bag,  remove  paper  napkins, 
unfold  and  place  on  newspaper.  Place  everything  that  is  taken  from  the 
bag  on  the  napkin  so  that  it  will  be  clean  to  return  to  the  bag.  Then  re- 
move the  bottle  of  green  soap,  orange  wood  stick  and  paper  towel.  Wash 
hands  thoroughly,  using  orange  stick  to  care  for  nails,  and  dry  hands  on 
paper  towel.  Remove  apron  from  bag  and  put  it  on,  then  take  out  all  ar- 
ticles that  are  required  for  the  visit.  Close  bag.  If  at  any  time  it  is  found 
necessary  to  open  the  bag  for  more  equipment,  wash  hands  thoroughly  be- 
fore doing  so." 

Take  temperature,  pulse  and  respiration,  rinsing  the  thermometer  in 
cold  water  before  using.  Adjust  the  sleeve  and  the  blood  pressure  appa- 
ratus while  the  thermometer  is  registering. 

See  that  the  patient  is  sitting  in  a  comfortable  position  with  arm  re- 
laxed on  a  table  or  the  bed.  Explain  process  carefully  so  that  she  will  not 
be  alarmed.  Push  her  sleeve  well  above  the  elbow  and  cover  her  arm  with 
paper  napkin  or  paper  arm  band.  "Apply  the  sleeve  of  the  blood  pressure 
apparatus  directly  over  the  brachial  artery;  wrap  the  remainder  of  the 
sleeve  around  the  arm  precisely  as  a  bandage,  tuck  the  end  under  the  pre- 
ceding fold.  Attach  the  monometer  or  dial  to  either  one  of  the  two  rub- 
ber tubes  leading  from  the  sleeve;  use  the  hook  on  the  sleeve  to  hold  the 
dial  in  a  convenient  position  to  read.  Attach  the  inflating  bulb  to  the 
second  tube. 

Before  inflating  the  sleeve  of  the  blood  pressure  apparatus,  remove  the 
thermometer  from  the  patient's  mouth,  record  temperature  and  cleanse 
thermometer  by  following  method: 

Four  pieces  of  absorbent  cotton  are  needed.  Scrub  thermometer  thor- 
oughly with  pledget  of  cotton  saturated  with  green  soap  and  use  two 
pledgets  with  cold  water  to  remove  soap,  and  remaining  piece  of  cotton  to 
dry  thermometer.  Return  to  case.  Place  all  used  pieces  of  cotton  in  the 
newspaper  envelope  or  bag.  Use  the  following  method  of  estimating  the 
systolic  blood  pressure:  (1)  Palpate  the  radial  artery.  (2)  Inflate  the 
sleeve,  observing  the  amount  of  pressure  required  to  extinguish  the  pulse 
entirely.  Advance  the  pressure  about  20  points  above  this.  (3)  Gradually 
lower  the  external  pressure,  adjusting  the  thumb  screw  until  the  pulse  re- 
appears. The  point  indicated  by  the  hand  on  the  dial  at  the  instant  that 
the  pulse  returns  marks  the  point  of  systolic  pressure.  Blood  pressure 
ranging  from  100  to  110  is  considered  normal — any  material  change,  rise 
or  drop  should  be  reported  to  physician  at  once." 

Again  scrub  hands  preparatory  to  inspecting  and  demonstrating  the 
care  of  the  nipples.  Instruct  the  mother  to  do  this  twice  daily  after  the 
seventh  month  if  the  nipples  are  erect.  If  they  are  inverted  or  flat,  care 
should  be  given  earlier.  With  a  cotton  ball  wash  each  nipple  with  warm 
water  and  white  soap  and  dry  with  a  clean  towel  or  cotton.  Apply  albo- 
lene,  pulling  nipple  out  gently  by  grasping  between  thumb  and  forefinger, 
hold  for  a  moment,  then  release.  Instruct  the  mother  to  do  this  several 
times,  each  time  the  nipples  are  washed  and  oiled.  Explain  to  her  that 
this  care  is  needed  because  during  pregnancy  there  is  a  secretion  in  the 
breasts  which  dries  and  forms  a  coating  or  crust  on  the  surface  of  the 
nipple.  Under  this  crust  the  skin  becomes  tender  and  the  baby's  first 
nursing  may  remove  it  and  leave  a  tender  area  which  is  very  likely  to 
crack  or  become  infected.  Breast  abscesses  are  nearly  always  caused  from 
infection  entering  these  cracks  and  not  from  cold.  If  the  nipples  are  thor- 
oughly cleansed  daily  with  soap  and  water,  followed  by  an  application  of 
liquid  albolene,  the  secretion  cannot  collect  and  there  will  be  no  tender 
area  and  the  nipples  by  such  care  will  be  prepared  for  the  baby's  nursing. 
Explain  again  the  importance  of  scrubbing  hands  before  caring  for  the 
nipples. 


9 

Look  for  edema  and  varicose  veins.  Do  not  take  the  patient's  word  for 
these  symptoms.  If  varicose  veins  are  causing  trouble,  teach  the  patient 
the  right  angle  position  and  apply  a  bandage  when  necessary.  The  right 
angle  position  may  also  be  taught  to  patients  suffering  from  pains,  cramps 
or  numbness  in  legs.  Explain  to  patient  that  when  she  first  takes  the 
right  angle  position,  she  may  feel  a  bit  uncomfortable  and  may  have  slight 
difficulty  in  breathing,  but  if  she  will  persist  by  taking  a  few  minutes  the 
first  day,  increasing  a  few  minutes  each  day,  she  will  gradually  be  able  to 
maintain  this  position  for  fifteen  or  twenty  minutes  several  times  daily, 
and  will  get  relief.  Explain  to  the  patient  the  reason  of  varicose  veins 
and  cramps — that  the  enlarging  uterus  pressing  on  the  large  veins  in  the 
thighs  causes  the  blood  to  flow  out  of  the  legs  more  slowly.  An  abdominal 
binder  that  really  gives  support  will  help  relieve  the  pressure  in  the  veins. 
Explain  that  round  garters  and  rolled  stockings  are  a  hindrance  to  circu- 
lation and  often  cause  varicose  veins.  Teach  elevated  Sims  position  for 
varicosities  of  vulva  and  hemorrhoids. 

Ask  the  patient  for  a  specimen  of  urine;  supply  her  with  paper  cup  to 
collect  the  specimen,  asking  her  to  cleanse  vulva  before  voiding.  If  the 
specimen  is  not  to  be  taken  to  a  Center  for  examination,  make  a  home 
urinalysis  which  includes  the  specific  gravity  and  test  for  albumen.  The 
following  method  may  be  used : 

Fill  the  urinometer  glass  two-thirds  full  of  urine.  Place  in  level  spot. 
"Float  urinometer  in  urine  and  spin  so  that  it  will  be  free  from  contact 
with  the  sides  of  the  glass,  then  read  figures  on  the  scale  level  with  urine. 
This  is  usually  between  1010-1020.  Variation  should  be  reported  to  the 
doctor." 

If  there  is  a  large  output  of  urine  with  a  high  specific  gravity,  it  should 
be  examined  for  sugar  as  well  as  albumen. 

If  the  urine  is  not  clear  it  should  be  filtered  before  testing  for  albumen, 
then  fill  test  tube  one-half  to  two-thirds  full  of  urine,  boil  the  top  portion 
over  a  Sterno  flame,  and  if  a  cloud  appears  add  a  few  drops  of  acetic  acid. 
If  the  cloud  disappears  and  the  urine  is  clear,  record  as  negative.  If  there 
is  any  abnormality  of  the  specimen,  report  immediately  to  the  doctor,  mid- 
wife or  hospital  in  charge  of  the  patient.  In  case  she  has  not  engaged  a 
physician,  make  every  effort  to  get  her  under  care  at  once. 

Carefully  wash  and  boil  the  test  tubes  and  urinometer  holder  in  instru- 
ment basin  to  avoid  contaminating  the  bag — cleanse  the  urinometer  with 
green  soap  and  water,  then  dry. 

Teach  the  patient  to  measure  amount  of  urine  voided  in  twenty-four 
hours.  Tell  her  to  use  the  toilet  on  getting  up  in  the  morning,  then  for 
the  rest  of  that  day  and  night  and  the  following  morning  to  void  in  a  suit- 
able vessel,  measure  with  a  pint  can  and  count  the  number  of  times  it  is 
filled.  There  should  not  be  less  than  three  pints.  If  it  is  much  less  urge 
drinking  more  water.  During  hot  weather  when  the  patient  perspires 
freely,  the  amount  of  urine  will  be  less  and  the  specific  gravity  higher. 

Emphasize  the  importance  of  a  balanced  diet,  that  it  should  be  adequate 
to  build  and  nourish  the  baby's  body  without  drawing  materials  from  the 
mother's  tissues.  Explain  that  when  teeth  decay  more  readily  at  this  time 
it  is  due  partly  to  increased  acidity  of  the  mouth  but  particularly  to  a  de- 
ficiency of  calcium  in  the  diet.  Since  both  sets  of  teeth  are  formed  in  the 
fetus  during  the  early  weeks  of  pregnancy,  the  teeth  and  bones  require 
lime  and  minerals  to  develop  properly,  and  that  the  chief  sources  of  this 
supply  are  in  milk,  leafy  vegetables  and  fruit.  The  use  of  coarse  cereals 
and  dark  breads  will  prevent  constipation.  Since  protein  makes  more 
work  for  the  kidneys  than  any  other  food,  meat,  fish,  eggs,  or  cheese  should 
be  eaten  only  once  a  day.  Emphasize  the  importance  of  eating  regularly 
and  moderately  and  chewing  food  thoroughly.  Urge  at  least  eight  glasses 
of  water  daily  which  assists  the  kidneys,  bowels  and  skin  in  elimination  of 
waste  material.  It  is  through  the  mother  that  the  waste  of  the  baby  is 
thrown  off. 

Advise  plenty  of  fresh  air  and  daily  exercise  in  the  open.     Stress  the 


10 

importance  of  keeping  happy,  cheerful  and  comfortable.  Avoid  heavy 
work,  lifting  and  reaching,  and  too  much  stair  climbing.  A  rest  period 
daily  is  very  important,  as  well  as  frequent  short  periods  of  rest.  Avoid 
fatigue. 

Advise  a  warm  daily  bath  to  keep  the  skin  clean  and  assist  in  elimina- 
tion. After  the  seventh  month  sponge  baths  only  should  be  taken  because 
of  the  possibility  of  infection  following  tub  baths. 

Urge  the  necessity  for  having  warm,  comfortable  and  attractive  clothing 
hung  from  the  shoulders. 

Talk  over  the  layette  and  advise  that  everything  be  ready  by  the  end  of 
the  seventh  month.  If  patient  is  to  be  delivered  at  home,  explain  what 
supplies  are  needed. 

Literature,  pamphlets  or  publications  may  be  left  which  emphasize  cer- 
tain special  points. 

STANDARDS  IN  OBSTETRICS 

Robert  L.  DeNormandie,  M.D. 
Boston,  Massachusetts 

At  first  thought  it  would  seem  almost  unnecessary  to  write  on  the  ques- 
tion of  standards  in  obstetrics.  They  have  been  talked  of,  written  about 
and  described  fully  many  times.  But  if  one  looks  at  the  results  that  have 
been  obtained  in  obstetrics  in  the  last  few  years  as  shown  by  the  mortality 
records  throughout  the  country,  one  realizes  at  once  that  there  must  be 
need  still  to  discuss  standards  in  obstetrics.  For  if  the  standards  which 
are  maintained  were  satisfactory  and  the  routines  were  carried  out  ac- 
cording to  the  best  teachings,  we  should  have  no  such  high  mortality  as  at 
present  occurs  in  this  state  and  in  this  country. 

In  speaking  of  standards  in  obstetrics,  the  work  may  at  once  be  divided 
into  three  definite  divisions:  the  standards  of  prenatal  care,  of  delivery 
care  and  of  postpartum  care.  It  has  been  demonstrated  again  and  again 
that  if  we  are  to  have  satisfactory  results  in  obstetrics  we  must  have  com- 
plete care  of  the  patient  from  the  beginning  of  pregnancy,  through  deliv- 
ery and  the  postpartum  period.  Prenatal  care  has  been  talked  of  so  much 
in  the  past  few  years  that  one  would  think  that  nearly  every  woman  would 
realize  that  she  should  have  medical  care  during  her  entire  pregnancy. 
Medical  care  cannot  be  given  to  the  pregnant  patient  unless  that  patient 
presents  herself  to  a  clinic  or  to  a  doctor  for  such  care,  but  as  soon  as  she 
does  present  herself  it  is  essential  for  the  physician  to  map  out  thoroughly 
and  minutely  the  care  that  he  intends  to  give  her  during  her  pregnancy. 

In  a  short  article  it  is  impossible  to  go  over  all  the  standards  that  have 
been  set  for  prenatal  work.  The  physician  knows  well  what  should  be 
done  for  the  care  of  the  patient.  Let  me  sum  up  this  care  in  a  few  words. 
As  soon  as  she  is  seen  a  complete  physical  examination  should  be  made  in 
order  to  establish  what  the  patient's  normal  is,  and  to  discover  anything 
that  is  abnormal  in  her  physical  condition ;  then,  as  pregnancy  goes  on,  to 
determine  whether  there  is  any  disproportion  between  the  baby  and  the 
pelvis,  and,  if  there  is  a  disproportion,  to  map  out  the  method  of  treatment 
intelligently ;  if  it  seems  probable  that  hard  operative  work  will  be  neces- 
sary, and  the  physician  is  not  able  to  safeguard  the  patient,  to  send  her  to 
some  clinic  or  consultant  who  will  be  able  to  do  so.  During  this  time  of 
prenatal  care,  it  can  easily  be  determined  whether  it  is  right  to  let  the  pa- 
tient stay  at  home  for  the  delivery  or  whether  she  must  be  sent  to  a  hos- 
pital. 

By  constant  supervision  and  intelligent  cooperation  of  the  patient,  the 
toxemias  of  pregnancy  will  be  discovered  early  and  eclampsia  will  not  oc- 
cur. At  the  present  time  physicians  cannot  prevent  toxemias,  but  if  the  rec- 
ognized suitable  standards  of  prenatal  care  are  carried  out  the  frequency 
of  eclamptic  cases  will  be  cut  almost  to  nothing.  The  physician  who  each 
year  has  cases  of  eclampsia  is  not  carrying  out  a  satisfactory  standard  of 


11 

prenatal  care,  and  if  he  wishes  to  avoid  much  criticism  he  will  at  once 
raise  his  standards  to  what  he  has  been  taught.  Except  in  a  few  cases 
where  bleeding  or  a  sudden  toxemia  develops,  practically  no  difficult  emer- 
gency work  should  be  necessary  if  intelligent,  careful,  thoroughgoing  pre- 
natal care  is  given.  To  carry  out  such  standards  satisfactorily  means  co- 
operation between  the  patient  and  the  doctor.  The  doctor  must  insist  that 
the  patient  follow  his  orders  absolutely,  and  on  his  part  he  must,  under  no 
circumstances,  allow  the  patient  to  lapse  from  the  routine  which  he  has 
laid  out  for  her. 

In  regard  to  the  delivery  care,  the  fundamental  thing  to  be  impressed 
upon  everybody,  the  laity  and  the  physician,  is  that  a  delivery  must  be 
managed  as  a  surgical  procedure.  By  that  is  meant  that  there  must  be 
absolute  cleanliness  on  the  part  of  the  physician,  and  that  the  patient  must 
be  brought  to  delivery  if  possible  without  any  infection  present.  The  lat- 
ter cannot  always  be  done,  and  it  is  in  those  cases  where  infection  is  pres- 
ent that  a  certain  number  of  complications  and  deaths  occur.  If  there  is 
satisfactory  prenatal  care,  it  has  been  discovered  before  delivery  whether 
the  patient  has  an  infection  or  not,  and  proper  means  may  be  taken  many 
times  to  overcome  a  possible  disaster. 

Between  30  per  cent  and  40  per  cent  of  all  obstetrical  deaths  are  caused 
by  septicemia,  and  it  is  a  well  known  fact  that  almost  all  septicemia  is 
caused  by  poor  technique  at  the  time  of  delivery.  In  the  best  medical 
schools  physicians  have  been  trained  in  good  technique.  While  they  were 
in  the  medical  schools  as  students  they  were  carefully  supervised.  When 
they  leave  the  medical  schools  and  start  practice  themselves,  they  have  in 
many,  if  not  the  majority,  of  cases  no  one  to  supervise  them.  They  have 
no  one  to  oversee  their  work,  no  one  to  check  them  up.  In  many  cases  men 
who  have  been  well  trained  in  a  careful  technique  and  who  have  done  satis- 
factory work  in  the  clinics,  lapse  very  much  in  their  technique  outside, 
and  use  very  careless  methods  of  delivery.  It  is  these  physicians  who  are 
adding  largely  to  our  high  obstetric  mortality. 

In  addition  to  the  necessity  of  carrying  out  an  excellent  technique,  the 
mechanism  of  labor  must  be  thoroughly  understood  and  mastered.  This  is 
essential  if  good  obstetrics  is  to  be  done. 

Progress  of  the  labor  can  in  most  cases  be  satisfactorily  followed  by 
studying  carefully  the  frequency  and  character  of  the  pains  together  with 
abdominal  palpation.  Rectal  examinations  have  largely  displaced  vaginal 
examinations,  but  even  these  must  not  be  done  frequently.  In  the  ma- 
jority of  cases  a  rectal  examination  will  tell  all  that  is  necessary.  Occa- 
sionally such  an  examination  is  not  conclusive  and  then  a  vaginal  exami- 
nation may  be  indicated.  If  it  is,  absolute  cleanliness  and  the  use  of  sterile 
gloves  must  be  insisted  upon.  Repeated  vaginal  examinations  during  la- 
bor greatly  increase  the  possibility  of  sepsis.  The  practice  some  physi- 
cians have  of  making  vaginals  every  hour  or  sometimes  oftener  is  only 
mentioned  to  be  severely  condemned.  No  good  can  come  of  such  exami- 
nations and  much  harm  may  arise. 

If  the  indication  for  operative  work  arises,  the  physician  must  know 
without  question  the  mechanism  of  labor  or  he  will  tear  badly  the  soft 
parts.  His  technique  must  be  good  or  sepsis  will  without  doubt  follow. 
The  excellent  results  that  some  men  in  rural  communities  have,  show  what 
can  be  accomplished  far  removed  from  hospital  resources  and  adequate 
help.  It  also  brings  out  the  more  strikingly  the  bad  results  that  not  in- 
frequently occur  in  cities  by  the  hurried,  careless  man.  Such  a  physician 
must  not  be  doing  obstetrics,  for  he  will  only  bring  misery  to  many  house- 
holds. 

Eclampsia  and  sepsis  account  for  nearly  50%  of  all  maternal  deaths  in 
any  series  of  deaths  studied.  With  cooperation  between  the  patient  and 
the  physician  eclampsia  should  be  all  but  eliminated  as  a  cause  of  death. 
The  continued  high  mortality  from  sepsis  in  this  state  is  a  serious  criti- 
cism of  the  medical  profession.  To  improve  this  situation  something  rad- 
ical must  be  done.    Writing  about  standards  will  not  accomplish  what  we 


12 

wish.  Investigation  of  every  maternal  death  and  suitable  action,  where 
continued  bad  results  are  obtained,  by  the  Board  of  Registration  in  Medi- 
cine would  very  quickly  improve  the  condition. 

The  physician's  part  in  the  postpartum  care  of  the  patient  is  chiefly  one 
of  supervision.  Adequate  nursing  standards  must  be  demanded.  The 
care  of  the  breasts,  the  diet,  the  bowels,  the  resumption  of  the  patient's 
daily  duties  are  all  points  that  he  must  supervise  if  he  would  have  her  re- 
turn to  her  regular  routine  in  excellent  condition.  I  suppose  the  majority 
of  women  who  have  children  resume  their  daily  tasks  within  two  weeks  of 
the  birth  of  the  baby.  They  do  it  at  great  cost  and  yet  from  their  own 
economic  point  of  view  it  must  be  done. 

The  visiting  nurse,  the  trained  attendant,  the  untrained  handy  woman 
all  take  an  active  part  in  looking  after  the  puerperal  patient.  The  less  the 
training  of  the  individual  who  looks  after  the  patient,  the  greater  the  re- 
sponsibility of  the  physician  in  the  supervision  of  the  nursing  care  that 
is  given. 

The  three  divisions  of  the  standards  of  obstetrics  dovetail  very  closely 
with  one  another.  If  one  breaks  down,  the  results  obtained  will  be  unsat- 
isfactory and  then  the  profession  as  a  whole  will  be  blamed  for  the  bad 
results  that  occur.  The  standards  that  are  taught  in  our  schools  are  not 
impossible  to  carry  out.  The  physicians  who  have  the  will  and  a  con- 
science do  good  work  and  their  results  are  beyond  criticism.  However,  it 
is  the  relatively  small  group  who  have  neither  a  will  nor  a  conscience  that 
bring  criticism  to  obstetrics.  It  is  to  this  group  that  standards  in  obstet- 
rics mean  but  little,  and  it  is  a  great  problem  how  to  reach  them. 

n      MATERNITY  AS  A  PUBLIC  HEALTH  PROBLEM* 

Matthias  Nicoll,  Jr.,  M.D.,  Fellow  A.  P.  H.  A. 
Former  Commissioner  of  Health,  State  of  New  York,  Albany,  N.  Y. 

Before  the  advent  of  what  is  commonly  called  modern  public  health, 
health  administration  was  comparatively  simple;  its  field  was  narrow;  and 
the  duties  and  prerogatives  of  health  officials  were  generally  accepted 
without  dispute,  not  only  by  the  public  but  by  the  medical  profession. 

With  the  constant  expansion  of  the  field  of  public  health,  due  to  popular 
demand,  unquestionably  stimulated  and  rendered  vocal  and  effective  by  the 
activities  of  official  and  nonofficial  health  agencies,  the  administration  of 
public  health  is  becoming  increasingly  difficult,  largely  because  the  bor- 
ders of  the  field  are  continually  impinging  on  the  rights  and  prerogatives, 
real  and  fancied,  of  other  official  and  nonofficial  agencies.  This  leads  to 
frequent  disputes,  bad  feeling,  lack  of  cooperation,  working  agreements, 
and  all  sorts  of  more  or  less  futile  compromises.  Yet  the  health  official, 
who  seeks  to  limit  his  work  to  the  quarantine  and  control  of  infectious 
diseases,  the  protection  of  water  and  food  supplies,  and  such  matters  of 
routine  as  daily  come  to  his  attention,  can  hardly  expect  to  keep  abreast  of 
the  demands  of  modern  life. 

It  is  safe  to  say  that  the  average  health  officer  does  not,  of  his  own  vo- 
lition, seek  to  enlarge  greatly  the  scope  of  his  activity.  Most  of  them 
would  prefer  to  perform  more  efficiently  the  fundamental  and  essential 
work  of  their  office  with  the  production  of  more  immediately  measurable 
results  than  is  usually  possible  in  the  majority  of  the  newer  fields ;  but  the 
powers  and  responsibilities  conferred  by  law  upon  health  officers  of  larger 
jurisdictions  are  so  far  reaching  and  inescapable  that  they  cannot  be 
avoided  with  self-respect  and  a  sense  of  obligation  to  the  oath  of  office. 

Among  the  more  recent  activities  in  which  health  officers  must  engage 
may  be  mentioned  the  control  of  venereal  disease,  cancer,  well  baby  clinics, 
periodic  health  examinations,  and  the  reduction  of  maternal  mortality.  I 
have  chosen  the  latter  as  a  basis  for  some  general  observations — not  that 


*  Presidential  Address  delivered  before  the  State  and  Provincial  Health  Authorities  of  North 
America  at  the  44th  Annual  Conference  at  Washington,  D.  C,  May  31,  1929.  Reprinted  from 
the  American   Journal  of   Public  Health,   Vol.   XIX,   No.   9,    September,    1929. 


13 

it  is  by  any  means  the  most  important  branch  of  public  health,  but  be- 
cause it  presents  a  problem  which  includes  possibly  as  many  controversial 
elements  as  any  of  the  others  mentioned,  and  because  no  other  phase  of 
public  health  has  produced  more  widespread  discussion  throughout  the  na- 
tion, or  more  heated  arguments  pro  and  con,  than  that  of  the  care  of  the 
pregnant  woman,  involving  as  it  does  questions  of  federal  and  state  finan- 
cial policy,  political  expediency,  personal  prejudices,  authority  for  the  con- 
duct of  the  work,  and,  most  important  of.  all,  the  control  of  methods  of 
medical  practice  in  the  home  and  hospital. 

Briefly  stated,  what  is  the  problem  which  we  as  health  officers  are  called 
upon  to  solve?  In  the  40  states  and  the  District  of  Columbia,  comprising 
the  registration  area  for  1927,  13,837  women  died  from  causes  directly 
connected  with  childbirth.  From  a  statistical  standpoint,  the  figures 
themselves  are  not  startling  compared  with  those  for  the  principal  causes 
of  death,  but  when  the  fact  is  taken  into  consideration  that  we  are  dealing 
not  with  a  disease  but  with  a  physiological  process,  they  are  most  dis- 
heartening, and  a  reproach  to  public  health  administration  and  its  fre- 
quently vaunted  claims  of  rapid  progress  in  the  achievement  of  definite 
results. 

The  deaths  annually  of  14,000  or  15,000  women  from  causes  directly 
connected  with  childbirth,  and  the  chronic  invalidism  of  many  times  that 
number,  constitute  a  much  graver  problem  than  an  equal  number  of  deaths 
among  the  general  population  or  among  infants  and  young  children,  since 
in  a  large  number  of  cases  the  death  of  a  woman  in  childbirth  involves  the 
disruption  of  a  home,  the  future  welfare  of  many  dependent  children,  and 
other  sociologic  and  economic  factors,  with  which  it  is  frequently  very 
difficult  to  deal. 

The  definite  recognition  of  maternal  mortality  as  a  public  health  prob- 
lem in  this  country  can  be  said  to  date  from  the  enactment  of  the  Shep- 
pard-Towner  Act,  by  which  funds  were  made  available  to  the  states  for 
work  in  maternity  and  child  hygiene.  Before  that  time  little  was  done 
for  the  welfare  of  the  expectant  mother  except  in  a  few  large  cities  and  by 
unofficial  organizations.  During  the  last  five  years  with  greatly  increased 
financial  resources  within  the  states,  directly  and  indirectly  as  a  result  of 
the  federal  act,  and  an  immensely  aroused  public  interest,  especially 
among  representative  American  women,  the  work  has  gone  forward  with 
a  degree  of  success  which  is  not  easily  estimated — certainly  not  statisti- 
cally— and  yet  only  the  most  prejudiced  critic  would  dare  to  assert  that 
no  progress  has  been  made  toward  the  solution  of  what  is  and  for  a  long 
time  will  be  an  extremely  difficult  problem. 

As  good  Americans,  we  claim  and  frequently  exercise  the  inalienable 
right  to  criticise  and  condemn  our  own  shortcomings  as  a  nation,  and  in 
this  spirit  most  of  us  at  one  time  or  another  in  our  moments  of  oratorical 
inspiration  have  called  upon  our  audiences  to  witness  the  disgraceful  neg- 
lect of  expectant  mothers  prevailing  throughout  this  country,  resulting  in 
a  higher  maternal  death  rate  than  in  most  of  the  civilized  nations.  This 
fact  would  seem  to  be  proved  statistically,  and  yet  before  permitting  our- 
selves to  indulge  in  too  violent  self-condemnation,  let  us  be  certain  that 
the  figures  of  other  countries  are  as  accurate  as  ours,  and  based  on  identi- 
cal methods  of  allocating  causes  of  deaths.  Furthermore,  those  countries 
that  show  the  lowest  maternal  death  rate  are  very  small  in  area  compared 
with  the  United  States,  and  contain  a  much  more  homogeneous  population 
than  that  with  which  we  have  to  deal.  No  nation,  except  ours,  is  called 
upon  to  face  such  a  racial  variation  in  fitness  for  motherhood.  It  can 
hardly  be  supposed  that  maternity  work  in  certain  states  in  the  northwest 
is  accountable  for  the  low  maternal  mortality  as  compared  with  that  of 
most  other  states ;  it  is  rather  the  physical  development  and  habits  of  peo- 
ple of  Scandinavian  blood,  among  whom  in  their  mother  country  the  ma- 
ternal death  rate  is  exceedingly  low,  and,  incidentally,  lower  than  among 
the  immigrants  of  that  race  and  their  descendants  in  this  country. 

In  a  recent  pamphlet  published  by  the  Maternity  Center  Association  of 


14 

New  York,  N.  Y.,  the  problem  with  which  we  are  confronted  is  summed 
up  as  follows : 

In  the  United  States  there  are: 

3,026,789  square  miles  of  territory. 

Whole  communities  without  roads. 

Wide  stretches  of  territory  without  doctors. 

1,900  counties  without  a  public  health  nurse  (almost  one-half  of  the 
counties  in  the  United  States). 

At  any  given  time  more  than  2,000,000  pregnant  mothers  distrib- 
uted over  this  vast  territory. 

Let  me  point  out  other  inherent  difficulties  which  we,  as  health  officers 
are  facing,  and  will  have  to  face  for  many  years  to  come.  I  had  hoped  to 
present  an  analysis  of  the  facts  regarding  some  3,000  maternal  deaths  in 
the  State  of  New  York,  based  on  a  questionnaire  sent  out  to  all  the  physi- 
cians in  the  state  in  whose  practice  such  deaths  had  occurred.  Unfortu- 
nately, tabulation  of  the  results  has  proved  much  more  time  consuming 
than  was  at  first  anticipated.  It  may  be  of  interest,  however,  to  record 
the  fact  that  more  than  80  per  cent  of  the  physicians  who  were  asked  to 
fill  in  this  confidential  questionnaire  responded  promptly  and  fully — a 
splendid  example  of  cooperation  between  the  medical  profession  and  pub- 
lic health  authorities.  The  same  kind  of  questionnaire  sent  to  the  various 
hospitals  received  far  less  consideration.  A  preliminary  analysis  of  696 
replies  received  for  the  year  1925  brought  out  these  facts  among  others : 

Of  the  696  cases,  hospital  care  had  been  involved  in  74  per  cent, 
about  half  of  which  were  delivered  and  died  in  the  hospital,  and 
the  rest  delivered  in  the  home  but  died  in  the  hospital  later. 

Only  one-third  of  these  cases  reached  full  term ;  one-fifth  were 
under  5  months  gestation. 

The  lapse  of  time  between  the  delivery  and  the  death  of  the 
mother  was  as  follows :  In  one-fifth  of  the  cases  death  and  deliv- 
ery were  practically  simultaneous;  in  one-fourth  there  was  a 
lapse  of  from  1  to  5  days  between  delivery  and  death ;  in  one-fifth 
6  to  14  days,  and  in  one-eighth  16  to  50  days. 

As  to  nationality — 75  per  cent  were  American  born,  9  per  cent 
Italians,  and  4  per  cent  Poles. 

Over  5  per  cent  were  illegitimate  births. 

There  were  230  questionnaires  which  stated  at  what  stage  the 
patient  had  entered  the  hospital.  Only  13  per  cent  entered  be- 
fore delivery,  37  per  cent  during  labor,  and  50  per  cent  after  de- 
livery. 

What  chance  did  the  doctors  have  as  indicated  by  the  number 
of  days  under  care  before  death?  To  this  question  there  were 
483  replies.  Fifty  per  cent  had  the  case  1  week  or  less ;  over  10 
per  cent  had  the  case  less  than  1  day ;  the  balance  were  under  care 
for  varying  periods,  but  only  13  cases  were  reported  as  having 
been  carried  the  whole  9  months. 

Only  16  cases  were  reported  as  having  been  delivered  by  a  mid- 
wife, but  others  had  a  midwife  in  attendance  at  some  time.  A 
midwife  was  involved  in  1  death,  but  was  later  exonerated. 

As  to  prenatal  care,  41  per  cent  falied  to  answer.  Of  the  408 
answers,  65  per  cent  reported  Yes;  35  per  cent  reported  No. 
From  the  meager  information  as  to  the  details  of  prenatal  care, 
it  was  most  difficult  to  gauge  the  effectiveness  of  such  care. 
Judged  by  the  generally  accepted  standards — the  minimum  stand- 
ards as  issued  by  the  State  Department  of  Health  some  five  years 
ago — it  would  appear  that  few  cases  had  enjoyed  what  might  be 
termed  adequate  prenatal  care.  An  attempt  to  ascertain  when 
such  care  began  showed  that  34  per  cent  did  not  have  prenatal 
supervision  until  the  7th,  8th  or  9th  month. 


15 

The  most  important  fact  to  be  derived  from  this  analysis  is  that  74  per 
cent  of  these  patients  had  been  hospitalized,  but  that  half  of  them  had 
been  delivered  before  going  to  the  hospital,  and  later  died  therein.  This 
represents  a  very  high  degree  of  emergency,  with  the  inevitable  conclusion 
that  the  patients  received  little  medical  supervision  until  it  was  too  late. 

During  the  hearings  on  the  Newton  Bill  before  the  Committee  of  Inter- 
state and  Foreign  Commerce  of  the  70th  Congress,  the  remarks  of  Dr. 
George  W.  Kosmak  of  New  York  were  especially  interesting.  He  repre- 
sented, I  believe,  the  state  medical  society,  and  is  incidentally  one  of  the 
dozen  consulting  obstetricians  whose  services  the  State  Department  of 
Health  placed  at  the  disposal  of  the  county  medical  societies  of  the  state 
by  the  use  of  federal  funds.  The  object  was  the  imparting  by  lectures  and 
demonstrations  to  the  general  practitioners  of  the  state  an  up-to-date 
knowledge  of  obstetrical  procedures.  Dr.  Kosmak  expressed  the  opinion 
that  the  work  in  maternal  hygiene,  as  conducted  in  the  various  states  un- 
der the  provisions  of  the  Sheppard-Towner  Act,  dealt  too  largely  with 
what  he  regarded  as  the  non-essentials  of  the  problem,  namely,  prenatal 
care  and  instruction;  that  the  question  was  largely  one  of  obstetrical 
practice;  and  that  failure  to  obtain  more  striking  results  in  the  diminu- 
tion of  maternal  deaths  was  due  in  a  large  degree  to  bad  obstetrical  pro- 
cedure. With  the  latter  part  of  this  statement  I  think  most  of  us  will 
agree ;  but  that  good  prenatal  and  postnatal  care  cannot  be  characterized 
as  a  non-essential  is  adequately  proved  by  the  results  which  have  followed 
well-organized  work  in  this  field. 

Through  the  courtesy  of  the  Child  Health  Demonstration  Committee  of 
The  Commonwealth  Fund,  I  am  permitted  to  call  attention  to  the  work  of 
that  organization  in  Clarke  County,  Ga.,  and  Rutherford  County,  Tenn., 
from  1925  to  1928.  This  involves  a  group  of  some  5,000  women,  approxi- 
mately proportioned  2  to  1  as  regards  white  and  colored.  Of  these,  1,271 
were  under  maternity  care  and  3,755  not  under  maternity  care  supervised 
by  the  health  department.  The  maternal  mortality  per  1,000  live  births 
in  the  combined  group  of  white  and  colored,  supervised  and  not  super- 
vised, was  9.4  (5.9  among  the  white,  16.4  among  the  colored)  ;  in  the 
whole  group  not  under  official  supervision  11.2  (6.9  among  the  white  and 
20.9  among  the  colored)  ;  under  maternity  care  3.9  for  the  whole  group 
(2.6  among  the  white  and  6.0  among  the  colored). 

The  cases  under  supervision  in  relation  to  maternal  deaths  include  those 
visited  by  health  department  nurses  for  prenatal  and,  in  most  instances, 
for  postnatal  care.  This  is  a  striking  example  of  what  may  be  accom- 
plished by  thorough-going  prenatal  care,  and  presumably  does  not  include 
supervision  over  the  kind  of  obstetrical  practice  which  these  women  re- 
ceived. 

For  what  they  are  worth,  data  are  submitted  of  the  results  among  ap- 
proximately 1,000  expectant  mothers  attending  the  prenatal  consultation 
clinics  held  by  the  New  York  State  Department  of  Health  during  the  past 
5  years.  By  these  it  is  shown  that  the  mortality  among  mothers  who  vis- 
ited these  clinics  was  14.6  per  cent  lower  than  the  general  puerperal  mor- 
tality rate  of  the  state,  exclusive  of  the  City  of  New  York.  The  total 
number  of  deaths  in  this  group  was  so  small,  however,  that  the  figures  in 
themselves  cannot  be  regarded  as  of  any  great  significance.  Numerous 
other  examples  could  be  quoted  of  efficient  and  persistent  prenatal  and 
postnatal  supervision  which  have  produced  definite  results  in  lowering  ma- 
ternal mortality. 

To  return  to  the  question  of  the  practice  of  obstetrics  as  influencing  ma- 
ternal mortality — while  undoubtedly  the  lives  of  a  great  many  pregnant 
women  are  sacrificed  annually  in  this  country  through  the  inaccessibility 
of  medical  care,  or  the  entire  lack  of  it,  when  the  fact  is  considered  that 
a  large  part  of  these  deaths — certainly  more  than  half — occur  in  cities  and 
communities  where  doctors  are  available  and  do  take  charge  of  such  cases, 
it  is  essential  that  the  methods  of  obstetrical  practice  in  this  country  be 


16 

taken  into  account,  however  difficult  it  may  be  for  health  officers  to  ascer- 
tain the  facts  regarding  them. 

No  one  will  question  the  oft-repeated  statement,  especially  by  members 
of  the  medical  profession,  that  the  teaching  of  obstetrics  in  most  of  our 
medical  schools  is  totally  inadequate.  In  many  the  instruction  and  experi- 
ence afforded  students  is  far  less  than  that  required  of  midwives  in  those 
states  which  supervise  their  work  and  license  them.  Indeed  in  some  of  our 
medical  schools  the  faculties  have  not  departed  from  the  original  concep- 
tion that  the  practice  of  obstetrics  is  hardly  a  man's  job,  and  can  be  mas- 
tered apparently  by  inspiration  or  after  the  observation  of  a  few  normal 
cases,  in  the  actual  delivery  of  which  the  student  takes  no  part.  The  med- 
ical schools  must  then  be  held  directly  responsible  for  the  kind  of  obstetri- 
cians which  are  being  turned  out  in  many  parts  of  the  country. 

On  the  other  hand,  there  has  arisen  of  late  years  a  school  of  meddlesome 
obstetrics  founded  on  the  practice  and  teaching  of  certain  unquestionably 
skilled  obstetricians,  the  popularity  of  whose  practice  is  undoubtedly  based 
on  the  very  natural  desire  of  women  to  be  relieved  in  so  far  as  possible  of 
the  sufferings  of  childbirth — even  though  among  the  more  intelligent 
there  must  be  knowledge  of  the  additional  risk  to  their  lives  and  health, 
as  well  as  to  the  children.  These  men  have  little  or  no  regard  for  the 
processes  of  parturition  which  nature  has  perfected  and  which  cannot  be 
improved  upon  in  a  vast  majority  of  cases.  Yet  some  of  them  as  a  matter 
of  routine  resort  to  artificial  methods  of  manual  delivery;  use  instru- 
ments; and  perform  Cesarean  operations  on  the  slightest  provocation,  or 
with  none  at  all.  I  have  had  occasion  to  analyze  the  results  of  this  kind 
of  practice  and,  for  one,  am  ready  to  state  that  in  the  broader  sense  it  con- 
stitutes malpractice,  even  though  it  cannot  be  legally  so  adjudged. 

As  health  officers,  we  are  helpless  to  remedy  this  condition  of  affairs, 
and  it  is  time  that  the  organized  medical  profession  should  be  empowered 
by  law  and  stand  ready  to  clean  house  in  the  interest  of  the  lives  and 
health  of  prospective  mothers  in  this  country.  If  they  do  not  do  so,  the 
health  authorities  will  be  obliged  to  perform  the  task  with  a  weapon,  al- 
ways at  their  command — pitiless  publicity. 

In  the  study  that  I  have  had  prepared  by  the  New  York  Division  of 
Vital  Statistics  of  death  rates  from  specified  puerperal  causes  in  the  origi- 
nal birth  registration  area  from  1915  to  1925,  omitting  the  years  1918, 
1919  and  1920,  which  showed  abnormally  high  rates  owing  to  the  preva- 
lence of  influenza,  the  following  facts  are  elicited: 

The  death  rate  per  10,000  live  births,  due  to  accidents  of  preg- 
nancy, increased  on  the  average  2.4  per  cent  annually. 

From  puerperal  hemorrhage  1.5  per  cent. 

Other  accidents  of  labor  2.9  per  cent. 

Puerperal  phlegmasia  alba  dolens,  embolus,  sudden  death,  5.2 
per  cent,  while  deaths  from  puerperal  albuminuria  and  convul- 
sions decreased  2.0  per  cent,  and  puerperal  septicemia  0.9  per  cent. 

Incidentally,  it  may  be  stated  that  the  mortality  of  infants  from  injuries 
at  birth  for  the  10-year  period  1915-1925  has  risen  on  an  average  3.6  per 
cent  annually.  If  these  figures  mean  anything — and  they  are  based  on  a 
sufficiently  large  number  of  cases  to  be  significant — they  represent  the  re- 
sults of  meddlesome  and  unskillful  obstetrical  practice. 

While  progress  is  slow,  the  trend  of  maternal  mortality  in  this  country 
since  the  beginning  of  the  campaign  is  definitely  downward.  The  work  of 
reducing  maternal  mortality  differs  widely  from  such  procedures  as  im- 
munizing the  population  against  diphtheria;  protecting  a  community 
against  a  water-borne  outbreak  of  typhoid  fever;  or  controlling  infant 
mortality  partly  by  means  of  the  supervision  of  the  milk  supply.  It  is  and 
always  will  be  a  more  or  less  piecemeal  affair.  The  cases  are  widely  scat- 
tered throughout  the  country,  and  the  conduct  of  a  campaign  must  be 
based  not  only  on  general  principles  affecting  the  whole  problem,  but  on 
racial  peculiarities,  and  numerous  other  local  conditions. 


17 

It  is  well  to  point  out  the  fact  that  very  little  work  is  being  done  in  the 
greater  centers  of  population  where,  of  all  places,  facilities  should  be  at 
hand  capable  of  producing  definitely  good  results.  It  is  also  of  immense 
importance  that  knowledge  should  be  forthcoming  as  to  the  kind  of  ob- 
stetrical practice  afforded  by  hospitals  of  various  types.  Here  again,  the 
medical  profession  must  assume  the  task  in  large  measure.  It  will  re- 
quire independence,  unselfishness,  and  a  much  greater  indifference  to  that 
much  abused  term  "medical  ethics"  than  has  hitherto  prevailed.  The  work 
of  public  health  education  in  regard  to  maternity  must  go  on  and  be  more 
effectively  developed.  Notwithstanding  the  criticisms  to  which  it  is  con- 
stantly subjected  it  has  produced  and  will  continue  to  produce  far-reach- 
ing results. 

Many  years  ago  Dr.  Abram  Jacobi  of  New  York  delivered  an  address  in 
classic  Latin  before  the  Roman  Medical  Congress.  If  I  remember  cor- 
rectly, he  deprecated  the  then  growing  tendency  to  perform  operations  on 
the  brain  for  the  relief  or  cure  of  various  pathological  conditions.  The 
title  of  his  paper  was  "Non  Nocete"  (Do  no  Harm),  an  admonition  which 
those  who  are  responsible  for  the  care  of  the  expectant  mother  may  well 
take  to  heart. 

MATERNAL  NURSING 

E.  P.  Ruggles,  M.D.,  Chief  Obstetrician 
Robinson  Memorial  of  the  Massachusetts  Memorial  Hospitals 

The  subject  of  Maternal  Nursing  is  in  itself  not  a  highly  entertaining 
one  and  we  are  not  apt  to  enthuse  over  it  as  we  do  over  the  low  incision  in 
abdominal  section  for  delivery,  but  that  may  be  the  very  reason  why  it  is 
neglected  and  left  in  a  hit  or  miss  fashion  to  success  or  failure. 

If  we  study  the  function  with  a  broad  outlook  we  find  a  valuable  ally  to 
the  health  and  well-being  of  the  parturient  mother  and  especially  so  to  her 
child  who  may  be  deprived  of  the  most  valuable  food  that  can  be  procured 
for  it. 

The  scarcity  of  literature  upon  the  subject — physiological,  anatomical, 
and  psychological,  is  apparent  and  thus  we  have  to  learn  by  our  own  ex- 
perience or  that  gained  by  others.  Research  has  offered  very  little  to  our 
knowledge.  True,  we  know  more  of  the  value  of  colostrum  to  the  new- 
born child  and  some  studies  have  been  made  upon  the  principles  of  inter- 
nal secretion  as  effecting  lactation.  But  whether  the  placenta  is  the  origi- 
nator or  the  recipient  of  the  hormone  or  whether  the  yellow  corpus  luteum 
in  the  ovary  is  the  sole  instigator  of  the  marvelous  change  in  the  raam- 
mory  glands  is  not  the  practical  question  at  present. 

The  question  is — how  can  we  best  advise  the  mother  and  through  her 
afford  the  child  the  best  food  and  the  best  way  to  obtain  it  that  we  know 
of.  Our  labors  should  begin  in  the  prenatal  period.  We  hear  a  good  deal 
about  prenatal  care,  about  preventive  medical  care  during  that  period  and 
its  results  have  been  remarkable. 

In  the  matter  of  nursing,  there  is  a  certain  amount  of  prenatal  care  that 
should  be  exercised.  Every  woman  whom  you  see  in  your  office  or  in  your 
clinic  or  in  your  daily  rounds  should  be  educated  as  to  the  value  of  nurs- 
ing. The  patient  is  coming  to  us  very  much  earlier  in  pregnancy  than  she 
ever  did.  Time  cannot  be  our  alibi.  The  want  of  knowledge  is  certainly 
not  the  reason.  We  neglect  to  even  consider  the  subject  and  we  may  be 
humiliated  to  have  the  patient  herself  broach  the  subject  or  ask  to  be  ex- 
amined and  tell  her  whether  she  can  nurse  her  baby  or  not.  The  woman 
who  is  willing  and  desirous  of  nursing  needs  little  moral  suasion,  yet  even 
she  may  be  helped.  The  one  who  is  unwilling  from  sheer  selfishness  to 
adapt  herself  to  the  needs  of  her  child  or  who  wishes  to  spend  her  time 
otherwise,  is  a  problem.  She  will  often  tax  our  patience  and  often  our 
temper,  but  nearly  always  can  be  dealt  with  with  patient  handling  and  ad- 
vice. 

The  mother  who  does  not  desire  to  nurse  her  baby  because  of  labor  out- 


18 

side  her  home,  must  be  helped  by  some  agency  so  that  she  may  see  her  way 
clear  to  give  her  child  at  least  a  few  months  of  nursing  care. 

Also  remember  there  is  another  small  class  who  are  virtually  afraid  of 
nursing — either  because  of  some  other  unfortunate  example,  a  hidden  fear 
of  transmitting  something  to  her  offspring,  she  knows  not  just  what;  an 
inferior  complex  suggesting  too  small  a  gland,  etc.,  or  a  natural  timidity. 

Any  observant  nurse  can  tell  us  that  the  physician  does  not  always  real- 
ize the  excitement  and  nervousness  that  comes  with  the  first  nursing 
periods  in  this  latter  class.  It  is  no  wonder  that  puerperal  manias  are  so 
often  directed  to  lactation.  Two  lines  of  endeavor  should  be  thought  of 
during  this  period: 

1.  Increasing  resistance  of  the  mother.  This  is  as  vital  to  the  nursing 
function  as  it  is  to  the  prevention  of  any  other  puerperal  infection.  The 
more  we  study  the  breast  infections,  the  more  we  come  to  believe  that  it  is 
as  much  dependent  upon  the  low  resistance  of  the  mother's  general  health 
as  it  is  to  any  specific  care  of  the  nipple.  Have  you  not  seen  a  mother  with 
sore,  bleeding  nipples,  lacerated  at  each  interval  of  nursing,  shielded, 
salved,  benzoinated  or  what  not  and  still  have  no  symptoms  of  infection; 
while  another  with  good,  intact  nipples  will  have  repeated  inflammation. 
The  former  lack  of  infection  is  due  to  that  inherent  resistance,  while  the 
latter  is  not  due  to  carelessness  of  the  nurse.  Anything  that  promotes 
good  general  health,  such  as  fresh  air,  sufficient  rest  and  good  food  and 
exercise,  should  be  our  advice.  Her  food  should  consist  of  whole  grains 
especially  fruits,  vegetables,  proteids,  milk  preparations,  meat  and  eggs, 
unless  contra-indicated  because  of  symptoms  of  toxemia,  with  a  minimum 
of  carbo-hydrates,  butter  fats  and  sugar.  Plenty  of  water  in  addition  to 
the  above  will  not  only  supply  the  necessary  ingredients  for  the  health  of 
the  mother,  but  also  the  necessary  nitrogen  and  phosphates  for  the  unborn 
child. 

2.  The  care  of  the  breast  itself  may  be  very  simple.  Fortunately  the 
dress  of  the  modern  young  woman  is  not  much  of  a  factor  and  is  surely 
not  a  cause  of  injury  to  the  breast  and  needs  no  prolonged  consideration, 
at  least  from  a  medical  standpoint.  Ordinary  cleanliness,  followed  fey  rub- 
bing the  breast  with  cold  water  or  salt  water  is  far  better  than  any  other 
hardening  process  which  is  sometimes  advocated. 

The  small  or  shortened  nipples  can  be  much  increased  in  size  by  massage 
as  regularly  as  the  bathing  and  should  be  resorted  to  as  one  factor  that 
will  save  much  trouble  later.  It  was  the  practice  in  some  primitive  people 
to  see  from  an  early  age  that  the  nipple  was  manipulated  in  such  a  manner 
that  it  was  universally  a  useful  member  of  society.  Inverted,  flattened  or 
unhealthy  nipples  are  practically  unknown  in  such  peoples. 

A  definite  flattening  or  inversion  is  difficult  and  attempts  to  eorrect  such 
deformities  must  be  made  during  the  prenatal  period  or  better  not  at  all. 
I  have  no  hesitancy  in  using  the  breast  pump  for  short  periods  regularly 
long  before  delivery,  and  many  times  it  is  helpful  in  correcting  this  con- 
dition. A  modification  of  the  ordinary  pump,  which  has  a  smaller  diam- 
eter in  the  cup,  is  more  desirable.  I  do  not  mean  that  we  should  be  too 
conservative  with  some  of  those  flattened  nipples  or  even  partial  inversion, 
particularly  if  it  is  possible  to  project  them  by  pressure  between  the 
thumb  and  finger.  It  has  been  very  gratifying  to  see  the  results  of  nurs- 
ing when  the  child  is  vigorous. 

After  birth  of  the  child,  treatment  and  care  should  be  immediately  in- 
stituted. I  have  been  impressed  with  the  technique  used  in  some  materni- 
ties immediately  after  delivery  while  the  patient  is  being  watched:  The 
nurse,  after  carefully  preparing  her  own  hands,  washes  the  breast  with 
soap  and  water  followed  by  40-50%  alcohol,  and  then  covers  the  nipples 
with  sterile  dressing  of  cerate  and  tissue  dressing,  not  to  be  disturbed  un- 
til the  first  nursing. 

With  the  advent  of  nursing,  there  are  many  and  varied  methods  of  care 
of  the  nipples.  Most  of  them  are  good  and  the  same  general  rules  should 
be  observed  in  all.     The  length  of  time  of  nursing  during  the  first  two 


19 


CHART  I 


Daij  of  Month 

26 

27 

26 

29; 

50 

31 

1 

2 

3 

4 

5    6    7    8    9  10 

Daij  of  Disease 

1 

2 

3 

4 

5 

6 

7 

a 

9 

10  11  12  13  14  15 

104 

103 

102 

101 

100 

99 

98 

97 

/ 

' 

i 

r 

\ 

/ 

N 

V 

r 

«/ 

'\ 

V 

\ 

i 

^ 

\~ 

> 

' 

Pulse 

76 

64 

64 

64 

64 

72 

72  7 

878 

80 

88 

64 

37 

8410 

0100 

108 

807 

2  72 

6468  72  64 

CHART  II 


DaijofMonlh 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

zz 

23 

Daij  of  Disease 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

104 

103 

102 

101 

100 

99 

98 

97 

1 

1 

a 

\ 

i 

/ 

f 

V 

\ 

v 

\ 

r 

s/ 

/ 

V 

Pulse 

38 

34 

K 

76 

72 

88 

% 

M 

84 

64 

76 

88 

80 

88 

H 

80 

68 

Ffi 

70 

72 

84 

72 

90 

% 

104 

132 

96 

88 

80 

20 
days  should  be  limited  to  five  or  six  minutes  and  the  child  given  the  re- 
quired liquid  immediately  afterward.  It  is  not  advisable  to  allow  the 
child  to  nurse  upon  one  nipple  20-25  minutes  from  a  breast  during  the 
congested  period  before  the  secretion  is  established  as  it  adds  to  our  diffi- 
culty by  injuring  the  nipple. 

Both  breasts  should  be  nursed  at  the  same  period  of  nursing  if  the  child 
is  vigorous  and  the  nipples  are  good.  A  comfortable  position  for  the 
mother  with  one  or  two  pillows  tucked  under  her  head  and  down  the 
shoulders  and  upper  back  is  essential. 

Visitors  at  this  time  are  a  distraction  and  should  be  discouraged. 

Treatment  or  care  of  the  nipples  should  be  done  after  nursing  rather 
than  before.  It  is  usually  sufficient  to  cleanse  the  base  of  the  breast  and 
the  nipple  with  soap  and  water  and  sterile  cotton,  normal  saline,  borax  so- 
lution, not  boric,  and  to  protect  the  nipple  until  the  next  interval.  If  a 
mild  antiseptic  is  thought  necessary,  use  alcohol  half  strength  or  chlori- 
nated water  1  per  cent. 

Infection  from  the  child's  mouth  may  be  possible  but  not  probable  and 
if  it  is  deemed  wise  to  use  anything  in  the  cavity,  a  solution  of  borax,  or 
better  still  a  solution  of  glycerine  with  20-25%  boron  is  sufficient.  If 
the  nipples  are  still  sore  and  cracked,  I  am  opposed  to  any  application  that 
tends  to  harden  the  skin,  as  this  predisposes  to  deepen  the  cracks  as  the 
child  nurses.  A  sterilized  emollient  protective  application  after  the  nurs- 
ing and  which  only  needs  to  be  wiped  off  with  the  removal  of  the  gauze  or 
cotton  before  the  next  nursing,  gives  greater  relief  and  cure.  More  severe 
cases  where  prenatal  treatment  has  not  availed,  require  intervals  of  rest 
from  nursing  or  it  may  be  necessary  to  discontinue  the 'nursing. 

Weak,  frail,  premature  babies  or  those  following  difficult  labors  should 
not  be  disturbed  unduly.  These  should  be  treated  differently  unless  nurs- 
ing is  unusually  easy.  Under  no  condition  should  the  strength  of  the  child 
be  taxed.  The  food  should  be  procured  by  use  of  the  pump  and  given  in 
sufficient  quantities  by  easy  bottling  or  use  of  the  nasal  tube.  We  have 
been  able  to  continue  this  process  for  weeks  until  the  child  was  able  to 
nurse  in  the  natural  way. 

A  statement  was  made  by  Famulener  ten  years  ago  that  it  is  most 
highly  desirable  that  every  new  born  infant  should  receive  its  full  ration 
of  human  colostrum.  Force  has  been  added  to  this  statement  by  the  find- 
ings of  numerous  workers  reviewed  in  an  article  published  by  Lewis  and 
Wells  in  the  Journal  of  the  American  Medical  Association  of  March  25, 
1922.  Their  studies  show  that  the  blood  of  new  born  infants  contains  lit- 
tle or  none  of  the  serum  protein  known  as  euglobulin.  This  seems  to  be 
supplied  chiefly  by  the  colostrum  which  contains  a  large  amount  of  this 
protein  secreted  directly  from  the  blood.  Evidently  the  colostrum  fur- 
nishes to  the  new  born  mammal  protective  anti-bodies  which  may  add 
much  to  its  capactiy  to  resist  infection  in  early  life.  It  is  not  probable 
that  there  is  any  equivalent  substitute  for  human  colostrum  for  the  new 
born  infant. 

In  closing,  may  I  add  a  few  words  in  regard  to  mastitis  or  inflammation 
of  the  breast  ?  The  causes  of  breast  infection  may  be  summed  up  as  germ 
contamination  plus  lowered  resistance.  Breasts  in  which  nursing  is  sus- 
pended or  not  attempted,  rarely  show  mastitis.  It  is  probable  that  manip- 
ulation of  distended  breasts  may  diminish  the  natural  resistance  of  the 
tissues  and  increase  the  liability  to  infection. 

Damage  to  nipples,  contamination  from  physician,  nurse,  mother  or 
child  and  the  prevalence  of  intercurrent  infections  may  be  factors.  The 
incidence  is  commonly  between  the  7-12th  day,  but  may  be  later.  Usually 
rapid  resolution  without  abscess  formation  with  continuance  of  nursing  is 
the  result.  In  85  per  cent  of  these  cases,  the  temperature  chart  will  diag- 
nose the  condition  and  visualize  its  own  record.  (Charts  I  and  II.)  The 
letter  "M"  denoting  mastitis  will  nearly  always  be  seen  near  the  top  of 
the  temperature  curve. 


21 
CHART  III 


DaHof  Month  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30 

MDis««,  1    2    3    4   5    6    7    6    9   10  11  12  13  14  15  16 

irM 

1U4 

1U£                                                     I  ijn 

mi                                -         L    _!__  ' 

I        [ 
mn                                       -J         L         -*. 

iuu                                                  \         A 

QQ                                                           I                X        /  ' 

9U                                                                  "       4|                                                   "^ 

Q7                                                             - 

y  / 

PuUe 

CHART  IV 

Da4of Monfh  14  15  16  17  16  19  20  21  22  23  24  Zb  26  27  Zb  Z9 

D,HofDi,«»e  1    2    3    4   5    6    7    8    9  10  11  12  13  14  15  16 

AHA 

1U4 

1  n  ?                                                                     -a-    t* 

.                                            Aii 

inn                   '5                              /     Ti 

A       Jl                                                               T                5 

fov    tys/*sJ    ">    7        1/ 

Qf7           / 

y  / 

Pu  Ise           76  88  96  76  84  78  76  96  96  76  72  72  92  64  80  80  76  80  74  70  84  74  80  96  90 100  ICO  88  78  70  80 

If  the  resolution  is  delayed  or  slowed  or  repeated  again  later,  they  are 
very  suspicious  of  pus  formation  or  at  least  an  extension  to  other  seg- 
ments of  the  breast.  (Charts  III  and  IV.)  In  these  cases,  the  condition 
of  mother  nipples  and  breasts  must  be  carefully  watched  and  it  may  be 


22 

necessary  to  discontinue  nursing  entirely  as  resolution  takes  place,  so  as 
to  prevent  abscess  formation  later. 

Development  in  the  opposite  breast  soon  after  usually  means  that  you 
should  consider  discontinuance  of  nursing.    (Charts  III  and  V.) 

CHART  V 


Daij  of  Month 

IE 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

Daij  of  Diseass 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

104 

103 

102 

101 

100 

99 

98 

97 

1  i 

A 

\ 

■ 

{ 

a 

, 

f 

Pulse 

Abscess  formation,  if  inevitable,  should  be  localized,  opened  and  drained 
and  nursing  discontinued  permanently.  Small  abscess  formations  near 
the  surface,  may  be  treated  without  disturbing  nursing.  Treatment  of 
the  simpler  types  is  usually  complete  rest,  support  of  the  breasts,  limita- 
tion of  liquids  and  the  use  of  the  ice-bag.  In  the  simpler  types  with  no 
symptoms  of  pus  formation,  some  prefer  hot  applications  and  gentle  mas- 
sage. 

CERTAIN    COMMUNICABLE    DISEASES;    THEIR    RELATION    TO 
THE  PROSPECTIVE  MOTHER,  THE  INFANT  AND  THE  PRE- 
SCHOOL CHILD 

Clarence  L.  Scam  man,  M.D. 

Director,  Division  of  Communicable  Diseases 
Massachusetts  Department  of  Public  Health 

The  Prospective  Mother 

While  pregnancy  is  said  to  be  a  physiological  process,  any  additional 
physical  strain  such  as  an  acute  infectious  disease  may  lead  to  a  serious 
outcome.  The  less  serious  consequence  may  be  the  premature  birth  of  the 
child,  and  the  most  serious  may  be  the  death  of  the  mother  and  the  child. 
Smallpox,  scarlet  fever,  diphtheria,  septic  sore  throat,  typhoid  fever, 
measles,  influenza  and  pneumonia  in  this  climate  sometimes  complicate 
pregnancy.  While  all  of  these  are  serious  complications  for  the  prospec- 
tive mother,  influenza,  pneumonia  and  typhoid  fever  and  the  hemorrhagic 
type  of  smallpox,  are  exceedingly  dangerous  complications.  Neither  scar- 
let fever  nor  measles  is  apparently  a  frequent  complication  of  pregnancy, 
but  both  of  them  may  cause  premature  delivery  and  are  more  serious  com- 
plications of  the  immediate  period  postpartum.    This  is  particularly  true 


23 

of  scarlet  fever.  In  smallpox  certainly,  and  probably  in  measles  and  ty- 
phoid fever,  intra-uterine  transmission  of  the  disease  to  the  baby  is  pos- 
sible. From  the  evidence  given  above,  protection  for  the  prospective 
mother  against  exposure  to  any  of  the  diseases  mentioned  cannot  be  over 
emphasized. 

The  Infant 

Most  infants,  during  their  first  six  months  of  life,  have  some  immunity 
to  most  communicable  diseases.  This  immunity  may  depend  upon  the  im- 
munity of  the  mother  to  the  disease  in  question ;  but  there  are  other  fac- 
tors concerned  in  this  problem,  many  of  which  are  not  known.  The  mere 
fact  that  the  mother  is  susceptible  to  certain  communicable  diseases  does 
not  mean  that  the  baby  in  the  first  six  months  is  equally  susceptible.  This 
is  definitely  known  to  be  so  in  the  disease,  diphtheria,  where  approxi- 
mately eighty-five  per  cent  of  infants  at  the  age  of  six  months  show  a 
natural  specific  immunity  to  the  disease.  This  specific  immunity  is  in 
most  of  the  diseases  mentioned  rapidly  lost  during  the  second  six  months 
of  life.  For  this  reason  it  is  important  to  protect  children  early  in  life  by 
artificial  means  where  the  protective  measure  has  been  shown  to  be  of  dis- 
tinct value,  as  is  the  case  in  smallpox  and  diphtheria. 

The  best  time  to  vaccinate  a  child  against  smallpox  is  when  it  is  about 
two  months  old.  The  child  lies  quiet  in  his  bed  and  cannot  injure  his  arm 
in  play.  The  arm  will  not  be  so  sore  at  this  age.  The  immunity  of  the 
child  should  be  retested  when  he  enters  school.  Though  few  people  realize 
it,  before  the  days  of  vaccination  smallpox  was  as  much  a  disease  of  child- 
hood as  is  measles  today.  Modern  methods  of  vaccination  leave  scars  so 
small  and  superficial  that  they  are  rarely  unsightly.  One  of  the  most  im- 
portant advantages  of  the  modern  vaccination  method  is  its  painlessness. 

Every  infant  should  be  protected  against  diphtheria  before  it  reaches 
its  first  birthday.  The  best  time  to  have  a  child  immunized  with  toxin- 
antitoxin  is  shortly  after  it  is  six  months  old.  All  children  should  be  given 
the  Schick  test  six  months  after  receiving  toxin-antitoxin. 

The  Pre-School  Child 

The  child  from  two  to  six  is  in  the  truest  sense  of  the  word  a  "run- 
about" child.  For  this  reason  his  contacts  with  people  increase  literally 
by  leaps  and  bounds,  and  it  follows  then  that  his  exposure  to  communi- 
cable disease  is  increased  also.  It  is  important,  therefore,  to  protect  chil- 
dren against  communicable  disease  as  early  in  their  lives  as  is  practicable. 
The  value  of  such  protection  against  smallpox  and  diphtheria  has  already 
been  mentioned.  Children  who  have  not  been  protected  during  their  first 
year  of  life  by  vaccination  against  smallpox  or  immunization  against  diph- 
theria should  certainly  be  protected  early  in  their  second  year  of  life. 

The  use  of  Dick  toxin  for  the  protection  of  children  against  scarlet 
fever*  has  not  yet  been  advocated  on  a  popular  basis  as  has  protection 
against  smallpox  and  diphtheria*  because  of  the  possibility  of  disappoint- 
ing results.  Proper  doses  of  toxin,  properly  spaced,  will  undoubtedly  give 
a  certain  amount  of  immunity  to  scarlet  fever. 

In  the  age  group  2-6  measles  is  a  serious  disease.  Especially  is  this 
true  of  children  contracting  the  disease  under  the  age  of  three  or  four. 
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  dis- 
ease. It  is  given  during  the  seven  days  after  the  first  exposure.  If  pro- 
tection is  complete,  immunity  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.  Fur- 
thermore, these  mild  cases  acquire  a  lasting  immunity.  A  serious  draw- 
back to  this  method  is  the  difficulty  of  getting  serum. 


*  The  curative  value  of  both  diphtheria  and  scarlet  fever  antitoxin  cannot  be  over-emphasized. 


24 

Whooping  cough  at  any  age  is  an  unpleasant  disease.  But  it  is  decid- 
edly serious  under  the  age  of  three  on  account  of  the  possible  complicating 
pneumonia.  Unfortunately,  we  have  no  method  of  control  which  is  effica- 
cious in  the  prevention  of  this  disease.  There  is  little  evidence  that  whoop- 
ing cough  vaccine,  used  either  as  a  preventive  or  curative  measure,  is 
effective. 

Chicken  pox,  German  measles  and  mumps  are  with  us  always.  There 
is  no  specific  protective  measure  which  can  be  used  against  them.  Fortu- 
nately, under  the  age  of  adolescence  there  is  almost  never  a  complication 
and  seldom  a  fatality. 

Common  colds  are  undoubtedly  contagious  and  should  be  so  considered. 
Parents  and  others  should  refrain  from  intimate  contacts  with  children 
when  suffering  from  colds.  While  their  control  is  not  yet — their  spread 
within  the  family  may  be  at  least  decreased  when  parents  and  fond  rela- 
tives realize  that  an  infected  person  by  means  of  his  discharges  may 
spread  disease  to  uninfected  persons. 

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. 

Never  expose  children  intentionally  to  "catching"  diseases.  Be  espe- 
cially careful  of  those  under  five.  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. 

DENTAL  HYGIENE 

E.  Melville  Quinby,  M.R.C.S.,  L.R.C.P.,  M.D. 

Boston,  Massachusetts 

Introduction 

(A)  To  use  the  language  of  fairy  stories:  "Once  upon  a  time"  there 
was  a  mill  of  imposing  proportions  which  was  known  to  the  inhabitants 
of  that  region  as  the  Medosan.  In  this  edifice  were  many  rooms,  some  con- 
taining intricate  machinery  intended  for  working  up  raw  material,  others 
filled  with  delicate  apparatus  designed  for  subtle  chemical  activities. 

For  the  perfect  functioning  of  the  various  machines  absolute  cleanli- 
ness was  of  paramount  necessity;  but  lo  and  behold!  the  manager  of  the 
mill  permitted  the  vestibule  thereof  to  accumulate  all  kinds  of  rubbish. 
Consequently  when  the  doors  of  the  various  chambers  were  opened,  there 
ensued  an  inrush  of  wind  which  scattered  particles  of  filth  helter-skelter, 
and  clogged  the  delicate  machinery. 

Owing  to  interference  with  function  all  kinds  of  troubles  were  the  re- 
sult. 

(B)  A  certain  railroad  company  known  as  "the  Dentosan"  about  to 
open  up  a  new  line  for  passenger  traffic,  to  connect  with  two  larger  sys- 
tems of  operation,  decided  that  strict  economy  was  necessary.  Conse- 
quently they  procured  a  ramshackle  engine  with  frame  badly  built,  wheels 
and  gears  out  of  alignment  and  suffering  for  want  of  grease,  oil,  and  pol- 
ish.   What  to  do?    Why — patch  it  up  of  course! 

So  after  much  repairing  the  old  engine  was  attached  to  the  cars,  put  in 
charge  of  an  engineer,  and  sent  on  its  way  to  carry  passengers  presumably 
in  safety. 

N.B.    Remember  "Old  Peppersass"  last  year  on  Mt.  Washington. 


Dental  Hygiene 

Any  attempt  to  upset  standardized  opinions  of  a  group  of  human  beings, 
is  recognized  by  philosophers  and  teachers  as  being  a  most  difficult  thing 
to  do — for  various  reasons,  not  to  be  dwelt  upon  in  this  article.    As  Ed- 


25 

gar  Swift  says :  "The  capacity  of  the  human  mind  for  withstanding  useful 
information  cannot  be  over  estimated."  As  an  apt  illustration  of  this  well 
known  fact  one  might  call  to  mind  the  difficulty  that  Copernicus  had  in  the 
fifteenth  century  to  make  people  believe  that  the  earth  is  round  and  moves, 
instead  of  being  flat  and  stationary.  According  to  the  mob  Copernicus 
was  a  crank:  now  the  crank  is  he  who  says  this  planet  is  flat! 

When  the  practice  of  dentistry  was  officially  recognized  as  a  profession 
in  1839,  after  a  vain  attempt  for  adoption  by  the  medical  profession,  it 
was  perfectly  natural  that  the  most  obvious  need  of  the  public,  from  a  den- 
tal point  of  view,  should  be  studied  and  treated.  Odontoclasia  or  caries 
of  teeth  and  its  sequelae  seemed  to  demand  the  most  attention ;  and  efforts 
to  repair  devastated  areas  of  teeth  became  the  most  absorbing  task  of  the 
dentist.  The  acquisition  of  more  and  more  notable  mechanical  skill  on 
such  lines  has  characterized  the  work  of  the  dental  profession  for  the  past 
90  years  and  far  be  it  from  any  of  us  to  disparage  such  efforts. 

But  now  in  the  year  of  grace  1930  we  are  invited  to  discuss  Dental  Hy- 
giene— healthy  or  wholesome  teeth,  in  other  words — Dens  sana  in  corpore 
sano.  How  is  this  very  unusual  feat  to  be  accomplished?  Up  to  date  for 
the  aforesaid  90  years  we  have  focussed  mainly  upon  mechanical  skills  in 
repairing  diseased  teeth  or  providing  substitutes  for  lost  dental  units. 
With  what  result?  Dr.  Puterbaugh  of  Chicago  says  it  would  take  the 
20,000  dentists  of  U.  S.  A.  112  years  to  carry  out  repair  work  needed  at 
this  minute.  This  statement  is  not  exactly  encouraging  to  our  methods  of 
practice  from  the  point  of  view  of  prevention.  Furthermore  we  under- 
stand that  about  2,000  molars  and  bicuspids  are  erupted  every  minute  of 
the  24  hours!    (Hyatt  and  Dublin.) 

Destructive  criticism  of  any  method  is  worse  than  useless  unless  one  is 
prepared  to  suggest  a  remedy;  and  in  this  paper  is  presented  a  scheme, 
which  the  author  thereof  feels  confident  would  prove  a  more  satisfactory 
basis  for  measures  which,  if  carried  out  completely,  might  well  be  called 
Preventive,  and  the  end  results  would  include  all  the  tissues  of  the  mouth, 
and  secondarily  the  whole  system.  Our  slogan  is  "Good  Health,  Good 
Teeth;  Good  Teeth,  Good  Health" — a  health  cycle  in  other  words. 

To  fulfill  such  a  laudable  aspiration  requires  that  we  are  willing  to  have 
open  minds,  and  be  prepared  to  change  our  point  of  view  on  the  subject  of 
dental  education  and  ideals.  So  the  first  thought  is,  that  we  speak  in 
terms  of  Dental  Health  Service,  leaving  out  for  the  time  being,  the  term 
Dentistry,  which  being  interpreted,  signifies  attention  to  teeth  only — quite 
correctly  too,  in  so  far  as  it  describes  the  main  work  of  our  dental  fore- 
fathers. But  times  are  changed;  and  it  is  incumbent  upon  us  to  be  at  least 
up-to-date,  or  in  the  van  of  progress. 

With  Dental  Health  Service  then  as  our  new  ideal,  the  next  thought  in- 
vited is  to  accept  the  analogy  between  the  dental  apparatus,  including  sup- 
porting structures,  and  any  ordinary  machine,  such  as  a  motor  car  or  a 
steamship.  Any  machine  requires  for  stability,  smooth  working  and  effi- 
ciency (1)  that  the  "frame  work  be  built  solidly;  (2)  that  the  mechanical 
units  are  in  alignment;  (3)  that  a  system  of  cleaning  and  lubrication  be 
carried  out;  (4)  that  occasional  repairs  be  made." 

N.B.  This  idea  is  utilized  in  other  and  similar  ways  as  herein  in- 
stanced : — 

H.  K.  Box  and  G.  R.  Anderson  (Physics) 

Today  our  interest  is  being  centred  on  the  functions  of  the  teeth,  and 
especially  on  the  functions  of  their  supporting  tissues ;  .  .  and  also  that 
departure  from  normal  function  renders  possible  the  initiation  of  the 
early  lesions  of  periodontal  disease.  Correlation — structure  and,  function. 
In  order  that  any  machine  may  properly  perform  its  normal  functions,  it 
must  be  suitably  designed;  it  must  possess  sufficient  strength  in  its  vari- 
ous parts  to  withstand  stresses  put  upon  it  with  a  margin  for  safety ;  the 
various  moving  parts  must  fit  each  other  accurately,  and  the  power  must 
be  sufficient  for  the  work,  and  applied  efficiently. 


26 

These  conditions  being  fulfilled,  then  with  proper  care  the  machine  may 
be  expected  to  give  satisfactory  service. 

The  analogy  of  the  machine  is  utilized  by  Sir  Robert  Armstrong- Jones 
of  London  to  illustrate  the  working  of  the  mind: — "The  mind  has  been 
described  very  properly  as  a  most  complex  piece  of  machinery,  and  not 
inaptly  compared  to  a  motor  car  in  its  mechanism,  for  the  motor  car  de- 
pends normally  for  efficiency  upon  the 

f  co-ordination  f  water  circulation 

proper  -J  correlation  of  the  \  lubrication 

[  association  [  electrical  fittings 

all  associated  with  the  steering  wheel — the  mind." 

The  first  factor  is  building  for  strength,  and  in  the  case  of  the  dental 
machine,  measures  must  be  taken  in  the  prenatal  stage  of  existence,  to 
promote  strong  and  sturdy  development  of  the  skeleton  bones  and  teeth. 

In  order  to  attain  such  results  the  proper  nutrition  and  general  health 
of  the  prospective  mother  must  be  insisted  upon ;  and  the  said  prospective 
mother  must  be  made  to  understand  that  the  oncoming  child  is  dependent 
upon  her  for  its  physical  and  mental  development.  Digestion  should  meet 
with  especial  attention;  the  ancient  myth  with  regard  to  inevitable  loss 
of  teeth  as  a  result  of  pregnancy  must  be  abolished;  and  fears  in  connec- 
tion with  dental  procedures  at  that  period  should  be  relegated  to  the  scrap 
heap  of  the  mind.  Regular  visits  to  the  dentist  could  prevent  toothache, 
caries,  abscesses  and  pyorrhea,  and  other  lesions  of  the  periodontium. 
Careful  and  scientific  diagnosis  and  treatment  by  a  dental  physician  will 
go  a  long  way  towards  preventing  focal  infection  and  the  various  sequelae 
incident  upon  that  lesion. 

While  all  the  local  and  general  health  measures  should  be  cared  for  dur- 
ing pregnancy,  the  factor  of  nutrition  must  be  doubly  stressed,  for  the 
reason  that  the  prospective  mother  is  obliged  to  nourish  two  human 
beings — not  one.  Here  is  a  simple  definition  of  nutrition  (Logan  Glen- 
dening)  :  "After  the  foodstuffs  have  been  converted  by  the  digestive 
juices,  after  they  have  been  absorbed  by  the  blood  or  lymph;  after  the 
oxygen  from  the  air  has  likewise  been  absorbed  into  the  blood ;  after  the 
blood  driven  by  the  heart  has  been  carried  in  the  arteries  to  all  parts  of 
the  body,  these  materials  are  utilized  for  the  production  of  energy,  for 
production  of  heat,  and  for  replacement  of  broken  down  cells — this  crucial 
process  is  called  nutrition." 

As  results  of  malnutrition  of  the  mother  we  may  get : — 

(a)  Actual  loss  of  tooth  germ  in  child's  jaw; 

(b)  Improper  development  of  tooth  substance; 

(c)  Malocclusion  in  first  dentition. 

To  prevent  this  malnutrition  a  mixed  diet  for  the  mother  is  considered 
to  be  the  best.  But  whatever  diet  is  prescribed,  it  is  absolutely  essential 
that  thorough  mastication  of  foodstuffs  takes  place — for  good  health  and 
good  teeth.  Note — (1)  Mastication  especially  of  starchy  foods  for  chew- 
ing liquefies  starch  and  helps  to  convert  into  sugar;  (2)  result  is  that  the 
mixture  with  saliva  renders  food  more  easily  worked  upon  by  gastric  and 
intestinal  juices. 

For  more  complete  directions  as  to  the  right  and  proper  kinds  of  diet 
under  various  circumstances  of  age  and  environment  reference  can  be 
made  to  the  literature  circulated  by  the  State  Department  of  Public 
Health,  State  House,  Boston,  and  to  the  bulletins  issued  by  the  Academy 
of  Periodontology  to  be  obtained  from  the  Bureau  of  Dental  Health,  Amer- 
ican Dental  Association,  52  East  Washington  Square,  Chicago,  Illinois. 

It  has  been  said  with  truth  that  "the  mother  is  the  factor  of  safety  in 
the  nourishment  of  the  young."  Among  the  important  needs  in  diet  of 
the  prospective  mother  the  element  of  calcium  or  lime  must  receive  careful 
attention — not  only  as  to  the  amount  taken,  but  also  as  to  the  ratio  of 
assimilation.  In  other  words  it  is  possible  to  take  in  an  excess  of  calcium, 
but  absorb  very  little.    To  correct  the  process  of  absorption  and  assimila- 


27 
tion  the  vitamin  C  is  used.  Howe  has  shown  clearly  that  a  lower  jaw  of 
a  guinea  pig  riddled  with  decalcification  under  scorbutic  diet,  can  be  re- 
generated through  the  use  of  orange  juice.  It  should  be  understood  that 
an  excess  of  calcium  does  little  harm  except  perhaps  in  some  kidney  affec- 
tions— it  is  merely  excreted.  But  a  deficiency  of  calcium  does  harm — be- 
fore birth  the  embryo  demands  its  proper  share  of  lime,  and  failing  the 
legitimate  source  of  supply  in  the  blood  of  the  properly  nourished  mother, 
draws  upon  the  teeth  and  skeleton  of  the  parent.  In  growing  children  de- 
ficiency of  lime  also  helps  to  bring  about  unsound  teeth  and  supporting 
tissues,  and  also  various  neuroses. 

Calcium  controls  the  balance  between  nerve  and  muscle  action  and  is  a 
regulator  of  almost  any  disturbance  in  balance  of  the  inorganic  constitu- 
ents of  the  body  and  it  is  the  element  most  constantly  lacking  in  food. 
"The  student  should  know  calcium-containing  foods;  he  should  under- 
stand the  way  in  which  calcium  is  or  is  not  properly  utilized  by  the  sys- 
tem; and  the  place  of  absorption  and  excretion"  (Howe).  The  effect  of 
endocrine  disturbance  upon  calcium  metabolism,  must  be  studied.  For 
sound  teeth,  then,  calcium-containing  foods  and  the  agents  necessary  for 
fixation — fats  and  vitamin  C — are  needed. 

We  must  always  remember  that  the  pregnant  mother  needs  more  cal- 
cium and  a  growing  child  also  needs  more. 

So  far  in  the  development  of  the  ideal  dental  machine  the  necessity  of 
the  right  kind  of  nutrition  for  the  mother  has  been  stressed;  but  after 
birth  of  the  child  our  efforts  must  not  relax. 

But  now  instead  of  focussing  our  attention  on  the  diet  of  the  mother, 
we  must  consider  both  mother  and  child.  In  the  case  of  the  former,  a 
similar  diet  and  hygiene  should  be  prescribed  as  in  the  prenatal  period, 
but  more  especially  that  the  right  kind  of  milk  may  be  provided  for  the 
infant — as  every  child  should  be  breast  fed  if  humanly  possible. 

The  baby  should  be  breast  fed  to  about  the  ninth  month.  Orange  juice 
or  tomato  juice  may  be  added  in  small  amounts  after  the  fourth  month; 
about  the  eighth  to  the  twelfth  month  solids  such  as  well  cooked  cereal, 
toast  and  cooked  fruit,  at  the  discretion  of  the  attendant  pediatrician,  may 
be  considered.  The  use  of  orange  juice  is  at  least  twofold,  first  to  pro- 
vide vitamin  C  and  after  tooth  eruption  to  help  in  cleansing. 

Breast  feeding  not  only  provides  the  right  kind  of  nutrition  for  human 
babies  but,  by  calling  into  use  muscular  exercise,  helps  in  development  of 
dental  arches. 

Gradually  such  food  as  spinach,  carrots,  cauliflower,  string  beans  well 
strained,  may  be  added;  also  cooked  apples,  prunes,  pears  and  peaches. 
But  in  every  case  the  advice  of  the  pediatrician  must  be  taken  as  diet  is 
an  individual  problem.  Some  think  that  eggs  should  not  be  taken  before 
the  second  year,  but  whatever  diet  is  prescribed  there  must  be  a  wary  eye 
kept  on  the  calcium  element  as  to  amount  taken  and  the  assimilation 
thereof. 

As  the  child  grows  on  in  the  pre-school  age,  such  measures  must  be 
taken  that  the  dental  machine  may  be  developed  to  the  optimal  not  only 
as  to  the  teeth  themselves,  but  also  as  to  the  supporting  tissues.  No 
house  can  be  stable,  however  well  built,  without  solid  foundations.  There 
is  no  adequate  reason  why,  if  proper  measures  are  taken,  that  at  least  50 
per  cent  of  the  incoming  dental  machines  cannot  be  more  or  less  perfect  in 
our  opinion!  It  is  at  least  worth  while  to  make  the  attempt — and  not 
wait  until  the  machine  is  crippled  for  life. 

SUMMARY 

1.  Dental  hygiene  all  in  all  is  a  health  measure. 

2.  All  the  tissues  in  the  oral  cavity,  as  well  as  of  the  system  generally 
must  enter  into  our  calculations. 

3.  The  reasonable  analogy  or  resemblance  of  the  teeth,  its  supporting 
structures,  and  functions  to  any  kind  of  machine. 


28 

4.  The  necessity  for  carrying  out  measures  dating  from  the  earliest 
period  of  existence,  in  order  that  the  dental  machine  may  be  strongly 
built  up — and  especially  so  in  the  prenatal  and  pre-school  stages. 

5.  Note — The  adoption  of  the  philosophy  of  dental  health  service  as  out- 
lined in  charts  "What  can  be  done  for  the  oral  machine"  would  help 
the  practitioner  in  forming  a  real  diagnosis,  prognosis  and  outline  of 
treatment  in  each  case  and  minimize  the  danger  of  missing  some  im- 
portant if  subtle  factor  in  etiology. 

6.  The  prevailing  policy  in  waiting  until  the  dental  machine  is  broken 
down,  and  then  depending  on  repair  or  patching  up  for  the  rest  of  the 
patient's  life,  must  sooner  or  later  give  way  to  a  more  sane  procedure. 
Note — A  set  of  teeth  may  be  ruined  at  birth ! 

7.  The  medical  profession  is  earnestly  recommended  to  extend  their  edu- 
cational curriculum  to  include,  at  least,  a  nodding  acquaintance  with 
oral  conditions  in  health  and  disease. 

8.  There  is  an  enormous  field  for  education  of  the  multitude  in  the  ele- 
ments of  dental  health  service  and  herein  the  adequately  trained  dental 
hygienist  and  medical  nurse  could  do  yeoman  service. 

9.  First — last — and  all  the  time  the  ideals  of  the  dental  profession  must 
be  based  upon  more  solid  and  inclusive  foundations.  The  engine  or 
the  motor  car  or  the  dental  machine  cannot  be  made  safe  by  repair  of 
a  broken  down  mechanism. 

STANDARDS  OF  PRESCHOOL  HYGIENE 

Susan  M.  Coffin,  M.D. 

Child  Welfare  Physician 
Massachusetts  Department  of  Public  Health 

Preventive  work  has  stepped  back  steadily,  year  by  year,  to  earlier  age 
groups.  Modern  infant  hygiene  has  lowered  infant  mortality  to  no  small 
degree,  barring  the  first  month  period  of  infancy  which  is  still  the  strong- 
hold of  fatalities.  Fifty-four  per  cent  of  our  infant  deaths  occur  in  that 
hazardous  first  month,  a  constant  reminder  of  our  task  ahead.  Also,  ade- 
quate prenatal  care  and  delivery  service  where  available,  have  assisted 
greatly  in  bringing  down  maternal  mortality  to  its  present  rate,  but  here 
again  we  meet  with  obstinate  figures  which  refuse  to  drop  beyond  a  cer- 
tain point  and  again  it  is  clearly  indicated  that  new  and  strenuous  effort 
is  needed. 

School  and  adult  hygiene,  when  it  includes  regular  and  thorough  yearly 
health  examination  with  correction  of  remediable  defects,  has  raised  our 
standards  of  health  noticeably.  For  example,  no  one  at  any  age,  who 
shows  poor  nutrition  is  considered  "healthy"  nowadays,  no  matter  how 
"well"  he  may  claim  to  be. 

These  are  matters  of  greatest  interest  to  all  of  us  but  we  have  still 
another  life  period,  that  of  the  pre-school  child  (1  to  6  years),  which  needs 
more  of  our  attention  than  it  gets  even  now.  During  this  period  of  child- 
hood, often  termed  the  "neglected  age"  by  our  pediatricians,  the  child  be- 
gins to  live  a  more  and  more  exposed  life.  Infections  and  accidents  pile 
up  in  pre-school  statistics.  In  1928  in  Massachusetts,  698  children  under 
two  years  had  scarlet  fever  and  1,562  between  the  ages  of  two  and  four 
years.  Accidents  increase  at  the  age  of  three  when  the  child  becomes 
especially  active,  and  normal  curiosity  is  great.  This  pre-school  period, 
though  equal  in  importance  to  infancy,  is  often  regarded  of  less  signifi- 
cance by  both  parents  and  physicians. 

"He's  a  big  boy  now,  I  don't  worry  much  about  him,"  says  the  busy 
mother  of  her  one  to  six  year  old.  "He  will  be  all  right,  let  him  outgrow 
it,"  says  the  busy  doctor  all  too  often  when  asked  for  advice  about  some 
"minor"  defect  of  the  pre-school  youngster  by  anxious  parents.  "First 
teeth  go  anyway,  no  use  treating  them,"  says  the  busy  dentist  who  has  not 
yet  realized  the  importance  of  nutrition  and  dental  care  in  the  pre-school 


29 

years.  Generally  there  is  a  public  health  nurse  in  the  background  who  has 
urged  all  this  consultation  and  who  retires,  silenced  but  unconvinced,  when 
parents  announce  that  "the  doctor  and  dentist  said  Johnny  would  be  all 
right,  he  doesn't  need  anything  done." 

Adequate  pre-school  hygiene  standards  cannot  be  maintained  in  the 
home  without  the  cooperation  of  physicians,  nurses  and  dentists  who  are 
the  strongest  teaching  force  in  hygiene  at  the  present  time.  One  con- 
vincing personal  contact  with  parents  along  these  lines  is  worth  a  half 
dozen  radio  talks  or  magazine  articles,  valuable  as  they  may  be. 

Proper  feeding,  good  habit  training,  prompt  attention  to  defects,  these 
are  the  essentials  of  child  hygiene  in  the  home,  that  greatest  of  teaching 
and  training  centres. 

Physicians,  entering  as  they  do  so  closely  into  the  life  of  the  family, 
especially  where  there  are  young  children,  need  to  keep  constantly  in  mind 
the  necessity  of  urging  good  pre-school  hygiene.  Here  is  a  big  group  of 
children  with  whom  the  doctor  comes  in  contact.  "The  office  of  every 
physician,"  as  Dr.  Wilinsky  once  put  it,  "should  be  a  little  health  unit." 
Here  the  family  comes  for  advice  for  its  members  of  all  ages.  It  is  quite 
true  that  when  prenatal  care  has  been  faithfully  carried  out,  breast  feed- 
ing successfully  accomplished  and  the  baby  graduated  from  the  "infant 
class"  to  the  "run-abouts,"  the  best  of  family  doctors,  as  well  as  the  par- 
ent, tends  to  relax  his  vigilance  and  does  not  always  keep  his  end  up  in 
emphasizing  the  importance  of  proper  hygiene  at  this  period.  Regular 
physical  examination,  yearly  at  least,  is  still  very  necessary.  Diagnosis 
of  defects  when  the  parent  brings  the  child  to  the  doctor  for  examination 
must  be  followed  by  patient  discussion,  if  need  be,  of  the  disastrous  re- 
sults of  uncorrected  defects.  Ways  and  means  of  accomplishing  correc- 
tions must  also  be  suggested.  (It  is  at  this  point  that  the  community 
nursing  service  is  especially  valuable  as  has  been  well  demonstrated  re- 
cently in  our  Summer  Round-Up  programs.)  As  fathers  and  mothers 
must  teach  the  young  child  how  to  care  for  his  body  and  mind,  so  physi- 
cian, dentist  and  nurse  need  to  teach  parents  how  essential  cooperation  is 
in  caring  for  the  child's  health. 

Our  ideal  today  is  not  just  to  be  "healthy"  but  to  reach  the  maximum 
health  possible  for  each  individual.  "More  and  better  health,"  is  the  mod- 
ern idea.  Diagnosis  of  defects,  whether  physical  or  habit  defects,  amounts 
to  little  unless  correction  and  training  follow. 

What  is  the  community's  part  in  pre-school  hygiene?  First  of  all,  to 
provide  good  nursing  service.  Ideal  nursing  service  starts  with  adequate 
prenatal  and  delivery  service,  extends  throughout  infancy  and  the  pre- 
school and  school  years.  The  nurse,  even  more  than  the  physician,  has 
opportunity  to  teach  parents  the  needs  of  children  during  the  pre-school 
years.  Her  training  should  include  thorough  instruction  in  the  standards 
of  prenatal,  infant,  pre-school  and  school  hygiene  and  her  growing  experi- 
ence will  add  increasing  value  to  her  teaching. 

The  community  should  offer  opportunity  and  arouse  interest  in  instruc- 
tion in  child  hygiene.  Informal  meetings,  with  a  leader  or  speaker  who 
can  present  such  subjects  acceptably  and  where  discussion  can  be  free,  are 
of  great  value.  Such  opportunities  should  be  open  to  all  mothers  and  not 
restricted  to  the  members  of  one  or  two  clubs  or  other  private  organiza- 
tions, or  to  any  one  mothers'  group,  as  is  so  often  the  case.  Meetings  for 
fathers,  and  for  mothers  and  fathers  together,  should  be  more  common. 
Education  for  parenthood  may  begin  early  in  life.  A  little  girl  learns 
much  with  her  dolls  and  the  boy  who  brings  up  a  puppy  in  the  way  it 
should  go,  learns  a  good  deal  of  hygiene.  This  learning  can  go  on  to  care 
of  babies  and  young  children  with  the  older  girls  and  boys. 

Larger  towns  should  provide  small  playgrounds  where  mothers  can  take 
their  babies  and  very  young  children  during  the.  warm  months  of  the  year. 
Such  playgrounds  should  be  properly  equipped  and  supervised. 

For  those  families  as  yet  financially  unable  to  consult  their  family  phy- 
sicians at  regular  intervals  for  examination  of  their  babies  and  pre-school 


30 

children,  the  well  child  conference  in  charge  of  a  competent  physician, 
with  access  to  reasonable  dental  service,  is  an  essential  community  service. 
We  present  the  school  child  with  the  so-called  free  physical  examination 
and  with  dental  service  at  low  cost.  Why  should  we  be  so  fearful  of  giv- 
ing the  same  service  to  the  child  before  school  entrance?  Such  service 
does  not,  and  certainly  should  not,  provide  any  form  of  treatment,  but 
diagnosis  and  discussion  of  defects  with  advice  as  to  correct  hygiene  ought 
to  be  as  easily  available  to  the  parents  of  Johnny  at  age  two  as  at  age  six. 
You  will  never  find  parents  more  receptive  than  when  their  children  are 
the  object  of  discussion.  The  educational  value  alone  of  the  well  child 
conference,  as  an  opportunity  to  demonstrate  the  need  of  careful  feeding, 
dental  care,  correction  of  defects,  etc.,  is  beyond  measuring  and  can  be  so 
conducted  as  to  keep  more  and  more  families  directly  in  touch  with  their 
own  physicians.  The  great  mass  of  experience  accumulated  in  the  years 
since  school  hygiene  came  to  the  front  furnishes  us  with  much  of  value  in 
dealing  with  the  pre-school  group. 

To  summarize  briefly,  pre-school  hygiene  standards  embrace — 

1.  Normal  homes  in  which  proper  feeding  and  habit  training  hold  their 
rightful  place,  with  regular  physical  examination  and  prompt  correction 
of  defects. 

2.  Interest  and  cooperation  of  physicians,  dentists  and  nurses  with  par- 
ents and  community  in  their  efforts  to  give  every  child  a  healthy  and 
happy  childhood. 

3.  Community  ideals  which  provide  adequate  parental  instruction  and 
maternal  and  child  hygiene  service  and  which  reach  out  to  help  all  parents 
with  their  many  problems. 

And  we  must  not  forget  the  influence  of  all  this  on  the  children  them- 
selves— young  as  they  are  they  get  the  idea.  "I've  come  myself  to  get 
ready  for  school,"  announced  a  very  young  person  arriving  at  one  of  our 
State  Demonstration  Well  Child  Conferences  in  a  snowstorm.  Another 
whole  sermon  could  be  preached  from  that  text — but  we  will  be  merciful ! 

THE  VALUE  OF  CHILD  HYGIENE  IN  THE  PUBLIC  HEALTH 

PROGRAM 

Charles  F.  Wilinsky,  M.D. 

Director,  Division  of  Child  Hygiene  and  Health  Units 
Boston  Health  Department 

The  definite  objective  of  any  sound  public  health  program  is  the  pro- 
motion of  health  and  the  prevention  of  disease.  In  no  aspect  of  this 
most  vitally  necessary  community  service  have  the  possibilities  in  the 
field  of  life-saving  been  so  aptly  realized  as  in  the  child  age  group. 
The  saving  of  lives  of  babies  and  young  children  during  the  past 
twenty-five  years  is  one  of  the  gratifying  accomplishments  of  public 
health,  and  it  is  true  indeed  that  we  are  living  in  the  "Century  of  the 
Child." 

Thirty  years  ago  a  city  in  Massachusetts  had  the  staggering  infant 
mortality  rate  of  300  and  some  cities  in  the  South  400.  Today  we  are 
not  content  with  an  infant  mortality  rate  of  75.  New  York"  City  in  1902 
had  an  infant  mortality  rate  of  181.  This  was  reduced  to  56  in  1927. 
The  horrible  pictures  of  the  past  revealed  by  studies  of  the  status  of 
infant  mortality  twenty-five  and  thirty  years  ago  really  emphasize  the 
significance  of  the  magnificent  performance  which  has  made  it  possible 
in  many  communities  to  reduce  the  mortality  in  young  children  from 
200  per  cent  to  300  per  cent. 

The  greatest  amount  of  improvement  has  taken  place  in  the  last 
twenty  years.  Brief  analysis  of  the  facts  and  figures  of  this  evolution- 
ary development  for  better  things  leads  to  conclusions  which  serve  as 
beacon  lights  for  future  public  health  planning  in  this  field.  What- 
ever progress  has  been  made,  no  matter  how  many  lives  of  babies  have 


31 

been  saved,  the  fact  is  glaringly  evident  that  this  life-saving  has  been 
limited  practically  to  after  one  month  of  life.  A  study  of  the  factors 
which  have  been  responsible  for  the  reduction  of  deaths  inevitably  re- 
sults in  the  definite  conclusion  that  our  improvement  has  been  in  the 
reduction  of  deaths  from  gastric  diseases.  We  note  with  satisfaction 
that  the  educational  emphasis  on  breast  feeding,  clean  milk,  proper 
milk  modification  and  better  hygiene  of  the  new-born  has  yielded  most 
gratifying  results.  Further  research  into  the  other  causes  of  death 
reveals  the  fact  that  there  has  been  practically  no  reduction  from 
prematurities,  the  influence  of  toxemias  of  pregnancy  and  from  injur- 
ies at  birth.  Death  of  women  in  pregnancy  and  labor  from  avoidable 
causes  is  indeed  a  challenge  and  an  indictment  of  the  medical  pro- 
fession and  our  public  health  workers.  Analyses  of  studies  of  mater- 
nal and  infant  deaths  wherever  conducted  lead  to  the  same  conclu- 
sions— that  many  of  these  deaths  are  avoidable  and  emphasize  the  sig- 
nificance of  the  following  life-saving  measures: 

1.  Early  and  periodic  prenatal  care. 

2.  The  practice  of  sound  obstetrics. 

3.  The  periodic  medical  supervision  of  the  new-born  baby. 

The  real  significance  of  the  relationship  of  child  hygiene  to  public 
health  is  most  graphically  illustrated  by  the  presentation  of  the  un- 
pleasant but  true  fact  that  twenty-five  years  ago  approximately  one- 
fourth  of  all  deaths  which  occurred  was  in  children  under  one  year  of 
age  and  that  one-third  of  all  of  our  mortality  was  in  youngsters  under 
five.  This  staggering  moral  and  economic  loss  has  been  substantially 
reduced  but  the  loss  of  child  life  from  preventable  causes  is  the  ever 
present  problem  for  intelligent  communities  and  the  field  of  endeavor 
of  the  wide-awake  health  officer.  It  is  in  this  group  that  more  lives 
have  been  saved  than  in  any  other  and  can  still  be  continued  to  be 
saved.  It  is  undoubtedly  the  realization  of  the  marked  slaughter  of 
the  innocents  from  preventable  causes  which  has  done  so  much  to 
change  the  tone,  calibre,  and  character  of  our  public  health  efforts 
and  medical  practice.  The  attempts  to  reduce  these  deaths  may  well 
be  said  to  have  aroused  the  imagination  and  stimulated  health  officers 
in  the  direction  of  constantly  increasing  child  health  efforts  and  serv- 
ice so  that  today  very  few  intelligent  communities  fail  to  demand  a 
decent  child  health  program  and  rarely  question  the  value  and  sig- 
nificance of  this  very  necessary  work,  and  very  few  communities  we 
speak  of  are  content  with  health  departments  which  do  not  exhibit 
the  proper  consciousness  about  this  aspect  of  Public  Health  work. 

How  can  we  remain  content  that  everything  is  being  done  which 
should  be  done  when  we  lose  almost  200,000  babies  annually  of  which 
group  over  50  per  cent  die  from  preventable  causes?  How  can  we  be 
satisfied  with  a  marked  reduction  of  deaths  from  gastric  diseases  with 
so  many  dying  from  injuries  at  birth  and  prematurity.  While  we  are 
in  a  measure  appreciative  of  the  value  and  significance  of  prenatal 
service,  yet  not  enough  expectant  mothers  avail  themselves  of  the  very 
important  benefits  which  result  from  the  proper  hygiene  of  pregnancy. 
Any  attempt  to  valuate  and  think  in  terms  of  a  satisfactory  child  hy- 
giene program  requires  that  proper  emphasis  be  placed  on  adequate 
prenatal  service.  It  is  impossible  to  think  in  terms  of  adequate  pro- 
tection for  the  new-born  without  safeguarding  pregnancy  and  labor. 
The  health  of  the  expectant  mother,  the  toxemias  of  pregnancy,  pre- 
maturities, and  injuries  at  birth — all  factors  which  markedly  affect 
the  life  and  future  health  of  the  new-born — are  in  turn  influenced 
materially  by  prenatal  service  and  any  program  which  has  for  its  ob- 
jective the  prevention  of  the  above  conditions  must  inevitably  result 
in  the  saving  of  maternal  and  child  life. 

An  analysis  of  the  figures  of  one  study  on  maternal  and  infant 
deaths  shows  that  90  per  cent  of  the  maternal  deaths  were  from  causes 


32 

which  would  appear  avoidable.  Another  study  reveals  the  fact  that 
a  supervised  group  of  expectant  mothers  had  a  maternal  mortality  of 
3.9  whereas  with  a  group  of  unsupervised  expectant  mothers  the  rate 
was  11.2.  It  is  perfectly  easy  to  present  fact  after  fact  in  support  of 
the  logic  that  the  proper  hygiene  of  pregnancy,  satisfactory  delivery 
of  the  new-born  baby,  breast  feeding  whenever  possible,  and  when  not, 
clean  milk  properly  modified,  and  periodic  supervision  of  the  new- 
born baby  will  markedly  promote  the  life  saving  of  infants. 

Communities  interested  in  protecting  their  child  population  from 
smallpox  and  diphtheria  and  having  organized  sound  efforts  in  this 
direction,  have  eliminated  these  diseases  as  death  factors.  A  number 
of  communities  boast  of  the  absence  of  deaths  from  diphtheria  because  of 
intensive  immunization  against  this  disease.  Other  cities  with  less  well- 
developed  programs  in  this  direction,  yet  carrying  on  considerable  diph- 
theria prevention  campaigns,  have  reduced  diphtheria  as  a  death  factor  in 
considerable  degree. 

Splendid  opportunities  for  betterment  exist  in  other  communicable  dis- 
eases of  childhood,  among  which  may  be  listed  measles,  chicken-pox, 
mumps,  whooping  cough,  scarlet  fever,  etc.,  regarded  erroneously  as  a  nec- 
essary accompaniment  of  early  childhood.  The  significance  and  danger  of 
pneumonia  which  so  frequently  accompanies  measles  and  whooping  cough 
must  be  stressed  and  these  diseases  postponed  as  far  as  humanly  possible 
until  the  child  is  older  and  better  equipped  from  a  resistance  point  of  view 
to  cope  with  these  complications. 

The  significance  of  the  relationship  of  mental  hygiene  to  early  child  life 
is  worthy  of  emphasis.  A  leader  in  the  field  of  mental  hygiene  whose  rep- 
utation justifies  confidence  informs  us  that  approximately  one  million 
children  are  headed  for  institutions  dealing  with  mental  disease.  While 
this  may  sound  radical  and  much  exaggerated,  it  is  important  to  remem- 
ber that  it  has  an  authoritative  ring  and  the  possibility  of  diverting  the 
course  of  these  youngsters  from  insane  asylums  to  the  normal  channels  of 
life  is  worthy  of  serious  consideration  of  public  health  thinkers.  Mal- 
adjustments of  home  environment,  physical  defects  and  the  many  faulty 
habits  which  are  the  frequent  accompaniment  of  early  childhood  require 
the  consideration  and  ability  of  the  well  qualified  mental  hygienist  func- 
tioning in  his  office  or  in  the  habit  clinic.  We  no  longer  regard  these  de- 
fects as  purely  necessary  accompaniments  of  early  childhood  and  think 
rather  in  terms  that  youngsters  are  entitled  to  proper  environment  and 
guidance  requiring  the  properly  trained  person  to  point  the  way.  Results 
already  achieved  in  this  field  through  the  instrumentality  of  the  habit  or 
guidance  clinic  are  very  encouraging. 

Much  is  to  be  said  about  the  great  need  of  medical  supervision  through 
the  pre-school  age  period,  very  properly  called  the  "neglected  age."  A 
realization  of  the  significance  of  this  formative  period  with  all  that  it  im- 
plies in  health  and  growth,  posture,  dental  care,  habit  formation,  etc., 
makes  it  all  the  more  difficult  to  find  a  cause  for  the  startling  phenomenon 
of  apparent  neglect  of  this  group  by  parents  and  guardians.  Mothers  al- 
ready trained  to  bring  their  babies  to  the  physician  or  baby  clinic  and 
fairly  conscientious  in  following  this  routine  until  the  youngsters  reach 
the  age  of  two  suddenly  seem  to  regard  the  toddler  or  growing  child  as 
able  to  take  care  of  himself.  To  change  this  viewpoint  and  to  impress 
parents  with  the  significance  and  importance  of  medical  supervision  dur- 
ing this  very  important  plastic  cycle  of  child  life  is  one  of  the  contribu- 
tions of  the  future  by  the  proper  public  health  personnel. 

We  are  mindful  of  the  fact  that  education  is  the  anchor  of  the  modern 
public  health  campaign.  It  is  in  the  well-functioning  baby  and  pre-school 
age  clinic  that  education  is  the  important  factor.  What  it  does  for  the 
improvement  of  child  health  and  the  significance  of  acquired  health  habits 
in  early  child  life,  remaining  with  the  individual  in  later  years,  cannot  be 
over-estimated.  This  training  is  a  significant  contribution  to  adult  health 
education. 


33 

School  child  hygiene  was  first  attempted  in  Boston  in  1894  as  a  protec- 
tive communicable  disease  measure.  The  rapid  extension  of  its  scope  was 
stimulated  by  the  almost  ever  presence  of  physical  defects  in  the  child  en- 
tering school.  School  Child  Hygiene  today  thinks  in  terms  of  every  phase 
of  child  health  and  watches  its  physical  and  mental  development  most  stu- 
diously. Open  air  classes,  nutrition,  growth,  cardiac  and  tuberculosis  ser- 
vice, the  safeguarding  of  the  vision  and  hearing  of  the  pupil,  and  many 
other  services  are  but  some  of  the  accomplishments  of  such  programs. 

In  concluding  this  effort  to  stress  the  value  and  significance  of  child  hy- 
giene in  a  public  health  program,  it  is  pertinent  to  call  attention  to  the 
fact  that  there  are  over  twenty-five  million  children  of  school  age  and  un- 
der in  the  United  States.  Equally  fortunate  for  them  as  well  as  for  our 
country  is  the  constantly  growing  appreciation  of  the  significance  and  re- 
lationship of  child  health  to  future  progress  and  its  importance  as  a  real 
economic  factor.  That  proper  physical  and  mental  child  health  is  affected 
materially  by  the  presence  or  absence  of  certain  definite  well-established 
public  health  services  goes  without  saying.  It  requires  no  stretch  of 
imagination  to  visualize  the  benefits  to  be  derived  from  the  definite  appli- 
cation of  a  sound  child  health  program  and  its  significance  and  relation  to 
the  extension  of  life.  We  may  justifiably  stress  again  that  adequate  child 
hygiene  stands  for  all  that  is  best  in  satisfactory  prenatal  service,  that  it 
thinks  in  terms  of  proper  emphasis  on  a  satisfactory  standard  of  obstetri- 
cal skill,  that  it  is  mindful  of  the  supervision  of  the  healthy  baby,  that  it 
is  conscious  of  the  significance  and  value  of  breast  feeding,  and  whenever 
that  is  impossible,  of  clean  milk  properly  modified.  Child  hygiene  thinks 
in  terms  of  adequate  supervision  of  the  pre-school  age  child  with  all  that 
this  implies.  It  endeavors  to  arouse  a  sufficient  consciousness  in  the  par- 
ent or  guardian  for  the  proper  development  of  child  health  and  the  eradi- 
cation of  physical  defects  during  this  period  so  that  the  children  may  be 
turned  over  to  the  school  in  healthy  condition  and  able  to  cope  with  the 
problems  of  the  classroom.  Surely  the  most  skeptic  will  yield  to  the  prin- 
ciple that  there  is  much  merit  in  the  theory  of  the  important  relationship 
of  child  hygiene  in  a  public  health  program. 

Satisfactory  indeed  and  very  pleasing  are  the  justifiable  conclusions  ar- 
rived at  from  a  study  of  the  vital  statistics  of  a  community,  the  bookkeep- 
ing of  public  health,  which  shows  us  how  many  lives  we  have  saved  be- 
cause of  adequate  prenatal  service,  because  of  a  campaign  of  immuniza- 
tion against  diphtheria,  vaccination  against  smallpox;  so  many  mental 
kinks  adjusted  because  of  a  proper  appreciation  of  mental  hygiene,  so 
many  physical  defects  eradicated  in  the  pre-school  age  child.  After  such 
an  analysis,  if  not  before,  we  will  surely  agree  that  child  hygiene  is  of 
significant  importance  and  great  value  in  the  public  health  program. 

HOME  VISIT  BY  INFANT  HYGIENE  NURSE 

M.  Gertrude  Martin,  R.N. 

Consultant  in  Public  Health  Nursing 
Massachusetts  Department  of  Public  Health 

In  the  ever  broadening  field  of  specialization  in  Public  Health  Nursing, 
the  infant  hygiene  nurse  next  to  the  bedside  nurse  is  the  most  welcome 
visitor  to  the  home,  hence,  her  work  is  easier  than  the  other  specialists  in 
that  she  does  not  have  to  overcome  indifference  or  hostility.  On  the  other 
hand  she  has  the  greater  responsibility  because  in  a  large  measure  the  fu- 
ture health  of  the  nation  depends  upon  her  knowledge  of  the  basic  rules  of 
right  living. 

It  is  necessary  to  pre-suppose  that  the  nurse  is  trained  for  the  work  she 
has  undertaken,  and  that  there  is  a  well  defined  infant  hygiene  program 
which  has  received  the  endorsement  of  the  local  physicians,  if  the  nurse 
is  going  to  be  free  to  accomplish  a  worth  while  piece  of  work. 

The  following  are  some  of  the  important  points  that  the  nurse  should 
emphasize  in  her  daily  work: 


34 

Explain  to  the  parents  their  responsibility  to  see  that  the  baby's  birth 
is  recorded. 

Many  babies  are  born  well  but  it  requires  medical  supervision  by  a  phy- 
sician trained  in  the  care  of  infants  to  keep  the  child  well. 

Routine  monthly  visits  to  the  doctor  are  necessary.  (If  people  cannot 
afford  this,  advise  supervision  of  Well  Child  Conference.) 

Steady  gain  in  weight  during  the  first  year  of  life  is  one  of  the  best  in- 
dications of  health.  The  average  weekly  gain  during  the  first  five  months 
should  be  six  ounces;  during  the  remaining  seven  months,  four  ounces. 
If  the  baby  does  not  gain  for  a  two-week  period  or  if  his  gains  are  unsatis- 
factory for  a  period  longer  than  two  weeks,  he  should  see  the  physician  at 
once.  He  should  double  his  weight  by  the  end  of  five  or  six  months  and 
treble  it  by  the  end  of  the  first  year. 

A  complete  physical  examination  should  be  given  every  three  months 
for  the  first  year.  This  examination  can  only  be  done  by  removing  all  the 
clothes. 

Practically  every  mother  can  nurse  her  baby  provided  she  has  received 
proper  instruction  as  to  the  care  of  her  own  health. 

a.  Daily  Diet:  She  should  have  as  a  minimum  a  quart  of  milk,  fresh 
vegetables,  raw  fruit  and  an  egg.  One  quart  of  water  should  be  taken. 
The  mother  may  eat  anything  that  does  not  upset  her  or  the  baby. 

b.  Constipation  is  a  common  but  unnecessary  condition  and  should  be 
guarded  against  by  regularity  of  habits,  exercise,  proper  foods  (coarse 
vegetables,  fruits  and  whole  grained  cereals  and  breads). 

c.  Daily  bath  especially  during  nursing  period  as  mother  perspires 
very  freely. 

d.  Sleep  and  rest:  A  tired  mother .cannot  nurse  her  baby.  A  nursing 
mother  should  have  eight  hours'  sleep  at  night  and  one  hour  rest  period 
during  the  day. 

e.  Work:  No  nursing  mother  should  assume  her  full  household  duties 
until  six  weeks  after  birth  of  baby.  By  this  time  the  milk  flow  is  estab- 
lished. 

f.  Recreation  and  Exercise  in  Fresh  Air  and  Sunshine  is  needed  to 
maintain  good  health  and  quiet  nerves  for  the  nursing  mother.  The 
mother  should  receive  a  post-partum  examination  by  her  physician  to  see 
if  the  uterus  has  returned  to  its  normal  size  and  position.  This  examina- 
tion should  also  include  examination  of  lungs,  heart,  etc.,  to  ascertain  how 
these  organs  stood  the  strain  of  pregnancy. 

Care  of  the  Mother's  Breasts  after  Baby  is  Born — Great  care  should  be 
taken  to  keep  the  nipples  free  from  infection.  The  mother  should  have 
clean  hands  and  the  nipples  should  be  washed  with  boiled  water  before  and 
after  each  nursing  and  covered  with  clean  linen  between  nursings. 

A  baby  should  never  be  weaned  because  of  caked  breast.  If  an  abscess 
should  develop,  emptying  the  breast  by  hand  at  regular  intervals  will  keep 
up  the  milk  supply  so  that  in  the  majority  of  cases  the  mother  can  resume 
nursing  when  the  breasts  are  well  again.  Emptying  the  breast  by  hand  is 
a  special  technique  that  the  nurse  should  demonstrate  to  the  mother. 

The  schedule  of  feeding  is  generally  every  four  hours  unless  physician 
ordered  otherwise.  Both  breast-fed  and  bottle-fed  babies  should  have 
boiled  unsweetened  water  regularly  between  feedings  two  or  three  times 
a  day.  Breast  feeding  should  continue  until  the  baby  is  seven  or  eight 
months  old  even  if  only  one  or  two  feedings  a  day  are  given.  Weaning 
should  be  done  gradually  and  it  should  be  completed  by  the  end  of  the 
ninth  month. 

If  artificial  feeding  must  be  resorted  to,  buy  pasteurized  grade  A  milk 
or  certified  milk.  The  physician  is  the  only  one  capable  of  deciding  on  the 
ingredients  of  the  feeding  and  upon  the  amounts  to  be  used.  Milk  must 
be  kept  clean,  cool  and  covered. 

Special  equipment  should  be  purchased  for  the  preparing  of  artificial 
food  and  should  not  be  used  for  any  other  purpose.  The  nurse  should 
demonstrate  the  making  of  the  formula,  the  proper  care  of  bottles  and  nip- 


35 

pies,  warming  the  feeding,  and  the  way  to  give  the  bottle.  Additional 
foods  are  needed  to  develop  strong  muscles,  good  teeth  and  well  formed 
bones. 

The  future  mental  and  physical  health  and  happiness  of  the  baby  de- 
pends upon  how  he  accepts  new  experiences.  Having  semi-solid  food  in 
his  mouth  is  a  novel  and  curious  sensation  and  only  by  patience  and  en- 
couragement by  the  mother  will  he  learn  to  swallow  this  new  food. 

Strained  tomato  juice  or  orange  juice  should  be  started  by  the  end  of 
the  first  month.  Increase  gradually.  Give  Cod  Liver  at  end  of  second 
week. 

Cooked  cereals  may  be  started  when  baby  is  five  months  old.  Give  one- 
half  to  one  teaspoonful  before  10  A.M.  and  6  P.M.  feedings. 

Egg  Yolk — added  in  the  fifth  month. 

Green  Vegetables  cooked  and  put  through  strainer  should  be  given  once 
daily  (2  P.M.)  in  the  sixth  month. 

Baked  'potato  added  at  ten  months.  Take  care  that  potato  does  not  take 
place  of  green  vegetable. 

Bread — give  unsweetened  zwieback  or  dried  bread  after  the  first  tooth 
comes. 

Stewed  fruits — put  through  strainer — may  be  given  for  supper  by  the 
tenth  month. 

Colic — Never  give  medicine  for  colic  except  when  ordered  by  a  physi- 
cian. It  is  generally  due  to  over-feeding  or  it  occurs  in  babies  who  are 
constipated.  Regulation  of  the  feeding  is  important  or  an  enema  may  be 
necessary. 

Spitting  Up  is  not  the  same  as  vomiting.  It  is  caused  by  pressure  of 
air  in  the  stomach.  It  will  be  prevented  if  the  baby  is  held  in  an  upright 
position  over  the  mother's  shoulder  before  and  after  feeding  and  gently 
patted  on  the  back  until  belching  occurs. 

Hiccoughs — Due  to  rapid  feeding  or  gas  on  stomach.  Relieved  by  giv- 
ing a  few  spoonfuls  of  warm  water. 

Stools — 'The  normal  stools  of  a  breast-fed  baby  are  bright  orange  yel- 
low. They  are  soft  and  mealy,  contain  very  small  soft  curds.  He  may 
have  one  to  three  a  day.  Never  give  drugs  except  when  ordered  by  phy- 
sician. 

The  baby  should  have  a  separate  room  if  possible.  It  should  be  sunny 
and  the  temperature  should  be  kept  as  even  as  possible,  not  above  70°  in 
day  time  and  60°  at  night.  A  well  baby  is  better  off  in  a  cool  room.  Ven- 
tilate by  keeping  a  window  open.  Be  sure  there  are  no  drafts.  The  room 
must  be  kept  thoroughly  cleaned  and  nothing  allowed  in  the  way  of  fur- 
nishings that  are  not  needed  for  the  care  of  the  baby. 

The  prime  essential  of  the  bed  is  that  it  should  allow  the  child  to  lie  per- 
fectly flat.  Never  use  a  baby  carriage  as  a  bed.  It  is  much  better  not  to 
use  a  pillow.  A  table  covered  with  oil  cloth  may  be  used  on  which  to 
change  the  baby's  diaper  and  to  dress  him.  A  tray  on  which  is  placed  all 
the  equipment  necessary  for  the  bath  is  a  time  saver.  A  chest  of  drawers 
for  clothing  and  two  low  chairs  are  all  the  furniture  that  is  necessary. 

The  baby's  bath  should  be  given  the  same  time  every  day.  Everything 
should  be  prepared  before  touching  baby.  Handle  baby  as  little  as  pos- 
sible. Do  not  rush  but  do  work  without  unnecessary  delay  or  confusion. 
The  temperature  of  the  room  should  be  75°.  The  mother  should  wash  her 
hands  before  beginning  the  bath.  Be  sure  that  there  are  no  pins  or  nee- 
dles in  her  clothing.  Baby  must  have  own  towels  and  wash  cloths.  Never 
bathe  a  baby  within  an  hour  after  feeding.  The  bath  water  should  be 
slightly  above  body  heat.  As  the  infant  gets  older,  lower  the  tempera- 
ture. Don't  guess  at  the  temperature,  have  a  bath  thermometer.  Never 
add  hot  water  to  bath  while  the  baby  is  in  the  tub.  Don't  bathe  baby  close 
to  kitchen  stove. 

Very  little  soap  is  needed.  Use  very  little  talcum  powder  as  it  cakes; 
mineral  oil  is  better.  Special  care  must  be  taken  of  head,  eyes,  nose, 
mouth,  ears  and  genital  organs.     Wash  the  top  of  head  thoroughly;  if 


36 
cradle  cap  appears,  rub  in  some  vaseline  at  night  and  wash  with  soap  and 
water  in  morning. 

Baby's  eyes  should  be  protected  from  direct  light.  When  taking  sun 
bath,  have  feet  pointed  away  from  sun  and  the  forehead  and  eyebrows  will 
protect  eyes  from  direct  light.  Wind  and  dust  will  cause  more  trouble 
than  sun. 

The  inside  of  the  mouth  of  a  well  baby  should  never  be  cleansed  before 
the  teeth  come. 

Nose  and  ears  should  be  cleaned  as  a  part  of  the  daily  toilet.  Never  put 
any  hard  instrument  in  either  nose  or  ears  to  clean  them. 

The  genital  organs  of  babies  of  both  sexes  should  be  kept  very  clean. 
The  genitals  of  a  girl  baby  should  be  carefully  washed  twice  daily.  The 
foreskin  should  be  drawn  back  two  or  three  times  a  week  at  bathing  time 
and  the  penis  cleansed. 

Teething  is  a  normal  process,  hence  it  does  not  cause  illness  in  the  baby. 

First  teeth  should  be  well  cared  for.  Regularity  in  visiting  the  dentist 
should  be  practiced  as  soon  as  the  first  tooth  appears,  otherwise  poor  di- 
gestion will  result  because  of  improper  mastication  caused  by  decayed 
teeth.  First  teeth  act  as  a  guide  to  the  permanent  teeth  and  if  extracted 
too  early  the  normal  development  of  the  jaw  is  hindered  with  the  result 
that  the  second  teeth  are  often  crowded.  Nutrition  plays  a  large  part  in 
the  formation  of  strong  teeth  and  the  baby's  diet  must  be  well  balanced. 

Remember  that  90  per  cent  of  all  molars  have  cracks  which  should  be 
cared  for  as  soon  as  they  erupt. 

The  baby  can  go  out-doors  when  he  is  two  weeks  old  provided  due  care 
is  taken.  He  needs  all  the  direct  sunshine  he  can  get  otherwise  he  will  not 
develop  into  a  strong,  healthy  baby.  It  depends  on  the  time  of  year  how 
sun  baths  are  given.  If  in  Spring  or  Summer,  out-door  sun  baths  may  be 
started  when  the  baby  is  three  weeks  old.  Fall  and  winter  babies  must 
receive  their  sun  bath  inside  by  an  open  window.  Great  care  must  be  ex- 
ercised so  that  the  skin  will  not  burn.  The  exposure  of  body  surface  to 
the  sun  should  be  gradual  and  of  short  duration  until  the  baby  becomes 
accustomed  to  it.  Most  babies  are  dressed  too  warmly.  He  should  be 
warm  to  touch,  not  hot  or  cold,  hence  the  amount  of  clothes  will  depend 
upon  the  weather  and  temperature.  The  most  important  article  of  cloth- 
ing is  the  diaper.  It  should  be  put  on  like  pants.  The  diaper  should  be 
changed  as  often  as  it  is  wet  or  soiled.  Wet  diapers  should  be  put  as  soon 
as  removed  in  a  covered  pail  in  cold  water  until  they  can  be  washed. 
Soiled  diapers  should  be  placed  in  a  covered  pail  as  soon  as  the  stool  is  re- 
moved. Only  mild  white  soap  should  be  used  in  washing  diapers.  Several 
rinsings  followed  by  a  good  boiling  and  drying  in  the  open  air  will  prevent 
the  severe  discomfort  of  chafed  buttocks.  Rubber  pants  should  never  be 
worn  except  on  special  occasions. 

Play — A  few  minutes  of  play  two  or  three  times  a  day  is  good  for  the 
baby.  The  morning  is  the  best  time  but  it  is  all  right  for  the  father  to 
play  with  his  baby  before  the  six  o'clock  feeding  provided  he  is  gentle 
about  it.  Babies  should  not  receive  too  much  attention.  Let  them  learn 
to  amuse  themselves.  A  baby  always  wants  to  put  everything  in  his 
mouth,  hence  this  must  be  borne  in  mind  when  buying  toys.  A  few  simple 
toys  that  are  unpainted,  blunt  and  not  too  small  are  the  best. 

Do  not  allow  the  baby  to  be  exposed  to  any  disease  on  the  theory  that 
he  will  get  it  anyway.  The  younger  a  child  is  the  more  serious  the  disease 
is  likely  to  be,  so  ward  it  off  as  long  as  possible.  Some  diseases  can  be 
prevented.  Every  baby  should  be  vaccinated  against  smallpox  before  he 
is  one  year  of  age.  When  the  baby  is  six  months  old  he  should  be  immu- 
nized against  diphtheria  and  in  six  months'  time  receive  a  Schick  test  to 
see  whether  the  toxin  antitoxin  has  protected  him  against  the  disease. 

Whooping  Cough  is  very  serious  in  a  baby  under  one  year.  If  the  baby 
has  been  exposed  he  may  be  inoculated  with  a  vaccine  that  may  not  pre- 
vent him  from  catching  the  disease  but  may  make  it  a  much  lighter  attack. 

Measles  seldom  attacks  infants  under  six  months  but  it  is  a  very  serious 


37 

disease  in  a  baby  and  many  physicians  give  convalescent  serum  to  modify 
the  attack. 

Tuberculosis  is  one  of  the  most  fatal  diseases  of  infancy.  Babies  be- 
come infected  by  drinking  unboiled  milk  from  tubercular  cows  or  from 
exposure  to  a  person  already  suffering  from  it.  Keep  baby  away  from  all 
persons  with  a  cough.  A  tubercular  mother  should  neither  nurse  nor  care 
for  her  infant. 

A  "Cold"  is  a  serious  matter  to  a  baby.  Avoid  overheating  of  room, 
keep  him  out  of  crowded  places.  Do  not  dress  him  too  warmly  when  he 
goes  out-doors.  All  persons  having  colds  should  not  go  near  the  baby. 
Constipation  can  be  prevented  by  proper  training  and  diet. 
Rickets  and  scurvy  are  known  as  the  deficiency  diseases  due  to  lack  of 
certain  vitamines  (D  and  C)  in  the  food.  These  diseases  can  be  prevented 
by  proper  diet. 

Habits — Babies  are  not  born  with  habits.  They  begin  at  birth  and  are 
learned  by  experience  and  training.  Regularity  is  the  keynote.  The  habit 
of  regularity  in  sleeping  and  feeding  can  be  begun  on  the  third  day  and 
once  established  it  must  not  be  interrupted  except  for  a  real  emergency. 

The  training  of  the  bowels  should  be  begun  by  the  third  month  and  by 
patience  there  will  be  no  more  soiled  diapers  by  the  time  the  baby  is  eight 
months  old. 

When  the  baby  is  ten  months  old,  begin  training  him  to  control  his  blad- 
der. At  eighteen  months  most  babies  have  learned  control  during  waking 
hours.  Any  undesirable  habits  may  lead  to  serious  difficulties.  Do  not 
trust  that  a  bad  habit  will  be  outgrown.  Find  the  cause  and  remove  it, 
and  then  train  the  child  in  the  right  habit. 
Tell  the  mother  to  send  for  the  physician 

If  he  has  a  cold  in  the  head  with  a  temperature  over  100°. 

If  temperature  is  above  100°. 

If  very  drowsy  or  irritable. 

If  he  has  diarrhea  or  vomits. 

If  he  has  symptoms  of  pain. 

If  he  has  a  croupy  cough  or  becomes  hoarse. 

If  he  has  a  rash  with  fever. 

A  PRESCHOOL  CHILD  VISIT 

Anna  K.  Donovan,  R.N. 

Consultant  in  Public  Health  Nursing 
Massachusetts  Department  of  Public  Health 

There  is  a  wealth  of  information  available  relative  to  the  needs  of 
the  pre-school  child  and  it  is  generally  agreed  that  this  information, 
in  order  to  be  most  effective,  should  be  carried  to  the  parent  in  the 
home  through  the  medium  of  the  public  health  nurse. 

This  pre-school  program  is  educational,  preventive  and  corrective. 
It  involves  medical  supervision  by  the  family  physician  or  at  a  Well 
Child  Conference  and  nursing  supervision  in  the  home. 

The  pre-school  period  is  one  of  most  rapid  growth — mentally  and 
physically.  Life  long  habits  are  formed,  physical  defects  develop, 
which  if  not  corrected  may  handicap  in  later  years.  About  8,000  chil- 
dren in  Massachusetts  repeat  the  first  grade  annually  and  it  is  es- 
timated that  a  large  per  cent  of  these  children  have  remediable  physi- 
cal defects,  and  had  these  defects  been  noted  and  corrected  or  pre- 
vented during  the  pre-school  age,  the  number  of  repeaters  might  have 
been  materially  reduced.  Is  it  not  obvious  that  there  is  need  for  a 
constructive  pre-school  health  program? 

The  aim  of  such  a  program  is  to  reduce  the  number  of  repeaters  by 
the  prevention  and  correction  of  physical  defects  and  by  the  control 
of  communicable  disease. 

Because  of  the  nature  of  this  program,  it  being  largely  educational, 


38 

a  well-trained  public  health  nurse  is  needed.  She  should  be  a  regis- 
tered nurse  with  public  health  training.  Her  personality  should  be 
pleasing,  she  should  have  the  ability  to  teach,  also  good  health  (men- 
tal and  physical),  poise,  tact,  sense  of  humor  and  tolerance.  This  well 
trained  nurse  will  know  her  program  and  believe  in  the  worth-while- 
ness  of  it.  She  will  know  the  community  resources — medical  and  so- 
cial, maternal  and  infant  mortality  rate,  water  and  milk  supply,  gar- 
bage and  sewage  disposal. 

While  her  contacts  in  the  home  must  be  definite,  her  approach  should 
be  simple  and  natural,  the  visits  should  never  appear  to  be  hurried, 
and  the  nurse  must  not  make  too  many  suggestions  at  one  time  as 
there  is  the  danger  of  confusing  the  family. 

The  family  being  considered  as  a  unit,  it  is  necessary  for  the  nurse 
to  know  the  health,  social  and  economic  history,  environment,  and  the 
relationships  and  attitudes  of  members  of  the  family  toward  each 
other.  Too  much  emphasis  cannot  be  placed  on  the  proper  recording 
of  the  above  information.     Adequate  records  are  indispensable. 

Many  visits  may  be  necessary  before  friendly  relationships  are  es- 
tablished, before  the  confidence  of  the  family  is  gained,  and  the  nurse 
must  not  become  discouraged;  neither  should  the  family  be  considered 
uncooperative,  but  rather  not  yet  convinced. 

The  success  of  this  program,  which  is  educational,  corrective  and 
preventive,  needs  the  interest  and  cooperation  of  the  family  and  the 
community,  and  the  measure  of  success  will  be  less  morbidity,  con- 
trol of  communicable  disease,  and  fewer  children  entering  school  with 
remediable  physical  defects,  which  will  mean  fewer  children  repeating 
the  earlier  grades. 

THE  IMPORTANCE  OF  HABIT  TRAINING  FOR  THE  INFANT  AND 

PRE-SCHOOL  CHILD 

Sybil  Foster,  Educational  Secretary 
Massachusetts  Society  for  Mental  Hygiene 

During  the  early  childhood  the  foundations  of  character  are  being 
laid.  At  this  time  the  personality  is  still  in  the  making  and  the  habit- 
ual patterns  and  trends  of  behavior  are  being  formed.  Many  of  these 
trends  will  carry  over  to  adult  life,  to  aid  or  hinder  the  individual  as 
the  case  may  be.  It  is,  therefore,  of  vital  importance  to  the  child's 
mental  health  and  future  adjustment  to  life,  that  some  thought  should  be 
given  to  the  careful  training  in  a  wise  routine  of  living. 

From  the  moment  of  birth,  the  infant  is  forming  habits  of  one  sort 
or  another.  Guidance  in  the  early  establishment  of  socially  desirable 
ones  relieves  the  child  of  much  strain  and  frees  his  energy  for  the 
other  things  he  must  learn  and  which  have  not  yet  become  habitual. 

During  infancy  and  the  pre-school  years,  the  child  is  laying  the 
basis  for  good  physical  and  mental  health  by  the  building  of  sound 
physical  habits.  This  foundation  of  well-organized  habits  of  eating, 
sleeping  and  eliminating  has  a  definite  bearing  on  the  child's  later 
well-being.  However,  during  the  establishment  of  these  same  habits 
many  of  the  personality  deviations  and  behavior  difficulties  have  their 
start. 

Take,  for  instance,  the  difficulties  that  arise  over  the  development  of 
good  habits  in  relation  to  the  intake  of  food.  Though  to  be  sure  food 
is  vital  to  life,  yet  mealtimes  should  be  only  incidents  in  the  day's 
program.  Yet  often  we  see  the  feeding  hour  holding  a  position  out 
of  all  proportion  in  the  day's  schedule  and  the  dinner  table  becomes 
the  scene  of  daily  battles  of  emotion  and  endurance. 

We  see  the  little  child  clinging  to  the  bottle  long  after  he  should  be 
drinking  from  a  cup  and  spoon-fed  when  well  able  to  feed  himself. 
He  demands  stories  and  playthings  and  coaxing  before  he  will  take  a 
reasonable  amount  of  food.     He  terrorizes  the  family  by  his  caprices 


39 

and  confers  a  favor  now  and  then  by  offering  to  eat  some  specified 
article. 

The  serious  part  of  this  situation  is  not  the  fact  that  he  is  taking 
too  little  nourishment,  for  with  all  the  coaxing  and  bribing  in  the 
course  of  a  day  more  food  is  taken  than  the  parent  realizes.  The  cause 
of  concern  is  the  type  of  technique  the  child  is  learning  to  use  in  con- 
trolling the  adults  in  his  environment.  Often  the  extremely  capri- 
cious eater  is  a  rosy,  round-cheeked,  little  rascal  well  in  command 
of  the  home  situation.  He  is  obtaining  attention  and  solicitude  in  this 
way  and  has  procured  for  himself  a  position  of  undue  prominence  in  the 
family  life. 

These  methods  he  is  learning  may  be  serviceable  to  him  while  within 
the  walls  of  his  home.  They  will  not,  however,  make  for  ease  of  social 
living  as  he  passes  on  to  contacts  in  the  community  and  he  will  find 
that  they  have  to  be  modified  and  changed. 

The  great  difficulty  in  the  wise  training  in  eating  habits  is  caused 
by  the  adult's  solicitude.  Intake  of  nourishment  obviously  relates  to 
physical  development  and  is  a  matter  of  concern  to  any  intelligent 
parent.  Yet  as  soon  as  the  child  senses  this  concern  it  becomes  a  tool 
in  his  hands  with  which  to  partially  control  his  surroundings. 

Mealtime  should  be  looked  upon  as  a  pleasant,  casual  incident  of  the  day 
over  which  no  great  amount  of  anxiety  is  shown.  If  by  chance  the  meal 
is  refused  or  neglected  this  may  be  accepted  quietly  or  ignored.  If  the 
child  is  physically  well  missing  a  few  meals  during  the  establishment  of 
a  routine  will  not  injure  him.  If  opposition  is  not  set  up  by  reference  to 
past  refusals  the  actual  pangs  of  hunger  will  soon  bring  him  to  terms.  At 
this  point,  when  he  capitulates,  his  surrender  should  not  be  gloried  in,  so 
making  the  defeat  more  painful,  but  rather  it  should  be  accepted  as  a 
commonplace  and  expected  fact  arousing  little  interest. 

A  well-ordered  rhythm  of  sleep  is  necessary  to  the  physical  growth  and 
mental  poise  of  the  little  child  and  in  the  early  months  and  years  should 
be  firmly  established.  It  is,  however,  easy  to  break  into  the  rhythm  acci- 
dentally and  almost  before  one  is  aware  of  it,  the  sleep  habits  are  disor- 
ganized. Travelling,  with  strange  sleeping  arrangements  involved,  or  vis- 
iting, when  it  is  inconvenient  to  carry  out  normal  home  routine,  will 
quickly  disrupt  habits  that  have  formerly  been  functioning  well.  It  will 
take  special  effort  and  thought  to  institute  the  old  regime  after  such  a 
breakdown. 

As  with  eating  habits,  difficulties  over  the  sleep  habits  may  serve  the 
child  as  a  means  to  more  adult  attention.  Calls  for  "drinks"  and  more 
covers,  night  crying  and  terrors,  may  be  a  way  to  make  mother  return 
time  after  time.  They  may  also  be  indications  of  some  vague  or  unknown 
fear  or  feeling  of  insecurity.  The  mere  response  in  a  loved  voice  may  be 
all  the  child  really  wants  to  obtain.  Each  situation  should  be  thought  out 
carefully.  If  it  is  just  a  habit  the  parent  has  allowed  the  child  to  slip  into 
thoughtlessly,  a  change  of  plan  may  be  started  and  adhered  to  carefully. 
If,  however,  the  difficulty  is  a  deeper  one  of  unsatisfied  craving  for  atten- 
tion, affection  or  security,  an  attempt  should  be  made  to  fully  understand 
the  child's  needs.  If  necessary,  study  of  the  child  should  be  made  by  a 
private  psychiatrist  or  children's  clinic  and  the  suggestions  carried  out 
carefully. 

The  process  of  developing  in  the  little  child  socially  acceptable  habits  of 
elimination  often  leads  to  the  building  of  undesirable  attitudes  and  ways 
of  behaving.  Take  for  instance  enuresis.  Besides  the  obvious  unpleas- 
antness and  inconvenience  of  a  wet  bed,  the  habit  has  far-reaching  effects. 
It  should  not  be  accepted  as  a  necessary  discomfort  which  will  later  be 
outgrown.  If  the  habit  persists  beyond  normal  babyhood,  it  indicates  a 
tendency  to  cling  to  infantile  ways,  it  makes  the  child  stand  out  as  differ- 
ent and  often  is  the  cause  of  feelings  of  inferiority  and  inadequacy.  These 
feelings  of  inadequacy  are  only  added  to  by  the  methods  of  punishment 


40 
and  shaming  so  often  used.    What  the  child  needs  is  confidence  in  himself 
and  his  ability  to  control  his  physical  machine,  this  cannot  be  gained  by 
disciplinary  measures.     Instead  a  goal  of  self  control  and  self  guidance 
should  be  held  up  to  the  child  toward  which  he  may  be  interested  to  work. 

Difficulties  in  establishing  toilet  habits  may  be  due  to  many  causes. 
Frequently  parents  are  puzzled  by  finding  that  the  routine  methods  used 
with  satisfactory  results  on  one  child  fail  utterly  with  another  child. 
Here  we  may  find  on  going  into  the  situation  that  some  unrecognized  fac- 
tor has  entered  in  to  act  as  a  handicap  to  training.  It  may  be  that  this 
child  was  frail  and  could  not  be  subjected  to  some  of  the  routine  measures 
— such  as  rousing  in  the  night,  etc.  Or  possibly  someone  in  the  family 
was  ill  and  quiet  was  necessary  at  all  costs,  at  the  time  when  training 
could  most  readily  have  been  instituted  with  this  particular  child.  Maybe 
the  mother  was  not  well  or  was  nervously  upset,  could  not  maintain  her 
poise  but  showed  irritation  and  annoyance  and  so  on.  These  are  only  a 
few  of  the  possible  causes  of  delay  in  the  establishment  of  dry  habits  in 
a  physically  well  child. 

We  occasionally  see  relapses  after  the  dry  habit  has  been  formed  and 
these  too  have  many  possible  causes.  Unhappiness,  fear,  jealousy  or  loss 
of  adult  attention  for  one  reason  or  another  may  be  found  in  the  back- 
ground. In  these  situations  both  the  symptom  and  the  cause  must  be 
handled  with  understanding  and  insight. 

Perhaps  the  first  task  of  the  infant  is  the  development  of  these  physical 
habits.  But  of  almost  equal  importance  is  the  early  development  of  self- 
reliance,  an  ideal  of  emotional  control  and  a  wholesome  response  to  pa- 
rental authority.  The  attitudes  the  child  forms  and  uses  habitually  in 
these  early  years  will  surely  color  his  adult  behavior,  to  his  social  advan- 
tage or  disadvantage. 

The  child  must  pass  from  the  complete  dependence  of  the  infant  to  adult 
self-reliance.  It  is  only  fair  that  he  should  have  the  opportunity  to  grad- 
ually learn  this  self-dependence.  We  find  it  great  fun  to  wait  on  and  do 
things  for  a  little  child,  and  it  is,  of  course,  quicker  than  to  let  him  try, 
blunder,  fail  and  try  again,  but  he  is  due  this  experience.  In  no  other  way 
can  he  build  up  his  knowledge  of  what  brings  success  or  failure  and  so 
gradually  come  to  make  his  own  judgments  wisely.  When  the  home  en- 
vironment is  padded  for  the  child,  when  he  is  coddled,  babied  and  sub- 
jected to  great  solicitude  he  is  totally  unfitted  to  meet  the  world  as  he  will 
find  it  beyond  the  shelter  of  his  home.  In  kindergarten,  often  his  first  so- 
cial contact,  he  may  find  himself  one  of  twenty  or  thirty  others  striving 
to  obtain  from  the  new  adults  in  the  situation  the  accustomed  special  at- 
tention and  protection.    The  experience  is  apt  to  be  a  cruel  one. 

Training  for  emotional  control  should  begin  in  early  childhood.  The 
infant  is  a  riot  of  unguided  emotions  which  he  must  gradually  learn  to 
direct  for  social  conformity.  His  self-control  grows  with  the  years  but 
his  ultimate  courage  and  maturity  are  determined  largely  by  the  ideal  of 
conduct  held  up  to  him  during  the  first  years  of  his  training  and  experi- 
ence. 

He  should  early  learn  that  whining,  temper  outbursts  and  emotional  dis- 
plays net  him  nothing  but  rather  that  control,  poise  and  thoughtfulness 
bring  approbation  and  approval  from  those  for  whose  opinions  he  cares. 

He  should  be  taught  to  face  hard  things  and  show  his  pluck.  It  is 
far  better  to  teach  a  child  that  the  dentist  or  doctor  will  probably 
hurt  him  and  to  help  him  to  display  courage  and  fortitude  rather  than 
to  tell  him  they  will  not  hurt — when  we  feel  very  sure  they  will — and 
so  break  the  child's  trust  and  feeling  of  security  in  the  adult's  state- 
ments. 

In  the  mere  saying  goodbye  to  a  little  child,  a  standard  of  control 
may  easily  be  taught.  It  may  be  made  a  jolly,  casual  adventure,  en- 
tered into  with  interest  or  it  may  be  made  an  emotional  orgy  on  the 
part  of  both  adult  and  child.  So  often  children  placed  away  from  home 
or  in  camp  will,  after  the  first  day  or  two,  make  an  entirely  happy  ad- 


41 

justment.  This  may  be  utterly  upset  by  a  visit  from  parents  who  have 
themselves  not  learned  to  control  their  feelings  for  the  good  of  the 
child.  The  visit  then  ends  in  a  recurrence  of  the  first  homesickness  or  in 
the  child's  returning  home  regardless  of  what  he  was  gaining  in  the  other 
setting. 

The  earlier  the  child  learns  to  face  small  disappointments  and  fail- 
ure with  courage  and  determination,  to  make  the  best  of  it,  the  easier 
it  will  be  for  him  in  later  years.  Disappointments  are  bound  to  come 
in  community  living  and  the  child  should  not  be  shielded  from  them 
in  the  early  years  and  then  left  unprepared  for  the  jolts  in  later  life. 

The  attitudes  formed  in  childhood  in  regard  to  parental  authority 
will  deeply  color  the  later  attitudes  to  social  authority  and  conformity. 
The  child,  of  course,  builds  his  attitudes  from  his  experience  in  dis- 
ciplinary matters.  He  should  be  trained  for  judgment  and  discern- 
ment and  not  simply  submission.  Often  the  revolt  of  a  little  child  is 
the  most  healthy  type  of  behavior  and  is  the  response  we  wish  to  see 
if  the  authority  exerted  by  the  adult  is  unjust  or  inconsistent. 

Discipline  means  the  breaking  down  of  an  unserviceable  habit  of 
behavior  and  substituting  for  it  one  that  is  socially  acceptable.  This 
means  that  the  one  substituted  must  in  one  way  or  another  be  made 
to  appear  more  desirable  to  the  child  or  he  may  feel  the  forbidden 
habit  is  worth  to  him  the  discomfort  of  the  punishment  which  he  knows 
will  follow. 

Punishment  is  for  the  purpose  of  changing  the  type  of  reaction  and 
is  not  for  social  revenge  as  it  would  sometimes  appear.  It  always  in- 
volves pain,  either  physical  or  mental  and  is  inflicted  to  deter  from  the 
undesirable  act. 

The  elements  in  the  success  of  punishment  are  its  inevitability,  its 
immediateness  and  its  adequateness.  But  we  must  always  be  sure  be- 
fore administering  punishment  that  the  child  understood  that  the 
act  was  wrong  and  we  must  also  be  sure  we  know  what  the  child  was 
trying  to  do.  Often  what  looks  like  gross  disobedience  is  the  outgrowth 
of  a  mistaken  effort  to  help. 

Physical  punishment  is  usually  overdone  and  so  quickly  becomes 
useless.  If  used  at  all  it  should  be  short,  sharp  and  solely  to  build  an 
unpleasant  reaction  to  the  thing  the  child  is  starting  to  do. 

Acute  psychological  punishment  such  as  scolding,  depriving  of  priv- 
ileges or  approbation  is  less  apt  to  bring  revolt  than  physical  methods. 
It  gives  a  chance  to  use  the  "indeterminate  sentence,"  to  send  a  child 
to  the  corner,  or  his  room  and  leaves  the  adult  free  to  use  discretion 
as  to  when  the  punishment  should  be  terminated. 

Prolonged  psychological  punishment  such  as  nagging,  repeated  re- 
ferring to  a'  past  misdemeanor,  continued  ostracism  and  loss  of  ap- 
proval is  bad  for  the  child  and  is  destructive  mental  hygiene.  Get  the 
matter  over  with,  then  clear  the  skies  and  give  the  child  a  chance  to 
start  afresh. 

The  home  is  the  bridge  to  the  community  and  if  the  child  early  learns 
to  accept  authority  as  just  and  consistent  he  will  be  far  more  ready 
to  submit  to  social  authority,  first  in  school  and  then  in  the  community. 
He  will  then  have  learned  much  of  adult  self-government  and  social 
conformity. 

JUDGING  NUTRITION 

Eli  C.  Romberg,  M.D. 

Boston,  Mass. 

The  problem  of  nutrition  has  more  recently  stimulated  the  attention  of 
doctors,  social  workers,  and  all  elements  of  society.  Even  nutrition  in  in- 
fancy and  childhood,  a  subject  about  which  so  much  has  been  written,  is 
now  receiving  more  attention  than  in  previous  years.  Perhaps  this  to  a 
great  degree  is  due  to  the  efforts  of  medical  men  and  their  co-workers  in 


42 
their  attempt  to  make  children  as  healthy  as  possible,  or  the  condition  of 
the  child  has  been  called  to  the  attention  of  the  mother  by  more  careful 
school  examinations,  or  the  situation  is  but  a  reflection  of  our  medical- 
mindedness  of  today.  It  is  obviously  impossible  for  me  to  cover  in  this 
short  paper  the  complicated  problem  of  nutrition  in  children.  All  I  can 
hope  to  do  is  to  hit  the  high  spots  and  perhaps  eliminate  some  of  the  ap- 
prehensions that  mothers  hold  about  the  malnourishment  of  their  child 
and  perhaps  to  suggest  some  means  of  meeting  the  situation.  Nearly 
every  day  we  doctors  are  asked  by  mothers  why  Mrs.  Jones'  baby  is  fat 
and  hers  is  thin,  or  Mrs.  Smith  tells  us  that  she  has  received  a  note  from 
the  school  doctor  saying  that  her  child  is  underweight.  We  must  all  first 
realize  that  we  come  from  different  stock,  that  through  centuries  certain 
nationalities  have  been  brought  up  under  different  climatic  conditions, 
have  been  fed  diets  peculiar  to  that  race,  and  that  many  physical  qualities 
are  transmitted  which  no  medical  interference  can  alter.  Some  are  nat- 
urally tall  or  short,  some  have  a  tendency  to  obesity,  others  to  leanness, 
and  others  have  distinctive  physical  differences.  We  know  that  in  our  own 
private  practice  or  in  our  hospital  clinics  we  have  children  who  are 
healthy,  active,  and  happy,  but  who  appear  to  be  thin.  We  make  extensive 
studies  to  determine  possible  glandular  disturbances ;  we  attempt  to  seek 
out  foci  of  infection  as  a  possible  cause  of  this  apparent  lack  of  weight, 
or  we  carefully  go  into  the  history  of  the  child's  habits  of  feeding,  play, 
and  sleep;  and  then  we  inquire  in  detail  as  to  the  character  of  the  diet, 
the  social  condition  and  the  child's  environment.  After  careful  considera- 
tion of  all  these  facts,  we  may  find  them  all  negative.  Regardless  of  what 
we  try  we  cannot  make  this  child  put  on  sufficient  weight  to  bring  him  up 
to  normal.  But  why  worry?  The  child  seems  to  conduct  himself  happily, 
both  physically  and  mentally,  and  he  seems  to  be  able  to  resist  the  usual 
infections  that  affect  other  children.  Aren't  we  then  allowing  ourselves  to 
become  unduly  concerned  merely  because  the  child  does  not  happen  to 
come  up  to  a  weight  measurement  which  is  essentially  empirical?  Then 
we  have  just  the  opposite  type  of  child  who  is  extremely  obese,  who  seems 
to  gain  weight  with  a  small  intake  of  food,  and  even  with  the  elimination 
of  such  foods  that  are  known  to  bring  about  excessive  weight.  We  again 
look  for  possible  endocrine  disturbances  and  other  faulty  factors,  and  yet 
we  cannot  tie  up  his  condition  with  any  particular  glandular  syndrome. 
Perhaps  there  is  some  glandular  disturbance  which  we  cannot,  with  our 
present  means  of  investigation,  identify.  This  type  should  bring  us  no 
particular  concern — he  generally  is  the  one  whose  weight  adjusts  itself  as 
he  gets  older.  We  who  practice  medicine  do  not  need  charts  indicating 
heights  and  weights  to  tell  us  whether  a  child  is  normal  or  abnormal. 
Simple  observation  can  disclose  these  facts  to  us.  I  feel  that  the  only  real 
value  of  such  charts  is  the  satisfaction  that  it  gives  to  the  mother.  Per- 
haps it  makes  her  feel  that  her  child  runs  true  to  normal  standards, 
whether  these  standards  be  false  or  true  is  apparently  no  concern  of  hers. 
How,  then,  shall  we  judge  properly  the  nutrition  of  a  child?  A  history  of 
a  child  who  previously  has  been  bright,  happy,  and  well-nourished,  who 
now  has  no  appetite,  who  is  losing  weight,  and  who  is  becoming  apathetic 
and  is  not  anxious  to  play  as  actively  as  he  used  to,  is  important.  Look- 
ing at  the  child  we  may  discover  that  he  is  obviously  underweight  and  his 
nutrition  as  indicated  by  his  tissue  discloses  a  loss  of  weight.  The  pos- 
sible causes  which  bring  about  such  a  condition  in  the  child  can  only  be 
determined  by  a  careful  history,  a  complete  investigation  into  the  social 
conditions  of  the  family,  a  thorough  physical  examination,  and  by  labora- 
tory aids  which  may  help  us  in  our  diagnosis.  For  instance,  this  loss  of 
appetite  may  be  caused  by  the  child's  not  giving  himself  sufficient  time  to 
eat  in  his  desire  to  get  out  into  the  street  and  play  with  his  companions; 
or  he  may  not  be  attracted  by  the  type  of  food  which  the  mother  is  giving 
him ;  or  the  mother  is  not  taking  the  trouble  to  give  him  properly  prepared 
food.  _  If  the  child  appears  to  be  tired  and  losing  weight,  it  may  be  that 
chronic  infections  of  some  kind  are  running  him  down ;  or  he  may  be  that 


43 

child  who  is  compelled  to  undertake  too  much  physical  and  mental  effort 
for  one  of  his  age.  We  have  many  children  who  not  only  have  to  carry 
on  their  school  work,  but  do  the  family  chores,  sell  newspapers,  do  other 
outside  jobs  which  carry  him  far  into  the  evening-  and  send  him  to  bed 
late;  he  may  be  the  one  who  has  been  exposed  to  tuberculosis  and  who 
shows  all  the  prodromal  signs  of  tuberculosis;  or  the  child  with  diabetes 
and  hyperthyroidism.  I  could  name  endless  causes  of  malnourishment  in 
children.  What  I  want  to  bring  out  is  that  these  findings  can  only  be  de- 
termined by  those  methods  which  I  have  just  described  and  which  condi- 
tions can  easily  be  relieved  by  eliminating  the  offending  situation.  I  be- 
lieve that  we  have  placed  too  great  emphasis  on  about  how  much  and  what 
a  child  should  eat  in  order  to  make  him  healthy  and  strong,  forgetting 
perhaps  the  pathological  situations  that  may  underlie  the  condition.  We 
know  that  many  a  child  in  the  slums  flourishes  in  spite  of  the  little  atten- 
tion that  is  paid  to  the  amount  and  character  of  his  diet. 

Many  children  reach  early  adolescence  carrying  with  them  difficulties 
that  have  been  brought  about  by  disturbances  in  nutrition  in  early  in- 
fancy. This  gives  me  an  opportunity  to  discuss  the  problem  of  breast 
feeding.  I  shall  not  go  into  statistical  detail,  but  records  show  that  the 
mortality  for  the  artificially  fed  is  about  five  times  as  great  as  the  breast 
fed.  However,  infant  mortality  is  not  the  only  problem.  In  later  life  the 
bad  effects  of  artificial  feeding  are  manifested  by  the  various  intestinal 
disorders  and  the  disturbances  of  nutrition  which  do  not  kill  the  child  but 
which  may  make  him  more  susceptible  to  acute  infections  or  may  hamper 
him  by  an  imperfect  or  deformed  physical  development.  A  mother  ought 
to  nurse  her  child.  This  is  the  only  fundamental  rule  of  feeding.  How- 
ever, it  is  a  rule  that  is  violated  daily,  violated  by  those  whose  duty  it  is 
to  perform,  and  violated  by  those  who  have  it  in  their  power  to  encourage 
it.  Some  physicians  are  so  enthusiastic  about  their  ability  to  feed  their 
children  artificially  that  they  say  their  formulas  are  just  as  good  as  breast 
milk.  I  was  very  much  surprised  to  hear  that  one  prominent  pediatrician 
was  so  confident  of  his  type  of  feeding  that  he  was  willing  to  start  on  arti- 
ficial feeding  at  birth,  even  though  the  mother  was  capable  of  nursing  her 
child.  We  frequently  read  in  our  medical  advertisements  of  milk  prepara- 
tions whose  chemical  and  physical  properties  simulate  exactly  that  of 
mother's  milk.  If  only  one  could  keep  in  mind  the  fundamental  principle 
that  breast  milk  is  the  only  milk  for  babies  and  there  is  no  substitute  for 
it !  This  unwillingness  to  nurse  the  infant  is  occurring  so  frequently  that 
it  ought  to  be  considered,  as  it  is  in  many  countries,  a  social  problem.  I 
am  emphasizing  the  importance  of  breast  feeding  because  frequent  depar- 
ture from  this  method  to  that  of  artificial  feeding  is  in  a  great  degree  due 
to  the  doctors,  nurses,  and  public  health  workers  who  do  not  insist  upon 
such  a  procedure.  Perhaps  they  are  to  a  very  great  degree  influenced  by 
the  insistent  mother  who  feels  that  she  has  already  given  up  too  much 
time  to  the  baby  during  her  period  of  pregnancy  and  now  wants  a  bit  of 
freedom.  However,  she  ought  to  be  made  to  realize  that  her  responsibility 
to  the  child  does  not  end  with  its  delivery,  that  an  uncomplicated  feeding 
period  in  its  early  life  means  much  for  the  later  health  of  the  child.  She 
ought  to  be  told  that  every  woman  is  endowed  by  nature  with  a  capacity 
to  nurse  her  child.  Lactation  is  a  physiological  problem.  It  is  said  that 
during  pregnancy  the  foetus  probably  secretes  something  which  causes  the 
mammary  glands  to  hypertrophy  but  which  prevents  secretion  from  tak- 
ing place.  When  the  foetus  is  brought  forth  and  this  inhibition  ceases, 
this  process  is  reversed  and  secretion  takes  place.  It  would  be  a  pity  to 
feel  that  our  modern  mother  has  become,  to  such  a  degree,  a  subject  of  our 
highly  active  life,  full  of  distractions  and  nervous  tension,  that  it  has  in 
some  way  rendered  her  unfit  to  carry  on  the  responsibilities  that  come 
with  pregnancy.  And  it  would  be  more  unfortunate  if  she  were  found  to 
be  capable  of  performing  her  duty,  yet  were  unwilling  to  undertake  this 
task  because  of  the  distractions  of  her  social  life.  She  perhaps  sees  her 
neighbor  who  feeds  her  child  artificially  and  the  child  is  fat,  while  hers 


44 

seems  thin  and  does  not  look  as  attractive  as  her  neighbor's.  Perhaps  the 
mother  has  fallen  in  with  the  view  that  modern  science  has  succeeded  in 
developing  a  food  as  good  as  breast  milk.  She  must  be  told  that  one  of  the 
most  important  facts  in  the  study  of  infant  feeding  and  the  prevention  of 
gastro-intestinal  disturbances  in  infants  is  that  mother's  milk  is  the  only- 
food  for  babies.  Whatever  science  has  accomplished  in  the  past  in  its 
efforts  to  create  a  substitute,  the  result  has  been  an  inferior  one.  Distur- 
bances of  digestion  occur  more  frequently  in  infants  who  are  artificially 
fed  than  in  those  who  are  breast  fed.  No  matter  how  carefully  we  pre- 
pare cow's  milk  in  our  attempt  to  make  it  replace  that  of  woman,  no  mat- 
ter how  we  regulate  the  infant's  feeding,  and  fulfill  other  necessary  re- 
quirements, intestinal  disturbances  occur  more  frequently  than  when  the 
child  is  on  breast  milk.  If  disturbances  do  occur  in  the  breast-fed  infant, 
they  probably  are  associated  with  some  other  constitutional  disturbance, 
like  an  acute  infection  or  difficulty  in  the  feeding,  or  some  irregularity  in 
the  habits  of  the  mother. 

The  insistence  upon  breast  feeding  has  been  the  most  important  means 
in  reducing  infant  mortality.  Our  past  experiences  have  shown  us  that 
even  under  difficult  economic  conditions,  where  there  has  been  milk  and 
food  shortages,  breast  feeding  is  possible  in  most  of  the  women  in  spite 
of  the  unfortunate  environment  in  which  they  are  compelled  to  live.  Many 
a  mother  states  that  she  cannot  nurse  her  child  because  she  is  tired  and 
worried,  that  she  must  get  her  children  ready  for  school,  that  she  has  to 
prepare  her  husband's  breakfast,  and  she  feels  that  with  all  these  duties 
and  with  all  these  anxieties,  her  milk  will  be  of  no  value.  But  this  argu- 
ment can  be  answered  by  the  recent  reports  of  the  East  Side  of  New  York 
where  the  infant  mortality  is  very  low.  There  sanitary  conditions  are 
poor,  there  is  no  sunlight,  people  live  in  crowded  rooms,  the  food  supply  is 
certainly  scarce,  domestic  difficulties  are  numerous  and  finances  are  lim- 
ited. These  factors  certainly  ought  to  bring  about  unhappiness  and  irri- 
tability in  the  mother.  Yet  she  successfully  nurses  her  children  and  car- 
ries them  through  the  precarious  first  year  of  infancy.  The  element  of 
nervous  and  psychic  disturbances  in  the  nursing  mother  has  been  greatly 
exaggerated.  If  a  mother  is  nervous  she  may  bring  about  some  temporary 
reduction  of  the  milk  supply  merely  because  this  nervous  manifestation 
may  reduce  her  food  intake  or  may  interfere  with  her  rest.  Some  infants 
quickly  reflect  the  nervous  behavior  of  their  parent  and  under  such  ner- 
vous influence  may  become  tired  and  nurse  very  poorly.  The  mother  will 
frequently  offer  innumerable  reasons  why  she  ought  not  to  nurse  her 
child.  Actually,  there  is  only  one  condition  which  is  a  contra-indication 
for  nursing,  and  that  is  acute  tuberculosis  where  the  child  is  constantly 
exposed  to  infection.  All  other  conditions  like  insanity,  epilepsy,  acute  in- 
fections, post-eclampsia  and  nephritis,  post-partem  debility,  severe  hemor- 
rhage, anemia,  malignancy,  syphilis,  menstruation,  pregnancy,  and  cracked 
nipples  are  all  relative  and  each  condition  has  to  be  carefully  weighed. 

In  this  article,  I  have  discussed  several  phases  of  nutrition.  If  I  have 
left  nothing  more  with  you  than  the  realization  that  breast  milk  is  the 
only  type  of  food  for  an  infant,  I  shall  have  fulfilled  my  purpose.  I  do  not 
believe  that  we  are  fulfilling  our  duty  as  medical  advisor  unless  we  exert 
every  means  to  influence  our  patient  to  give  her  child  her  best  initial  in- 
vestment for  health,  and  which  is  our  best  means  of  insuring  this  infant 
against  the  rigorous  demands  of  infancy.  Do  not  be  ashamed  to  admit 
that  you  are  sufficiently  old-fashioned  to  spread  this  propaganda,  for,  in 
spite  of  our  temporary  acceptance  of  the  fads  and  fancies  of  our  day,  we 
ultimately  return  to  our  old  method  of  feeding. 


45  f 

INTERSTITIAL  KERATITIS 

Joseph  J.  Skirball,  M.D.,  Boston,  Mass. 

Interstitial  keratitis,  as  the  term  indicates,  is  a  diffuse,  chronic  inflamma- 
tion of  the  entire  corneal  tissue  (usually  of  syphilitic  origin)  involving  the 
cornea  proper,  particularly  in  its  middle  and  deep  layers.  It  is  character- 
ized conspicuously  by  the  absence  of  any  tendency  toward  ulceration  or 
suppuration.  There  is,  however,  an  infiltration  of  some  exudative  substance 
within  the  cornea  that  causes  varying  degrees  of  cloudiness  that  may  reach 
a  complete  opalescent  opacity. 

Etiology 

This  is  a  disease  of  the  young,  appearing,  as  a  rule,  between  the  sixth  and 
twentieth  year.  The  incidence  in  females  is  slightly  higher  than  in  males. 
It  is  commonly  accepted  that  congenital  syphilis  is  responsible  for  about 
eighty-five  per  cent  of  all  cases.  Tuberculosis,  acute  infectious  diseases, 
particularly  malaria,  also  contribute  to  the  etiology. 

Symptoms  and  Course 

Interstitial  keratitis  usually  involves  both  eyes,  although  the  intervals 
between  the  attacks  may  be  very  long  and  may  extend  over  a  period  of 
years.  This  affection  may  run  its  course  in  two  ways,  depending  whether 
or  not  the  center  or  the  margins  of  the  cornea  are  first  involved. 

If  the  disease  invades  the  center,  there  is  cloudiness  due  to  small  gray 
maculi  lying  in  the  middle  and  deep  layers.  The  surface  becomes  lusterless 
and  dull.  As  the  number  of  these  maculi  gradually  increases,  the  cloudiness 
extends  further  and  further  toward  the  margin,  but  they  are  always  massed 
most  thickly  in  the  center  where  they  become  confluent.  The  entire  cornea 
increases  in  its  diffuse  cloudiness  and,  in  severe  cases,  may  become  uniformly 
gray,  giving  a  ground  glass  appearance.  As  the  opacity  of  the  cornea 
advances  further,  vascularization  or  the  penetration  of  new  blood  vessels 
into  the  cornea  pours  over  different  spots  upon  the  corneal  circumference. 
These  vascular  trunks  branch  into  tufts  like  a  brush  into  the  deep  layers  of 
the  cornea  and  often  give  a  dirty  red  or  grayish  red  color  because  they  are 
covered  by  the  cloudy  superficial  layers  of  the  cornea. 

When  the  disease  begins  at  the  margin  of  the  cornea,  the  first  thing  that 
appears  is  the  loss  of  luster  and  cloudiness  at  one  or  more  spots  along  this 
margin.  Similar  areas  soon  form  at  other  spots  on  the  margin  and  usually 
find  their  way  concentrically  forward  over  all  sides  toward  the  center  of  the 
cornea.     This,  again,  is  followed  by  vascularization. 

When  the  keratitis  is  at  its  height,  the  cornea  is  often  so  opaque  that  one 
can  scarcely  recognize  the  iris  through  it.  At  the  same  time,  it  loses  its 
luster.  Vision  may  be  so  greatly  reduced  that  the  patient  may  only  perceive 
hand  movements. 

Interstitial  keratitis  always  runs  a  chronic  course.  The  inflammatory 
symptoms  become  progressively  worse  for  a  period  of  one  to  three  months 
until  the  disease  has  reached  its  height.  Then,  the  irritative  symptoms  very 
soon  abate  and  the  process  of  clearing  up  the  cornea  makes  rapid  progress. 
Afterward,  the  course  of  clearing  becomes  slower  and  the  center  of  the  cornea, 
in  particular,  becomes  opaque  and  cloudy  for  a  long  period  of  time  so  that  the 
restoration  of  sight  does  not  occur  until  late  in  the  disease.  Usually  from 
six  months  to  one  year  or  more  may  elapse  before  the  cornea  clears  to  a  good 
degree  of  transparency.  In  mild  cases,  the  course  may  be  considerably 
shorter. 

The  early  symptoms  are  cloudiness  or  dullness  of  the  cornea,  redness, 
ciliary  injection,  lacrimation,  photophobia  and  blurred  vision.  Marked 
irritative  symptoms  from  deeper  involvement  of  the  uveal  tract  (iris  and 
ciliary  body)  may  present  themselves  in  the  early  stages. 


46 
Diagnosis 

The  diagnosis  of  this  disease  is  not  difficult,  especially  in  cases  of  syphilitic 
origin.  With  the  above  enumerated  local  symptoms  and  signs,  one  sees 
the  usual  signs  of  congenital  syphilis:  square  forehead,  prominent  frontal 
eminences,  Hutchinson's  lines  and  scars  about  the  angles  of  the  mouth  and 
the  characteristic  peg  shaped  teeth.  The  Wassermann  and  Hinton  tests 
should  be  made  in  every  case. 

Treatment 

1.  Prophylactic. 

The  routine  blood  examination  for  syphilis  early  in  pregnancy  and  inten- 
sive anti-luetic  treatment  during  the  entire  prenatal  period  in  those  cases 
which  show  positive  reactions.  Late  research  along  this  line  has  shown 
convincingly  the  birth  of  infants  clinically  free  from  this  disease  with  nega- 
tive blood  reactions. 

2.  Constitutional. 

Early  intensive  anti-luetic  treatment  which  must  be  well  managed  over  a 
long  period  of  time.  Recent  work  has  shown  that  involvement  of  the  second 
eye  has  been  forestalled  or  prevented  by  this  routine.  Since  this  is  a  chronic 
disease,  the  importance  of  hygienic  measures:  good  food,  exercise,  regulation 
of  the  bowels,  etc.,  play  as  important  a  role  as  the  specific  drugs. 

3.  Local. 

Usually  the  early  period  of  progression  consists  in  protecting  the  eyes  from 
light.  This  is  usually  done  by  dark  glasses  and  placing  the  eye  at  rest  by 
instilling  atropine.  This  latter  drug  may  prevent  complications  which  may 
arise  from  involvement  of  the  iris.  Hot,  moist  compresses  will  relieve  the 
symptoms  of  irritation  and  pain.  Dionin  may  be  used  for  the  pain  and 
photophobia.  In  the  regressive  period,  attempts  at  clearing  the  cornea 
should  be  made  as  early  as  possible.  Dionin,  mercury  and  calomel  are  used, 
but  these  drugs  should  be  used  with  caution  and  under  the  guidance  of  one 
qualified. 

ORGANIZATION  OF  A  COMMUNITY  HEALTH  COMMITTEE 

Helen  M.   Hackett,   R.  N.,    Consultant  in  Public  Health  Nursing,   and 

Albertine  P.  McKellar,  Public  Health  Education  Worker,  Massachusetts 

Department  of  Public  Health 

An  all-inclusive  Community  Health  Committee  composed  of  representa- 
tives of  all  organizations  in  a  community  seems  to  be  a  solution  of  this  present 
multi-committee  problem.  Our  small  communities  and  even  our  larger 
ones  are  organized  and  re-organized,  and  in  many  cases  the  same  persons 
serve  on  all  the  committees. 

A  careful  scrutiny  shows  that  health  is  the  fundamental  objective  of  each 
committee.  The  Community  Health  Committee  tieing  up  and  at  the  same 
time  weeding  out  has  worked  successfully  in  many  of  our  Massachusetts 
communities. 

Organization  of  Communities 

The  procedure  of  community  health  organization  has  been  in  some  cases 
similar  to  this:  The  Public  Health  Nursing  Consultant  having  aroused  a 
desire  for  community  unification,  calls  a  meeting  of  all  key  persons  in  the 
community,  that  is,  the  chairman  of  the  board  of  health,  superintendent  of 
schools,  representatives  of  the  nursing  organizations,  representatives  of  the 
Women's  Clubs,  of  the  fraternal  organizations,  service  clubs,  churches,  the 
youths'  clubs  and  the  board  of  trade. 

The  scheme  of  community  health  organization  is  outlined  and  the  group 
is  urged  to  elect  a  Community  Health  Chairman.  Various  sub-committees, 
depending  upon  the  size  of  the  community,  are  immediately  appointed.  A 
publicity  committee  is,  however,  essential,  regardless  of  the  size  of  the 
Community  Health  Committee,  so  that  the  public  in  general  may  be  in- 
formed of  the  organization,  plans  and  procedures  of  such  a  Committee. 


47 
A  Community  Survey 

The  first  duty  of  a  committee  is  to  study  the  health  status  of  the  com- 
munity—what is  the  infant  and  maternity  death  rate?  How  does  it  com- 
pare with  other  communities  of  equal  population  and  facilities?  How  many 
beds  are  available  for  maternity  eases  and  what  provision  is  made  for  delivery 
service?  Is  the  milk  supply  properly  protected?  Is  the  water  supply  safe? 
Is  there  adequate  disposal  of  garbage  and  sewage?  Does  the  community 
understand  the  rules  of  communicable  disease  control  and  does  it  co-operate? 

Now  that  the  conditions  of  the  community  have  been  studied  and  certain 
short  comings  have  become  apparent,  the  next  step  is  to  consider  the  avail- 
able resources.  Each  organization  represented  should  be  given  an  oppor- 
tunity to  outline  its  particular  function  and  in  this  manner  familiarize  the 
others  with  its  special  aims  and  activities. 

Making  the  Most  of  Community  Resources 

The  Official  Group. 

The  board  of  health,  the  school  committee,  superintendent  of  schools, 
school  physician  and  school  nurse  are  valuable  assets  of  every  community. 
To  them  belong  the  vaccination  and  toxin-antitoxin  programs,  the  physical 
examination  and  the  follow-up  for  the  correction  of  defects  for  the  school 
child.  In  some  communities  prenatal  service,  pre-school  conferences  and 
dental  clinics  are  sponsored  by  the  official  group.  Summer  Round-Up  reg- 
istration, Summer  Round-Up  conference,  May  Day  Child  Health  Day  are 
often  included  as  additional  projects. 

The  Non-Official  Group. 

This  includes  the  Visiting  Nursing  Association,  the  Red  Cr,oss,  Parent- 
Teacher  Association,  Grange,  American  Legion,  service  clubs,  fraternal 
organizations,  women's  clubs,  youths'  clubs,  etc.,  whose  part  in  the  com- 
munity is  to  give  assistance  to  the  official  group  and  in  some  cases  carry  on 
worth-while  projects  which  have  not  as  yet  been  taken  over  by  the  official 
bodies.  The  non-official  group  in  many  communities  has  under  its  juris- 
diction the  prenatal  work,  the  postnatal  and  the  care  of  the  pre-school  child. 

Some  Things  Health  Committees  Have  Done 

Any  project  presented  to  this  group  and  in  turn  carried  to  each  organ- 
ization in  the  community  comes  in  for  the  best  kind  of  publicity.  In  this 
manner  the  Community  Health  Committee  has  been  able  to  spread  interest, 
understanding,  and  to  create  enthusiasm  and  action.  A  splendid  example 
is  the  project  aiming  to  have  children  who  are  entering  school  for  the  first 
time — Physically  Fit.  The  community  having  seen  the  tremendous  value 
of  such  an  undertaking  to  parent,  student,  teacher  and  school  passes  the 
word  along  into  each  organization  and  likewise  into  home  and  to  parents. 
Parents  convinced  of  the  importance  of  starting  to  school  with  no  remedi- 
able physical  handicaps  take  the  will-be  first  graders  to  their  family  physi- 
cians in  the  spring  and  energetically  devote  the  summer  to  the  correction 
of  defects. 

The  Community  Health  Committee  has  provided  transportation  for  cer- 
tain jobs  of  the  nurse — carrying  children  for  various  needs  such  as  to  the 
dentist,  clinics,  hospitals,  etc.  It  has  arranged  for  children  and  parents 
having  no  means  of  transportation  to  be  brought  in  to  conferences  and 
clinics.  The  nurse  is  much  too  valuable  a  person  to  spend  her  time  on 
transportational  troubles  of  this  type. 

The  Committee  has  helped  with  the  installation  of  a  school  lunch,  a  dental 
clinic,  or  an  improved  playground.  It  has  spread  the  school  Child  Health 
Day  celebration  out  into  the  town  by  arranging  for  health  window  displays 
in  the  store  windows,  by  urging  that  health  meetings  be  held  by  all  the 
community  organizations  during  the  week  of  the  school  celebration,  by 
requesting  that  health  receive  some  recognition  in  the  church  services— in 
short,  creating  a  community  health  consciousness  to  dovetail  with  that  exist- 
ing in  the  school. 


48 

Looking  Ahead 

The  Community  Health  Committee,  a  representative  group  which  aims 
to  promote  the  health — and  all  conditions  making  for  health  in  the  com- 
munity— is  fundamentally  sound.  Such  correlation  and  co-operation  in- 
volved in  its  plan  can  make  for  systematized  community-wide  health  work. 
Its  plan  of  procedure  reaches  directly  to  the  parent  who,  according  to  the 
slogan  of  the  American  Child  Health  Association  for  this  year,  is  the  ulti- 
mate objective  of  all  health  work.  The  1930  slogan  is:  "Every  Parent  and 
Every  Community  United  for  Health  for  Every  Child." 


1/ 


THE  VALUE  OF  CHILD  HYGIENE  PUBLICITY 

Florence  L.  McKay,  M.D. 
Department  of  Health  Education,  Radcliffe  College 


Publicity  is  the  spade,  the  hoe,  and  the  rake  of  the  Child  Hygiene  field. 
It  prepares  the  ground  for  the  seed  which  grows  into  Child  Hygiene  activi- 
ties, nourished  by  showers  of  dollars  and  the  sunshine  of  enthusiastic  effort. 
It  is  no  over-statement  to  say  that  publicity  is  as  necessary  to  the  Child 
Hygiene  field  as  garden  tools  to  the  garden. 

Granted  that  the  objective  of  Child  Hygiene  publicity  is  to  disseminate 
information  concerning  Child  Hygiene  conditions  to  the  public,  such  pub- 
licity should  have  the  following  three  attributes:  it  should  attract  attention, 
it  should  arouse  and  hold  interest,  and  it  should  incite  to  action.  These 
three  attributes  are  not  necessarily  contained  in  one  type  of  publicity.  The 
type  which  attracts  attention  must  be  spectacular,  and  the  more  flamboyant, 
the  more  attention  it  will  attract.  Once  the  attention  is  arrested,  the  interest 
may  be  held  by  presenting  the  facts  in  a  manner  easily  grasped  by  the  ob- 
server of  varying  intelligence.  An  appeal  to  the  emotions,  together  with  an 
understanding  of  conditions,  is  usually  an  incentive  to  action. 

The  value  of  Child  Hygiene  publicity  depends  in  a  large  measure  on  the 
groups  of  people  to  whom  an  appeal  is  made.  Publicity  directed  to  mothers 
is  very  likely  to  prove  fruitful.  An  intelligent  mother,  who  realizes  that  her 
child  is  receiving  less  in  the  way  of  health  advantages  than  should  be  his 
right,  is  from  that  moment  an  ally.  She  can  be  relied  upon  to  arouse  the 
interest  of  her  husband  and  friends,  often  to  the  extent  of  productiveness 
of  both  effort  and  funds.  If  she  realizes  that  danger  threatens  her  child, 
her  alliance  and  her  efforts  are  increased  in  vigor.  While  the  father  is  still 
weighing  the  evidence  presented,  the  mother  is  in  action,  and  her  interest 
is  usually  insurance  of  a  similar  reaction  from  the  father.  The  mother  can 
be  easily  reached  through  some  such  organization  as  the  Parent-Teacher 
Association,  the  school  and  the  church. 

Attractive  and  arresting  leaflets  delivered  with  bottles  of  milk  or  with 
groceries,  are  excellent  means  of  arousing  the  interest  of  mothers.  Women's 
clubs  usually  contain  fewer  mothers  of  young  children,  but  they  are  often  a 
source  of  help  in  Child  Hygiene  activities  because  they  have  more  members 
with  time  at  their  disposal,  and  their  intelligent  and  active  interest  in  com- 
munity affairs  attains  results. 

Priests,  Sunday-school  and  day  school  teachers  are  often  overlooked  as 
agents  for  the  spread  of  Child  Hygiene  publicity.  Their  interest  in  the  chil- 
dren of  the  families  under  their  care  and  instruction  can  invariably  be 
counted  upon. 

Another  desirable  group  to  be  reached  is  the  business  or  commercial  group. 
Here,  competitive  statistics  may  be  useful.  The  Chamber  of  Commerce  is 
aroused  by  the  fact  that  an  infant  mortality  rate  higher  in  their  town  than 
in  that  of  their  rival  reflects  upon  their  good  name.  The  rancor  aroused 
in  one  town  by  the  publication  of  a  chart  which  showed  an  infant  mortality 
higher  than  that  of  any  other  town  of  its  size  in  the  state,  is  a  matter  of  record 
in  state-wide  publicity,  as  is  also  that  town's  resulting  fervent  and  productive 
Child  Hygiene  activities.  Rotary,  Kiwanis,  Lion's  Clubs  and  fraternal 
orders  are  known  for  their  interest  and  generosity  in  the  cause  of  improving 


49 

the  health  of  children,  particularly  when  they  become  aware  that  conditions 
in  their  own  town  are  more  deplorable  than  those  in  neighboring  towns. 

Local  conditions  graphically  displayed  make  an  excellent  type  of  pub- 
licity and  have  a  special  appeal  to  the  citizens  of  the  town.  A  sudden  rise 
in  gastro-enteritis  morbidity  or  mortality  rate  which  implicates  the  milk 
supply,  an  increase  in  the  number  of  undernourished  children,  or  of  dental 
or  other  defects,  are  of  interest  to  the  entire  community.  The  Health 
Officers  and  school  physicians  are  good  sources  of  supply  for  local  statistics. 

Good  results  are  often  as  good  publicity  material  as  bad  statistics,  if  used 
with  care.  It  is  often  helpful  to  arouse  in  the  community  a  mild  feeling  of 
self-righteousness  and  superiority,  but  as  a  rule  good  results  should  be  occa- 
sionally flavored  by  a  dash  of  bad  conditions,  in  order  to  make  them  fully 
appreciated. 

Inflation,  or  overstatement  of  conditions,  is  bad  policy.  It  may  improve 
the  appearance  of  posters,  but  it  spoils  the  temper  of  the  public  and  incites 
anger  rather  than  action.  Animosity  can  easily  be  aroused  by  mis-state- 
ments, and  the  entire  Child  Hygiene  activities  suffer  as  a  result. 

Publicity  is  necessary  to  arouse  the  public  to  action,  but  it  is  equally 
necessary  after  action  is  started.  It  is  needed  to  keep  action  continuous 
and  productive.  A  public  kept  adequately  informed  of  the  progress  of  Child 
Hygiene  work  and  of  its  growing  needs  and  results,  is  far  more  likely  to 
remain  interested  and  active.  The  spade  may  seldom  be  needed  after  the 
seed  of  action  has  grown  to  its  fullness,  but  the  hoe  and  the  rake  can  never 
be  abandoned,  if  full  fruition  is  to  be  attained. 

LINKING  UP  THE  PRE-SCHOOL  CHILD  AND  THE  SCHOOL  CHILD 

Fredrika  Moore,  M.  D., 

Pediatrician,  Massachusetts  Department  of  Public  Health 

When  September  comes  with  the  hum  and  bustle  of  a  new  school  year, 
first  grade  teachers  throughout  the  State  are  wondering  what  kind  of  human 
material  will  be  theirs  for  fashioning. 

They  may  well  feel  awed  by  their  responsibilities  for  they  must  take  forty 
ego-centric  little  ones  who  have  heretofore  chosen  their  own  occupations 
and  have  run  and  played  at  will  and  mold  them  into  a  social  unit  without 
creating  a  sense  of  inferiority  in  the  under-privileged,  handicapping  the 
superior,  or  injuring  the  mental  or  physical  health  of  any  of  them.  Upon 
her  handling  depends  their  "set"  toward  the  rest  of  their  school  lives — there 
their  entire  attitude  toward  life. 

Earnest  effort  should  be  made  by  those  in  authority  to  lighten  her  load 
and  to  give  the  children  the  best  possible  start  on  the  first  and  perhaps  the 
most  crucial  year  of  their  whole  school  career. 

An  equal  start  is,  of  course,  impossible  because  of  different  hereditary 
and  environmental  backgrounds — but  if  the  to-be  first-graders  should  be 
given  a  mental  test  before  entering  school —  a  grouping  according  to  ability 
may  be  made,  or  at  least  the  teacher  may  know  the  potentialities  of  her 
charges  when  they  arrive,  which  will  save  her  a  number  of  weeks  in  discov- 
ering aptitudes.     She  should,  of  course,  not  take  an  I.  Q.  as  absolutely  final. 

If  in  addition  to  the  mental  test,  a  careful  history  of  habits  is  taken,  it 
will  reveal  some  children  who  are  showing  unfortunate  reactions  to  certain 
situations — one  is  overtimid,  another  has  temper  tantrums,  and  so  on.  The 
path  of  the  teacher  and  of  the  children  themselves  will  be  greatly  smoothed 
if  readjustments  can  be  accomplished  before  the  child  starts  school  life. 

Nor  is  this  all!  No  child  suffering  from  a  physical  handicap  can  profit 
by  his  school  work.  Even  one  abscessed  tooth  can  dislocate  the  disposition 
and  the  school  work  for  some  time.  Deafened  ears  may  make  a  child  appear 
inattentive  and  dull — organic  heart  trouble  may  necessitate  modification 
of  his  school  work  for  some  particular  child. 

So  in  addition  to  the  mental  test  and  habit  history  there  should  be  a  thor- 
ough physical  examination  with  the  emphasis  on  thorough.  It  should  not 
be  the  "I've  known  the  child  all  his  life  and  he's  all  right"  type,  but  careful 


50 

enough  to  permit  at  the  least  the  filling  out  accurately  of  the  required  school 
physical  record  cardl 

These  tests  and  examination  are  merely  preliminary  to  the  real  work  for 
the  child  which  is  to  make  him  fit  emotionally  and  physically  to  enter  school. 
They  should,  therefore,  be  made  in  the  Spring  before  school  entrance,  in 
order  that  there  may  be  an  opportunity  to  have  all  defects  which  are  correct- 
able attended  to. 

The  Parent-Teacher  Association,  with  the  hearty  endorsement  of  the 
State  Department  of  Public  Health,  has  for  a  number  of  years  been  urging 
these  examinations  with  the  correction  of  defects  under  the  name  of  "The 
Summer  Round-Up."  The  examinations  of  The  Summer  Round-Up  may 
be  made  in  several  ways — by  the  family  physician,  by  an  established  well 
child  conference,  or  by  a  conference  held  especially  for  prospective  school 
children. 

If  the  examinations  are  made  in  any  other  way  than  by  the  family  physi- 
cian he  should  receive  reports  on  his  patients.  It  is  not  within  the  province 
of  a  well  child  conference  to  recommend  any  particular  type  of  treatment. 
The  school  is  interested  in  sound  children,  but  it  feels  that  the  responsibility 
for  producing  them  lies  with  the  parents  and  the  physician  whom  they  select. 

The  interest  of  the  school  in  the  children's  health  is  partly  altruistic,  partly 
financial.  It  costs  considerable  to  educate  a  child  and  every  child  who 
repeats  a  year  is  an  added  drain  to  the  treasury.  Very  naturally  the  below 
par,  maladjusted  group  furnishes  the  most  repeaters.  Of  the  children  entering 
school,  64%  have  been  found  to  be  physically  defective,  so  the  school  is  well 
justified  in  any  effort  it  may  make  to  interest  parents  in  the  Summer  Round- 
Up,  while  parents  themselves  will  be  repaid  for  their  effort  by  happy  children 
who  make  good  progress  in  school. 

PATH-FINDING  IN  ADULT  HYGIENE 

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

If  you  and  I  were  starting  out  to  explore  new  country,  we  should  be  quite 
likely,  instead  of  plunging  into  a  trackless  wilderness,  to  follow  a  beaten 
track,  if  there  should  be  one,  leading  toward  our  destination. 

Adult  Hygiene  is  new  country  and  uncharted  so  far  as  the  organized  health 
forces  of  this  State  are  concerned.  The  field  of  Child  Hygiene,  on  the  other 
hand,  is  traversed  by  many  familiar  and  well-beaten  paths,  worn  smooth 
by  an  ever-increasing  army  of  health  workers  and  their  followers  who  have 
been  treading  these  paths  for  the  last  decade  and  more.  They  lead  toward 
certain  well-defined  goals — prenatal  care,  breast  feeding,  balanced  nutrition, 
correction  of  minor  defects.  Some  of  the  paths  are  clearly  indicated: — the 
teaching  of  health  habits,  instruction  to  mothers  in  child  care,  medical 
supervision  of  the  well  child. 

It  may  not  be  without  profit  for  us  to  follow  a  few  of  these  beaten  tracks 
to  see  if  any  of  them  lead  into  the  new  country  which  we  are  calling  Adult 
Hygiene.  There  are  certain  definite  objectives  before  us  in  that  unknown 
field,  in  some  of  which  we  hope  headway  can  be  made.  Heart  disease,  now 
our  leading  cause  of  death;  arthritis;  diabetes;  nephritis;  and  the  whole 
group  of  cardio-vascular  conditons — all  these  and  other  chronic  diseases 
that  commonly  affect  grown  persons  have  been  declared  by  those  who  know 
to  be  amenable  to  control  measures.  It  remains  to  be  proven  to  what 
degree  and  what  those  measures  may  be. 

One  of  the  well-trodden  paths  to  child  health  is  medical  supervision  of  the 
individual  child  from  the  beginning  of  pregnancy,  through  infancy  and  the 
pre-school  years  on  to  the  end  of  school  life.  The  principle  of  "keeping  the 
well  child  well"  works.  If  we  should  carry  that  principle  on  into  adult  life, 
might  it  not  be  that  new  interest  would  be  created  in  personal  individual 
health,  not  health  for  its  own  sake  alone,  but  health  for  the  increased  effi- 
ciency and  the  greater  enjoyment  of  life  it  can  bring? 

Many  a  grown  person  who  is  perfectly  familiar  with  the  hygiene  of  every- 


51 
day  life  fails  to  adopt  it  through  sheer  inertia,  the  feeling  that  it  is  all  very 
well  for  other  folks,  but  he  guesses  it  won't  make  much  difference  with  him; 
he'll  get  by.  Such  a  one  may  conceivably  be  shocked  into  action  if  he 
learns  his  own  condition  and  becomes  convinced  that  wholesome  living 
habits  will  really  enable  him  to  think  more  clearly,  to  double  the  amount  of 
work  done,  and  to  ecjoy  living  more  keenly.  Our  real  task  is  to  convince 
this  person.  The  first  step  toward  conviction  is  to  give  him  knowledge  of 
his  present  physical  state. 

Someone  has  said  ironically  in  speaking  of  health  among  adults,  "The 
task  of  keeping  well  is  really  that  of  not  becoming  any  sicker."  Even  if  we 
accept  this  pessimistic  view,  who  can  question  the  wisdom  of  finding  out 
just  how  sick  we  are  and  where  we  are  sick,  that  we  may  mend  our  ways 
before  we  become  sicker? 

May  we  not  venture  the  hope  that  in  this  way  we  may  occasionally  fore- 
stall or  at  least  postpone  an  early  or  threatening  diabetes,  arthritis,  nephritis, 
or  cardio- vascular  condition? 

We  may  well  follow  this  trail  of  medical  supervision  into  the  new  country 
of  Adult  Hygiene,  for  clearly  it  leads  in  the  direction  in  which  we  want  to  go. 

This  accepted  and  approved  road  to  child  health  has  led  to  the  discovery 
of  many  defects  little  suspected  by  parent  or  teacher.  In  the  lists  of  such 
defects  we  find  those  of  the  teeth  leading  all  the  rest,  while  after  teeth  follow 
defects  of  the  throat,  of  nutrition  and  a  dozen  others  only  less  common. 

Why  are  we  spending  so  much  time,  thought,  and  money  on  children's 
teeth?  We  have  surely  been  led  to  believe  that  focal  infection  originating 
in  the  teeth  will  be  a  lesser  evil  to  future  generations  because  of  the  attention 
given  to  children's  teeth  today.  We  may  ask  ourselves,  "Is  the  adult,  espe- 
cially the  young  adult,  giving  as  much  intelligent  care  to  his  teeth  as  he 
might,  in  the  light  of  modern  knowledge  be  giving,  with  due  promise  of 
reward?" 

If  we  note  the  promptness  with  which  food  deficiency  shows  its  effect  on 
the  tooth  structure  of  experimental  laboratory  animals,  even  those  fully 
matured,  we  cannot  fail  to  ask  if  all  our  grown  people  are  aware  of  the  possi- 
bilities of  a  clean  mouth  and  an  adequate  diet  in  the  preservation  of  tooth 
structure.  Is  it  too  late,  then,  to  learn  in  adult  years  that  sound  teeth  pay 
dividends  in  future  health?  It  seems  that  there  may  be  something  ahead 
for  us  down  the  road  to  dental  hygiene.     Let  us  follow  it  and  see. 

With  such  wholesale  slaughter  of  children's  tonsils  and  adenoids  as  has 
been  going  on  during  the  past  two  decades,  we  ought  soon  to  be  able  to 
judge  with  some  degree  of  accuracy  what  is  happening  in  the  physical  sphere 
to  the  former  possessors  of  those  tonsils  and  adenoids.  Has  rheumatic 
fever,  recognized  as  one  of  three  leading  causes  of  heart  disease,  become  less 
prevalent?  If  so,  has  such  lessened  incidence  of  acute  rheumatic  infection 
been  accompanied  by  a  corresponding  decrease  in  heart  disease? 

Here  we  seem  to  be  groping  our  way  on  a  blind  trail.  No  one  is  ready  to 
answer  that  question.  Is  there  not  in  this  very  uncertainty  a  challenge  to 
us  to  blaze  that  trail  a  little  further? 

One  cannot  help  wondering  if  anywhere  in  the  scientific  world  more  rapid 
developments  are  taking  place  than  in  the  knowledge  and  theory  of  foods 
and  their  action  on  the  animal  organism.  Changes  have  come  so  rapidly 
as  to  bewilder  teachers  and  pupils  alike.  No  sooner  has  a  long-suffering 
public  been  assured  of  the  value  of  vitamins  in  an  ever-lengthening  alphabet 
than  they  are  asked  to  divide  one  letter  of  that  alphabet  into  two  and  to 
add  another.  At  the  same  time  they  are  told  that  they  must  readjust  all 
their  former  ideas  to  this  newer  knowledge.  We,  who  feel  that  we  have 
something  to  teach,  must  keep  very  close  to  one  another  and  learn  to  talk 
the  same  language  if  we  hope  to  bring  order  out  of  chaos  in  the  minds  of  the 
people  when  we  try  to  teach  nutrition. 

The  people  need  help  and  I  believe  they  are  eager  for  it.  We  have  only 
to  watch  the  crowds  at  a  food  fair  or  a  cooking  demonstration,  to  be  con- 
vinced that  the  housewife  of  today  is  interested  in  foods.  Is  she  giving  her 
family  a  balanced  diet?  Have  her  children  brought  home  from  school  all 
that  she  needs  to  know  of  modern  nutrition?     Would  she  not  accept  and 


52 

profit  by  further  instruction  in  practical  problems  of  feeding  the  family?  I 
believe  she  would. 

As  to  the  possible  effect  of  such  teaching  in  the  actual  control  of  disease, 
we  may  note  the  frequency  with  which  such  terms  as  "unbalanced  nutrition," 
"improper  diet,"  "malnutrition,"  occur  in  all  discussions  of  the  causation  of 
diabetes,  nephritis,  and  others  of  the  group  of  chronic  diseases. 

Are  we  too  sanguine  as  we  venture  a  hope  that  with  improvement  in 
dietary  habits  there  may  be  shown  a  lessened  predisposition  to  arthritis, 
diabetes,  nephritis?  Even  in  cardiac  conditions,  in  no  way  directly  attrib- 
utable to  nutritional  states,  the  action  of  heart  muscle  is  undoubtedly  sus- 
tained by  sound  nutrition.  May  not  the  breakdown  of  function  in  the 
damaged  heart  thus  be  delayed  by  improved  nutrition? 

Perhaps  we  have  traveled  far  enough  for  one  ramble  from  the  land  of 
child  health  into  the  new  country  of  adult  health.  As  we  follow  these  few 
time-worn  trails  we  shall  find  by-paths  on  every  side  into  which  we  shall  be 
tempted  to  wander.  It  is  my  belief  that  much  will  be  gained,  however,  if  we 
follow  the  main  roads  and  abide  by  a  few  of  these  principles  of  child  hygiene 
which  experience  has  proven  to  be  sound  until  we  know  better  than  we  know 
today  whither  they  may  lead  in  this  new  region  which  we  have  called  Adult 
Hygiene. 

ADDRESS  GIVEN  BY  MRS.  CHARLES  SUMNER  BIRD  AT  A  MEET- 
ING OF   THE   COMMITTEE   ON   GOVERNOR  ALLEN'S   PUBLIC 
WELFARE  PROGRAM 

His  Excellency  Governor  Allen  in  his  address  to  the  General  Court  on 
January  1st  used  these  words: 

"Massachusetts  has  always  been  a  progressive  State.  Its  people  have 
always  faced  forward.  The  work  of  Government  is  never  complete.  In 
the  past  experiences  of  legislature  and  administration  we  have  our  guide 
for  the  continuing  advancement  of  the  public  welfare." 

We  are  all  proud  to  know  and  to  feel  that  Massachusetts  has  done  and  is 
doing  splendid  work  in  all  departments  of  Public  Welfare.  We  also  recog- 
nize, as  does  the  Governor,  the  need  for  what  he  calls  "continuing  advance- 
ment." 

The  health  of  our  State  is  its  greatest  asset.  So,  too,  is  the  neglect  of 
health  its  greatest  liability.  It  has  been  pointed  out  by  the  best-known 
and  most  reliable  experts  that  the  economic  waste  caused  by  preventable 
diseases  has  been,  and  is,  most  appalling.  The  annual  cost  to  Massachusetts 
of  the  waste  caused  by  preventable  disease  is  300  million  dollars.  It  is 
estimated  that  an  intelligent  and  business-like  expenditure  of  six  million 
dollars  would  save  this  annual  waste  of  300  million  dollars.  These  facts 
were  stated  in  the  last  issue  of  "The  Commonhealth"  in  an  article  by  Dr. 
Louis  I.  Dublin,  the  famous  statistician  of  the  Metropolitan  Life  Insurance 
Company.  It  is  to  be  hoped  that  they  will  gradually  permeate  the  public 
consciousness.  We  must  strain  every  nerve  to  make  healthy  facts  and 
information  as  contagious  as  the  diseases  which  we  have  to  fight. 

As  I  look  over  the  different  phases  of  work  done  for  health  betterment, 
which  His  Excellency  has  brought  to  our  notice,  and  the  suggestions  for 
further  improvement,  I  am  impressed  with  the  fact  that  they  are  all  curative. 
Should  we  not  pay  more  attention  to  preventive  measures?  We  have  all 
heard  the  old  adage  "An  ounce  of  prevention  is  worth  a  pound  of  cure"  and 
know  its  truth.  The  experience  of  the  world  informs  us  that  prevention  is 
less  costly  and  more  efficacious  than  redemption,  as  to  form  is  less  difficult 
and  less  consuming  of  all  things  than  to  reform.  The  cost  to  our  State  in 
charitable  and  penal  institutions  owing  to  health  conditions  amounted  to 
70  per  cent  of  our  budget  last  year,  to  say  nothing  of  the  untold  suffering 
and  misery  affecting  our  past,  our  present,  and  our  future  generations — 
most  of  it  caused  by  preventable  diseases  and  their  consequences. 

Take  tuberculosis  alone — a  cause  that  has  been  and  is  still  of  great  suffer- 
ing— yes,  of  supreme  scourging,  of  sorrow,  of  waste,  social  and  economic. 
Such  a  terrible  waste  in  broken  men  and  women  often  the  verv  flower  of  our 


53 

State — all  beyond  computation — and  understanding.  The  Governor  re- 
minds us  of  this  when  he  said  in  his  address:  "In  finding  satisfaction  with 
the  achievements  in  Massachusetts  in  its  efforts  to  control  and  to  lessen 
tuberculosis,  we  need  constantly  to  keep  in  mind  that  this  problem  is  not 
solved.  Continuous  effort  and  activity  are  necessary  to  insure  progress." 
Much  of  this  dread  disease  could  have  been,  and  can  be  prevented, — prob- 
ably most  of  it. 

May  I  call  to  your  attention  a  method  which  would  go  far  as  a  preventive 
measure, — periodic  examination.  The  value  of  periodic  health  examinations 
has  been  established.  It  is  far  more  important  that  we  should  have  an  ac- 
count taken  of  our  health  at  least  once  a  year  than  it  is  that  the  books  of 
our  businesses  should  be  balanced.  Health  is  wealth,  the  most  valuable 
form  of  wealth — yes,  even  calculated  in  dollars  and  cents. 

Periodic  examination  will  be  an  outstanding  preventive  measure  and  I 
make  a  most  earnest  appeal  for  this  splendid  method  of  taking  the  offensive 
against  disease,  and  somehow  to  make  it  a  rule  that  all  our  school  children 
shall  undergo  periodic  examinations.  May  it  become  a  habit  with  all  our 
people.  We  should  then  know  more  exactly  health  conditions  and  the  right 
measures  to  take  for  prevention  and  control.  Public  health  is  a  public 
function  and  all  means  to  that  end  should  be  controlled  by  the  State. 

We  have  a  Governor  in  whose  zeal  for  humanity  we  can  have  confidence. 
He  is  well  supported  by  officials  such  as  Mr.  Conant,  Dr.  Bigelow,  and  Dr. 
Kline.  But  neither  the  Governor  nor  his  trusted  lieutenants  can  go  farther 
than  public  opinion  will  allow.  The  main  function,  therefore,  of  this  Com- 
mittee, as  I  see  it,  is  to  do  everything  in  its  power  to  rally  public  support  to 
the  State's  Welfare  Programme.  "The  new  day,"  as  it  has  been  called,  is  a 
very  "live"  one  and  to  meet  the  vast  opportunities  for  further  enlightenment 
and  the  demands  which  will  come  in  consequence,  we  must  be  alert  and  able 
to  meet  them. 

In  contemplating  the  300th  anniversary  of  our  Puritan  settlement  we 
should  conceive  of  it  as  a  tremendous  historic  occasion  and  do  some  big 
things  to  commemorate  it.  The  Puritans  are  the  patriarchs  of  liberty. 
They  opened  a  new  world  on  earth.  They  opened  a  new  path  for  the  human 
conscience.  They  created  a  new  society.  We  owe  to  them  all  that  is  best 
in  this  country  today,  for  they  laid  the  foundations.  They  urged  to  "avoid 
the  plague  while  it  is  foreseen  and  not  to  tarry  till  it  overtakes  them."  It 
may  be  said  that  their  motto  was  "Prevention  as  well  as  redemption."  The 
Puritans  built  for  posterity.  "They  builded  better  than  they  knew."  Why 
should  not  we  also  build  for  posterity? 

The  first  care  of  these  settlers  of  Massachusetts  was  to  provide  universal 
education  and  universal  worship,  combatting  all  principles  and  institutions 
they  felt  dangerous  to  philanthropy  or  the  rights  of  mankind,  displaying  a 
keen  sense  of  the  needs  for  the  safeguarding  and  promotion  of  public  welfare. 

May  we  in  reverent  remembrance  commemorate  this  300th  anniversary 
by  erecting  or  establishing  something  that  will  be  a  great  and  lasting  con- 
tribution to  the  welfare,  progress,  and  general  prosperity  of  our  people.  We 
are  making  every  effort  in  "this  new  day,"  looking  toward  the  advancement 
of  peace  among  all  nations,  trying  to  join  hands  to  make  henceforth  a 
"mighty  trust  for  Peace."  Let  us  not— pray  let  us  not  suggest  anything  that 
will  suggest  a  glorification  of  war.  We  must  bend  all  our  energies — with 
due  consideration  for  our  national  security — to  eliminate  the  word  "war" 
from  our  minds,  hoping  fervently  that  the  fight  is  done  and  that  we  can 
"take  up  the  nobler  strife  of  budding  up  the  larger  inner  life."  So,  I  for 
one  urge  His  Excellency  and  this  Committee  to  give  their  thought  and  influ- 
ence for  a  memorial  that  will  be  great  and  most  effective  in  advancing  the 
general  welfare  of  our  people. 

There  is  at  present  a  discussion  as  to  a  suitable  war  memorial,  but  if  we 
sincerely  desire  to  have  peace  we  must  abandon  the  glorification  of  war. 
Why  should  not  Massachusetts  lead  the  way  and  set  herself  free  from  the 
malignant  spell  of  exalted  bloodshed?  Why  should  she  not  show  her  grati- 
tude to  her  sons  who  fell  by  devoting  some  of  her  beautiful  countryside  as 
a  sanctuary  of  health  and  recreation  for  their  children  and  their  children's 


54 

children?  We  are  honoring  the  memories  of  those  who  laid  the  foundations 
of  our  State.  Is  there  any  doubt  how  their  choice  would  have  fallen  as 
between  a  monument  to  the  glorification  of  war  and  a  sanctuary  for  health 
and  recreation,  accessible  in  these  days  to  hundreds  of  thousands  of  our 
citizens?  A  sanctuary  where  they  could  win  health  through  refreshment 
of  soul  and  body. 

THE  EIGHTH  NEW  ENGLAND  HEALTH  INSTITUTE 

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

During  the  Massachusetts  Tercentenary  the  New  England  Health  Insti- 
tute will  meet  in  Boston,  April  14  to  18.  Because  of  this  and  many  new 
features  in  the  program  which  will  attract  new  professional  groups,  we  expect 
an  attendance  of  at  least  three  thousand. 

These  Institutes  are  sponsored  primarily  by  the  Health  Departments  of 
the  six  New  England  States,  and  the  Federal  Public  Health  Service,  local 
health  authorities,  universities,  colleges,  and  professional  societies  co-operate. 
Some  of  the  new  features  are: 

1.     For  Doctors  and  Dentists 

Clinics  are  offered  for  doctors  only,  by  such  notable  visitors  as  Dr.  Blood- 
good  of  Baltimore,  Drs.  Stokes  and  Pelouze  of  Philadelphia,  Dr.  James 
Alexander  Miller  of  New  York,  Dr.  Hugh  Cabot  of  Ann  Arbor,  Michigan, 
Dr.  Chadwick  now  of  Detroit,  and  others.  Among  the  Boston  men  holding 
clinics  will  be  Doctors  Greenough,  Robey,  Joslin,  Osgood,  Place,  Morton 
Smith,  Solomon,  Hinton,  Cheever,  Blackfan,  Graves,  Richard  Smith,  George 
Minot,  and  others.  It  is  some  time  since  such  a  wealth  of  clinics  has  been 
available  at  one  time  in  Boston,  and  all  on  matters  of  pressing  moment  to 
the  public  health. 

In  the  Medical  Section  meetings  there  will  be  such  speakers  as  Dr.  Osgood 
on  Arthritis,  Dr.  Joslin  on  Diabetes,  Dr.  Hasseltine  on  Undulant  Fever, 
Dr.  Givan  on  Congenital  Syphilis,  Dr.  Polak  on  Preventive  Obstetrics, 
Surgeon  General  Cumming,  and  others. 

For  dentists,  clinics  will  similarly  be  offered  at  the  Harvard  and  Tufts 
Dental  Schools  and  the  Forsyth  Dental  Infirmary  on  such  subjects  as  Oral 
Infections,  Children's  Dentistry,  and  Mouth  Cancer.  There  will  also  be 
Dental  Section  meetings. 

2.     Adult  Hygiene  Section 

The  most  crushing  disease  problem  today  is  that  associated  with  late 
middle  life,  which  kills  over  60  per  cent  of  our  people.  Whether  health 
officers  like  it  or  not,  they  or  their  successors  will  be  more  and  more  forced 
to  take  active  cognizance  of  it.  The  various  important  diseases,  their  ex- 
tent, economic  distribution  and  control  will  be  considered.  Perhaps  this 
section  will  consider  matters  as  near  the  heart  of  public  interest  as  any. 

3.     For  Private  Duty  and  Institutional  Nurses 

Just  as  we  are  attempting  to  attract  clinicians  through  our  Medical  Sec- 
tion, as  contrasted  with  the  health  officers  who  have  their  Administration, 
Communicable  Disease,  and  other  sections,  so  we  are  offering  for  "clinical" 
nurses  a  special  section,  as  contrasted  with  the  Public  Health  Nursing  Sec- 
tion which  has  so  long  had  a  prominent  place  in  such  programs.  The 
"clinical"  nurse  has  an  enormously  important  relation  to  the  adequate  solu- 
tion of  the  communicable  and  chronic  disease  problems  that  beset  us.  Miss 
Johnson  of  the  Massachusetts  General  Hospital  is  chairman  of  this  Section. 
There  are  such  speakers  as  Dr.  Haven  Emerson,  Miss  Fox  of  the  Red  Cross, 
Miss  Rice  of  Simmons  College,  Miss  Cannon  of  the  Massachusetts  General 
Hospital,  and  the  like. 


55 
4.     For  Public  Health  Social  Workers 

Through  the  individualization  of  needs  to  resources  the  social  worker 
can  help  to  save  us  from  the  curse  of  mass  treatment  of  preventive  medicine, 
just  as  she  already  is  from  the  mass  treatment  of  curative  medicine.  The 
Section  will  be  chairmaned  bv  Miss  McMahon  of  the  Boston  School  of  Social 
Work. 

5.     For  Hospital  Executives 

With  the  hideous  onrush  of  hospitalization,  to  which  no  end  is  in  sight, 
and  the  increasing  prominence  of  hospitalization  in  any  discussion  of  acute 
or  chronic  disease,  it  seems  high  time  that  this  feature  of  public  health  should 
receive  more  than  passing  attention  in  the  Section  on  Administration.  For 
this  reason  we  have  a  Hospital  Section  chairmaned  by  Dr.  Wilinsky,  who  as 
hospital  executive  and  health  officer,  sees  all  aspects  of  this  problem.  Dr. 
Richardson  of  Providence  and  local  administrators  will  speak. 

Other  Sections 

In  addition,  there  will  be  the  sections  with  which  all  those  attending 
previous  Institutes  are  familiar,  such  as  Administration,  Communicable 
Disease,  Tuberculosis,  Venereal  Disease,  Laboratory,  Child  Hygiene,  Public 
Health  Education,  Sanitary  Engineering,  Public  Health  Nursing,  Food  and 
Drugs,  and  the  like. 

General  Interest 

With  twenty  sections,  each  with  their  own  program,  there  will  be  from 
three  to  five  meetings  synchronously  from  which  to  choose  at  the  Hotel 
Statler,  as  well  as  some  at  the  John  Hancock  Auditorium  and  the  various 
clinics  for  doctors  and  dentists.  The  Institute  dinner  and  dance  comes  on 
April  15.  Governor  Allen,  Mayor  Curley,  Dr.  Farrand,  President  of  Cor- 
nell University;  Dr.  Rankin,  of  the  Duke  Foundation;  and  Dr.  Greenough, 
President  of  the  Massachusetts  Medical  Society,  will  speak,  but  it  is  hoped 
that  all  will  dance.  Another  dinner  on  April  17th  will  be  held  by  the  Massa- 
chusetts Central  Health  Council  at  which  Professor  Winslow  and  others 
will  speak.  Luncheons  of  the  Massachusetts  Tuberculosis  League  (April 
17)  will  be  addressed  by  Dr.  Kendall  Emerson  and  of  the  Massachusetts 
Society  of  Social  Hygiene  (April  18)  by  Dr.  Hugh  Cabot. 

Besides  this  it  is  felt  that  very  general  interest  outside  the  various  pro- 
fessional fields  already  referred  to  will  be  felt  in  the  addresses  by  Dr.  Ray 
Lyman  Wilbur,  Secretary  of  the  Interior,  ,who,  besides  his  multiplicity  of 
other  interests,  is  just  now  chairman  of  President  Hoover's  White  House 
Conference  on  Child  Health  and  Protection  and  of  the  Committee  on  the 
Cost  of  Medical  Care;  by  Dr.  Richard  Cabot,  who  will  speak  on  "Individ- 
ualization in  Public  Health";  by  Dr.  C.  C.  Little  of  the  American  Society 
for  the  Control  of  Cancer  and  the  Roscoe  B.  Jackson  Memorial  Laboratory 
at  Bar  Harbor,  who  will  talk  on  "Heredity  and  the  Public  Health";  by  Dr. 
Gladys  Dick  on  "The  Control  of  Scarlet  Fever";  by  Dr.  Alfred  Worcester 
on  "Social  Hygiene  and  the  College  Student";  by  Mr.  Frank  Winsor  on 
"The  Metropolitan  Water  Supply";  by  Professor  Milton  J.  Rosenau  on 
"Pasteurization";  by  Professor  C.  E.  Turner  on  "Health  Education";  by 
Dr.  Frost  of  Baltimore  on  "Influenza,"  and  others. 

It  is  a  long  while  since  so  many  persons  of  quality  have  been  brought 
together  in  the  name  of  public  health  in  Massachusetts.  May  we  in  New 
England  be  not  found  wanting  in  our  ability  to  profit  thereby. 


56 

Editorial  Comment 

Child  Health  Day  and  Summer  Round-Up,  1930.     Great  things  are  expected 

for  Child  Health  Day  and 
Summer  Round-Up  in  this  Massachusetts'  Tercentenary  Year.  Child 
Health  Day  programs  in  the  various  towns  will  naturally  include  recognition 
of  the  celebration  going  on  all  over  our  State.  The  demonstration  pageant 
as  given  by  the  State  Departments  of  Education  and  Public  Health  sets  forth 
ideals  of  healthy  living  in  simple  pictures  of  Indian  and  Pilgrim  life,  inform- 
ally presented.  The  pageant  was  an  effort  to  demonstrate  the  value  of  a 
Child  Health  Day  program  to  the  children  themselves  and  to  emphasize 
the  value  of  simplicity  and  originality  in  such  projects.  On  this  pageant 
are  founded  the  suggestions  for  plays,  pantomime  and  games  offered  for  use 
in  the  schools. 

The  1930  slogan  of  the  American  Child  Health  Association  puts  the  burden 
of  keeping  the  child  well  on  to  his  parents.  It  is  "Every  parent  and  every 
community  united  for  health  for  every  child." 

As  heretofore,  health  reward  tags  will  be  used  for  the  school  children — 
a  Physically  Fit  tag,  an  Improvement  tag,  and  a  Teeth  tag.  The  Physically 
Fit  tag  is  a  practical  application  of  the  1930  slogan,  placing  as  it  does  respon- 
sibility upon  the  parents  for  the  prevention  and  correction  of  defects.  With- 
out the  parents'  co-operation  such  community  undertakings  as  these  will 
be  of  little  value.  A  booklet  describing  the  tags  and  giving  a  list  of  material 
available  will  be  sent  upon  request  to  those  interested.  Practically  three- 
fourths  of  our  towns  ordered  Child  Health  Day  material  for  use  in  their 
schools  in  1929. 

Accompanying  Child  Health  Day  is  the  Summer  Round-Up  plan.  Its 
single  aim  is  to  have  the  children  who  are  to  enter  school  for  the  first  time 
in  September  arrive  well  prepared,  that  is,  with  all  remediable  defects  cor- 
rected and  with  vaccination  and  toxin  antitoxin  inoculation  accomplished. 
A  booklet  of  suggestions  for  Summer  Round-Up  is  also  available,  in  which 
plans  for  spring  registration  of  the  children  who  will  enter  school  for  the 
first  time  in  the  fall,  examination,  fodow-up  work  and  correction  of  defects, 
are  outlined.  Printed  suggestions  for  publicity,  window  displays  and  a 
poster  for  use  in  each  of  these  projects,  have  also  been  prepared. 

One  hundred  and  ninety-five  towns  in  Massachusetts  held  their  Summer 
Round-Up  last  year.  About  20  per  cent  of  the  entering  school  children 
were  examined,  and  as  over  half  of  this  group  showed  defects  needing  atten- 
tion we  are  convinced  of  the  necessity  of  a  careful  physical  examination  by 
the  family  doctor  of  every  child  who  is  to  enter  school  for  the  first  time  in 
the  fall.  This  examination  should  be  done  two  months  before  school  opens 
in  order  that  the  parents  may  have  ample  time  to  get  defects  corrected, 
vaccination  done  and  T.  A.  T.  completed.  Here  again,  the  responsibility 
of  the  parent  is  emphasized  in  preparing  the  child  for  school. 

Our  Tercentenary  Year  may  well  be  a  "banner"  year  with  both  Child 
Health  Day  and  Summer  Round-Up.  May  every  town  be  wide  awake  to 
the  needs  of  its  youngest  citizens  and  make  ready  early  in  the  year  to  offer 
the  help  that  Child  Health  Day  and  Summer  Round-Up  can  bring  to  the 
community  in  its  effort  to  increase  health  and  happiness  in  home  and  school. 

Well  Child  Conferences  in  1929.     Well  Child  Conferences  were  held  in  the 

twenty-five  towns  in  Franklin  County  and 
1,505  children  examined,  61  per  cent  showing  defects. 

Outside  of  Franklin  County  Demonstration  Well  Child  Conferences  were 
held  in  twenty-two  towns  and  700  children  were  examined,  making  a  total 
of  2,205  chddren  examined. 

In  the  Franklin  County  work  we  find  the  total  per  cent  of  children  with 
defects  decreasing  somewhat,  70  per  cent  at  the  first  conferences  in  1927  and 
61  per  cent  at  the  third  conferences  in  1929.  An  increase  in  the  per  cent  of 
defects  corrected  is  also  encouraging — 10  per  cent  of  the  children  examined 


57 

at  the  second  conferences  (1928)  had  had  defects  corrected  and  19  per  cent 
at  the  third  conferences  (1929). 

Twelve  per  cent  of  the  twenty-two  conferences  held  outside  Franklin 
County  were  planned  to  be  demonstrations  of  the  Summer  Round-Up,  and 
in  most  of  these  towns  it  is  expected  that  the  Summer  Round-Up  will  be 
carried  on  annually  hereafter  by  the  local  organizations. 

Demonstration  Well  Child  Conferences  have  now  been  held  in  189  of  our 
355  townships,  and  in  nearly  every  instance  we  can  feel  that  this  project 
has  been  definitely  useful  in  increasing  interest  in  child  hygiene  with  the 
mothers,  nurses,  and  community  generally. 

News  Notes 

HOW  TO  ATTEND  THE  NEW  ENGLAND  HEALTH  INSTITUTE 

Mildred  E.  Kennedy 

Massachusetts  Department  of  Public  Health 

The  New  England  Health  Institute  is  to  be  held  this  year  at  the  Hotel 
Statler  in  Boston,  Massachusetts,  April  14  to  18,  inclusive. 

This  being  the  Tercentenary  Year,  a  large  influx  of  visitors  to  the  city  is 
expected. 

Special  clinics  for  doctors  and  dentists  and  new  sections  on  Adult  Hygiene, 
Dentistry,  Hospitals  and  Public  Health  Social  Work  will  doubtless  result 
in  a  larger  attendance  than  is  usual  at  the  Institute. 

Clinics  will  be  held  Tuesday,  Wednesday,  Thursday  and  Friday  mornings 
from  10:00  to  12:00  at  the  various  Boston  hospitals  and  dental  schools. 
(See  Preliminary  Program,  pages  23  to  25.) 

Section  meetings  will  be  held  at  the  Hotel  Statler,  April  14  to  18,  in  the 
Ballroom,  Foyer,  Georgian  Room,  Parlors  A,  B,  C.  D,  and  also  at  the  John 
Hancock  Hall,  90  Saint  James  Avenue.  Lectures  begin  mornings  on  the 
half  hour,  afternoons  on  the  hour.  Each  lecturer  will  speak  for  forty  min- 
utes. There  will  be  ten  minutes  aUowed  for  discussion  and  an  interval  of 
ten  minutes  between  lectures. 

To  insure  giving  the  greatest  possible  benefit  with  a  minimum  of  effort,  a 
few  hints  may  be  in  order. 

Registration 

Clinics  for  Doctors  and  Dentists. 

Register  at  once,  using  blank  on  page  22  in  the  Preliminary  Program. 
Show  your  preference  for  clinics  in  squares  by  numbers  1,  2,  3,  etc.,  for  each 
morning.  Registration  fee  for  clinics  and  lectures  complete  is  $1.00.  As 
soon  as  blank  is  received  at  the  Institute  Headquarters,  clinic  tickets  will  be 
forwarded.     Make  check  payable  to  the  New  England  Health  Institute. 

At  the  Graduate  Course  in  Cancer  last  year,  there  were  many  disappoint- 
ments among  both  doctors  and  dentists,  because  they  had  either  failed  to 
register  or  to  signify  the  order  of  clinic  preference.  Therefore,  overcrowded 
clinics  failed  in  their  purpose  to  some  extent. 

The  capacity  of  the  amphitheatres  ranges  from  35  to  150.  Admission 
is  by  ticket  only,  tickets  being  assigned  in  order  of  receipt  of  registration. 
When  one  clinic  is  filled,  the  second  choice  is  assigned,  and  so  on. 

Section  Meetings. 

As  an  attendance  of  some  3,000  is  expected,  much  confusion  will  be  elim- 
inated by  early  registration  by  mail.  Registration  blanks  (page  30,  Prelim- 
inary Program)  sent  to  State  Department  of  Public  Health,  Room  315, 
15  Ashburton  Place,  Boston,  Mass.,  will  insure  your  lecture  card  being  ready 
at  the  Registration  Desk,  Mezzanine  Floor,  Hotel  Statler.  If  you  have  not 
received  a  program,  write  for  one. 


58 

Hotel  Reservations 

Make  Hotel  Reservations  Early.  The  increased  demand  for  accommo- 
dations already  noted  makes  it  advisable  to  do  this  at  once. 

Information 

For  information,  on  arrival,  go  to  the  Information  Desk  on  the  Mezzanine 
Floor,  Hotel  Statler.  Prior  to  the  opening  of  the  Institute,  information 
may  be  had  by  writing  to  the  State  Department  of  Public  Health,  Room 
315,  15  Ashburton  Place,  Boston,  Mass.,  or  telephoning  the  State  Depart- 
ment of  Public  Health,  Haymarket  6011. 

New  England  Health  Institute  Banquet  and  Ball 

Tuesday,  April  15th,  at  the  Hotel  Statler  at  7:00  P.  M.  in  the  Ballroom, 
•15.00  per  plate.  Speakers:  His  Excellency,  Governor  Frank  G.  Allen; 
His  Honor,  Mayor  James  M.  Curley;  Dr.  Livingston  Farrand,  President 
of  Cornell  University;  Dr.  W.  S.  Rankin,  Director  of  Hospital  and  Orphans 
Section  of  the  Duke  Foundation;  Dr.  Robert  B.  Greenough,  President  of  the 
Massachusetts  Medical  Society.  Send  reservation  blank  to  State  Depart- 
ment of  Public  Health,  Room  315,  15  Ashburton  Place,  Boston,  Mass. 

Dinners  and  Luncheons 

The  following  dinners  and  luncheons  will  be  held  during  the  New  Eng- 
land Health  Institute.  Reservations  should  be  in  the  hands  of  the  person 
in  charge  before  April  10th.  Fill  in  reservation  blanks  found  on  pages  30 
and  31  in  the  Preliminary  Program  and  send  as  indicated. 

The  Association  of  Women  in  Public  Health  Dinner  at  the  Pioneer  (Y.  W. 
C.  A.),  410  Stuart  Street,  Wednesday,  April  16th,  at  6:30  P.  M.,  $1.50  per 
plate.  Miss  Elizabeth  Fox,  Director  Public  Health  Nursing  Service  of  the 
American  Red  Cross,  will  be  the  speaker.  Send  reservation  blank  to  Dr. 
Fredrika  Moore,  Room  546,  State  House,  Boston,  Mass. 

The  New  England  District  of  the  American  Association  of  Hospital  Social 
Workers  Dinner  at  the  Women's  Republican  Club,  Wednesday,  April  16th, 
at  6:30  P.M.,  $1.25  per  plate.  Send  reservation  blank  to  Miss  Ruth  Brad- 
ford, Treasurer,  25  Bennet  Street,  Boston,  Mass. 

The  Massachusetts  Tuberculosis  League  Luncheon  for  its  members, 
Georgian  Room  of  the  Hotel  Statler,  Thursday,  April  17th,  at  1:00  P.M. 
Dr.  Kendall  Emerson,  Managing  Director  of  the  National  Tuberculosis 
Association,  will  speak. 

The  Massachusetts  Central  Health  Council  Dinner  at  the  Georgian  Room 
of  the  Hotel  Statler,  Thursday,  April  17th,  at  6:30  P.M.,  $3.00  per  plate. 
Official  Welfare  Program,  International,  National,  and  State.  Speakers: 
Professor  C. — E.  A.  Winslow  of  the  Yale  University  School  of  Medicine — 
International;  Dr.  Eugene  L.  Bishop,  Commissioner,  Tennessee  Depart- 
ment of  Health — National;  and  Mr.  Christian  A.  Herter,  Boston — State. 
Send  reservation  blank  to  Mr.  Frank  Kiernan,  1149  Little  Building,  Boylston 
Street,  Boston,  Mass. 

Massachusetts  Society  for  Social  Hygiene  Luncheon  at  the  Georgian  Room 
of  the  Hotel  Statler,  Friday,  April  18th,  at  1:00  P.M.,  $1.50  per  plate.  Dr. 
Hugh  Cabot  of  the  University  of  Michigan  Medical  School  will  be  the 
speaker.  Send  reservation  blank  to  Robert  M.  Tappan,  Treasurer,  41 
Mount  Vernon  Street,  Boston,  Mass. 

The  committee  in  charge  is  desirous  of  making  it  easy  for  everybody 
attending  the  Institute  to  receive  the  greatest  possible  advantage  from 
clinics  and  lectures  offered.  To  this  end  it  is  expected  that  members  will 
make  practical  use  of  the  Information  Service  whenever  questions  arise 
relative  to  the  arrangements  of  the  Institute. 

Summer  School  of  School  Nursing  and  Dental  Hygiene 
The  State  Normal  School  at  Hyannis  will  again  open  its  doors  for  the 
summer  session  to  nurses  and  dental  hygienists  as  well  as  teachers.     The 
mingling  of  these  groups  gives  to  each  a  better  understanding  of  the  prob- 
lems of  the  other. 


59 

Hyannis  is  by  the  shore  on  Cape  Cod,  which  insures  a  cooi  climate  during 
the  warm  weather  and  an  opportunity  for  bathing  and  other  outdoor  sports, 
which  is  an  advantage  for  nurses  who  take  their  vacations  for  study.  Part 
of  each  day  is  supposed  to  be  spent  either  out  of  doors  or  in  rest.  Three 
class  periods  a  day  are  permitted,  but  fewer  may  be  taken.  At  the  end  of 
nine  courses  satisfactorily  completed  a  nurse  receives  a  certificate  signed 
by  the  Commissioners  of  Health  and  Education.  Three  of  these  courses 
may  be  taken  at  other  institutions  if  they  are  acceptable  to  this  Department. 

These  courses  are  open  to  graduate  nurses  doing  or  desiring  to  do  school 
nursing,  whose  qualifications  are  satisfactory.  Tuition  is  free  to  nurses 
living  or  working  in  this  State.     For  others  there  is  a  fee  of  $20. 

The  1930  session  opens  June  30th  and  runs  for  six  weeks. 

The  Dental  Hygiene  Course  is  open  to  graduate  dental  hygienists  who  are 
doing  school  work  or  plan  to  do  it.  A  certificate  will  be  given  on  the  com- 
pletion of  six  courses.  Further  information  about  these  courses  may  be  ob- 
tained from  the  State  Department  of  Public  Health,  545  State  House,  Boston. 

This  Department,  together  with  the  Department  of  Education,  also 
offers  two  courses  for  teachers  who  desire  more  preparation  for  their  health 
teaching — one  on  School  Hygiene  and  Health  Education,  and  the  other, 
Factors  which  Influence  Health — the  latter  being  designed  to  give  a  factual 
background  for  health  teaching. 

Summer  Courses  in  Public  Health  and  Biology 

Courses  in  Public  Health  and  Biology  which  have  been  given  for  several 
years  past  by  the  Massachusetts  Institute  of  Technology  will  be  repeated 
this  summer. 

Following  is  a  list  of  the  courses  offered: 
Methods  of  Teaching  General  Biology. 
Bacteriology. 

Health  Education  Methods. 
Health  Education  Subject  Matter. 
Public  Health  Laboratory  Methods. 

A  Public  Health  Institute  for  Health  Officers  and  Other  Public  Health 
Workers. 
Further  information  regarding  the  courses  may  be  had  by  applying  to 
the  Committee  on  Summer  Session,  Massachusetts  Institute  of  Technology, 
Cambridge,  Massachusetts. 

Maternal  Deaths  in  Massachusetts 

Puerperal  septicemia 

Puerperal  albuminuria  and  convulsions 

Puerperal  hemorrhage    

Other  accidents  of  labor 

Cesarean  section    26 

Other  surgical  operations  and  instrumental  de- 
liveries         4 

Others  under  this  title    34 

Puerperal  phlegmasia  alba  dolens,  embolus,  sud- 
den death  

Accidents  of  pregnancy    

Abortion   12 

Ectopic  gestation 16 

Others  under  this  title    10 

Puerperal  diseases  of  breast 

Following  childbirth  (not  otherwise  defined) 

Total  456  486 

♦From  the  Annual  Report  of  tne  Vital  Statistics  of  Massachusetts. 


1928* 

1927 

123 

141 

98 

122 

86 

58 

64 

26 

9 
37 

72 

46 

59 

38 

8 
15 

7 

30 

1 

1 

0 

3 



m 

60 

Maternal  death  rate 5.8  5.9 

(456  deaths) 

Infant  death  rate 64 . 7       64. 7 

(5,118  deaths) 

There  were  89  cities  and  towns  from  which  maternal  deaths  were  reported. 
The  classification  used  is  that  of  the  International  List  of  Causes  of  Death. 

First  International  Congress  on  Mental  Hygiene 
To  be  held  at  Washington,  D.  C,  May  5-10,  1930 

Preliminary  Announcement 

There  will  be  a  maximum  of  discussion  and  a  minimum  of  formal  reading 
of  papers  at  the  morning  sessions.  A  chief  aim  of  the  Committee  is  to 
arrange  the  program  of  these  morning  (discussion)  sessions  so  as  to  encourage 
the  fullest  possible  exchange  of  ideas  and  information,  to  stimulate  debate 
on  specific  issues,  and  to  make  the  sessions  of  lively  interest  to  all  present. 
The  evening  general  meetings,  as  is  usual  at  such  sessions,  will  be  devoted 
to  addresses,  without  discussion. 

To  insure  ampler  time  for  discussion  at  the  morning  sessions,  formal 
papers,  prepared  for  the  occasion,  and  listed  in  the  official  program,  will  not 
be  read  in  full.  The  authors  of  such  papers  will  make  a  brief  verbal  summary 
of  their  papers  in  advance  of  the  discussion.  The  prepared  papers  will  be 
printed  in  full,  however,  in  the  official  languages  of  the  Congress,  English, 
French  and  German,  and  will  be  available  in  pamphlet  form  to  members  of 
the  Congress  in  advance  of  the  sessions. 

Selected  individuals,  who  will  have  studied  the  formal  papers  in  advance, 
will  open  the  discussions,  which  thereafter  will  be  open  to  members  of  the 
Congress.  Those  who  prepare  original  papers  may  take  the  floor  at  the 
end  of  the  discussion  period,  if  they  desire,  to  answer  questions  and  sum  up 
the  discussion. 

There  will  be  no  official  or  formal  sessions  of  the  Congress  in  the  afternoon. 
Afternoons  will  be  free  for  recreation;  for  informal  gatherings  of  various 
kinds;  for  informal  conferences  of  persons  interested  in  special  phases  of 
mental  hygiene  work. 

Among  the  subjects  to  be  discussed  at  the  morning  sessions  are  those  listed 
below.  These  subjects  are  not  to  be  understood  as  titles  of  papers,  but  as 
general  descriptions  of  suggested  topics. 

Partial  List  of  Subjects  for  Morning  Sessions 

a.  Magnitude  of  the  mental  hygiene  problem  as  a  health  problem. 

b.  Organization  of  community  facilities  for  prevention,  care  and  treatment. 

c.  Organization  of  the  mental  hospital  and  its  role  in  community  life. 

d.  Psychopathic  hospitals  and  psychopathic  wards  in  general  hospitals. 

e.  Care  and  treatment  of  mental  patients  outside  of  institutions. 

f.  Organization  of  special  types  of  clinical  service,  as  in  courts  of  justice, 

out-patient  departments  of  hospitals,  community  clinics,  grade  and 
high  school  clinics,  college  clinics,  and  clinics  in  social  welfare  agencies. 

g.  Types  of  personnel  required  in  mental  hygiene  work  (physician,  psy- 

chologist, nurse,  social  worker,  and  occupational  therapist). 

h.     Methods  of  training  of  different  types  of  personnel. 

i.      Clinical  and  social  research  in  the  field  of  mental  hygiene. 

j.  Teaching  of  mental  hygiene  and  psychiatry  in  the  medical  schools:  (1) 
courses  for  the  general  student;  (2)  courses  for  the  student  special- 
izing. 

k.     Mental  hygiene  in  industry,  personnel  work  and  vocational  guidance. 

1.      Psychiatric  social  work;  its  scope  and  functions. 

m.  Mental  hygiene  aspects  of  delinquency,  dependency,  and  other  types  of 
social  maladjustment. 

n.     Marital  relationships. 


61 

o.     Social  aspects  of  mental  deficiency. 

p.     Mental  hygiene  and  education;   grade  school,  high  school,  college. 

q.     Special  problems  of  adolescence. 

r.  Problems  presented  by  children  of  special  type:  (1)  the  child  with  supe- 
rior intelligence;  (2)  the  neurotic  child;  (3)  the  child  with  sensory  and 
motor  defects. 

s.     Methods  and  possibilities  of  the  child  guidance  clinic. 

t.  Significance  of  parent-child  and  teacher-child  relationships  in  character 
and  personality  development. 

u.     Parent  and  teacher  training. 

v.     Mental  hygiene  of  religious,  ethical  and  moral  teaching. 

w.    Problems  of  the  pre-school  period. 

x.  Significance  of  these  problems  for  the  future  of  the  child  as  individual 
and  as  citizen. 

y.  Possibilities  in  the  future  of  human  relationships  in  the  light  of  an  in- 
creasing knowledge  of  those  factors  that  help  and  hinder  the  emo- 
tional, physical,  and  intellectual  development  of  the  individual. 

Full  membership  in  the  First  International  Congress  is  open  to  individuals 
upon  application  to  the  Administrative  Secretary  (Mr.  John  R.  Shillady) 
at  370  Seventh  Avenue,  New  York  City,  U.  S.  A.,  upon  payment  of  five 
dollars  ($5.00),  or  its  equivalent  in  the  money  of  any  given  country.  Full 
membership  entitles  a  member  to  receive  all  notices,  announcements  and 
publications  of  the  Congress,  including  the  Proceedings  of  the  sessions,  as 
and  when  published.  Checks  or  drafts  or  money  orders  should  be  made 
payable  to  Thomas  W.  Lamont,  Treasurer,  and  forwarded  to  the  Adminis- 
trative Secretary  of  the  Congress. 

Membership,  without  the  printed  Proceedings,  which  will  contain  the 
papers  presented  at  the  Congress,  is  three  dollars  ($3.00) ;  the  Proceedings, 
if  ordered  separately,  will  be  three  dollars  and  fifty  cents  ($3.50),  which,  as 
now  estimated,  will  be  less  than  the  cost  of  preparation  and  printing. 

Headquarters  for  the  First  International  Congress  on  Mental  Hygiene 
are  to  be  established  at  the  Hotel  Willard  in  Washington,  D.  C,  at  which, 
during  the  Congress,  the  Congress  Bureau  and  Headquarters  will  be  located. 
The  headquarters  of  the  American  Psychiatric  Association  is  to  be  at  the 
Hotel  Willard,  that  of  the  American  Association  for  the  Study  of  the  Feeble- 
minded at  the  Hotel  Washington,  a  few  doors  distant. 

Railroad  rates  in  the  United  States  and  Canada:  All  the  railroad  com- 
panies of  the  United  States  and  Canada  offer  reduced  rates  for  the  round 
trip,  to  all  who  travel  by  rail  to  attend  the  First  International  Congress,  of 
one  and  one-half  times  the  single  fare. 

Massachusetts  Department  op  Mental  Diseases  Quarterly  Bulletin 

We  note  with  interest  the  "Danvers  Hospital  Number"  of  the  quarterly 
Bulletin  of  the  Massachusetts  Department  of  Mental  Diseases. 

Among  the  interesting  articles  is  one  entitled  "The  Importance  of  Mental 
Hygiene  in  the  Public  Health  Program"  by  C.  A.  Bonner,  M.  D.,  Superin- 
tendent of  the  Danvers  State  Hospital. 

For  further  information  regarding  the  bulletin  address  the  Department  of 
Mental  Diseases,  State  House,  Boston,  Mass. 


62 

Book  Notes 

From  Boston  to  Boston 

By  Annie  Russell  Marble,  Boston:  Lothrop,  Shepard  and  Company, 
1930.     300  pp.     Price,  $2.00. 

Annie  Russell  Marble  has  given  us  a  delightful  story  of  childhood  of  three 
hundred  years  ago. 

Over  in  Old  Boston  a  prospective  trip  across  the  bleak  ocean  made  Hannah 
and  Richard  Garrett  eager  with  enthusiasm.  Their  young  minds  conceived 
only  the  joyous  and  adventurous  prospects  of  this  serious  and  courageous 
undertaking. 

Preparations  completed,  Richard  Garrett,  his  wife,  Mercy,  and  their 
three  children  sailed  on  the  "Arabella"  on  April  5th  ("at  the  rate  of  5  pounds 
each  for  a  person,  4  pounds  for  goods,  and  minor  children  carried  free"),  and 
landed  in  Salem  Harbor  on  June  14th.  The  children  "enjoyed  tag  and  other 
games  on  deck"  between  spasms  of  sickness  of  the  sea. 

The  settling  of  New  Boston  brightened  with  numerable  adventures  of  the 
children,  comprises  the  rest  of  the  book.  A  description  of  Hannah's  treat- 
ment by  theNauset  Indians  shows  the  sterling  qualities  of  our  first  Americans. 

It  is  most  apropos  that  "From  Boston  to  Boston"  should  be  published  in 
this,  the  Tercentenary  year.  Here  is  good  foundational  material  for  the 
building  of  pageants,  plays  and  pantomimes,  a  wealth  of  information  con- 
cerning home  life  among  our  earliest  settlers  and,  all  in  all,  an  interesting 
novel  for  both  children  and  grown-ups. 

Children  Well  and  Happy 

There  has  been  issued  a  revised  edition  of  "Children  Well  and  Happy"  by 
May  Dickinson  Kimball,  R.  N.,  Chairman  of  the  Mothercraft  and  Child 
Welfare  Department  of  the  Massachusetts  State  Federation  of  Women's 
Clubs. 

All  royalties  from  the  sale  of  the  book  go  by  arrangement  with  the  pub- 
lisher to  the  Mothercraft  Maintenance  Fund. 

Copies  of  this  book  may  be  obtained  from  the  Massachusetts  State  Fed- 
eration of  Women's  Clubs. 

The  Public  Health  Nurse — March  Number 

The  March  number  of  The  Public  Health  Nurse  contains  three  long  arti- 
cles which  touch  the  rural  nurse,  the  urban  nurse,  and  all  nurses. 

They  are: 

"Trail  Blazing  in  Social  Work,"  by  Katharine  D.  Hardwick  of  the  Boston 
School  of  Social  Work.  The  article  presents  the  problem  of  social  service 
work  which  the  rural  nurse  faces. 

"Public  Health  Nursing  under  the  Englewood  Plan,"  by  Mary  E.  Edge- 
comb  of  Englewood,  N.  J.,  which  describes  an  unusually  successful  amalga- 
mation of  public  health  nursing  and  hospital  service  work. 

And  for  all  nurses,  "A  Community  Program  in  Mental  Hygiene,"  by 
Stanley  P.  Davies. 

The  first  report  of  the  study  of  industrial  nurses  which  is  being  carried  on 
by  the  N.  O.  P.  H.  N.  is  also  in  this  number. 


63 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  October,  November,  and  December,  1929,  samples 
were  collected  in  212  cities  and  towns. 

There  were  1,856  samples  of  milk  examined,  of  which  345  were  below 
standard;  from  24  samples  the  cream  had  been  in  part  removed,  and  29 
samples  contained  added  water. 

There  were  757  samples  of  food  examined,  of  which  246  were  adulterated. 
These  consisted  of  2  samples  of  cream  which  were  not  labeled  in  accordance 
with  the  law;  170  samples  of  eggs,  45  samples  of  which  were  sold  as  fresh 
eggs  but  were  not  fresh,  116  samples  were  cold  storage  not  marked,  and  9 
samples  were  decomposed;  7  samples  of  maple  syrup  which  contained  cane 
sugar;  44  samples  of  sausage,  21  of  which  contained  starch  in  excess  of  2 
per  cent,  1  of  which  also  contained  coloring  matter,  16  contained  a  com- 
pound of  sulphur  dioxide  not  properly  labeled,  and  7  samples  contained 
coloring  matter;  3  samples  of  hamburg  steak  which  contained  a  compound 
of  sulphur  dioxide  not  properly  labeled;  4  samples  of  vinegar  which  were 
low  in  acid;  5  samples  sold  as  butter  which  proved  to  be  oleomargarine,  4 
of  which  contained  coloring  matter;  1  sample  of  ammonia  not  bearing  the 
poison  label  as  required  by  law;  1  sample  of  dried  apricots  containing  sul- 
phur dioxide  not  properly  labeled;  2  samples  of  olive  oil  which  contained 
cottonseed  oil ;  1  sample  of  relish  which  contained  broken  glass ;  4  samples  of 
eider,  all  of  which  were  adulterated  as  they  contained  sugar  and  water ;  and 
2  samples  of  mattress  fillings  improperly  labeled  as  to  the  character  of  ma- 
terial used  for  filling. 

There  were  37  samples  of  drugs  examined,  of  which  9  were  adulterated. 
These  consisted  of  9  samples  of  spirit  of  nitrous  ether,  all  of  which  were 
deficient  in  the  active  ingredient. 

The  police  departments  submitted  1,491  samples  of  liquor  for  examina- 
tion, 1,468  of  which  were  above  0.5  per  cent  in  alcohol.  The  police  depart- 
ments also  submitted  20  samples  of  narcotics,  etc.,  for  examination,  10  of 
which  were  morphine,  3  opium,  1  tincture  of  iodine,  1  syrup  of  squill,  1  white 
powder  which  was  sodium  sulphite,  1  sample  examined  for  ergot  with  nega- 
tive results,  1  sample  of  cigarettes  examined  for  tobacco  with  negative 
results,  1  sample  of  a  tea  infusion  which  was  examined  for  poison  with  nega- 
tive results,  and  1  a  pink  liquid  which  showed  it  to  consist  of  alcohol,  ether, 
water  and  salt,  and  was  colored  with  a  dye  (magenta).  The  Amesbury 
Hospital  submitted  1  sample  of  pills  which  contained  strychnine;  The  Fish 
and  Game  Division  submitted  1  sample  of  frankfort  sausage  which  con- 
tained strychnine;  the  Watertown  Board  of  Health  submitted  1  sample  of 
apples  which  was  tested  for  poisons  with  negative  results,  and  the  Walpole 
Police  submitted  1  sample  of  milk  which  was  tested  for  poisons  with  negative 
results. 

There  were  16  bacteriological  examinations  made  of  milk,  and  4  bacterio- 
logical examinations  made  of  candy. 

There  were  18  bacteriological  examinations  made  of  soft-shell  clams, 
shucked,  none  of  which  were  polluted. 

There  were  96  hearings  held,  19  pertaining  to  violations  of  the  Pasteuriz- 
ing Laws  and  Regulations,  27  pertaining  to  violations  of  the  Milk  Laws,  47 
pertaining  to  violations  of  the  Food  and  Drug  Laws,  and  3  pertaining  to 
violations  of  the  Slaughtering  Laws. 

There  were  65  cities  and  towns  visited  for  the  inspection  of  pasteurizing 
plants,  and  221  plants  were  inspected. 

There  were  107  convictions  for  violations  of  the  law,  $2,108  in  fines  being 
imposed. 

Linus  Adler  and  Iver  Werner  of  Ashby;  Frank  Alibozek  of  Adams;  Es- 
telle  Beattie  of  Harwichport;  Max  Deeg  and  Nina  C.  Ferguson  of  Salisbury; 
John  Dmytryck  of  Millis;  James  J.  Sughrue  of  Whitinsville ;  Apolnaire 
Dragon  of  Easthampton;  James  F.  Leland  of  Framingham;  Forrest  W.  Rust 
of  Topsfield;  Herbert  H.  Whitcomb  of  Littleton;  Paulina  Bigis  of  Chicopee; 
John  Dundulis  of  Norwood;  Charles  M.  Edwards  of  Sterling;  H.  P.  Hood  & 
Sons,  Incorporated,  of  Maiden;    Thomas  L.  Hynes  of  Wayland;    Harry  J. 


64 

Jermyn  of  Marblehead;  Agatha  Sankalowitz  of  Millville;  Angelo  Zanchi 
of  Natick;  John  D.  Brown  of  Fitchburg;  Fred  Zamboni  of  Plymouth; 
Charles  Bury  and  Alexander  Caras  of  Taunton;  and  Louie  George,  2  cases, 
of  Sturbridge,  were  all  convicted  for  violations  of  the  milk  laws.  Apolnaire 
Dragon  of  Easthampton,  Paulina  Bigis  of  Chicopee,  appealed  their  cases. 

Waldorf  System  Incorporated  and  Maurice  M.  Mades  of  Boston;  George 
Corey  and  Wadae  Maloof  of  Lawrence ;  First  National  Stores  Incorporated, 
2  cases,  of  Framingham;  Caron  Magloire  of  Fitchburg;  William  Stewart,  2 
cases,  of  South  Barre;  Robert  Stringer  of  Lowell;  Harry  Wong  and  Waltham 
Provision  Company  Incorporated,  of  Waltham;  Christy  Ganas  of  Webster; 
and  Michael  Borowick  of  Fali  River,  were  all  convicted  for  violations  of  the 
food  laws. 

Donato  Greco  and  Louis  Squatrito  of  Lawrence;  Isadore  Krazitz  and 
Rhodes  Brothers  Company  of  Brookline;  Sarkis  Boyajian  of  Lowell;  The 
Cloverdale  Company  of  Taunton;  First  National  Stores,  Incorporated,  of 
Waltham;  Edward  Spieler  of  Methuen;  James  Van  Dyk  Company  of 
Springfield;  John  A.  Zuskiewicz  of  Southbridge;  Lawrence  E.  Conrad  of 
Peabody;  and  First  National  Stores,  Incorporated,  of  Blackstone,  were  all 
convicted  for  false  advertising. 

Rosario  Contarino,  Ned  Fichera,  Antonio  Iannucelli,  John  Zinno,  John 
Balian,  Guisseppe  Cappalano,  Salvatore  Di  Barba,  and  Stanley  Grotsky, 
all  of  Lawrence;  Samuel  Hodes  of  Worcester;  Edward  Bouchard,  Israel 
Chanski,  Napoleon  Laporte,  Nelson  Nersasian,  Felix  C.  Rybicki,  and  Lewis 
Sobocinski,  all  of  Salem;  Rhodes  Brothers  Company  of  Brookline;  Joseph 
Arciszewski  of  Maynard ;  Stanley  Klek  and  John  Zagorski  of  Ware ;  Steven 
Pantapas,  Clement  L.  Gutsky,  George  Laberis,  Alex  Dzierzak,  James  Ballas, 
Antonio  Phillips,  Allie  Doffiiar,  Anthony  Sacovitch,  all  of  Peabody;  Frank 
Bonerba,  Oreste  Cerulli,  Michael  Ricci,  Frank  Corte,  Joseph  Pevrisky,  and 
Michael  Pisani,  all  of  Beverly;  Charles  F.  Clement  and  Joseph  Skomial  of 
Holyoke;  Francis  E.  Donald  of  Erving;  Tefoil  Eliase,  Andrew  Gawell,  and 
Wasyl  Patrylo,  all  of  Blackstone;  Mack  Georgeson  and  Fred  J.  Whitcomb 
of  Clinton;  George  Jeranian  of  Watertown;  Nicholas  Mann  and  James  F. 
Pine  of  Fitchburg;  John  J.  Tracey,  McPherson  Symmes  Market,  Incorpo- 
rated, Joseph  F.  Silva,  and  Roland  H.  Smith,  all  of  Gloucester;  Oci  K. 
Monohan  of  Pittsfield;  and  John  C.  Morey  and  James  Ross  of  Newbury- 
port,  were  all  convicted  for  violations  of  the  cold  storage  law.  Michael 
Ricci  and  Michael  Pisani,  both  of  Beverly;  and  Joseph  F.  Suva  of  Gloucester, 
appealed  their  cases. 

Dzois  Dairy  and  H.  P.  Hood  of  Fall  River  were  convicted  for  violations 
of  the  pasteurizing  law. 

Great  Eastern  Bedding  Company  of  Roxbury,  and  National  Mattress 
Company  of  Boston,  were  convicted  for  violations  of  the  mattress  law. 
Each  company  appealed  their  case. 

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  packages 
from  manufacturers,  wholesalers,  or  producers: 

Milk  which  contained  added  water  was  produced  as  follows:  1  sample 
each,  by  Charles  Bury  of  Taunton,  and  Ralph  Packard  of  Northampton. 

Two  samples  of  milk  which  had  the  cream  removed  was  produced  by 
Ralph  Packard  of  Northampton. 

Cream  which  was  not  labeled  in  accordance  with  the  law  was  obtained  as 
follows: 

One  sample  each  from  First  National  Stores,  Incorporated,  of  Framing- 
ham,  and  Brockton  Public  Market  of  Brockton. 

Four  samples  of  cider  which  were  also  labeled  "Apple  Jack"  and  were 
misbranded,  as  they  contained  no  apple  jack,  were  obtained  from  Causeway 
Bottling  Company  of  Boston. 

Maple  syrup  which  contained  cane  sugar  was  obtained  as  follows:  2 
samples,  from  A.  E.  Skinner  of  Meirose;  1  sample  each,  from  The  Atlantic 
&  Pacific  Tea  Company  of  Florence;  Asia  American  &  Chinese  Restaurant 
of  Marlboro;  Union  Street  Market  of  Ayer;  and  Coney  Island  Lunch  of 
Webster. 


65 

One  sample  of  olive  oil  which  contained  cottonseed  oil  was  obtained  from 
Laconia  Grocery  Company  of  Boston. 

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

Two  samples  each,  from  Globe  Provision  Company  of  Fall  River;  Eugene 
Barthel  of  Gardner;  Albert  W.  Manley  of  Methuen;  Henry  Staveley  of 
Fitchburg;   and  Herbert  K.  Smaha  of  Lawrence. 

One  sample  each,  from  Swanson  Brothers,  Depot  Cash  Market,  Dionne 
Brothers,  and  Robert  Stringer,  all  of  Lowell;  Carl  A.  Weitz  of  Boston; 
Magloire  Caron  of  Fitchburg;   and  William  Stewart  of  South  Barre. 

Sausage  which  contained  coloring  matter  was  obtained  as  follows: 

Five  samples,  from  J.  Correia  &  Son  of  South  Dartmouth;  and  1  sample, 
from  Joseph  Flynn  of  Lowell. 

One  sample  of  sausage  which  contained  starch  in  excess  of  2  per  cent,  and 
also  contained  coloring  matter,  was  obtained  from  William  Stewart  of  South 
Barre. 

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

One  sample  each,  from  Joseph  Trytko  of  Easthampton;  Arthur  H.  Las- 
selle  of  Northampton;  Peter  H.  Laurion  of  Florence;  August  Kisiel  of  Ware; 
Michael  Gritz  of  Adams ;  and  McCann  Brothers  and  Wallace  Bell  of  Lawrence. 

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

One  sample  each,  from  The  Great  Atlantic  &  Pacific  Tea  Company  of 
Whitinsville ;  Sirloin  Store  of  Lynn;  and  Waltham  Provision  Company, 
Incorporated,  of  Waltham. 

Vinegar  which  was  low  in  acid  was  obtained  as  follows:  2  samples,  from 
Charles  F.  Cushman  of  Rock;  and  1  sample,  from  S.  J.  Andrews  of  Bay  State. 

There  were  sixteen  confiscations,  consisting  of  six  cases  (300  pounds)  of 
decomposed  eggs,  12  dozens  of  decomposed  eggs;  28  pounds  of  tainted 
chickens,  32  pounds  of  decomposed  fowl,  51  pounds  of  decomposed  turkeys, 
25  pounds  of  decomposed  poultry,  75  pounds  of  decomposed  beef,  44  pounds 
of  tainted  lamb,  14  pounds  of  decomposed  hamburg  steak,  5  pounds  of  de- 
composed pig's  liver,  2  pounds  of  decomposed  pig's  liver,  25  pounds  of  tainted 
bacon,  and  100  pounds  of  decomposed  pork  products. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  September,  1929:  772,440  dozens 
of  case  eggs;  668,248  pounds  of  broken  out  eggs;  1,821,472  pounds  of  butter; 
1,426,151  pounds  of  poultry;  4,534,752  pounds  of  fresh  meat  and  fresh  meat 
products;    and  3,574,353  pounds  of  fresh  food  fish. 

There  was  on  hand  October  1,  1929:  9,230,130  dozens  of  case  eggs; 
1,930,542  pounds  of  broken  out  eggs;  14,836,171  pounds  of  butter;  3,906,- 
293 K  pounds  of  poultry;  12,565,506%  pounds  of  fresh  meat  and  fresh  meat 
products;   and  22,771,986  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  October,  1929:  643,830  dozens 
of  case  eggs;  642,053  pounds  of  broken  out  eggs;  1,385,374  pounds  of  but- 
ter; 1,888,829%  pounds  of  poultry;  4,401,695  pounds  of  fresh  meat  and 
fresh  meat  products;   and  5,006,290  pounds  of  fresh  food  fish. 

There  was  on  hand  November  1,  1929:  6,722,430  dozens  of  case  eggs; 
1,801,386  pounds  of  broken  out  eggs;  13,069,257  pounds  of  butter;  4,987,- 
068%  pounds  of  poultry;  8,630,275%  pounds  of  fresh  meat  and  fresh  meat 
products;  and  21,679,578  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  November,  1929: — 348,990  dozens 
of  case  eggs;  620,412  pounds  of  broken  out  eggs;  846,584  pounds  of  butter; 
2,326,123  pounds  of  poultry;  4,132,657  pounds  of  fresh  meat  and  fresh  meat 
products;   and  3,292,773  pounds  of  fresh  food  fish. 

There  was  on  hand  December  1,  1929:—  4,091,325  dozens  of  case  eggs; 
1,653,112  pounds  of  broken  out  eggs;  9,694,577  pounds  of  butter;  6,420,- 
8663^  pounds  of  poultry;  8,874,242  pounds  of  fresh  meat  and  fresh  meat 
products;   and  18,441,366  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 

Division  of  Communicable  Diseases    . 

Division  of  Water  and  Sewage  Lab- 
oratories  

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. 

Charles  B.  Mack,  M.D.,  Boston. 

Wilson  W.Knowlton,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 


PU3LSCATI0N    OF    THIS    DOCUMENT   APPROVED    BY    THE    COMMISSION    ON    ADMINISTRATION    AND    FlNANOB 

6,500.      3-30.    Order  8261. 


suibHOuae,  boston 


THE 
COMMONHEALTH 


Volume  17  ^y       Apr.-May-June 

NO.  2  ,    ^   |  1930 


THE  DEAF 

AND 

HARD  OF  HEARING 


MASSACHUSETTS 
DEPARTMENT  OF  PUBLIC  HEALTH 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston   Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 
Hygiene  and  Physiology  of  the  Normal  Ear,  by  Philip  E.  Meltzer, 

M.D .69 

Ear  Aches,  by  Margaret  Noyes  Kleinert,  M.D.       .  .  .71 

Abstracts  from  The  Treatment  of  Chronic  Running  Ears  or  Chronic 
Suppurative    Otitis   Media,   by   George    Morrison    Coates, 

A.B.,   M.D 74 

The  Education  of  the  Hard-of-Hearing  and  Deaf,  by  Arthur  B.  Lord     78 
Diagnostic  Clinics  for  the  Deafened,  by  Edmund  Prince  Fowler, 

M.D.       ...  79 

The  Teacher's  and  Nurse's  Part  in  Detecting  Hearing  Defects,  by 

Fredrika  Moore,  M.D 82 

The  4-A  and  Other  Audiometers,  by  Mrs.  James  F.  Norris  82 

Group  Service  and  Use  of  the  4-A  Audiometer  in  Schools  of  Ply- 
mouth County,  Mass.,  by  Anna  J.  Foley,  R.N.  .  85 
National  Work  for  the  Deaf  and  the  Hard  of  Hearing,  by  Gordon 

Berry,  M.D 88 

The  Use  of  Hearing  Aids,  by  Mrs.  James  F.  Norris         .  .  .92 

Lip  Reading  in  Massachusetts,  by  Ena  G.  MacNutt  .  .96 

Hearing  Defects  in  the  Pre-School  Child,  by  Susan  M.  Coffin,  M.D.     99 
Please  Walk  In,  by  Mildred  Kennedy   ......    101 

Editorial  Comment: 

Mental  Hygiene  and  the  Eye,  Ear,  Nose  and  Throat  Specialist  104 
News  Notes: 

The  Beverly  School  for  the  Deaf  as  an  Educational  Institution, 

by  Helen  Wales 104 

"Dental  Clinics"  by  Frank  A.  Delabarre,  D.D.S.     .  .107 

The  Scope  and  Aim  of  the  Committee  on  the  Cost  of  Medical 

Care 109 

Survey  ..........    Ill 

Hearing  of  School  Children  as  Measured  by  the  Audiometer 

and  as  Related  to  School  Work        .  .  .  .    Ill 

Book  Note — The  Diagnosis  of  Health,  by  William  R.  P.  Emer- 
son,  M.D Ill 

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

March,  1930 112 


69 

HYGIENE  AND  PHYSIOLOGY  OF  THE  NORMAL  EAR 

Philip  E.  Meltzer,  M.  D. 
Boston,  Mass. 

Part  I — Anatomy  and  Physiology 

The  physiology  of  the  ear  is  difficult  to  understand  unless  one  has  made 
a  special  study  of  its  component  parts  anatomically.  I  assume  that  the 
majority  of  the  readers  of  this  article  are  not  familiar  with  the  ear 
apparatus  and  I  have,  therefore,  prepared  the  subject  in  an  elementary 
manner. 

The  ear  apparatus  in  man  serves  a  twofold  function;  namely,  hearing 
and  assisting  in  the  maintenance  of  equilibrium.  Anatomically  the  ear 
is  composed  of  three  parts,  (1)  external  ear,  (2)  middle  ear,  (3)  internal 
ear.  The  first  two  deal  exclusively  with  the  conduction  of  sound  waves 
to  the  third  part,  namely,  the  inner  ear  which  receives  the  sound  waves 
which  are  ultimately  carried  to  the  brain  centers.  It  also  contains  the 
organs  which  deal  with  maintaining  our  equilibrium  whether  in  motion 
in  the  three  dimensions  of  space,  or  when  at  rest,  also  in  vertical  or 
forward  motion. 

It  appears  then,  that  the  external  and  middle  ear  are  purely  mechanical 
in  function,  while  the  internal  ear  is  a  highly  specialized  structure  with 
direct  connection  with  the  central  nervous  system  (brain  and  spinal 
cord) . 

The  external  ear  consists  of  the  auricle  and  external  canal.  The  auricle 
exists  essentially  for  the  purpose  of  catching  the  sound  waves  and  direct- 
ing them  inward  into  the  canal  to  the  drum  membrane  which  blindly  closes 
off  the  inner  end  of  the  canal.  At  the  outer  end  of  the  canal  we  see, 
particularly  in  the  adult  male,  many  short  hairs  which  serve  to  prevent 
foreign  substances  from  entering  it.  We  also  find  at  this  end  many  wax 
or  cerumen  glands  which  normally  secrete  a  light  brownish  sticky 
material.  This  ear  wax  or  cerumen  may  accumulate  to  such  a  degree  so 
as  to  obstruct  the  passage  of  sound  waves  to  the  drum  membrane. 

The  middle  ear  proper  is  a  surprisingly  small  chamber  interposed 
between  the  external  and  internal  ear.  However,  it  has  within  it,  or 
associated  with  it,  many  structures  which  give  this  particular  cavity 
great  clinical  importance.  Diseases  affecting  this  part  interfere  greatly 
with  its  function,  resulting  in  deafness.  I  will  briefly  mention  the  com- 
ponent parts  of  the  middle  ear  with  a  word  about  their  function.  The 
drum  membrane  is  a  rather  strong  fibrous  membrane  stretched  across  the 
inner  end  of  the  canal  and  separates  the  external  ear  from  the  middle  ear. 
It  is  an  important  part  of  the  middle  ear  mechanism,  as  we  shall  see. 
Within  the  middle  ear  cavity  we  have  three  extremely  small  bones  called 
the  ossicles.  These  bones  are  united  by  ligaments  and  act  in  such  as  a 
unit  in  conducting  the  sound  waves  to  the  inner  ear.  The  malleus  is 
firmly  attached  to  the  drum  membrane  while  the  stapes  lodges  in  a 
window  leading  into  the  inner  ear;  the  third  ossicle,  the  incus,  is  inter- 
posed between  the  two  mentioned.  There  are  muscles  attached  to  the 
first  two  mentioned  which  act  as  antagonists  so  that  violent  movements 
against  the  drum  would  not  force  the  stapes  into  the  inner  ear  too  far, 
and  they  also  permit  fine  movements  to  be  amplified.  Thus  it  will  be 
seen  that  normally  sound  waves  are  caught  by  the  auricle,  shunted  into 
the  canal  to  the  drum  membrane,  thence  through  the  chain  of  ossicles  in 
the  middle  ear  where  they  are  either  toned  down  or  amplified,  through 
the  stapes  into  the  inner  ear  where  the  waves  are  transmitted  to  the 
organs  of  Corti  which  is  the  specialized  structure  receiving  the  sound 
waves. 

The  eustachian  tube  is  a  very  important  structure,  which  extends  from 
the  middle  ear  chamber  to  the  space  called  the  nasopharynx.  This  space 
lies  behind  the  nose  just  above  the  level  of  the  soft  palate.     This  tube 


70 
opens  and  closes  during  the  act  of  swallowing,  permitting  air  to  enter  the 
middle  ear  cavity.  Any  interference  with  the  patency  of  this  tube  causes 
symptoms  which  sooner  or  later  affect  the  function  of  the  conducting 
apparatus.  It  is  important  that  a  normal  air  pressure  balance  is  main- 
tained in  the  middle  ear  with  that  of  the  external  atmosphere.  It  is  by 
means  of  this  tube  that  infections  extend  from  the  nose  and  throat  into 
this  chamber  which  may  lead  to  serious  complications. 

The  mastoid  cells  are  air  cells  varying  in  size  or  number  which  connect 
by  means  of  a  narrow  channel  with  the  middle  ear  cavity  proper.  I  don't 
know  of  any  particular  function  that  has  been  attributed  to  them,  but 
from  the  standpoint  of  infection  they  are  of  utmost  importance.  The 
inner  ear  is  a  complicated  structure  anatomically  and  physiologically 
speaking.  Any  written  description  without  pictures  is  almost  impossible 
to  understand  and  I  therefore  refer  the  reader  to  any  modern  textbook 
of  otology  or  anatomy. 

Just  a  word  to  complete  my  description  however.  The  inner  ear  is 
firmly  imbedded  in  the  substance  of  the  temporal  bone.  Its  outer  struc- 
ture is  bony  and  is  known  as  the  osseous  labyrinth,  within  which  is  a 
membranous  structure  called  the  membranous  labyrinth,  which  is  the 
structure  to  be  remembered  when  we  talk  of  the  labyrinth,  as  this  is  the 
functioning  portion.  There  are  three  semi-circular  canals  lying  in  the 
three  planes  of  space,  the  function  of  which  is  to  maintain  our  equilibrium 
while  in  motion.  There  is  another  structure  called  the  otolith  apparatus 
which  is  also  for  equilibrium  but  only  when  at  rest  or  in  a  forward  or 
vertical  plane.  The  cochlea  is  that  part  of  the  labyrinth  which  deals  with 
hearing  and  hearing  only.  It  contains  the  organs  of  Corti  which  presum- 
ably are  capable  of  receiving  sound  waves  from  16  to  36,000  or  more 
double  vibrations. 

It  should  be  mentioned  at  this  time  that  there  are  two  distinct  fluids 
in  the  labyrinth,  one  of  which  is  enclosed  in  the  membranous  labyrinth 
and  is  known  as  the  endolymph.  It  is  the  movement  of  this  fluid  in  the 
semi-circular  canals  which  stimulates  the  nerve  elements  of  orientation, 
and  also  transmits  the  sound  waves  through  the  cochlea  to  the  organs  of 
Corti. 

The  nerves  of  the  inner  ear,  that  is,  from  the  cochlea  semi-circular 
canals  and  the  otolith  apparatus,  are  collected  into  one  bundle  and 
known  as  the  auditory  nerve.  The  fibres  do  not  intermingle  and  are  dis- 
tributed to  the  various  parts  of  the  brain  according  to  function. 

Part  II — Hygiene  of  the  Normal  Ear 

Ordinarily  the  ears  require  but  little  hygienic  care.  If  the  nose  and 
nasopharynx  function  well  and  are  free  from  obstruction  or  infection, 
the  ears  most  likely  will  be.  Of  course  ear  disease  or  symptoms  which 
are  manifestations  of  a  general  disorder  of  the  body  require  treatment  of 
the  general  disorder  rather  than  to  the  ear  itself.  It  stands  to  reason 
then  that  hygienic  care  of  the  body  is  conducive  to  healthy  ears. 

The  canals  of  an  infant  are  usually  collapsed  or  but  slightly  open 
because  the  cartilage  is  still  soft.  Ear  wax  or  epithelial  (skin)  scales 
usually  obstructs  the  canal.  It  is  best  removed  by  wiping  out  the  canal 
with  a  cotton  wound  applicator  dipped  in  sterile  olive  oil.  Never  use  a 
large  applicator  as  you  most  likely  will  push  everything  deeper  into 
the  canal. 

Normally  the  glands  in  the  canal,  secrete  a  brownish  sticky  substance 
called  cerumen;  the  excess  secretion  usually  takes  care  of  itself  by 
appearing  at  the  orifice  and  is  cleaned  away  by  the  towel  in  the  process 
of  wiping  and  drying  the  ears. 

Injury  and  infection  of  the  canal  is  most  likely  to  occur  should  one 
attempt  to  use  the  finger  nail,  hairpin,  match,  ear  spud,  etc.,  injudiciously. 
Should  any  ear  symptom  persist  the  cause  of  same  should  be  investigated. 


71 

It  is  the  painless  symptoms  which  are  the  most  neglected  and  usually 
cause  insidious  irreparable  damage  to  the  ear. 

If  children  show  evidence  of  failure  to  progress  normally,  the  ears 
should  be  examined  to  determine  if  they  appear  normal  and  hear 
normally.  In  young  children  this  is,  of  course,  a  difficult  point  to 
determine. 

Beware  of  the  persistently  running  ear.  It  leads  to  complications 
sooner  or  later,  particularly  deafness.  You  rightfully  should  question 
the  judgment  and  ability  of  a  physician  who  will  tell  a  patient  that  they 
will  outgrow  the  discharge. 

Children  or  adults  who  are  known  to  have  a  perforation  in  their  drum 
membrane  must  be  thoroughly  informed  about  the  danger  of  water 
entering  the  ears.  Diving,  under  water  swimming,  etc.,  is,  of  course, 
forbidden. 

Normal  individuals  should  never  forcefully  blow  the  nose  by  grasping 
the  nostrils,  after  immersion  in  water.  It  is  best  to  blow  the  nose 
without  touching  the  nostrils  at  all  times.  If  one  will  remember  that  ear 
disease,  whether  infectious  or  noninfectious,  practically  always  has  its 
beginning  elsewhere,  particularly  the  nose  and  throat,  they  will  do  well  to 
look  to  these  regions  early  to  avoid  complications  later. 

Unfortunately,  in  spite  of  all  our  efforts,  there  are  ear  diseases  which 
make  their  onset  insidiously  and  go  on  persistently.  It  is  fair  to  state, 
however,  that  many  ear  diseases,  or  their  complications,  for  the  most 
part  are  preventable. 

EAR  ACHES 

Margaret  Noyes  Kleinert,  M.  D. 
Boston 

Pains  in  the  ear  may  be  classified  under  three  headings : 

1.  Acute  Otitis  Media 

2.  Furunculosis 

3.  Referred  pain 

Acute  Otitis  Media  is  an  abscess  in  the  middle  ear.  It  starts  with 
a  pain  of  such  severity  that  it  is  difficult  to  bear,  accompanied  by  deaf- 
ness and  in  adults  a  ringing.  The  abscess  is  due  to  some  infection 
gaining  access  to  the  middle  ear,  which  is  that  part  of  the  ear  just  in 
back  of  the  drum  membrane.  The  drum  is  located  about  an  inch  and  a 
quarter  in  from  the  external  ear  and  is  reached  through  the  external 
auditory  canal.  There  is  only  one  external  opening  into  the  middle  ear. 
It  leads  from  the  throat  to  the  ear  through  a  tube  about  the  diameter  of  a 
knitting  needle,  and  about  one  and  a  half  inches  long,  and  is  called  the 
Eustachian  Tube.  Through  this  little  tube  the  infection  gains  access 
into  the  middle  ear  and  starts  the  abscess.  When  an  abscess  is  thus 
formed,  there  is  first  an  inflammation  of  the  tissues,  and  then  a  weeping 
of  the  mucous  membranes  with  the  formation  of  serum.  The  collection 
of  fluids  brings  about  a  pressure  in  the  vessels  and  spaces,  which  causes 
the  very  severe  pain.  Often  the  patient  is  wakened  suddenly  in  the 
night  with  an  unbearable  pain.  With  the  beginning  of  pus  formation  the 
pain  becomes  boring  and  throbbing,  making  sleep  impossible.  The  serum 
then  changes  into  pus  and  burrows  its  way  into  every  available  corner. 
There  are  three  ways  for  it  to  escape;  down  the  Eustachian  Tube,  out 
through  the  ear  drum,  and  into  the  mastoid  process.  In  the  beginning 
inflammatory  stage  the  thin  serum  can  frequently  find  its  way  down  the 
Eustachian  Tube,  providing  there  is  no  obstruction  to  drainage  in  this 
direction.  The  inflammation  itself  often  causes  obstruction  at  the  middle 
ear  end  of  the  tube  through  swollen  mucous  membranes.  The  common 
cause  for  retarding  drainage  is  at  the  throat  end  of  the  tube  where  the 
adenoid  is  located. 

The  second  way  for  the  pus  to  escape  is  through  the  membrana  tympani 


72 

or  ear  drum.  As  the  pus  increases  in  quantity,  it  seeks  an  exit,  causing 
the  drum  to  bulge.  Spontaneous  rupture  will  occur  if  steps  are  not  taken 
to  prevent  it. 

The  third  way  for  the  pus  to  spread  is  through  a  little  opening 
from  the  middle  ear  space  into  the  mastoid  process.  In  this  way  a 
mastoiditis  is  started,  and  is  more  likely  to  become  a  complication  of  the 
acute  otitis  if  the  proper  treatment  in  the  beginning  stages  of  the  abscess 
is  delayed.    Early  Paracentesis  is  desirable. 

Acute  infections  such  as  the  common  cold,  scarlet  fever,  measles,  and 
influenza,  are  frequently  complicated  by  infections  of  the  middle  ear.  Of 
the  acute  infectious  diseases  causing  complications,  scarlet  fever  is  to  be 
the  most  feared  because  of  the  frequency  with  which  it  attacks  these 
parts  and  the  great  destruction  brought  about.  Many  bad  ears  of  later 
life  are  traced  to  scarlatinal  otitis.  Measles  has  almost  as  bad  a  record. 
Influenza  in  certain  epidemics  has  a  predilection  for  the  middle  ear  and 
mastoid  involvement.  As  compared  with  the  above,  diptheria,  typhoid 
fever  and  mumps  result  in  an  otitis  less  frequently.  When  mumps  attacks 
the  ear,  however,  it  frequently  will  cause  a  labyrinthitis  with  resulting 
deafness. 

Special  emphasis  should  be  placed  upon  the  common  cold  as  a  source  of 
infection  in  acute  otitis,  from  which  children  suffer  more  often  than 
adults  because  of  the  hypertrophy  of  the  adenoids.  The  latter  grow  in 
the  space  at  the  top  of  the  throat  or  pharynx,  just  out  of  sight  behind  the 
soft  palate  and  posterior  to  the  nose.  When  a  child  has  a  cold,  the 
adenoid  acts  in  two  ways.  It  becomes  a  source  of  infection  due  to  its 
proximity  to  the  Eustachian  Tube,  and  it  swells  like  a  sponge  obstructing 
the  drainage  from  the  throat  end  of  the  Tube.  The  successful  removal 
of  the  adenoids  and  tonsils  affords  a  better  opportunity  for  the  recovery 
from  a  cold  without  a  complicating  acute  otitis.  Even  infants  can  have 
the  adenoids  removed  with  great  benefit  to  the  ear.  Care  must  be  taken 
to  remove  the  lymphoid  tissue  in  the  pharynx  completely,  for  remaining 
small  nodes  will  enlarge  in  a  child  prolific  in  the  growth  of  lymphoid 
tissue.  It  is  important  also  that  no  injury  be  done  to  the  area  located 
about  the  Eustachian  Tube,  for  too  much  rough  manipulation  may  result 
in  scar  tissue  and  synechia. 

Swimming  and  diving  bring  many  ear  aches  to  the  doctor.  The  water 
taken  into  the  mouth  or  nose  may  enter  the  ear  through  the  Eustachian 
Tube.  If  there  is  any  infection  present  in  the  mucous  membranes,  or 
germs  in  the  water,  an  otitis  may  be  started.  To  guard  against  this 
casualty,  swimming  should  not  be  indulged  in  when  there  is  an  acute 
coryza.  It  is  also  wise  not  to  enter  the  water  where  one  is  exposed  to  the 
acute  infections  of  others.  The  quiet  waters  of  ponds  and  swimming 
tanks  are  the  most  dangerous  in  this  respect,  but  where  there  is  too 
great  crowding  in  the  ocean  the  same  thing  may  occur.  Blowing  of  the 
nose  with  water  in  it,  or  soon  after  water  has  entered  it,  is  to  be  guarded 
against,  as  it  may  spread  an  infection  by  forcing  the  fluid  through  the 
Eustachian  Tube. 

The  treatment  in  acute  otitis  consists  of  general,  non-surgical,  and 
surgical.  The  patient  should  go  to  bed  on  the  first  indications  of  ear 
involvement.  In  very  young  children  having  fevers  of  unknown  cause, 
an  examination  of  the  middle  ear  will  often  show  an  acute  inflammation. 
Symptomatic  treatment  of  the  general  symptoms  must  be  carried  out, 
such  as  rest  and  diet.  The  non-surgical  treatment  consists  of  relieving 
the  pain  by  the  use  of  dry  heat  in  the  form  of  a  hot  water  bag  or  hot 
salt  bag.  Poultices  are  not  used.  Drops  of  phenol  and  glycerine  may 
allay  the  pain  slightly,  but  if  the  inflammation  continues  the  surgical 
treatment  is  indicated.  Paracentesis  must  not  be  delayed  unduly  as  the 
best  results  are  obtained  by  an  early  incision  in  the  drum  to  establish 
free  drainage.  After  the  paracentesis  is  done,  the  ear  must  be  kept  clean. 
This     is    accomplished    by   frequent   douching    with   sterile    antiseptic 


73 
solutions.  Then  a  gauze  wick  may  be  placed  in  the  canal  to  aid  drainage. 
The  irrigation  must  be  very  gentle  and  directed  against  the  posterior  wall 
of  the  canal  to  avoid  further  injury  to  the  inflamed  parts.  Where  there 
is  a  mastoid  sensitiveness,  ascertained  by  pressure  made  behind  the  ear, 
ice  may  be  used  for  the  first  twenty-four  hours.  If  the  mastoid  tender- 
ness and  fever  persist  after  the  drainage  has  been  well  established,  an 
X-Ray  of  the  mastoid  must  be  taken.  A  cloudiness  of  the  cells  is  to  be 
expected  in  any  severe  otitis  with  mastoid  symptoms,  but  as  soon  as 
destruction  of  the  cells  begins  to  show  it  is  time  to  intervene  surgically. 
In  the  scarlatinal  infections  an  early  mastoid  operation  is  frequently  a 
safeguard. 

Furunculosis  of  the  external  ear  is  an  infection  in  the  canal.  It  takes 
the  form  of  an  abscess  under  the  skin.  The  trouble  begins  with  a  sore- 
ness about  the  ear,  which  is  intensified  by  any  motion  of  the  jaw  or 
external  ear.  The  cause  is  always  a  local  infection  which  may  be  brought 
about  by  an  abrasion  in  the  skin  from  a  habit  which  some  people  have 
of  scratching  the  ear  with  the  finger  nail  or  even  using  a  hairpin  or 
tooth  pick.    Germs  may  enter  through  any  break  in  the  skin. 

After  the  first  soreness  the  pain  increases,  gradually  becoming  very 
severe,  reaching  in  some  cases  a  severity  equal  to  that  in  acute  otitis. 
But  the  characteristic  in  this  pain  is  the  great  soreness  of  the  external 
parts.  Ringing  in  the  ear  is  present  and  some  degree  of  deafness  occurs 
as  the  congestion  and  swelling  increase.  The  furuncle  ruptures  into  the 
canal  and  discharges,  but  oftener  than  not,  the  first  inflammatory  process 
spreads  and  after  an  interval  other  furuncles  develop  on  each  of  the  other 
walls.  Each  new  furuncle  follows  through  the  same  course  with  its  severe 
pain.  All  possible  sources  of  infection  should  be  investigated.  The  teeth 
will  bear  careful  personal  examination,  as  devitalized  or  dead  teeth  as  well 
as  abscessed  teeth  are  a  frequent  source  of  trouble  in  this  region.  The 
treatment  consists  in  the  local  cleansing  of  the  canal  and  pledgets  of 
phenol  and  glycerine  or  astringens  according  to  the  progress.  Incision  of 
the  furuncle  may  become  necessary.  Occasionally  vaccine  is  the  only 
method  of  control  in  repeated  attacks. 

Referred  Oral  Pains.  All  pains  in  the  ear  may  not  be  caused  from 
within  the  ear  itself.  They  may  be  referred  from  any  of  the  surrounding 
parts.  An  impacted  wisdom  tooth  may  send  shooting  pains  to  the  ear  and 
be  the  first  indication  that  there  is  such  a  condition  in  the  jaw.  An  X-Ray 
of  the  teeth  will  reveal  this,  and  at  the  same  time  other  reasons  for  annoy- 
ing pains  or  shut-up  feeling  in  the  ear.  Sinusitis,  acute  or  chronic 
tonsillitis,  adenoids,  and  disturbances  in  the  Eustachian  Tube  may  each 
give  pain  or  discomfort  in  the  region  of  the  ear. 

If  we  consider  what  might  be  accomplished  in  preventing  diseases  of 
the  ear,  our  field  is  a  large  one.  Much  is  now  being  done  in  the  schools 
and  clinics  to  help  people  to  understand  the  seriousness  of  neglected 
middle  ear  infection,  and  the  resulting  deafness.  The  way  to  prevent 
these  complications  is  showing  steady  gain.  When  a  child  is  taken  to  the 
doctor  with  an  abscess  in  the  ear  it  is  the  responsibility  of  that  physician 
to  see  that  the  child  receives  proper  attention.  If  he  is  not  prepared  to 
give  the  necessary  examination  and  surgical  care,  the  patient  should  be 
referred  to  the  specialist  or  to  one  of  the  many  clinics  in  the  cities  pre- 
pared to  do  justice  to  all  ears  and  attend  to  each  symptom  as  it  develops. 
Each  patient  must  have  the  ear  examined  and  the  hearing  test  made 
after  the  cessation  of  the  discharge  following  each  acute  otitis,  and  every 
effort  should  be  made  to  see  that  the  drum  is  healed  in  all  cases,  and  the 
hearing  brought  back  to  normal  if  possible.  Finally,  many  cases  can  be 
successfully  carried  through  to  complete  recovery  by  correct  diagnosis 
and  careful  treatment. 


74 
ABSTRACTS  FROM  THE  TREATMENT  OF  CHRONIC  RUNNING 

EARS* 

or 

CHRONIC  SUPPURATIVE  OTITIS  MEDIA 

George  Morrison  Coates,  A.  B.,  M.  D., 

Professor  of  Otology,  Graduate  School  of  Medicine, 
University  of  Pennsylvania. 

An  adequate  discussion  of  the  treatment  of  chronic  running  ears 
demands  a  chapter  in  a  text-book  rather  than  a  paper,  and  it  is,  there- 
fore, evident  that  many  details  of  treatment,  therapeutic  or  surgical,  must 
be  passed  by.  The  writer  has,  however,  definite  ideas  about  the  relative 
value  of  conservative  and  operative  procedures  dependent  upon  the 
pathology  and  symptoms  present  and  will  undertake  to  demonstrate  an 
orderly  method  of  consideration  for  the  treatment  of  this  undeniably 
obstinate,  troublesome  and  often  dangerous  condition.  Most  of  the  run- 
ning ears  of  the  chronic  class  that  come  to  us  have  been  diseased  for 
long  periods  of  time  without  other  than  local  symptoms  and  we  have 
therefore  usually  time  enough  at  our  disposal,  the  patient  being  willing 
to  submit  to  this  orderly  procedure,  for  careful  study  and  trial  of  various 
more  conservative  agencies  before  resorting  to  those  most  radical.  The 
one  condition  calling  for  urgency  is  the  development  of  symptoms  of 
labyrinthine  or  intracranial  invasion,  in  which  instance,  all  conservative 
efforts  must  be  abandoned  without  trial  and  radical  operation  undertaken 
as  a  life  saving  measure. 

Not  many  years  ago  it  was  common  otological  opinion  that  all  chronic 
running  ears  were  a  grave  menace  to  life,  calling  for  little  temporizing 
before  radical  surgical  intervention,  even  the  intermittent  type,  with 
long  periods  of  dryness,  being  denounced  for  giving  the  patient  but  a 
false  sense  of  security  and  thereby  increasing  his  danger.  The  pendulum 
has  swung  somewhat  in  more  recent  years,  as  pendulums  will,  and  the 
general  opinion  now  is  that  conservative  measures  will  secure  dry  and 
reasonably  normal  ears  in  a  large  proportion  of  cases,  and  that,  with 
the  patient  under  fairly  close  observation  and  instruction,  the  develop- 
ment of  disturbing  or  dangerous  symptoms  is  gradual  enough  to  give 
ample  time  for  proper  radical  intervention. 

A  proper  study  of  the  case  calls  for: 

(1)  A  careful  history  of  the  local  condition,  its  etiology,  onset,  compli- 
cations, course,  previous  treatment,  duration,  intermittency,  acute  exacer- 
bations, nose  and  throat  history,  previous  operations,  general  health  and 
previous  attacks  of  illness,  home,  personal,  and  school  hygiene,  swimming 
habits,  diet,  etc. 

(2)  A  complete  hearing  test,  both  qualitative  and  quantitative,  by  voice, 
whisper,  forks,  Galton  whistle,  etc.,  and  an  audiometer  record  if  possible. 

(3)  A  study  of  the  function  of  the  static  labyrinth  by  turning  methods, 
and  at  times,  guardedly,  by  the  caloric  test,  with  especial  attention  to  the 
test  for  labyrinthine  fistula. 

(4)  As  definite  a  pathological  diagnosis  of  the  local  condition  as 
possible,  probing  for  carious  bone,  examination  of  the  pus,  note  as  to  odor 
and  consistency,  portion  of  middle  ear  from  which  it  apparently  comes, 
amount  of  drum  membrane  remaining,  location  of  perforation,  culture  to 
determine  probable  offending  organisms,  always  multiple. 

(5)  A  thorough  general  physical  examination  by  a  competent  internist, 
including  blood  studies,  tests  for  syphilis,  tuberculosis,  sugar  tolerance, 
anaemias,  cardio-renal  function,  endocrine  dysfunction,  etc. 

(6)  A  comprehensive  nose  and  throat  examination,  noting  any  abnor- 
mality that  might  act  to  prolong  the  ear  infection  or  contribute  to  its 

*  Read  by  invitation  before  the  Eye,  Ear,  Nose  and  Throat  Section  of  the  Medical  Society  of 
the  State  of  Ohio,   Columbus,    Ohio,   May   14th,    1930. 


, 


75 
recurrence.    Septal  irregularities,  unless  gross,  are  not  usually  considered 
definite  etiological  factors,  but  infection  of  the  accessory  sinuses,  whether 
hyperplastic  or  suppurative,  is  so  considered,  and  a  deviated  septum  may 
well  be  the  underlying  cause  of  the  sinus  infection. 
(7)      An  X-Ray  study  of  the  mastoids  will  give  valuable  information. 

What  is  a  chronic  running  ear?  Chronicity  means  extension  of  the 
disease  beyond  a  period  when  it  can  no  longer  be  called  acute,  but  the 
length  of  this  period  is  arbitrarily  set  differently  by  individual  observers. 
Roughly  speaking,  a  running  ear  passes  out  of  the  acute  or  sub-acute 
class  when  the  discharge  continues  unabated  after  all  acute  symptoms 
have  subsided  and  in  spite  of  all  the  remedies  usually  applied  to  acute 
conditions.  Many  cases  classed  as  early  chronic  will,  however,  clear  up 
with  a  little  more  persistence  and  care  in  the  original  treatment  or  the 
removal  of  some  complicating  factor. 

Having  obtained  the  information  called  for  above,  before  expecting  to 
obtain  a  rapid  cure  of  the  case  by  either  conservative  or  radical  treatment, 
certain  measures  are  definitely  indicated,  and  if  these  are  neglected,  ces- 
sation of  discharge,  if  secured,  will  rarely  be  permanent,  nor  will  the 
ultimate  radical  operation  be  a  success.  Preliminary  treatment  then, 
calls  for: 

(1)  Putting  the  individual  in  the  best  general  physical  condition  obtain- 
able by  eradication  or  control  of  any  general  abnormalities,  attention  to 
living  conditions,  exercise,  fresh  air,  sunlight,  clothing,  food  (including  a 
properly  balanced  diet) . 

(2)  Removal  or  cure  of  any  contributing  factor  in  the  nose  and  throat. 
This  means  removal  of  tonsils  and  adenoids,  or  their  remnants,  drainage 
of  sinuses,  or  removal  by  radical  operation  of  hyperplastic  lining  mucosa, 
correction  of  gross  contributing  septal  deformities  and  hypertrophied 
posterior  turbinal  tips,  as  well  as  attention  to  atrophic  rhinitis  with 
crusting. 

The  advent  of  symptoms  indicating  beginning  extension  to  the 
labyrinth  or  to  the  intracranial  structures,  the  presence  of  a  definite, 
large  cavitation  in  the  mastoid  when  it  can  be  diagnosed  by  X-Ray  or 
otherwise,  and  the  development  of  an  acute  exacerbation  in  the  mastoid 
process  usually  calls  for  radical  intervention  at  once  and  a  cessation  of 
conservative  effort  if  already  undertaken. 

After  steps  have  been  taken  to  put  the  patient  in  the  best  physical 
condition  and  the  best  hygienic  surroundings  obtainable,  advice  as  to 
nose  blowing  and  bathing  is  in  order.  It  is  well  established  that  certain 
cases  of  chronic  suppurations  are  maintained  by  improper,  forcible  blow- 
ing of  infective  secretion  through  the  eustachian  tube.  Blowing  with 
one  or  both  nostrils  open  will  eliminate  this  source  of  trouble,  and  a 
small  proportion  of  cases  will  need  no  further  treatment.  Water  entering 
either  the  actively  or  latent  suppurating  middle  ear,  through  the 
eustachian  tube  or  a  perforation  in  the  membrana  tympani,  is  badly 
tolerated  by  the  irritated  and  inflamed  mucosa  and  is  a  frequent  cause 
of  chronicity  and  recurrences.  The  water  need  not  necessarily  be  in- 
fected since  the  average  nose  normally  contains  infective  organisms,  and 
it  may  come  from  a  garden  hose,  a  shower  or  tub  bath,  or  from  swim- 
ming with  the  head  under  water,  diving  or  jumping  in  feet  foremost. 
The  prevention  of  water  entering  the  ear  through  a  patulous  eustachian 
tube  is  only  possible  by  keeping  the  nose  and  mouth  out  of  water,  but  a 
proper  ear  protector,  bathing  cap  with  suction  ear  piece,  or  oily  wool  or 
cotton  ear  plug  will  prevent  the  entrance  of  water  through  the  external 
canal  and  perforation.  Elimination  of  this  source  of  irritation  or  infec- 
tion will  obtain  a  few  more  dry  ears. 

With  these  two  sources  of  infection  ruled  out  an  orderly  procedure 
calls  for: 

(1)  Local  cleansing,  drying  and  medication  by  the  patient  at  home. 

(2)  Local  cleansing  at  frequent  intervals  by  the  otologist. 


76 

(3)  The  administration  of  Vaccines,  stock  or  autogenous. 

(4)  The  removal  of  obstructions  to  drainage  from  the  middle  ear. 

(5)  The  removal  of  osseous  necrosis. 

(6)  The  treatment  of  inflamed  and  infected  mucosa.  • 

(7)  The  use  by  instillation  or  insufflation  of  various  remedial  agents. 

(8)  The  employment  of  electricity. 

(9)  The  operative  closure  of  the  eustachian  tube  to  prevent  rein- 
fection. 

(10)  Ossiculectomy. 

(11)  The  modified  radical  mastoid  operation. 

(12)  The  radical  mastoid  operation. 

(13)  Labyrinthine  drainage  where  there  is  a  complicating  suppur- 
ative labyrinthitis. 

Each  of  these  successive  steps  will  obtain  some  dry  ears,  leaving  in 
the  end,  if  the  various  procedures  have  been  conscientiously  carried  out, 
but  a  few  cases  where  the  more  radical  procedures  will  be  called  for. 
There  will  always  be  a  small  residue  of  cases,  however,  where  radical 
operation  is  the  final  resort,  all  else  having  failed  and  where  the  small 
residuum  of  hearing  is  not  worth  considering. 

Almost  the  last  resort  for  the  cure  of  the  chronically  discharging  ear 
is  the  Radical  Mastoid  Operation  and,  except  as  before  noted,  it  should 
not  be  performed  until  more  conservative  measures  have  been  tried 
without  success.  There  are  several  apparently  good  reasons  for  this 
statement.  Under  the  most  propitious  circumstances  the  radical  opera- 
tion does  not  necessarily  assure  a  perfectly  or  permanently  dry  ear, 
although  in  the  vast  majority  of  cases  it  does  remove  from  the  patient 
the  danger  of  intracranial  complications.  It  is  a  capital  operation  and 
therefore  the  patient  should  not  lightly  be  subjected  to  it.  There  is  some 
danger,  not  great  in  skillful  hands,  to  the  facial  nerve,  labyrinth  or 
intracranial  structures,  and  there  is  less  chance  of  improvement  of  the 
hearing  following  its  performance.  Indeed  the  possession  of  fair  to  good 
hearing  in  the  diseased  ear  is  in  the  nature  of  a  contra-indication  to 
radical  surgery,  unless  called  for  by  serious  complications.  Finally  it  is 
the  belief  of  the  writer  that  the  radical  operation  is  not  indicated  when 
it  is  reasonably  certain  that  the  mastoid  process  is  sclerosed  throughout, 
containing  no  cavities  of  necrotic  bone  or  advancing  erosion  and  bony 
absorption  from  the  pressure  of  cholesteatomatous  masses.  To  make 
this  negative  diagnosis  the  aid  of  the  X-Ray  is  invaluable  although  not 
infallible.  Where  the  mastoid  process  and  cells  are  definitely  not 
involved,  where  they  never  were  involved  or  where  spontaneous  cure  and 
obliteration  has  taken  place  through  replacement  of  the  pneumatic  spaces 
and  diploetic  bone  by  sclerotic  bone,  all  that  the  radical  undertakes  to  do 
can  be  done  equally  well  and  with  better  end  results,  especially  as  to 
hearing,  by  less  extensive  surgery. 

Now  it  is  not  always  possible  to  accurately  diagnose  the  condition  of 
the  mastoid  prior  to  operation,  but  the  ultimate  type  of  surgery  to  be 
employed,  can  at  times  be  left  until  the  mastoid  process  is  opened.  One 
may  start  out  to  do  a  modified  radical  and  possibly  find  such  pathology 
present  that  nothing  but  a  radical  will  suffice;  or  starting  to  do  a 
radical,  the  amount  and  situation  of  the  pathology  discovered  may  con- 
vince the  operator  that  a  modified  operation  offers  the  best  chance  of 
success.  If  a  facial  paralysis  develops  during  the  course  of  a  chronic 
suppurative  otitis  media,  a  radical  operation  must  be  done  at  once  in  an 
endeavor  to  locate  and  remove  the  source  of  trouble,  although  that  source 
may  be  in  the  middle  ear.  It  must  never  be  forgotten  that  the  radical 
mastoid  operation  is  often  a  life  saving  procedure  and  it  must  be 
employed  without  hesitation  when  serious  symptoms  develop,  as  well  as 
in  those  cases  where  every  other  means  has  been  employed  unsuccess- 
fully to  eliminate  the  discharge.  In  such  cases  it  is  common  experience 
to  find  much  greater  bone  involvement  in  the  mastoid  process  than  X-Ray 


77 
and  other  examinations  had  lead  the  operator  to  suspect,  which  is  an 
additional  reason,  in  obstinate  cases,  for  not  waiting  indefinitely. 

There  is  one  more  point  which  should  properly  have  been  made  much 
earlier  in  this  discussion  and  that  is  the  use  of  the  simple  mastoid 
operation.  Many  acutely  suppurating  middle  ears  can  be  prevented  from 
falling  into  the  chronic  class  by  the  timely  drainage  of  the  mastoid  and 
middle  ear  by  this  operation.  The  only  question  that  arises  in  this  con- 
nection is  the  length  of  time  that  the  acute  suppuration  should  be  allowed 
to  continue  before  intervention  is  called  for.  If  done  at  a  reasonable  date 
after  acute  symptoms  have  subsided  but  with  a  continuing  discharge, 
chronicity  may  usually  or  even  certainly,  be  prevented. 

Even  with  chronicity  established,  a  simple  mastoid  drainage  will  be 
successful  in  a  fair  proportion  of  cases  and  is  often  the  operation  of 
choice  in  children  under  10  years  of  age.  The  hearing  function  is  not 
damaged  by  this  operation  and  may  even  be  much  improved,  provided 
it  is  successful  in  stopping  the  aural  discharge  and  it  does  not  in  any 
way  interfere  with  any  of  the  other  methods  of  treatment  outlined  above, 
either  at  the  time  or  at  a  much  later  period.  Even  in  ears  diseased  for 
two  or  more  years,  occasional  cures  will  result.  Dench  calls  it  the  opera- 
tion of  choice  in  children,  to  be  followed  by  the  radical  operation,  if 
necessary,  after  full  development  of  the  mastoid  is  obtained. 

SUMMARY 

Since  this  paper  is  in  itself  but  a  summary  of  the  various  procedures 
in  common  use  for  combating  the  malady  under  discussion,  further 
summarization  would  seem  to  be  not  only  needless  but  a  repetition  of 
the  already  brief  outline  given.  The  point  may  be  stressed,  however, 
that  no  one  therapeutical  or  surgical  procedure  will  cause  a  preponder- 
ating number  of  suppurating  middle  ears  to  become  dry,  although  each 
one  will  create  a  certain  number  of  cures,  the  percentage  differing  under 
different  conditions  and  when  carried  out  by  different  individuals.  Since 
no  one  procedure  will  cure  all  cases  and  since  every  procedure  will  cure 
some  cases,  and  since  we  have  a  great  many  remedial  measures  at  our 
disposal,  it  is  good  logic  to  assume  that  the  great  majority  of  these 
sufferers  can  be  relieved,  if  treatment  is  based  on  rational  principals 
applied  according  to  the  pathology  present  in  the  individual  ear  under 
study,  and  when  persistently  and  carefully  followed. 

The  word  "cure"  has  been  frequently  used  as  a  convenient  expression 
but,  as  in  other  diseases,  notably  cancer,  syphilis,  tuberculosis,  etc., 
"arrest"  is  the  better  term,  since  any  chronic  running  ear  that  has 
become  or  has  been  made  "dry"  may  be  reinfected,  with  renewal  of  the 
active  suppurating  process.  This  renewal  may  be  caused  by  traumatism, 
an  acute  or  chronic  general  condition  accompanied  by  lowered  resistance, 
the  entrance  of  water  into  the  ear  and  other  factors.  Again  a  "cure"  does 
not  mean,  ever,  complete  restoration  of  hearing  although  improvement 
is  at  times  obtained ;  the  hearing  in  the  dry  ear  may  be  much  worse  than 
when  the  ear  was  discharging.  And  finally,  an  ear  which  has  at  times 
a  little  moisture,  usually  mucoid  in  character,  most  commonly  from  the 
tubal  membrane  or  from  an  unreachable  tubal  cell,  when  such  discharge 
is  without  odor,  and  when  there  are  no  other  evidences  of  extension  of 
the  suppurative  or  necrotic  process,  may  be  considered  to  be  in  a  satis- 
factory condition.  Logan  Turner  and  J.  S.  Fraser  admit  that  such  a 
residual  discharge  is  encountered  after  radical  mastoid  operations  in  a 
definite  percentage  of  cases,  and  such  cases,  they  say,  must  be  placed  in 
the  class  of  satisfactory  end  results. 


78 
THE  EDUCATION  OF  THE  HARD  OF  HEARING  AND  DEAF 

Arthur  B.  Lord 

Supervisor  of  Special  Schools  and  Classes 
Massachusetts  Department  of  Education 

Massachusetts  has  two  distinct  problems  in  educating  children  who 
are  deaf.  Examinations  testing  the  hearing  of  public  school  children 
have  been  made,  in  recent  years,  by  the  use  of  the  audiometer  in  the 
majority  of  our  cities  and  larger  towns.  In  those  communities  where 
the  audiometer  has  been  used  it  is  very  apparent  that  under  the 
previous  method  of  examination  many  children  who  were  hard-of- 
hearing  were  passed  as  normal.  It  is  now  very  evident  that 
larger  numbers  of  children  both  in  the  elementary  and  high  schools 
are  hard-of -hearing  to  an  extent  which  handicaps  their  prog- 
ress in  their  school  work.  They  are  not  deaf  in  the  sense  that  they  need 
instruction  in  a  school  for  the  deaf  but  they  do  need  instruction  in  lip 
reading,  or  more  properly,  speech  reading.  The  hard-of-hearing  child 
who  has  training  in  speech  reading  finds  himself  on  an  equal  footing 
with  the  normal  hearing  child  and  his  progress  in  school  is  not  affected 
by  his  handicap.  It  is  disappointing  that  cities  and  towns  have  been 
somewhat  slow  in  making  available  instruction  in  speech  reading  to 
these  large  numbers  of  boys  and  girls  in  their  communities  who  so  seri- 
ously need  this  opportunity.  Lip  reading  or  speech  reading  classes  are 
maintained  in  Boston,  Fall  River,  Cambridge,  Somerville,  Lynn,  Spring- 
field and  West  Springfield.  There  may  be  a  few  other  communities 
where  full  or  part-time  service  is  available  which  have  not  come  to  the 
attention  of  the  Department. 

In  some  towns  and  cities  serious  cases  of  hard-of-hearing  children 
are  sent  to  classes  in  adjoining  towns  or  cities.  The  hard-of-hearing 
child  is  excused  from  his  regular  academic  studies  during  two  periods 
each  week  when  the  instructor  of  speech  reading  meets  the  group  of 
which  he  is  a  part.  The  teacher  of  speech  reading  has  a  program  which 
takes  her  from  building  to  building  throughout  the  school  system  where 
she  meets  the  various  groups  who  need  her  attention.  One  factor  which 
is  open  to  criticism  is  the  reported  attitude  of  many  classroom  teachers 
who  make  objection  to  excusing  the  pupil  for  the  speech  reading  period 
on  the  grounds  that  he  needs  the  time  on  his  academic  subjects.  Every- 
one connected  with  the  school  system  should  realize  that  the  most  im- 
portant periods  of  the  week  to  the  particular  individual  are  the  periods 
which  he  gives  to  speech  reading.  His  progress  in  academic  work  will 
be  possible  only  insofar  as  he  makes  progress  in  speech  reading. 

The  teacher  of  speech  reading  is  really  a  traveling  teacher  going 
from  building  to  building  as  do  other  special  teachers.  Her  salary  is 
paid  entirely  by  the  local  community,  the  city  or  town  receiving  only 
such  reimbursement  as  it  receives  on  regular  classroom  teachers.  There 
is  a  belief  on  the  part  of  many  people  who  are  interested  in  this  work 
that  in  order  to  encourage  towns  and  cities  to  introduce  this  much 
needed  opportunity,  the  State  should  give  additional  reimbursement  on 
the  employment  of  such  teachers. 

The  education  of  children  who  are  deaf  is  an  entirely  different  prob- 
lem from  that  of  educating  the  hard-of-hearing  children.  The  child  who 
is  deaf  is  the  individual  who  is  totally  deaf,  being  unable  to  hear  sounds 
or  who  has  lost  his  hearing  to  the  extent  that  it  is  impossible  for  him 
to  do  school  work  even  with  the  help  of  speech  reading. 

In  Massachusetts  for  more  than  one  hundred  years  education  for  this 
type  of  child  has  been  available.  Existing  laws  of  Massachusetts  re- 
lating to  the  education  of  the  deaf  provide  for  the  placing  of  such  chil- 
dren in  boarding  schools  and  day  classes  for  the  deaf  at  the  expense 
of  the  Commonwealth.  The  law  provides  that  the  Department  of  Edu- 
cation "shall  direct  and  supervise  the  education  of  all  such  pupils." 


79 

During  the  present  school  year  the  State  is  educating  619  deaf 
children  placed  in  the  American  School  for  the  Deaf,  West  Hartford, 
Connecticut;  Beverly  School  for  the  Deaf,  Beverly;  Boston  School  for 
Deaf,  Randolph;  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 
unable  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  voca- 
tional 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 
primarily  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. 

DIAGNOSTIC  CLINICS  FOR  THE  DEAFENED 

Schools,  City,  Rural  and  by  the  Leagues  for  the  Hard  of  Hearing 
Edmund  Prince  Fowler,  M.  D.,  New  York  City 

Harvey  Fletcher  and  the  writer,  in  1926,  came  to  the  conclusion  that 
the  Western  Electric  Phonograph  Audiometer  was  the  only  practical 
instrument  available  for  the  examination  of  the  hearing  of  school 
children  on  a  large  scale,  and  since  that  time  considerable  progress  has 
been  made  in  determining  the  incidence  of  deafness  in  the  schools. 
Exhaustive  tests  were  made  by  tuning  forks,  whistles,  watch  ticks  and 
the  human  voice  with  results  so  confusing  that  it  was  obvious  that  these 
old  methods  were  inapplicable  except  in  cases  where  there  were  few 
children  to  be  examined.  The  methods  employed  for  detecting  deafness 
should  depend  largely  upon  the  number  of  children  to  be  examined.  In 
schools  of  a  thousand  to  twelve  hundred  students  using  the  Phonograph 
Audiometer  not  over  three  days  are  required  for  the  tests  and  retests 
and  questionnaires  necessary  to  weed  out  all  children  whose  hearing  is 
defective.*     It  is  not  difficult  to  train  a  technician  for  this  part  of  the 

*  Three  Million  Deafened  School  Children,   1926,  J.A.M.A.  Vol.   87 — pp.  1877. 


80 
work    or  for  that  matter    the  subsequent    tests  by  the    2  A  Western 
Electric  Audiometer. 

My  writings  and  the  more  recent  contributions  of  others  give  in  detail 
the  management  of  this  part  of  the  examination  in  the  school  and  it  would 
seem  superfluous  to  repeat  it  here. 

The  point  that  I  wish  to  stress  is  that  following  all  primary  tests 
and  retests  every  child  with  a  loss  of  hearing  of  nine  or  more  sensation 
units  should  have  an  audiometric  examination  at  all  frequencies  with 
the  2  A  Audiometer.  To  conserve  time  it  is  advisable  that  this  be  done 
in  each  city  school  or  rural  district  immediately  following  the  tests  by 
the  Phonograph  Audiometer. 

Unless  something  is  to  be  done  about  it,  it  is  useless  to  determine  the 
hearing  deficiency  in  children,  therefore,  careful  otological  attention 
should  be  given  all  the  children  found  defective.  If  it  can  be  arranged, 
it  is  advisable  that  a  physician  visit  the  schools  or  district  headquarters 
and  examine  each  child's  ears,  and  make  a  diagnosis  with  the  aid  of  the 
audiogram  previously  taken. 

One  full  day's  attendance  at  a  school  of  one  thousand  pupils  should 
be  sufficient  to  adequately  examine  even  more  than  the  sixty  or  seventy 
deafened  students  such  a  school  would  contain,  on  the  average.  A  con- 
venient number  to  report  at  one  time  to  the  medical  examiner  is  twelve. 
The  squad  of  twelve  to  follow  would  be  on  call  in  case  the  examiner  had 
time  for  them  during  the  period.  It  is  inadvisable  to  call  students  in 
twos  or  threes. 

The  medical  examiner  should,  if  necessary,  check  up  on  the  audiometric 
tests  and  take  a  careful  history  of  any  disease  in  the  ear  or  other 
organs,  especially  in  the  nose,  mouth,  throat  and  lungs.  The  removal  of 
large  or  diseased  tonsils  or  adenoids  should  be  urged  unless  contra- 
indicated. 

At  this  time,  if  proper  authority  is  obtained,  impacted  cerumen  and 
loose  foreign  bodies  may  be  removed  from  the  external  auditory  canal 
by  syringing.  If  the  hearing  is  restored  by  this  procedure  to  within 
normal  limits  and  no  further  pathology  is  present,  the  child's  name  may 
be  removed  from  the  list  of  those  requiring  further  treatment.  All  the 
other  cases,  unless  they  consult  a  private  otologist,  should  be  sent  to  an 
otological  clinic  situated  preferably  near  to  the  school  or  home  of  the 
child. 

A  duplicate  of  the  medical  card  made  out  by  the  medical  examiner  in 
the  school  should  accompany  each  child.  Unless  this  is  done  in  most 
instances  incomplete  examinations  will  be  made.  Everything  should  be 
done  to  further  better  examinations  in  the  clinics  and  by  otologists.  The 
history  cards  should  contain  a  space  for  recommendations  of  the  clinics 
or  otologists,  but  it  is  usually  inadvisable  for  the  school  medical  examiner 
to  place  any  recommendation  upon  the  card  except  in  so  far  as  indicated 
by  the  pathology.  The  duplicate  medical  card  should  have  a  space  for 
remarks  such  as:  "To  conserve  time,  please  have  this  patient  receive 
home  treatment  if  such  be  possible."  "If  the  school  nurse  may  be  of 
service,  please  so  advise."  "Write  out  the  treatment  you  desired 
carried  out,"  etc. 

It  will  be  impossible  to  obtain  uniformity  in  taking  and  reporting 
history  in  these  cases  unless  proper  history  blanks  are  supplied.  I, 
therefore,  recommend  that  history  cards  should  be  prepared  in  duplicate, 
the  original  remaining  in  the  school  files  and  to  follow  the  child  if  trans- 
ferred to  another  school  in  the  same  town.  A  duplicate  should  be  taken 
by  the  child  to  the  otologist  or  clinic.  These  histories  should  cover  at 
least  the  following  subjects : 

1.  A  brief  family  history,  especially  of  ear  disease. 

2.  Special  notation  of  the  frequency  of  colds  in  the  head,  throat  and 
chest,  and  diseases  of  childhood  (exanthemata,  flu,  pneumonia  and 
digestive  system  with  approximate  dates,  etc.). 


81 

3.  The  symptoms  accompanying  the  onset  and  course  of  the  disease 
and  the  probable  cause. 

4.  Previous  operations. 

5.  Question  Regarding  noises  in  the  ears,  dizziness,  nausea  or 
vomiting,  and  the  characteristics  of  these. 

6.  Presence  or  abscence  of  pain  or  discharge  from  the  ear. 

7.  Note  the  luster,  transparency,  congestion,  edema,  bulging,  retrac- 
tion, tension,  perforation,  scars,  adhesions,  calcium  and  movability  in 
the  drum  membrane,  and  any  detectable  pathology  in  the  middle  ear, 
especially  a  reddish  glow  from  the  promontory,  (best  detected  with  a 
daylight  lamp). 

8.  Condition  of  the  nose. 

The  otologist  must  remember  that  these  deafened  school  children  are 
coming  to  him  in  a  slightly  different  manner  than  usual.  They  are 
coming  to  him  not  primarily  on  their  own  volition,  but  because  a  careful 
examination  has  found  them  deficient  in  hearing  (many  of  them  only 
slightly  deficient).  They  are  coming  to  him  that  their  hearing  may  be 
preserved;  therefore,  the  ordinary  tests  and  management  may  be  inade- 
quate. Each  case  should  receive  a  careful  otoscopic  examination  and 
with  the  magnifying  penumatic  speculum  and  all  abnormalities  sketched. 

The  Galton  whistle  or  monocord  should  be  used  for  testing  the  higher 
tones  and  the  highest  calibration  heard  noted  on  the  chart.  Bone  con- 
duction for  at  least  256,  1024  and  4096,  double  vibrations,  should  be 
determined  and  plotted  or  noted  upon  the  audiogram  chart  under  these 
frequencies.  Unless  this  is  done,  many  cases  will  be  erroneously 
diagnosed. 

When  there  is  suppuration  in  the  ear  roentgenograms  of  ear  and  nasal , 
sinuses  are  made,  not  only  for  immediate  aid  in  diagnosis,  but  for  treat- 
ment and  future  comparisons. 

If  there  is  history  of  coughs,  memoptesis,  night  sweats  or  loss  of 
weight,  roentgenograms  of  the  chest  are  advised  in  addition  to  a  thorough 
medical  examination,  especially  of  the  lungs. 

A  search  should  be  made  to  discover  any  source  of  poisoning  from 
toxines,  such  as  food,  focal  infections  of  the  sinuses,  teeth,  tonsils,  naso- 
pharanx,  kidneys,  tuberculosis  and  congenital  syphilis,  (hence  intracu- 
taneous tests  and  Wassermann)  of  the  deafened  children  and  all  cases 
should  be  required  to  report  to  the  clinic  or  otologist  regularly  for 
treatment  or  for  a  check  up  upon  their  ear  disease  and  their  hearing. 

If  some  such  scheme  as  I  have  outlined  is  followed  and  especially  if 
every  community  will  institute  a  service  for  the  prevention  and  allevi- 
ation of  diseases  of  the  ear,  a  duplicate  of  the  medical  history  of  each 
child  would  be  obtainable  for  transfer  to  whatever  location  the  child 
might  go.  Benefits  would  then  accrue  not  only  to  each  individual  child, 
but  valuable  data  as  to  etiology,  pathology  and  treatment  of  all  forms 
of  deafness  and  diseases  of  the  ear  would  be  accumulated. 

If  one  is  to  be  satisfied  by  merely  detecting  those  who  are  deafened  so 
that  they  may  have  front  seats  in  their  school  rooms  or  be  assigned  to 
special  classes  for  lip  reading,  little  real  progress  can  be  made  in  the 
solution  of  the  problem  for  the  deafened  in  the  schools. 

If  one  is  to  be  satisfied  by  merely  advising  the  deafened  students  to 
apply  for  treatment,  little  more  will  be  accomplished  because  many  will 
fail  to  carry  on. 

If  one  is  to  be  satisfied  with  the  ordinary  medical  examinations,  much 
good  will  result,  but  not  enough. 

If  one  is  satisfied  only  by  a  complete  audiometric,  otoscopic  and  medical 
examination  and  a  follow-up  to  insure  consecutive  observation  or  treat- 
ment in  each  case,  then  and  only  then  will  the  greatest  good  result  to 
the  potentially  or  actually  deafened.  This  is  not  theory  because  practice 
has  proved  it  true. 


82 
THE  TEACHER'S  AND  NURSE'S  PART  IN  DETECTING  HEARING 

DEFECTS 

Fredrika  Moore,  M.  D.  Pediatrician 

Massachusetts  Department  of  Public  Health 

Long  before  the  laws  requiring  school  doctors  and  nurses  were  passed, 
even  before  the  relationship  between  the  various  defects,  with  which 
school  children  are  so  commonly  burdened,  and  school  progress  was 
appreciated,  the  serious  handicap  imposed  by  two  defects  did  attract 
enough  attention  to  cause  the  passage  of  a  law  requiring  teachers  to 
examine  once  a  year  the  eyes  and  ears  of  their  children.  The  passage  of 
the  medical  and  nursing  laws  did  not  affect  the  older  law,  so  teachers  are 
still  required  to  make  the  eye  and  ear  tests  though  either  doctor  or  nurse 
may  check  up  on  special  cases. 

The  test  most  commonly  used  is  that  of  the  whispered  voice.  Teachers 
who  are  normal  school  graduates  have  had  practice  in  giving  it,  neverthe- 
less it  is  easy  to  slip,  in  technique,  with  conditions  as  they  are  in  some 
schools.  Hence  at  the  beginning  of  the  school  year,  instruction  and  a 
demonstration  ought  to  be  given  for  the  benefit  of  the  new  teacher  and 
as  a  stimulus  to  the  others. 

To  be  of  the  greatest  benefit  to  the  children,  the  test  should  be  made 
soon  after  the  opening  of  school  and  the  results  recorded  on  the  physical 
record  card.  The  next  move  is  made  by  the  nurse  who  visits  the  homes 
of  the  deafened  children  to  talk  over  the  situation  with  the  parents  and  to 
help  those  of  them  who  are  too  poor  or  too  ignorant  to  help  themselves. 

At  the  same  time  the  teacher  will  give  the  afflicted  ones  the  benefit  of 
front  seats  and  will  give  them  also  as  much  personal  attention  as  can 
possibly  be  spared  from  the  large  and  eager  group. 

The  annual  test  does  not  end  the  teacher's  responsibility.  A  perfect 
record  many  be  spoiled  during  the  winter  by  colds,  infected  tonsils, 
one  of  the  communicable  diseases,  or  middle  ear  and  other  infec- 
tions. Dullness,  misunderstandings,  strained  attention,  should  make  the 
teacher  suspect  trouble  with  the  ears.  Children  will  frequently  camou- 
flage partial  deafness  so  cleverly  through  imitating  others  that  their 
difficulty  goes  a  long  time  without  detection. 

The  teacher,  because  she  is  constantly  with  the  children  is  the  one  who 
must  be  alert  to  detect  any  abnormal  signs.  The  nurse  must  be  ready  to 
help  the  teacher  with  advice,  instruct  her  in  the  technique  of  testing 
when  necessary  and  see  to  it  that  all  who  are  deafened  get  whatever  care 
is  indicated. 

THE  4-A  AND  OTHER  AUDIOMETERS 

Mrs.  James  F.  Norris,  Chairman 

Committee  on  Hard  of  Hearing  Children 

American  Federation  of  Organizations  for  the  Hard  of  Hearing,  Inc. 

Audiometers  are  instruments  by  which  the  acuteness  of  hearing  can 
be  gaged  and  recorded. 

Those  with  which  we  are  now  concerned  were  developed  in  the  Bell 
Telephone  Laboratories.  They  are  electrically  equipped  and  are  of  five 
types : 

The  1-A  Audiometer  is  the  largest  type  and  was  designed  to  fulfill 
requirements  for  an  extensive  examination  of  the  acuity  and  quality  of 
hearing. 

The  2-A  Audiometer  was  designed  to  combine  qualities  of  accuracy 
and  portability.  The  results  obtained  are  essentially  the  same  as  those 
with  the  1-A  Audiometer,  except  the  exploring  range  is  less. 

These  two  are  instruments  of  precision  and  are  used  in  doctors'  offices, 
hospitals  and  research  laboratories. 


83 

The  3-A  Audiometer  was  developed  to  fulfill  the  requirements  of 
physicians,  athletic  directors  and  others  interested  in  a  single  quick  test 
of  acuity  of  hearing  speech.  For  this  purpose  it  is  necessary  to  employ, 
instead  of  a  pure  tone,  a  complex  tone  covering  a  wide  pitch  range.  This 
is  a  portable  set.  It  can  be  used  for  individual  tests  of  those  children 
considered  too  young  to  be  tested  satisfactorily  with  the  4-A. 

The  5-A  Audiometer  is  essentially  the  same  as  the  3-A  but  is  smaller 
in  size  though  about  the  same  weight.  It  was  developed  to  eliminate  the 
use  of  batteries. 

The  4-A  or  Phono-audiometer  is  that  with  which  this  article  is 
especially  concerned.  It  was  developed  in  1925  as  a  direct  result  of  a 
request  of  the  newly  formed  Committee  on  the  Survey  of  Hard  of 
Hearing  Children  of  the  American  Federation  of  Organizations  for  the 
Hard  of  Hearing.  The  findings  of  this  committee  relative  to  hearing 
tests  of  school  children  and  the  number  found  to  have  defective  hearing 
brought  to  light  the  fact  that  a  more  accurate  test  than  the  ones  in  use 
was  needed. 

An  appeal  was  made  to  the  Federation's  Scientific  Committee,  of 
which  Harvey  Fletcher,  Ph.D.,  was  the  chairman.  He,  in  turn,  obtained 
permission  to  conduct  research  along  these  lines  in  the  Bell  Telephone 
Laboratories. 

In  describing  the  4-A  or  Phono-Audiometer  the  writer  here  makes  use 
of  an  article  previously  prepared  by  her  entitled  "Technique  of  Testing 
the  Hearing  of  School  Children"  and  used  in  connection  with  this 
instrument : 

"The  4-A  Audiometer  consists  of  the  instrument  itself,  which  looks  not 
unlike  a  medium  size  suit  case,  this  containing  the  electrically  equipped 
device  by  means  of  which  a  voice  coming  from  a  record  is  heard  by  the 
children  through  wires  and  receivers,  first  in  one  ear  and  then  in  the 
other.  In  addition  to  the  main  instrument  with  its  one  ear  piece  are 
trays,  each  tray  containing  eight  receivers  with  accompanying  cords; 
these  trays  can  be  jacked  together  and  then  to  the  phonograph.  'This 
arrangement  makes  it  possible  to  set  up  the  instrument  for  work  under 
varying  space  conditions.  It  has  been  used  in  class  rooms,  assembly 
rooms,  gymnasiums  and  even  in  the  hall  of  the  school.'     (F.  W.  B.) 

"As  the  arrangement  of  desks  in  school  rooms  varies  it  will  be 
necessary  for  the  tester  to  view  each  room  and  plan  for  the  correct 
placing  of  the  trays  so  that  if  all  40  receivers  are  needed  they  can  be  used. 
Certain  aisles  must  be  left  "open"  or  free  from  cords  so  that  the  children 
can  pass  to  and  from  the  seats  without  getting  their  feet  entangled  in 
the  cords. 

"When  the  trays  are  properly  placed,  the  cords  must  be  carefully 
unwound  from  the  receivers  and  each  receiver  placed  on  the  desk  with 
the  hole  up,  so  that  the  child  can  see  it  when  it  is  being  talked  about, 
and  the  wire  head  band  turned  in  the  opposite  direction  from  the  cord 
running  into  the  receiver.  When  the  child  places  the  receiver  to  his  ear 
the  cord  must  hang  downward. 

"When  a  city  or  town  owns  its  audiometer  it  is  best  that  the  testing 
should  be  in  charge  of  one  person :  this  is  sometimes  the  nurse  and  some- 
times the  lip  reading  teacher.  She  should  be  supplied  with  an  assistant. 
If  possible  the  assistant  should  accompany  her  from  school  to  school. 
It  may,  however,  be  best  for  the  assistant  to  be  furnished  by  the  school 
where  the  test  is  to  be  made.  In  this  case  the  assistant  should  always 
attend  a  test  being  conducted  in  another  school  previous  to  the  one  in 
her  own  school,  so  that  she  may  be  well  acquainted  with  her  duties  before 
her  own  task  begins. 

"The  tester  should  always  take  into  consideration  that  she  is  disturbing 
a  school  program,  and  though  the  day  for  the  test  was  duly  appointed, 
she  must  be  cooperative  in  order  to  interrupt  the  day's  program  as  little 
as  possible.    Before  conducting  a  test  in  a  school  she  should  have  a  con- 


84 
ference  with  the  principal  in  order  to  formulate  a  program  of  action  and 
develop  the  schedule  so  that  when  the  test  is  conducted  it  will  run 
smoothly.  It  is  recommended  that  the  tests  be  conducted  in  the  mornings, 
the  afternoons  being  reserved  for  the  correction  of  papers.  Too  great 
stress  cannot  be  laid  on  the  fact  that  the  quietest  room  be  set  aside  for 
the  test  in  order  that  outside  noises  may  not  disturb  the  child's  hearing 
of  the  voice  which  comes  from  the  audiometer.  This  is  of  vital  im- 
portance, as  slight  noises  will  lower  acuity  and  move  children  into  a 
group  in  which  they  do  not  belong.  She  should  also  ask  the  children  to 
bring  with  them  two  sharpened  pencils,  two  because  sometimes  the  point 
of  one  may  break  in  the  middle  of  a  test.  It  might  be  well  here  to  note 
that  formerly  we  advised  having  two  pencils  on  each  desk  in  the  room 
where  the  test  is  being  conducted.  We  have  found  this  to  be  impractic- 
able, because,  without  meaning  to  do  so,  the  children  have  often  taken 
the  pencils  away,  and  there  has  had  to  be  a  constant  supply  of  them 
throughout  the  test.  If  each  child  brings  his  own  pencils,  this  difficulty 
is  obviated. 

"Aside  from  her  assistant  it  is  expedient  that  the  tester  should  be 
furnished  with  one  or  two  monitors.  These  monitors  can  be  school 
children  whose  duty  it  will  be  to  stand  outside  the  test  room  to  prevent 
people  from  passing  noisily  through  the  corridor  or  opening  the  door 
while  the  test  is  being  conducted.  It  is  also  helpful  for  the  monitor  to 
inform  the  room  teacher  five  minutes  before  it  will  be  her  turn  to  take 
her  children  to  the  testing  room. 

"Because  the  class  room  door,  as  well  as  the  windows,  must  be  kept 
closed  during  the  test,  it  is  well  to  have  the  monitors  open  the  windows 
and  then  close  them,  during  the  change  of  classes.  When  the  children 
come  in  to  take  the  test  the  monitors  can  help  in  directing  them  to  those 
aisles  which  are  free  from  cords,  as  will  be  seen  later. 

"  'The  4-A  or  Phono-audiometer  is  by  far  the  most  accurate  and  quick- 
est method  yet  found;  it  lends  itself  to  accurate  recording;  it  permits 
the  finding  of  the  child  with  only  one  ear  impaired ;  any  intelligent  person 
can  conduct  the  test ;  it  is  run  by  a  spring  motor,  not  by  outside  electrical 
energy  or  by  batteries;  it  is  as  easy  to  run  as  a  phonograph;  it  does 
not  get  out  of  repair  easily  and  can  be  used  indefinitely.  The  simple 
phonograph  record  permits  substitution  of  other  numbers,  sentences 
and  gradations  of  sound,  for  new  records  can  be  easily  made  and  secured 
at  slight  expense.  The  child  enters  into  the  test  with  zest ....  By  these 
more  accurate  means,  it  is  being  found  that  partial  deafness  is  far  more 
prevalent  than  had  been  supposed.'     (Dr.  Gordon  Berry  in  Hygeia)." 

4-A  Audiometers  are  now  owned  by  more  than  112  cities,  4  clubs  for  the 
hard  of  hearing,  7  hospitals  and  clinics,  6  County  Health  Associations 
and  22  miscellaneous  groups  such  as  Boards  of  Education,  Universities, 
Junior  Social  Service  Leagues,  Normal  Schools,  etc.,  etc.,  and  by  them 
the  hearing  of  thousands  of  school  children  from  the  fourth  grade  up 
has  been  and  is  being  tested.  It  has  been  reported  that  in  many  places 
successful  tests  have  been  conducted  in  the  third  grades.  In  a  city 
where  children  are  given  arithmetic  in  the  second  grade  even  they  have 
written  remarkable  test  papers,  practice  in  writing  numbers  from  dicta- 
tion having  previously  been  given  by  the  room  teacher.  Indeed,  one 
tester  reports  that  she  obtained  satisfactory  results  with  the  children  in 
the  first  grade  by  writing  down  herself  what  the  little  children  with 
receivers  at  their  ears  said  they  heard.  It  would  be  helpful  if  proof  were 
available  as  to  the  value  of  results  so  obtained. 

The  4-A  is  not  an  instrument  of  precision,  but  rather  one  of  detection. 
For  an  accurate  rating  use  should  be  made  of  one  of  the  other  audiometers 
The  testing  of  the  hearing  of  school  children  has  been  revolutionized  b; 
the  development  of  this  instrument.  Its  introduction  has  been  a  large 
step  forward  and  has  yielded  greater,  truer  and  more  informative  results 
than  have  before  been  obtained.     Its  advocates  far  outnumber  its  critics 


! 


85 

In  time  the  training  of  the  testing  staffs  will  be  improved  and  with  such 
training  will  come  a  better  technique  of  testing  and  more  conservative 
and  trustworthy  reports  on  conditions  discovered  and  results  obtained. 

GROUP  SERVICE  AND  USE  OF  THE  4-A  AUDIOMETER  IN 
SCHOOLS  OF  PLYMOUTH  COUNTY,  MASS. 

Anna  J.  Foley,  R.  N.,  Executive  Secretary 
Plymouth  County  Health  Association,  Incorporated 

The  Plymouth  County  Health  Association  recognizing  the  need  for  a 
more  scientific  method  of  testing  hearing  sensitivity,  and  always  on  the 
alert  for  the  opportunity  of  rendering  to  local  organizations  that  service 
which  they  are  not  able  to  provide,  decided  to  "look  into"  the  matter  of 
purchasing  an  audiometer.  This  was  suggested  by  Dr.  J.  Holbrook  Shaw, 
Plymouth.  After  due  consideration  at  the  regular  business  meeting  of 
November  1928,  Mr.  Frederic  T.  Bailey,  President,  appointed  Dr.  Shaw 
and  Dr.  Bradford  H.  Pierce,  South  Hanson,  as  an  "audiometer  com- 
mittee" with  purchasing  power. 

After  many  delays  the  full  equipment  arrived  so  that  work  was 
started  in  April,  1929.  Letters  had  been  sent  to  superintendents  of 
schools  notifying  them  of  this  service  which  would.be  available  FREE. 
Tentative  dates  for  the  use  of  the  audiometer  were  given.  The  response 
was  immediate  and  almost  100%.  There  was  no  doubt  about  the  need 
for  this  service  and  the  popularity  continues  100%  at  the  present  time. 

Interest  in  the  "hard  of  hearing  child"  is  not  a  new  health  project. 
Interest  in  the  audiometer  method  of  testing  hearing  sensitivity  is  com- 
paratively new,  as  indeed  is  the  instrument  itself.  There  are  other 
types  of  audiometer  but  at  this  time  we  are  interested  in  the  "service 
and  use"  of  the  number  4-A. 

Even  though  the  number  4-A  has  become  a  very  familiar  "adjunct"  to 
school  work  I  am  tempted  to  give  an  outline  of  its  physical  properties. 
It  is  similar  to  a  portable  phonograph,  and  consists  of  a  spring  phono- 
graph motor  and  turntable  with  speed  control  and  stop,  a  magnetic 
phonograph  reproducer,  a  receiver  and  two  phonograph  records.  The 
sound  is  heard  through  the  receiver.  For  group  testing  receiver  holders 
are  attached.  Each  receiver  holder  contains  eight  ear  phones  and  the 
4-A  will  accommodate  five  holders  so  that  the  maximum  number  of 
persons  which  may  be  tested  at  one  time  is  forty. 


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86 

Procedure  of  Test  in  the  Class  Room 

Preliminary  plans  having  been  made  with  the  superintendent  and 
others  concerned,  on  the  day  appointed  for  the  test  the  operator  arrives 
at  the  school  about  one-half  hour  before  the  opening  session.  Two  main 
points  MUST  be  considered  in  the  selection  of  the  room  for  the  test — the 
room  must  be  quiet — and  it  should  be  one  which  will  interfere  least  with 
the  general  school  procedure.  This  room  may  be  a  class  room,  an  audi- 
torium, a  large  library  or  any  other  room  which  satisfactorily  may  be 
used.  Our  equipment  has  four  trays  or  receiver  holders  so  that  the 
maximum  number  which  we  may  test  at  one  time  is  thirty-two.  The 
class  room,  in  so  far  as  the  test  is  concerned,  is  the  most  satisfactory 
room  of  any  used  up  to  the  present  time.  However,  the  use  of  the  class 
room  for  the  test  means  that  the  class  room  group  must  be  "entertained" 
elsewhere  during  the  entire  test  as  children  are  brought  to  the  testing 
room  in  groups  of  thirty-two. 

When  the  equipment  has  been  set  up  and  the  proper  record  placed  upon 
the  turntable  of  the  phonograph  the  first  group  of  thirty-two  children  is 
admitted.  Pupils  to  be  tested  are  seated  at  the  desks,  or  in  chairs  with 
proper  facilities  for  caring  for  the  record  papers.  Tables  are  not  used 
except  when  other  equipment  cannot  be  provided  as  this  is  the  least 
satisfactory  manner  of  conducting  the  test.  Each  pupil  has  been  provided 
with  a  record  paper  on  which  he  is  instructed  to  write  his  name,  age, 
grade  and  date.  The  operator  gives  careful  instructions  to  the  group  as 
to  what  they  are  doing,  why  the  test  is  given,  how  it  is  to  be  given,  etc. 
The  ear  phones  are  adjusted  first  to  the  right  ear  and  then  the  phono- 
graph is  started. 

At  first  a  woman's  voice  is  heard  repeating  numbers  as  54-41-84  or 
526-348-414.  (There  are  two  phonographic  records — one  of  two  digit 
numbers  for  classes  below  the  fifth  grade — one  of  three  digit  numbers 
for  the  fifth  grade  and  above).  The  voice  decreases  in  volume  three 
sensation  units  (3SU)  with  each  succeeding  number  until  it  fades  to 
a  slight  whisper.  After  repeating  a  series  of  twelve  numbers  in  this 
manner  the  same  voice  resumes,  after  a  slight  pause,  with  a  new  set  of 
numbers.  Then  a  man's  voice  is  heard  and  two  different  sets  of  numbers 
are  heard.  This  completes  the  test  for  the  right  ear.  The  pupil  records 
as  many  numbers  as  he  hears.  The  ear  phones  are  then  placed  on  the 
left  ear  and  the  process  is  repeated  with  a  different  set  of  numbers. 

Time 

The  average  time  required  for  the  test  is  fifteen  minutes  under  favor- 
able conditions.  Children  in  the  third  grade  and  those  in  the  lower 
fourth  require  more  time  than  those  in  the  upper  grades  and  high  school. 
Four  hundred  may  be  tested  in  one  day  but  this  is  not  the  daily  average. 

Correction  of  Record  Papers 

Master  cards  are  provided  for  the  test  records.  These  cards  are 
printed  so  that  they  may  be  placed  alongside  the  numbers  written  in  the 
columns  by  the  child.  Results  are  checked  or  recorded  in  sensation  unit 
loss — or  hearing  loss.  A  child  with  "no  hearing  loss"  should  be  able 
to  record  correctly  as  far  as  the  line  marked  "0  Hearing  Loss."  Each 
number  missed  or  in  error  represents  a  hearing  loss  of  3SU.  Any  pupil 
who  shows  a  hearing  loss  of  9SU  or  over  in  either  or  both  ears  is  given 
a  retest.  The  same  general  procedure  is  followed  during  the  retest. 
Children  who  are  obviously  slow  in  grasping  the  meaning  of  the  test  or 
in  recording  should  be  given  an  individual  test. 

Results 

The  audiometer  has  been  used  in  all  towns  and  in  Brockton.  Several 
thousands  of  children  have  been  tested.      (We  are  now  repeating  the 


87 

test  throughout  the  county.)  About  four  per  cent  of  the  school  group 
were  found  to  have  a  hearing  loss  of  9SU  or  over,  (7-1/2%  and  over)  in 
one  or  both  ears.  It  is  of  interest  to  note  that  children  who  have  a  more 
definite  hearing  loss —  18SU  and  over — uniformly  are  receiving  special 
attention  from  teachers,  the  medical  staff  and  their  homes — whereas 
those  having  a  less  definite  loss,  in  many  instances,  were  not  suspected 
of  being  "hard  of  hearing."  (Since  beginning  this  paper  I  have  been 
informed  by  Dr.  R.  H.  Gilpatrick,  President  of  the  Speech  Readers  Guild, 
Boston,  that  I  must  discriminate  between  the  "hard  of  hearing"  child 
and  the  deaf  child.) 

The  Follow-Up  or  What  Next? 

Obviously  it  would  be  a  waste  of  time,  effort  and  money  to  continue 
the  use  of  the  audiometer  if  nothing  more  than  compilation  of  statistics 
were  accomplished.  From  the  beginning  this  was  recognized  by  our 
audiometer  committee  so  that  a  form  letter  was  drafted  for  use  by  the 
school  physician  informing  parents  when  their  children  were  found  to 
have  definite  hearing  losses.  This  is  a  mere  suggestion  for  the  school 
physician  and  superintendent.  In  many  instances  physicians  and  superin- 
tendents rewrite  or  produce  an  entirely  different  letter — the  main  point 
being  to  inform  the  parents  that  special  attention  is  needed. 

Teachers  are  instructed  by  the  superintendent,  principal  or  school 
physician  to  place  in  the .  front  rows  those  children  who  have  hearing 
losses — those  most  seriously  affected  being  given  the  preference.  Clin- 
ical service  should  be  provided  for  those  who  have  no  family  physician. 
Lip  reading  classes  should  be  provided  for  those  who  are  definitely  hard 
of  hearing.  Last  but  of  prime  importance,  a  program  of  general  health 
building,  with  particular  attention  to  the  correction  of  remediable  defects 
such  as  diseased  tonsils,  adenoid  vegetation,  foreign  objects  in  ears  and 
nose,  wax  in  the  ears — and  a  well  balanced  diet.  Marked  improvement 
was  recorded  in  one  instance  where  there  was  a  history  of  a  "running 
ear"  for  several  years.  Private,  personal  discussion  with  this  child 
brought  out  the  fact  that  during  the  past  year  there  had  been  a  complete 
rearranging  of  the  home  life.  Many  more  hours  of  sleep;  no  tea  or 
coffee;  more  than  a  pint  of  milk  daily;  introduction  of  green  vegetables 
heretofore  disdained  and  resting  on  the  grass  in  the  sun  were  some  of  the 
major  improvements  noted.  At  the  time  of  this  conversation  there  had 
been  no  discharge  from  the  ear  for  several  months. 

Too  much  credit  cannot  be  given  for  the  splendid  attitude  of  coopera- 
tion evidenced  by  school  committees,  superintendents,  school  physicians, 
nurses,  teachers  and  parents.  Special  otological  care  is  comparatively  a 
simple  matter  in  urban  centers,  but  a  most  difficult  one  in  rural  com- 
munities. How  then  shall  we  secure  for  these  children  the  care  they 
should  have?  Discussion  with  the  school  physician  and  nurse  invariably 
brings  about  a  definite  plan. 

Through  the  interest  of  a  few  hard  of  hearing  adults  in  Brockton  and 
nearby  towns  last  year  a  lip  reading  class  was  conducted  at  the  Y.  W.  C.  A. 
We  were  permitted  to  refer  to  this  class  students  who  were  known  to 
have  definite  hearing  losses.  The  class  is  to  be  continued  next  year  and 
plans  are  now  under  way  for  the  organization  of  a  Speech  Readers 
Guild  in  Brockton. 

Altogether  my  audiometer  experience  has  been  a  very  happy  one.  It 
has  brought  about  a  better  understanding  and  knowledge  of  the  general 
health  program  of  the  County  Health  Association — and  I  have  acquired 
a  much  better  understanding  of  the  splendid  health  work  which  is  daily 
routine  in  the  classroom.  It  has  given  me  the  opportunity  to  observe  at 
close  range  the  general  condition  of  the  children,  and  opportunity  also 
for  more  definite  discussion  of  the  health  program. 

We  plan  to  continue  the  use  of  the  audiometer  throughout  the  county — 
to  assist  in  so  far  as  we  are  able  the  follow-up — to  co-operate  at  all  times 


88 
with  the  committees    interested  in    the  forming  and  conducting    of  lip 
reading  classes  and  speech  readers  guilds.    WE  HOPE  that  the  interest 
will  continue  at  the  high  water  level  manifested  during  the  past  year. 

NATIONAL  WORK  FOR  THE  DEAF  AND  THE  HARD  OF  HEARING 

Gordon  Berry,  M.  D. 

Worcester,  Mass. 

A  National  111 

Deafness  is  a  national  ill.  Many  of  us  are  so  afflicted.  In  one  ear  or 
the  other,  a  large  proportion  of  us  would  show  a  deficiency  in  our  hearing 
if  a  careful  audiometric  test  was  made.  Estimating  from  the  many 
thousands  of  school  children  that  already  have  been  tested,  it  is  stated 
that  three  million  of  the  young  in  our  land  have  an  appreciable  loss  of 
hearing  and  that  at  least  ten  million,  possibly  fifteen  million,  adults  are 
similarly  handicapped.  We  do  not  like  to  face  such  facts;  and  if  we 
do  consider  them  seriously,  we  try  to  feel  that  the  matter  is  no  immediate 
concern  of  ours.  Fortunately  for  us,  there  have  been  those  who  have 
given  it  serious  thought  and  have  laboriously  through  the  years  formed 
a  partial  remedy. 

Early  Work  for  the  Deaf 

It  was  early  in  the  last  century  that  the  Abbe  Siccard  set  about  seeing 
what  he  could  do  to  help  a  few  deaf  convent  children  under  his  care.  He 
developed  a  sign  language  and  in  this  way  was  able  to  talk  with  them  and 
train  them.  This  was  one  of  the  first  successful  attempts  ever  made  to 
hold  intercourse  with  the  deaf,  and  between  deaf  individuals.  Other  deaf 
children  came  to  the  Abbe.  People  in  this  country  heard  about  it  and 
some  went  over  to  Europe  to  learn  the  method.  The  result  was  the  found- 
ing in  1817  of  the  Hartford  School  for  the  Deaf,  the  first  in  the  United 
States.  But  signs  did  not  prove  exact  enough  and  an  alphabet  was 
devised  so  that  the  deaf  children  could  do  finger  spelling  (or  manual 
writing).  By  this  means,  the  teacher  could  train  the  child  in  our 
language,  and  our  books  became  an  open  treasure  house  for  the  deaf. 
Some  wanted  a  higher  education  and  as  our  universities  did  not  employ 
finger  spelling,  Gallaudet  College  was  founded  in  1857,  in  Washington, 
D.  C.  This  still  continues  its  fine  work  and  is  our  only  institution 
offering  advanced  education  to  the  deaf  exclusively. 

The  Oral  Method  of  Teaching 

Lip-reading  and  vocal  training  with  all  its  difficulties  and  with  all  its 
advantages  had  not  yet  been  devised.  Only  those  with  special  knowledge 
could  converse  with  the  deaf;  they  remained  an  isolated  group.  Jeanie 
Lippitt,  the  daughter  of  the  Governor  of  Rhode  Island,  and  Mabel 
Hubbard,  the  daughter  of  a  Boston  manufacturer,  became  deaf  before 
they  had  learned  to  speak.  Their  mothers  searched  in  the  hope  of  finding 
some  means  of  so  training  their  children  that  they  could  talk  more  as 
normal  people,  even  with  their  deaf  handicap.  They  heard  that  the 
Germans  had  perfected  a  method.  They  investigated;  then  began  to  try 
themselves  to  teach  their  children  this  new  form  of  "lip-reading."  The 
children's  ability  to  speak  was  dormant;  the  mothers  had  to  patiently 
develop  this  speech,  without  the  child's  hearing  to  guide  and  help.  It 
was  these  two  little  girls  who  made  the  dramatic  appearance  before  our 
legislators  on  Beacon  Hill  and  through  their  proficiency  in  speech  and 
lip-reading  gained  in  1867  a  charter  for  the  Clarke  School  for  the  Deaf 
at  Northampton,  the  first  school  in  America  dedicated  to  teach  the  deaf 
by  the  so-called  oral  method.  This  permitted  the  deaf  to  converse  with 
normal  people  and  so  did  away  with  the  isolation  and  segregation  which 
the  sign  and  finger-spelling  methods  brought  about.     Other  schools  have 


89 

adopted  this  method.  Graduates  from  the  many  deaf  schools  throughout 
the  country  can  now  carry  their  studies  further  in  college  or  professional 
school,  or  can  enter  at  once  into  the  economic  and  social  life  of  their 
community.  Thus  was  gained  a  great  step  forward  in  adjusting  the  deaf 
to  their  handicap  and  in  placing  them  back  into  a  fairly  normal  life  with 
their  fellows.  There  are  now  196  schools  for  the  deaf  in  the  United 
States,  with  a  staff  of  2,522  teachers  and  enrolling  18,212  pupils.  In 
Massachusetts  we  have  three  residential  schools  and  four  day  schools 
with  a  combined  teaching  staff  of  ninety-five  and  an  enrollment  of  642. 
Canada  has  eight  schools  with  179  teachers  and  1,006  pupils.  Thus  have 
we  striven  to  care  for  our  deaf.  Moreover  we  are  carrying  forward 
researches  looking  toward  evaluating  our  present  teaching  methods  and 
improving  them  along  modern  lines.  We  are  studying  the  causes  and 
detailed  nature  of  these  deaf  cases,  are  finding  by  careful  audiometric 
measurements  that  many  of  the  children  are  not  as  deaf  as  was  supposed, 
that  they  have  remnants  or  islands  of  audition  which  can  be  utilized  and 
developed  to  make  their  education  easier  and  their  lives  happier.  Here 
is  an  absorbing  field  of  investigation  which  offers  great  promise. 

Efforts  for  the  Hard  of  Hearing 

What  of  the  partially  deaf;  the  many  who  had  sufficient  hearing  to 
learn  speech  and  to  commence  or  even  complete  their  education  and  then 
through  the  inroads  of  some  aural  disease  have  found  themselves  failing 
in  their  classes  or  losing  their  jobs  or  being  isolated  from  the  society  of 
their  fellow  men?  Here  we  find  the  millions  of  hard  of  hearing  children 
and  adults  cited  in  our  opening  paragraph.  Let  us  first  consider  the 
child  who  is  unconsciously  losing  his  hearing  and  does  not  know  just 
what  is  the  matter  with  him.  His  parents  call  him  inattentive,  his 
teacher  pronounces  him  a  dreamer  or  stupid.  It  is  this  boy  that  the  uni- 
versal audiometric  test  will  find.  Thus  will  constructive  efforts  be  made 
by  the  teacher  to  adjust  his  curriculum,  by  the  parent  to  protect  and 
guide  him,  by  the  doctor  to  cure  his  malady.  By  so  early  an  effort  can 
much  more  be  done  and  harm  prevented.  If  success  is  not  gained  or 
adjustments  made  this  boy  drops  back  with  children  his  junior  in  years 
and  his  inferior  in  physique.  What  wonder  the  boy  finds  himself  out  of 
tune  with  his  environment.  He  is  looked  down  upon  by  younger  children, 
comes  to  think  of  himself  as  an  inferior,  seeks  to  get  ahead  by  petty 
deceptions  and  dishonest  measures.  He  may  perform  a  minor  misde- 
meanor and  become  a  delinquent  or  a  criminal;  he  may  shut  himself  away 
as  an  economic  misfit  and  end  up  as  a  dependent  or  a  pauper.  In  any 
event  his  lot  is  unhappy  and  so  is  that  of  those  with  whom  he  lives. 

A  second  type  is  the  young  adult  who  looks  forward  enthusiastically 
to  a  full  and  useful  life  only  to  discover  that  an  encroaching  deafness 
makes  difficult  or  impossible  the  trade  or  profession  for  which  he  is 
prepared.  He  lacks  both  time  and  money  to  stop  and  learn  another. 
Discouraged  he  does  not  know  which  way  to  turn.  Possibly  he  should 
have  selected  another  activity  in  the  first  place,  perhaps  the  use  of  an 
ear-phone  or  the  learning  of  lip-reading  will  be  all  that  is  necessary, 
perhaps  the  employer  fails  to  realize  that  in  that  particular  task  the 
deafness  is  no  handicap.  Who  will  guide  this  young  man  or  woman,  who 
will  set  in  motion  the  adjustments  that  will  take  care  of  the  whole  trouble? 

A  third  type  deals  with  the  man  passing  his  prime.  Senile  changes  in 
the  ear  may  have  set  in.  His  habits  are  fixed.  This  man  cannot  change 
his  whole  mode  of  life.  Unhappy  is  his  lot  unless  he  can  discover  some 
remedy  which  will  place  him  back  into  his  normal  surroundings  as  a 
useful  and  welcome  member. 

Constructive  Help  for  the  Handicapped 

How  shall  we  solve  these  problems  ?  Must  these  hard  of  hearing  think 
of  themselves  as  undesirable,  inferior,  better  placed  on  the  shelf?    Should 


90 

they  retire  from  the  striving  and  useful  toil,  to  be  a  heavy  burden  on 
others  and  a  keen  disappointment  to  themselves?  Our  modern  world 
finds  many  crippled  physically  or  mentally,  but  it  finds  it  better  both  for 
the  handicapped  and  for  his  community  that  he  be  urged  to  make  the 
best  of  it,  do  what  he  can.  And  his  best  is  often  a  boon  to  his  race  and 
age.  Supposing  Beethoven  had  given  up  trying  when  deafness  began  to 
shut  him  in!  The  deaf  and  the  hard  of  hearing  have  a  right  to  "their 
place  in  the  sun."  They  should  assert  this  right,  challenge  the  world  and 
claim  from  it  a  living  wage,  a  useful  existence,  a  happy  life.  He  who 
makes  believe  he  hears,  who  is  "too  proud"  to  wear  an  ear-phone,  who  is 
unwilling  to  strive  against  the  odds,  is  false  to  his  privilege  and  with- 
holds his  positive  influence  in  behalf  of  the  many  who  are  similarly 
afflicted. 

Lip-Reading 
The  hard  of  hearing  are  making  these  adjustments  and  solving  these 
problems  along  three  concrete  lines.  First  they  are  learning  lip-reading. 
This  is  difficult  to  acquire  and  of  course  does  not  take  the  place  of  good 
hearing,  but  crutch  though  it  is,  it  does  serve  to  let  him  who  learns 
converse  with  comparative  ease  with  his  neighbor.  Perhaps  the  most 
notable  mass  effort  of  this  kind  ever  made  was  with  our  deaf  soldiers  sent 
to  the  reconstruction  hospital  at  Cape  May  in  1918.  108  men  came  there. 
They  were  taught  intensively,  saturated  with  lip-reading,  each  man 
had  an  individual  teacher  and  took  2  or  3  lessons  daily,  not  per  week. 
In  two  months,  most  of  the  men  could  converse  with  reasonable  ease  with 
a  stranger. 

Mechanical  Hearing  Aids 

Another  help  is  the  many  devices  to  magnify  hearing.  These  have 
made  rapid  strides  in  their  improvement  during  recent  years.  They  can 
be  grouped  into  two  main  divisions.  First  we  have  the  trumpet  in 
different  forms.  This  brings  to  a  focus  approaching  sound  waves.  The 
two  limitations  are  in  size  and  in  proximity.  We  cannot  carry  a  large 
megaphone  to  catch  sounds  for  us  nor  can  we  carry  a  speaking  tube  that 
would  be  long  enough  for  the  average  talker.  The  advantage  in  the 
various  modifications  on  the  market  is  that  if  the  speaker  is  near  enough, 
the  sound  comes  to  the  ear  clearly  magnified,  in  its  true  proportions,  not 
distorted.  Because  of  the  inadequacy  of  the  trumpet  form  of  magnifica- 
tion we  are  increasingly  relying  upon  the  second  type  which  is  the 
electrical  hearing  aid  or  ear-phone.  The  mechanism  is  similar  to  that  of 
the  telephone  which  by  step-up  processes  can  carry  conversation  across 
the  country  or  by  a  loud  speaker  so  magnify  the  voice  that  it  can  be  heard 
over  a  large  auditorium  or  across  the  Hudson  River  or  down  from  an 
aeroplane.  Such  magnification  gives  some  distortion  to  the  sound.  Here 
too  the  chief  limits  are  in  the  size  of  the  equipment.  The  individual  can 
carry  with  comfort  only  a  small  receiver  and  a  light  electric  battery  and 
he  naturally  prefers  that  the  instrument  shall  not  be  cumbersome  or 
conspicuous.  The  manufacturer  has  the  further  handicap  of  trying  to 
construct  so  delicate  an  apparatus  in  sufficient  quantity  to  make  the  price 
suitable  for  our  pocket-books  and  yet  of  trying  to  make  a  sufficient 
variety  to  suit  the  widely  differing  types  of  deafness.  The  obstructive 
deafness  of  youth  is  deficient  in  low  tones  and  hears  high  notes  well ;  the 
nerve  deafness  of  advanced  years  hears  the  low  tones  fairly  well  and  the 
upper  tone  scale  is  cut  off.  Manifestly  the  same  hearing  aid  will  not 
serve  both.  We  are  all  looking  forward  to  the  day  when  acoustic 
engineers  can  take  a  chart  or  graph  of  the  hearing  impairment  as  shown 
in  the  otologist's  audiometric  test,  and  from  that  graph  prescribe  the 
proper  corrective  ear-phone,  somewhat  as  the  ophthalmologist  and  the 
optician  prescribe  glasses  for  a  refractive  error.  Until  that  happy  day, 
we  should  secure  and  use  the  best  available  hearing  device,  and  even  for  a 
moderate  hearing  impairment.     Why?     We  may  cite  four  reasons.     (1) 


91 

We  owe  it  to  our  fellow-deafened.  To  see  us  surmounting  our  troubles 
will  give  them  courage  to  try.  (2)  We  owe  it  to  our  friends.  They 
want  to  talk  to  us;  they  want  to  work  with  us.  They  probably  will  any- 
way, but  why  willfully  make  it  hard  for  them?  (3)  We  owe  it  to  the 
manufacturer.  If  more  instruments  are  purchased,  better  and  cheaper 
ear-phones  will  result.  (4)  We  owe  it  to  ourselves.  Why  not  be  as 
efficient  and  as  useful  as  we  can  ?  The  best  way  to  discover  what  make  of 
ear-phone  to  secure  is  to  try  the  different  standard  types  assembled  for 
just  this  purpose  by  the  many  leagues  for  the  hard  of  hearing.  In  Massa- 
chusetts one  can  go  to  the  Boston  Speech  Readers  Guild  (339  Common- 
wealth Avenue)  or  the  Worcester  League  for  the  Hard  of  Hearing 
(Woman's  Club  Building)  or  the  Springfield  Speech  Reader's  Club  (V&TVz 
State  Street).  Here  too  can  be  secured  information  concerning  lip- 
reading  teachers. 

Quackery  and  Nostrums 

A  word  of  warning  may  well  be  inserted  here.  The  hard  of  hearing 
reader  may  have  earnestly  sought  help  from  his  skilled  otologist  and  have 
been  told  that  no  more  can  be  done.  Desperate  and  not  resigned  to  his 
increasing  deafness,  he  is  tempted  by  nostrums  and  cure-alls.  The 
advertising  columns  of  our  newspapers  give  us  glowing  promises  of 
relief.  Not  stopping  to  realize  that  what  little  hearing  is  left  is  all  the 
more  precious  and  that  he  is  gambling  his  all  on  a  quack  remedy  that 
claims  to  cure  almost  every  known  and  unknown  malady,  he  tries  one 
panacea  after  another,  at  much  expense  and  with  increasing  discourage- 
ment, and  often  with  real  harm.  Before  starting  on  this  broad  and  easy 
road,  he  should  first  ask  his  otologist,  or  communicate  with  the  nearest 
league  for  the  hard  of  hearing  or  with  national  headquarters  at  the 
Volta  Bureau,  Washington,  D.  C.  A  close  contact  with  the  quackery 
investigation  department  of  the  American  Medical  Association  give3 
access  to  just  the  information  he  needs. 

Organized  Efforts  for  the  Deafened 

There  remains  one  more  "aid"  to  be  discussed.  This  is  the  national 
movement  as  headed  by  the  American  Federation  of  Organizations  for 
the  Hard  of  Hearing,  with  headquarters  at  the  Volta  Bureau,  1601  35th 
Street,  N.  W.,  Washington,  D.  C.  Early  in  this  century  groups  of  adults 
who  had  united  to  study  lip-reading  under  some  teacher,  conceived  the 
idea  first  in  New  York,  then  in  Boston,  Chicago,  Philadelphia  and  so  on, 
of  forming  leagues  for  mutual  help  and  encouragement.  In  1918  these 
joined  in  an  American  Federation.  There  are  now  82  separate  groups 
scattered  over  this  land  and  2  in  Canada.  The  national  body  serves  as  a 
stimulating  and  organizing  center.  The  local  leagues  are  the  efficient 
zones  where  the  activities  go  forward.  Here  we  find  the  fun  of  a  social 
club,  the  education  of  a  lip-reading  school,  the  incentives  of  dramatic  or 
editorial  work,  the  help  of  an  employment  agency.  Here  are  outlets 
aplenty  for  every  member.  It  becomes  a  zealous  agency  for  good  in  the 
community.  It  serves  two  distinct  groups.  As  an  active  philanthropic 
body,  it  helps  in  every  way  it  can  the  community's  deafened,  whether 
adult  or  child.  It  fosters  hearing  tests  in  the  schools;  it  encourages  the 
formation  of  diagnostic  ear  clinics  which  will  try  to  discover  deafness  in 
its  incipiency  and  control  it  if  possible;  it  urges  lip-reading  instruction 
in  the  schools  for  those  deafened  who  are  backward  in  their  work  but  who 
will  go  forward  with  their  normal  class  mates  if  they  can  secure  this 
help;  it  tries  to  gain  social  service  aid  which  will  seek  cooperation  and 
mutual  understanding  between  parent  and  child  and  teacher.  Again, 
the  League  serves  by  trying  to  secure  fitting  employment  for  those  whose 
increasing  deafness  necessitates  a  change.  Or  the  League  protects  its 
members  against  quackery,  or  helps  through  lip-reading  classes  or  dem- 
onstrates assembled  standard  hearing  aids  or  ear-phones.    A  pretty  large 


92 
order  to  fill;  but  almost  of  more  importance  is  its  second  distinctive 
phase  of  service.  This  is  its  less  tangible  but  very  real  help  within  its 
own  membership,  the  psychological  or  spiritual  aid  it  invariably  renders. 
The  blind  are  usually  happy;  the  deafened  are  usually  retiring,  fearful 
of  being  misjudged,  tending  to  isolate  themselves,  unhappy,  even  morbid. 
It  has  been  said  that  more  become  insane  from  the  loss  of  hearing  than 
from  the  loss  of  any  other  sense.  To  the  many  deafened  the  League 
offers  cogent  and  timely  aid.  Here  we  find  those  who  have  mastered 
their  infirmity,  made  good  in  their  community,  are  glad  that  life  is  gay. 
These  contacts  are  inspiring,  the  self-centered  sensitive  soul  blossoms 
again  under  such  sunshine,  finds  that  there  is  work  to  do  and  that  he 
can  do  it,  that  he  is  not  on  the  shelf  and  does  belong  in  the  scheme 
of  things.  And  if  the  reader  knows  of  one  who  is  becoming  shut  in  by 
his  decreasing  hearing,  pray  guide  him  along  the  paths  here  outlined. 

Conclusion 

In  conclusion,  the  world  is  a  far  easier  place  for  a  deaf  man  to  live  in 
than  it  used  to  be.  We  are  making  progress.  Better  educational  advan- 
tages, keener  medical  diagnosis,  earlier  corrective  therapy,  a  more 
perfect  technique  in  the  art  of  lip-reading,  much  improved  ear-phones, 
organizations  devoted  to  the  social,  economic  and  educational  betterment 
of  those  so  handicapped,  a  change  in  our  national  viewpoint  toward  those 
who  may  be  lacking  in  one  sense  but  who  can  make  more  efficient  the 
other  senses:  all  these  contribute.  Let  us  see  to  it  that  in  deafness  pre- 
vention and  in  caring  for  those  so  handicapped,  the  next  generation  will 
be  yet  farther  advanced. 

THE  USE  OF  HEARING  AIDS 

Mrs.  James  F.  Norris 

Chairman  of  the  Subcommittee  on  the  Deaf  and  the  Hard  of  Hearing 

Section  of  Education  and  Training,  White  House  Conference  on 

Child  Health  and  Protection 

"Instruments  for  the  use  of  the  hard  of  hearing  may  be  broadly  divided 
into  two  classes:  electrical  and  non-electrical. 

"In  the  practical  application  of  all  such  devices  of  either  class  three 
factors  are  to  be  considered:  perfection  of  articulation,  intensity  and 
introduction  of  noise  or  rattle. 

"The  non-electrical  devices  are  various  types  of  ear  trumpet,  speaking 
tube  or  auricle,  the  latter  being  either  single  or  double."  These  were 
invented  before  the  days  of  the  telephone.  "They  are  designed  that  they 
may,  (1)  catch  sound,  (2)  suppress  undesirable  noises,  and  (3)  reproduce 
in  greater  magnitude  (by  means  of  resonance)  those  sounds  which  it  is 
desired  to  hear ;  they  must  be  amplified,  as  nearly  as  possible,  in  the  same 
proportion  as  they  are  presented  to  the  instrument.  The  material  of 
which  the  aid  is  constructed  is  of  considerable  importance  in  the  character 
of  the  sound  produced.  For  example,  wood  and  vulcanite  are  better 
than  tin. 

"The  speaking  tube  comes  in  a  class  separate  from  the  other  non- 
electrical aids.  Its  effect  is  as  though  the  user  were  speaking  directly 
into  the  ear.  The  tube  walls  prevent  the  dispersion  of  sound,  and  allow 
the  direct  force  of  the  voice  to  be  exerted  in  the  ear,  via  the  small  column 
of  air." — Douglass  Macfarlan,  M.  D.,  Chairman  Committee  on  Survey  of 
Hearing  Aids,  American  Federation  of  Organizations  for  the  Hard  of 
Hearing,  Inc. 

Another  kind  of  non-electrical  aid  is  the  celluloid  or  paper  fan,  the  edge 
of  which  is  placed  against  the  teeth.  If  the  deafness  is  not  very  severe 
and  if  the  bone  conduction  is  good,  the  hard  of  hearing  person  can  hear 
the  voice  of  a  nearby  speaker,  as  well  as  once  more  enjoy  music  without 
distortion  of  sound. 


93 

Advertisements  of  small  invisible  ear  drums  lure  many  persons  just 
facing  impaired  hearing  to  purchase  them.  Because  they  are  inexpensive 
and  invisible  they  seem,  to  the  uninitiated  at  least,  well  worth  a  trial. 
In  "Ears  and  the  Man"  it  is  stated  that  "they  should  never  be  used  without 
the  advice  of  a  physician.  In  some  cases  of  deafness  they  are  positively 
harmful;  the  drum  can  become  injured  or  infected,  resulting  in  greater 
loss  of  hearing." 

The  advantages  of  most  of  the  non-electrical  aids  are  that  the  sound 
which  comes  to  the  ear  is  not  unduly  distorted  and  that  the  extraneous 
noises  are  not  heard  by  the  one  using  the  aid.  The  disadvantages  will  be 
noted  by  both  the  hard  of  hearing  person  and  the  one  speaking  to  him. 
The  speaker  must  usually  raise  his  voice  to  the  extent  of  tiring  him. 
Talking  into  a  tube  is  unsanitary  and  is  especially  unpleasant  when 
several  persons  enter  into  the  conversation;  it  is  indeed  unfortunate 
when  what  should  be  mutually  pleasing  intercourse  between  persons 
becomes  a  tax  on  the  strength  and  patience  of  both.  Still  other  dis- 
advantages are  that  one  or  both  hands  of  the  deafened  person  are  needed 
to  manipulate  the  tube,  also  that  he  hears  only  what  is  said  directly  to 
him.  This  last  fact  is  of  considerable  psychological  and  sociological 
importance.  One  wearies  of  having  said  to  him  only  those  things  which 
concern  himself,  or  in  which  the  speaker  thinks  he  is  interested.  He  is, 
or  should  be,  interested  in  matters  which  directly  concern  others  as 
well  as  himself.  The  thoughts  and  ideas  of  those  around  him  are  of 
value  to  him  and  should  lead  to  a  broadening  of  his  own.  Further,  there 
is  an  added  fatigue  to  the  deafened  person  who  finds  himself  the  center 
of  the  conversation.  It  is  restful,  on  the  other  hand,  when  he  is  one  of 
a  conversational  group  and  able  to  be  a  part  of  the  "give  and  take." 
Many  hard  of  hearing  persons,  themselves,  fail  to  realize  the  importance 
of  such  a  situation  and  are  apt  to  allow  themselves  the  easier  course  of 
slipping  back  into  the  circle  of  their  own  thoughts. 

The  electrical  aids  came  into  existence  after  the  invention  of  the  tele- 
phone and  are  built  on  the  same  principle.  They  consist  of  three  parts: 
a  transmitter,  receiver  and  battery,  or  batteries.  If  a  deafened  person 
can  understand  when  spoken  to  directly  into  the  ear  and  within  three 
inches  of  it,  it  should  be  possible  for  him  to  have  the  assistance  of  an 
electrical  aid. 

"Loss  of  hearing  is  not  a  simple  matter,  not  even  one  that  varies  in 
quantity  only,  but  an  extremely  varying  phenomenon  that  takes  many 
forms.  It  is  comparatively  easy  to  make  a  hearing  aid  that  is  merely 
a  sound  amplifier,  which  to  many  might  seem  sufficient,  but  to  make  one 
that  will  aid  the  greatest  number  of  deafened  people  to  understand  the 
largest  percentage  of  spoken  words  requires  a  knowledge  that  can  be 
obtained  only  from  extensive  studies  of  hearing  and  can  be  applied 
successfully  only  by  those  widely  experienced  in  the  art  of  electrical 
communication. 

"There  is  a  level  of  loudness  above  which  sounds  begin  to  affect  the 
sense  not  of  hearing  but  of  touch,  causing  a  sensation  of  tickling  in  the 
ears  which  very  soon  becomes  painful.  This  represents  the  upper  limit 
of  hearing  and  is  called  the  'threshold  of  sensation'  since  feeling  then 
begins.  It  is  useless  to  amplify  sounds  above  this  point,  for  were  this 
done  the  sounds  would  produce  pain  and  not  hearing.  At  the  other 
extreme  there  is  a  level  of  minimum  loudness,  referred  to  as  the  'thres- 
hold of  audibility.'  Below  this  level  sounds  are  not  sensed  at  all.  All 
speech  must  therefore  fall  between  these  two  limits." 

The  above  quotation  is  taken  from  an  interesting  and  helpful  article 
which  appeared  some  time  ago  in  the  Bell  Laboratories  Record  and  was 
written  by  its  Director  of  Acoustic  Research,  Harvey  Fletcher,  Ph.D. 
While  the  following  statements  are  also  taken  from  this  article,  some 
of  them  are  not  direct  quotations: 

Deafness  in  any  form  cuts  down  the  auditory  sensation  area  but  it  may 


94 

do  so  in  a  large  number  of  ways.  The  threshold  of  feeling  is  about  the 
same  for  all  people  whether  deaf  or  not.  The  effect  of  deafness  is  to 
raise  or  modify  in  some  manner  the  threshold  of  audibility. 

Sounds  of  speech  as  they  are  normally  pronounced  differ  in  loudness. 
That  of  "aw"  is  the  loudest  of  them  all,  and  the  sound  of  "th"  as  in 
"thin"  is  one  of  the  weakest.  In  general,  vowels  are  loud  and  consonants 
are  weak.  If  the  weak  consonant  sounds  are  amplified  so  that  they  fall 
within  the  auditory  sensation  area,  the  louder  vowel  sounds  would  at  the 
same  time  be  raised  above  the  threshold  of  feeling  and  become  unendur- 
able ;  while  if  the  vowels  were  kept  satisfactorily  low  the  consonants  would 
be  inaudible.  An  improperly  designed  hearing  aid  might  actually  raise 
the  vowel  sounds  more  than  the  consonants,  which  would  aggravate  this 
situation. 

Noise  is  a  factor  which  forcibly  enters  any  hearing  problem.  Obviously 
amplifying  speech  sounds  amplifies  noises  also.  Improper  design  might 
even  cause  a  set  to  amplify  slight  noises  more  than  ordinary  sounds  and 
thus  be  inexcusably  noisy.  Noise  also  limits  the  range  of  a  hearing  aid. 
The  greater  the  distance  between  a  speaker  and  the  hearing  aid  of  a 
listener,  the  greater  will  be  the  effective  amount  of  noise  which  the  set 
will  pick  up  and  so  the  poorer  will  be  the  result. 

In  these  facts  we  find  some  of  the  reasons  why  satisfactory  portable 
electrical  sets  are  not  more  numerous  and  why  results  obtained  from  them 
are  so  varied  among  the  different  users. 

The  sets  available  at  the  time  of  writing  are,  with  but  a  few  additions, 
carefully  listed  in  the  Report  of  the  Committee  on  the  Survey  of  Hearing 
Aids  of  the  American  Federation  of  Organizations  for  the  Hard  of  Hear- 
ing which  was  published  in  the  Volta  Review  for  October  1927.  Since 
the  completion  of  this  survey  of  65  different  instruments  which,  upon 
request,  were  kindly  submitted  for  tests  by  30  different  manufacturers, 
there  has  been  considerable  improvement  in  the  make-up  of  instruments 
without  a  corresponding  improvement  in  the  degree  of  their  usefulness 
to  the  deafened  person.  It  has  been  stated  that  it  would  probably  be 
impossible  to  produce  a  small  portable  hearing  aid  which  would  give 
satisfactory  results  if  a  person  were  deafened  50%  or  over  and  the 
speaker  was  more  than  ten  feet  away.  Research  work  along  this  line  is 
being  carried  on  at  the  present  time  in  a  large  and  important  acoustical 
research  laboratory.  Results  so  far  indicate  that  in  the  near  future  the 
above  supposition  will  be  disproved  and  that  a  person  with  a  loss  of  as 
great  as  even  60%  can  be  equipped  with  a  small  portable  set  which  will 
give  results  far  more  helpful  than  those  obtainable  from  small  instru- 
ments on  the  market  at  the  present  time. 

Dr.  Douglas  Macfarlan  of  Philadelphia  has  stated  that  "instruments 
are  individuals  just  as  the  hard  of  hearing  person  is  an  individual  and 
the  instrument  may  or  may  not  be  suitable  to  that  particular  kind  of 
deafness.  A  hearing  aid  should  be  used  as  an  accessory  to  lip  reading 
and  a  device  should  be  used  when  deafness  first  develops  and  the  study 
of  lip  reading  should  commence  immediately,  because  in  the  majority  of 
cases  the  deafness  is  progressive.  When  an  audiometer  test  shows  a  loss 
of  50%  in  both  ears,  incapacitating  deafness  has  arrived.  A  hearing  aid 
should  be  used  though  not  depended  upon  entirely;  lip  reading  should 
not  be  forgotten."  In  many  persons  who  have  a  hearing  loss  of  35%  in 
one  ear  and,  let  us  say  37%  in  the  other,  it  can  indeed  be  considered 
handicapping  deafness  if  not  incapacitating. 

The  advice  as  to  the  study  of  lip-reading  (also  called  speech  reading) 
is  valuable  and  should  be  followed  even  though  the  hard  of  hearing  person 
is  more  or  less  of  a  "natural  born  lip  reader."  A  baffling  situation  exists 
for  the  social  worker  who  is  asked  to  help  a  hard  of  hearing  person, 
because  of  the  fact  that  a  large  majority  of  otologists  tell  their  patients 
not  to  study  lip  reading.  Such  advice  can  usually  well  be  called  harmful 
and  cruel.    Among  the  hundreds  of  hard  of  hearing  persons  known  to  the 


95 

author,  not  only  have  none  of  them  been  harmed  nervously,  physically, 
educationally  or  socially  by  studying  this  subtle  art  but  many  of  them 
have  been  strengthened  in  all  these  ways  and,  in  addition,  have  attained 
a  poise  and  often  a  spirituality  that  has  assisted  in  making  them  more 
valuable  members  of  society.  Ability  to  read  the  lips,  no  matter  how 
great,  will  never  replace  normal  hearing  or  the  benefits  derived  from  a 
satisfactory  electrical  aid,  but  the  two  should  go  hand  in  hand. 

Contrary  to  the  advice  given  in  the  sales  offices  of  some  manufacturers 
of  hearing  aids,  it  is  believed  that  instruments  should  not  be  worn  all  the 
time.  For  the  routine  of  the  day  a  dependence  on  lip  reading  is  well 
nigh  invaluable,  and  can  be  supplemented  by  the  use  of  an  instrument 
when  a  speaker  wishes  to  say  more  than  just  a  few  words.  Such  a 
procedure  tends  to  slowly  but  surely  increase  one's  ability  to  "read  the 
lips"  as  well  as  fortify  him  against  the  day  when  he  will  be  too  deaf  to 
use  an  aid  if  his  is  the  type  of  deafness  which  may  lead  to  such  a 
condition. 

In  addition  to  individual  aids  there  are  also  group  hearing  sets.  These 
are  quite  satisfactory  as  to  amplifying  qualities,  but  are  large  and  cum- 
bersome, and  hence  difficult  if  not  impossible  to  move  around,  and  are 
rather  expensive.  Such  sets  are  sometimes  installed  in  churches,  lecture 
halls,  leagues  for  the  hard  of  hearing  and  schools  for  the  deaf. 

There  are  also  several  types  of  attachments  designed  to  assist  deafened 
persons  to  hear;  some  of  these  are  the  desk  telephone  attachment;  a 
small  unit  used  with  the  radio ;  and  vibratory  instruments  which,  though 
not  aids,  are  thought  by  some  to  stimulate  residual  hearing  and  thus 
re-educate  it,  and  bring  it  within  the  possibility  of  again  using  the  tele- 
phone or  an  electrical  aid.  Instead  of  having  an  amplifying  attachment 
on  their  telephone  some  persons  prefer  to  place  the  telephone  receiver 
against  the  transmitter  of  the  hearing  aid  which  they  are  wearing,  thus 
obtaining  sufficient  amplification  to  use  any  telephone. 

The  selection  by  the  deafened  person  of  an  aid  which  will  be  of 
practical  help  to  him  is  often  a  long  and  difficult  matter.  Valuable  assist- 
ance in  this  regard  is  now  obtainable  through  a  fairly  recently  organized 
service  maintained  in  such  groups  for  the  hard  of  hearing  as  The  Speech 
Readers  Guild  of  Boston,  Inc.,  and  the  New  York  (City)  League  for  the 
Hard  of  Hearing,  Inc.  Manufacturers  of  the  best  sets  have  kindly 
cooperated  by  lending  samples  to  these  clubs  maintained  for  and  largely 
by  the  hard  of  hearing.  The  club  furnishes  a  consultant  who,  by 
appointment,  gives  the  inquirer  a  hearing  test  by  means  of  the  3-A 
Audiometer,  and  then  permits  him  to  try  those  instruments  which  may 
be  of  help  to  him.  Other  clubs  throughout  the  country  offer  such 
gratuitous  service  to  their  communities  and  more  should  do  so.  It  is  of 
greatest  value  to  a  would-be  purchaser  to  have  such  an  opportunity  to 
try  all  makes  instead  of  visiting  an  agency  where  but  one  type  is  on  sale, 
and  where  comparison  is  impossible.  Further,  an  over-zealous  sales 
person  sometimes  prevents  an  unbiased  decision. 

A  hard  of  hearing  person  must  be  encouraged  in  every  way  by  his 
doctor,  family  and  friends  to  study  lip  reading  and  to  search  until  he 
finds  the  instrument  most  helpful  to  him,  buy  it,  use  it  and  make  a 
veritable  companion  of  it.  The  aids  are  not  cheap,  they  are  fairly  heavy 
and  somewhat  of  a  bother  to  manipulate,  but  they  can  be  made  a  boon  to 
the  deafened  person  as  well  as  to  those  with  whom  he  comes  in  contact. 

Some  makers  of  instruments  allow  a  ten-day  free  trial,  while  others 
reasonably  require  a  deposit  for  same.  Private  schools  of  lip  reading 
give  demonstration  lessons  free  of  charge,  and  the  cost  of  the  regular 
course  of  30  to  35  lessons  is  low,  especially  when  it  is  realized  that 
endowment  and  subsidies,  from  which  most  educational  institutions 
benefit,  have  not  yet  helped  these  special  training  centers. 

The  fact  that  a  hearing  aid  or  lip-reading  cannot  be  the  means  by  which 
the  person  with  acquired  deafness  can  return  to  his  former  ability  to 


96 

hear  everything,  is  no  reason  for  his  refraining  from  using  each  or 
both  to  the  fullest  extent.  The  often  heard  lame  excuses  of  the  deafened 
that  to  wear  an  aid  would  let  those  about  them  know  of  their  deafness, 
or  the  acquisition  of  lip-reading  lessen  their  use  of  what  hearing  they 
have  and  also  strain  their  eyes,  should  be  abandoned. 

People  around  them  already  know  they  are  deaf  and  are  often  incon- 
venienced by  the  fact  to  a  far  greater  extent  than  the  hard  of  hearing 
persons  themselves  realize.  The  nervous  tension  of  straining  to  hear 
taxes  the  system  and  reacts  unfavorably  on  the  hearing  acuity.  One  will 
hear  what  he  hears  whether  he  lip  reads  or  not,  and  when  he  has  a 
certain  loss  there  are  sounds  such  as  "th"  which  he  cannot  possibly  hear 
but  which  he  can  "get"  when  he  lip  reads  because  most  of  these,  are 
visible  speech  sounds. 

With  rare  exceptions,  such  as  that  of  Thomas  A.  Edison,  most  of  the 
deafened  people  want  to  hear  and  yet  today  we  have  a  commission 
studying  the  ill  effects  of  noise  upon  individuals.  Surely  there  are  assets 
as  well  as  liabilities  in  being  deaf!  Let  deafened  persons  seek  comfort 
in  the  silence  of  their  world  when  to  do  so  is  a  help,  and  put  on  an  aid  to 
hear  their  friends  when  they  are  spoken  to,  for  sound  is  the  natural 
accompaniment  of  speech. 

LIP  READING  IN  MASSACHUSETTS 

Ena  G.  Macnutt 
Boston,  Mass. 

Massachusetts  was  one  of  the  first  states  to  be  settled  as  our  tercen- 
tenary celebration  reminds  us,  it  has  always  held  high  rank  in  educational 
lines,  and  so  it  is  not  surprising  to  find  it  among  the  leading  states  in 
educating  the  deaf  and  hard  of  hearing  by  means  of  lip  reading. 

First,  let  us  get  a  clear  idea  of  what  lip  reading,  or  speech  reading,  as 
it  is  often  called,  really  is.  One  of  the  best  definitions  is  that  it  is  the  art 
of  reading  speech  from  the  movements  of  the  speaker's  face.  There  are 
hundreds  of  deaf  and  hard  of  hearing  people  who  can  carry  on  conversa- 
tion with  ease  without  hearing  a  sound  of  the  speaker's  voice,  simply  by 
watching  the  movements  of  his  face.  If  the  lips  were  the  only  visible 
part  of  the  speaker's  face,  this  would  be  very  difficult,  but  when  we  add 
to  the  lip  movement  the  whole  facial  movement  and  expression  we  have 
an  easier  task.  Therefore,  speech  reading  seems  a  more  accurate  term 
than  lip  reading,  though  it  is  not  in  such  common  usage. 

We  have  said  that  lip  reading  is  an  art.  The  dictionary  tells  us  that 
an  art  is  the  skillful  and  systematic  adaptation  of  means  for  the  attain- 
ment of  some  end,  and  that  is  just  what  lip  reading  is,  not  something 
acquired  in  a  short  time,  but  like  all  other  arts,  requiring  faithful  and 
systematic  study. 

There  are  two  classes  of  people  to  whom  lip  reading  is  invaluable,  the 
deaf  and  the  hard  of  hearing.  One  of  the  finest  schools  for  the  deaf 
in  our  country  and  the  first  to  be  established  for  pure  oral  method  of 
instruction  is  the  Clarke  School  at  Northampton.  Other  residential 
schools  for  the  deaf  are  located  at  Beverly  and  Randolph.  We  also  have  a 
fine  day  school  for  the  deaf  in  Boston  and  day  classes  in  Lynn,  Spring- 
field and  Worcester.  Formerly  the  deaf  communicated  largely  by  signs 
and  manual  spelling,  but  this,  as  a  means  of  instruction,  has  now  been 
largely  abolished  and  speech  and  lip  reading  take  its  place. 

There  seems  to  be  nothing  that  is  of  more  practical  help  or  more  valu- 
able to  the  adult  who  is  losing  or  has  lost  his  hearing  than  lip  reading. 
Many  questions  are  asked  in  regard  to  it,  such  as,  "Am  I  too  old  to 
learn?,"  "How  long  does  it  take?,"  "Will  I  be  able  to  follow  sermons  and 
lectures?,"  "Can  I  follow  conversations?,"  etc. 

There  seems  to  be  no  age  limit  for  the  study  of  lip  reading.  More 
than  one   ambitious  person,  who  was  nearer  eighty  than   seventy  has 


97 

made  a  success  of  lip  reading  and  no  child  who  has  speech  and  language 
is  too  young  to  read  the  lips.  Many  persons  are  what  we  might  call 
"born  speech  readers."  They  read  the  lips  naturally,  and  with  very  little 
study  become  proficient  speech  readers.  Others  have  to  spend  a  much 
longer  time,  for  lip  reading,  like  playing  the  piano,  requires  faithful  study 
and  continual,  systematic  practice  to  become  proficient  in  it,  unless  one  is 
a  genius  in  that  line,  but  there  are  few  persons  who  cannot,  by  means 
of  perseverance  and  practice,  acquire  enough  of  the  art  to  make  it  an 
almost  invaluable  help  to  them.  When  the  hard  of  hearing  person  goes 
to  church,  or  to  a  lecture,  it  is  very  difficult  to  get  a  good  view  of  the 
speaker's  face  and  the  right  light  upon  it.  It  also  often  happens  that 
the  speaker  has  poor  enunciation,  making  his  lips  almost  impossible  to 
read.  Because  of  these  adverse  conditions,  it  is  rarely  that  one  can 
follow  either  sermons  or  lectures  entirely  by  lip  reading,  and  for  the 
same  reasons,  conversation  with  large  groups  of  people  is  difficult  but 
conversation  with  two  or  three  people  can  often  be  readily  followed,  and 
with  one  person,  it  is  comparatively  easy. 

The  first  lip  reading  school  for  hard  of  hearing  adults  in  the  United 
States  was  established  in  Boston  in  1902.  Two  other  schools  have  been 
established  since  that  time,  so  that  the  hard  of  hearing  of  Boston  and  its 
suburbs  have  every  opportunity  for  the  study  of  this  art.  These  schools 
are  in  session  from  October  to  June,  and  one  of  the  schools  has  a  summer 
session  in  Burlington  on  Lake  Champlain,  Vermont,  where  people  from 
all  over  the  country  gather  for  study  and  recreation.  At  these  schools 
one  may  have  private  lessons  and  practice  classes  in  lip  reading,  beginning 
at  any  time  during  the  school  year.  Here  also  the  hard  of  hearing  find 
that  friendly  sympathy  and  understanding  which  they  need  so  much,  as 
well  as  the  social  contacts  that  help  to  lift  them  from  the  despondency 
and  discouragement  which  so  often  follow  loss  of  hearing,  and  help  to 
restore  their  happiness  and  efficiency  in  the  social  and  business  world. 
Smaller  schools  have  been  established  in  Springfield,  Worcester,  Lowell 
and  Haverhill,  and  the  same  friendly,  helpful  spirit  prevails  in  these. 

The  hard  of  hearing  are  often  very  reticent  about  allowing  their  handi- 
cap to  be  known,  but  this  is  being  overcome  by  the  formation  of  clubs  for 
the  hard  of  hearing.  In  many  cities  these  people  have  banded  together 
in  groups  and  formed  clubs  that  are  social,  recreational  and  educational 
centers  for  their  members.  Many  of  these  clubs  originated  in  some 
school  or  class  for  the  hard  of  hearing.  One  of  the  first  in  the  country 
and  one  of  the  largest  is  the  Speech  Readers  Guild  of  Boston,  which  has 
between  four  and  five  hundred  members. 

This  club  offers,  for  a  very  nominal  membership  fee  practice  in  speech 
reading  in  evening  classes  throughout  the  winter  season.  It  also  gives 
scholarships  in  the  various  schools  to  worthy  persons  who  cannot  afford 
to  pay  for  instruction.  Similar  clubs  have  recently  been  established  in 
Worcester  and  Springfield,  still  others  are  in  the  embryo,  and  we  hope 
that  the  time  will  soon  come  when  every  city  in  our  state  will  have  an 
organization  for  the  hard  of  hearing,  which  will  promote  the  study  of 
lip  reading  for  both  children  and  adults. 

Classes  in  lip  reading  have  been  established  in  the  evening  schools  in 
several  cities  of  Massachusetts.  These  classes  are  free  to  residents  of 
the  city.  While  the  progress  is  not  so  rapid  in  class  as  in  individual 
instruction,  this  is  a  splendid  opportunity  for  those  who  cannot  attend 
the  private  schools.  Boston,  Cambridge  and  Newton  are  among  the  cities 
that  offer  such  instruction.  If  application  were  made  to  school  authorities, 
no  doubt  other  cities  would  add  lip  reading  to  the  subjects  taught  in  their 
evening  schools. 

Even  more  important  than  lip  reading  for  the  adult  is  lip  reading  for 
the  hard  of  hearing  child  in  our  public  schools.  Lynn  is  our  pioneer 
city  in  this  work.  Miss  Caroline  Kimball,  a  hard  of  hearing  school 
teacher,  realized  that  there  were  hard  of  hearing  children  struggling 


98 

through  our  schools,  continually  retarded  and  misunderstood  because  of 
their  aural  handicap,  and  offered  her  services  to  teach  them  lip  reading. 
One  experimental  year  of  the  work  proved  the  value  of  lip  reading  for 
these  children  to  the  school  authorities  and  Miss  Kimball  was  given  a 
permanent  position.  Several  other  cities  have  added  speech  reading  for 
children  to  their  school  curriculum,  Fall  River  next  to  Lynn,  and  more 
recently  Cambridge,  Somerville,  Gloucester,  Springfield  and  West  Spring- 
field. The  work  has  been  started  in  Chelsea,  and  Newton  is  to  have 
speech  reading  when  the  schools  open  in  the  Fall. 

In  spite  of  the  fact  that  Massachusetts  is  one  of  the  leading  states  in 
the  work  for  the  hard  of  hearing  child,  the  work  is  progressing  far  too 
slowly,  even  here.  It  is  appalling  to  think  of  the  number  of  hard  of 
hearing  children  in  our  schools,  (the  estimate  is  3,000,000  for  the 
country)  not  a  few  of  which  we  know  are  being  placed  in  classes  for  the 
mentally  deficient,  though  their  mentality  is  unimpaired.  Many  are 
grouping  their  way  through  the  grades  at  the  foot  of  their  classes  with- 
out knowing  why,  simply  because  sounds  that  the  other  pupils  hear 
easily  are  just  beyond  their  auditory  capacity.  They  are  retarded  many 
times  more  often  than  their  classmates,  and  leave  school  with  a  sense  of 
inferiority  and  discouragement  that  is  entirely  unnecessary  and  unjust 
for  them  to  have. 

Have  you  ever  attended  a  lecture  when  your  seat  was  just  out  of  range 
of  the  speaker's  voice,  making  it  a  conscious  effort  for  you  to  hear?  Did 
you  not  find  your  mind  wandering  in  a  short  time,  to  be  called  back  by 
a  louder  tone  or  an  unusual  gesture,  resolve  to  follow  what  is  being  said, 
only  to  realize  that  you  had  again  lost  the  trend  of  thought?  If  so,  you 
may  be  able  to  imagine  a  few  of  the  difficulties  of  the  daily  life  of  the 
hard  of  hearing  child;  a  few,  because  there  is  no  one  to  chide  you  for 
your  seeming  lack  of  interest,  to  think  you  stupid  and  lazy. 

The  first  step  to  relieve  this  situation  is  to  find  the  hard  of  hearing 
child  and  make  him,  his  parents,  teachers  and  school  officials  realize  what 
the  underlying  cause  of  his  trouble  is.  Until  recently  this  was  a  difficult 
task,  but  now,  thanks  to  the  American  Federation  of  Organizations  for 
the  Hard  of  Hearing,  and  the  engineers  of  the  Bell  Telephone  Company, 
we  have  the  4-A  audiometer,  which  may  well  be  called  the  salvation  of 
the  hard  of  hearing  child.  By  means  of  this  machine,  which  is  described 
elsewhere  in  this  magazine,  the  hard  of  hearing  child  is  easily  detected. 
When  he  is  found  every  effort  should  be  made  toward  the  prevention  of 
increasing  deafness,  and  the  cure  of  whatever  trouble  the  child  may  have, 
for  it  is,  as  a  rule,  only  in  the  early  stages  that  deafness  is  curable. 
Unfortunately,  many  of  these  children  are  found  too  late,  and  the 
prognosis  of  the  examining  otologist  is  far  from  hopeful.  Though  there 
are  many  whose  hearing  we  cannot  restore,  and  who  face  the  problem  of 
increasing  deafness,  their  cases  are  far  from  hopeless,  if  they  are  given 
that  staunch  friend  of  the  deafened  adult,  LIP  READING,  which  is  no 
less  staunch  a  friend  of  the  hard  of  hearing  child. 

A  child's  mind  is  in  the  plastic  stage,  he  has  few  fixed  habits  to  over- 
come, he  learns  more  readily  than  the  adult,  and  lip  reading  for  him  is  a 
much  easier  task.  A  short  time  ago  the  teacher  of  a  hard  of  hearing  boy 
remarked,  "The  first  of  the  year  Benjamin  was  a  discipline  case,  but  I 
rarely  have  to  speak  to  him  now."  The  reason  for  the  change  in  Ben- 
jamin was  that  he  had  had  lessons  in  lip  reading  the  last  half  of  the  year 
and  could  follow  at  least  a  part  of  what  was  going  on  in  the  room,  so  he 
exerted  his  energy  on  seeing  how  much  he  could  follow  instead  of  annoy- 
ing his  teacher  and  disturbing  the  class.  Many  a  discipline  case  could  be 
as  easily  disposed  of,  but  not  all  hard  of  hearing  children  are  discipline 
cases.  Many  are  patient  plodders,  doing  their  best  and  accomplishing 
little. 

Mary  left  school  last  year  at  the  age  of  sixteen,  with  a  fourth  grade 
education.     She  progressed  so  slowly  in  the  grades  that  she  was  placed 


99 

in  the  mentally  deficient  class.  Her  teacher,  who  makes  a  study  of  the 
individual  children  in  her  care  said  she  felt  that  Mary  was  not 
mentally  deficient,  but  that  her  loss  of  hearing  had  been  her  only  trouble 
from  the  first  grade  up.  A  few  lessons  in  lip  reading  last  year  showed 
her  to  be  unusually  quick  to  grasp  the  work,  but  they  came  too  late, 
for  she  was  obliged  to  leave  school  to  help  to  support  the  family. 

Our  great  hope  is  that  the  day  will  soon  come  when  our  state  and  all 
others  will  not  only  require  that  every  child's  hearing  shall  be  tested, 
but  that  it  shall  be  tested  with  an  audiometer,  and  that  every  child  who 
needs  it  shall  have  speech  reading  to  save  him  from  the  humiliation,  dis- 
couragement and  despair  which  he  is  now  experiencing. 

Any  information  in  regard  to  lip  reading  for  the  hard  of  hearing  child 
or  adult,  or  any  other  phase  of  the  work  for  the  deafened  can  be  obtained 
from  the  American  Federation  of  Organizations  for  the  Hard  of  Hearing, 
1601  35th  Street,  Washington,  D.  C. 

HEARING  DEFECTS  IN  THE  PRE-SCHOOL  CHILD 

Susan  M.  Coffin,  M.  D. 
Child  Welfare  Physician,  Massachusetts  Department  of  Public  Health 

How  early  must  we  look  for  hearing  defects  among  children?  And 
how  can  we  discover  them?  These  are  question  of  great  interest  to  all 
dealing  with  pre-school  children  and  to  everybody  who  is  interested  in 
helping  to  prevent  deafness.  There  is  remarkably  little  in  medical 
literature  on  the  subject.  Deafness  never  has  excited  the  interest  or 
pity  that  blindness  has,  yet  the  untaught  deaf  child  is  as  isolated  as 
Robinson  Crusoe. 

A  survey  made  of  school  children  in  the  U.  S.  by  Fowler  and  Fletcher 
in  1926  and  1928  *  indicated  that  nearly  3,000,000  have  hearing  defects. 
We  have  it,  too,  on  good  authority,  that  there  are  some  45,000  deaf-mutes 
in  our  country.  That  in  thousands  of  these  unfortunate  cases  deafness 
could  have  been  prevented  or  cured,  or  at  least  a  workable  degree  of 
hearing  preserved  had  early  training  and  treatment  been  carried  out,  is 
agreed  by  all. 

The  school  child  gets  at  least  routine  hearing  tests  which  show  up 
gross  defects,  but  the  pre-school  child  is  dependent  on  the  intelligence  of 
his  parents  for  discovery  of  decreased  hearing. 

Again  we  are  impressed  with  the  value  of  a  complete  periodic  health 
examination  for  the  infant  and  young  child  as  well  as  for  school 
children  and  adults.  At  one  of  our  Well  Child  Conferences  recently  a 
girl  of  five,  who  will  enter  school  in  September,  could  not  hear  hand  clap 
or  bell  at  a  distance  at  which  they  were  clearly  audible  to  the  other 
children  examined.  She  could  not  hear  our  trusty  Ingersoll  at  all  at  a 
distance  of  four  inches  from  either  ear.  The  mother  claimed  that  the 
child  "didn't  pay  attention" — a  fairly  common  parental  complaint  and 
one  which  calls  for  hearing  tests  before  a  child  is  pronounced  a  "case" 
for  the  habit  clinic. 

The  simple  tests  employed  by  the  family  physician  or  the  Well  Child 
Conference  physician,  should  be  followed  by  thorough  examination  by  an 
otologist  with  all  children  where  there  is  any  doubt.  Every  physical 
examination  should  include  examination  of  the  ears  for  the  presence  of 
discharge,  wax  plugs  or  foreign  bodies,  and  a  careful  family  and  childhood 
history  taken  of  those  children  showing  deafness. 

Supervised  education  needs  to  begin  early  with  the  deaf  child.  The 
normal-hearing  child  can  afford  to  "waste"  the  first  five  or  six  years  of 
life,  learning  as  he  does  so  much  unaided,  but  the  deaf  child  needs  special 
help  as  early  as  two  or  three  years  to  become  able  to  have  an  auditory 


*  Journal  of  the  American  Medical  Assoc.  December    4,    1926    and 
"        "     "  "  "  "       October  20,  1928. 


100 
education  later.    This  involves  teaching  of  parents  and  help  from  special 
"home"  teachers  or  in  special  classes.     The  Wright  Oral  School,  New 
York  City,  has,  by  the  way,  a  correspondence  course  for  parents  pre- 
pared by  Mr.  John  Dutton  Wright. 

In  regard  to  testing  these  very  young  children,  Dr.  Douglas  MacFarlan 
(Philadelphia)  permits  us  to  quote  him  as  follows: 

"For  young  children  with  language  I  use  a  phonograph  record  with  the 
simplest  familiar  monosyllables,  and  I  control  the  intensity  with  a 
rheostat.  For  the  deafened  children  I  use  music  with  a  phonograph  and 
try  to  elicit  whether  or  not  the  child  hears  by  turning  the  music  off  and 
on  at  different  intensities.  It  must  be  remembered  that  if  loud  intensi- 
ties have  to  be  used  for  the  deafened  child  you  must  be  sure  that  the 
child  is  reporting  hearing  and  not  feeling  vibrations.  Many  children  who 
have  never  had  hearing  have  no  conception  or  memories  of  sounds  that 
will  allow  them  to  report  them  as  such,  yet  all  but  5%  of  the  profoundly 
deaf  have  some  residual  hearing  and  in  most  cases  it  can  be  used  to 
educate  them  by  the  auditory  method." 

"In  the  examination  of  any  given  case  it  is  only  by  the  collection  of  a 
mass  of  evidence  from  much  ingenious  examination  that  you  will  find  the 
amount  of  residual  hearing.  But  you  should  expect  to  find  considerable 
residual  hearing  where  you  least  expect  it." 

Dr.  Harold  Babcock  (Boston)  believes  that  the  audiometer  is  not  the 
proper  test  for  pre-school  children  and  urges  that  the  annual  examination 
always  be  combined  with  thorough  eye,  nose  and  throat  examinations  in 
every  case. 

Dintenfass  is  willing  to  state  that  adenoids  are  responsible  for 
four-fifths  of  all  cases  of  impaired  hearing  in  children.* 

As  congenital  syphilis  is  among  the  causes  of  congenital  deafness  we 
have  still  another  reason  for  urging  a  careful  history  and  thorough  exam- 
ination of  the  expectant  mother  followed  by  adequate  treatment  if 
syphilis  is  diagnosed.  Deafness  from  this  cause  is  usually  bilateral  and 
of  the  most  serious  type. 

Various  authorities  warn  sharply  against  inter-marriage  among  fam- 
ilies in  which  there  is  a  taint  of  hereditary  deafness  as  defective  hearing 
in  the  offspring  is  so  frequent  an  occurrence. 

Children's  diseases  are  frequently  accompanied  or  followed  by  middle 
ear  disease  and  later  hearing  defects.  It  is  during  the  first  ten  years 
that  ears  are  most  likely  to  suffer  injury.  Bacon  claims  that  10%  of  all 
cases  of  impaired  hearing  are  due  to  scarlet  fever  alone,  so  when  we 
finally  get  scarlet  fever  under  control  we  should  expect  to  see  a  consider- 
able drop  in  the  number  of  deafened  children. 

Feldman  states  that  in  1923,  eight  children  per  1,000  suffered  from 
middle  ear  disease  in  England  and  Wales  while  in  London  the  proportion 
was  as  high  as  17  per  1,000  which  statement  gives  us  food  for  thought. 
Feldman  also  claims  that  in  about  50%  of  those  children  sufficiently  deaf 
to  require  education  in  special  schools,  the  defects  are  due  to  preventable 
middle  ear  disease. 

In  a  series  of  100  autopsies  of  children  under  four  years,  evidence  of 
ear  disease  was  found  in  91  cases  although  in  only  10  was  diagnosis  made 
during  life.f 

All  such  data  emphasize  the  need  of  careful  ear,  as  well  as  nose  and 
throat  examinations,  with  sick  children  if  we  are  to  prevent  hearing 
defects  due  to  infection. 

Normal  range  of  sound  perception  is  20  to  20,000  vibrations  per  second. 
Ordinary  conversation  has  a  range  of  120  to  520,  so  a  child  can  have  a 
considerable  defect  and  yet  not  be  considered  hard  of  hearing.  Defects 
which  come  on  during  the  first  three  or  four  years  of  life  with  the 
child  who  has  no  one  to  train  him  to  speech  and  lip  reading  usually 

*  Atlantic   Medical   Journal — January,    1925. 
t  Archives  of  Pediatrics — 1916 — p.   434. 


101 
cause  deaf -mutism,  hence  the  great  need  of  early  diagnosis  and  training 
of  those  who  have  irremediable  defects.  The  deafened  child  who  is 
trained  to  use  his  voice  from  babyhood  possesses  a  much  better  voice  than 
the  child  who  has  never  talked  or  who  has  not  talked  for  a  very  long 
period.  Modern  training  begins  with  the  deaf  or  partially  deaf  baby  and 
employs  constantly  adult  speech  which  requires  response  from  the  child, 
the  child's  attention  being  directed  to  the  adult's  mouth,  not  to  gestures 
and  actions.  The  deafened  child  is  now  taught  to  "listen"  with  his  eyes 
to  a  considerable  extent  and  this  is  proving  a  great  advantage  as  it 
enables  him  to  mingle  with  normal  children  more  easily. 

PLEASE  WALK  IN 

Mildred  Kennedy 
Speech  Readers  Guild 

Born  of  a  desire  to  mutually  help  one  another  to  overcome  a  common 
handicap  of  deafness,  the  Speech  Readers  Guild  of  Boston  has  entered 
upon  its  fifteenth  year  of  activity. 

It  becomes  more  and  more  difficult  to  realize  that  rehabilitation  work 
for  the  deafened  is  a  comparatively  new  field  of  activity.  A  score  of 
years  ago  such  service  was  practically  unthought  of.  Today  some 
seventy-five  or  eighty  local  groups  are  scattered  throughout  the  length 
and  breadth  of  the  United  States  and  Canada:  this  chain  is  proud  to 
recognize  itself  as  being  the  very  warp  and  woof  of  our  American 
Federation  of  Organizations  for  the  Hard  of  Hearing. 

The  Speech  Readers  Guild  of  Boston  stands  among  the  pioneers  in  this 
field  work,  being  the  second  oldest  welfare  centre  of  this  kind  in  the 
country.  The  purpose  and  determination  on  the  part  of  the  Guild 
executives  to  endeavor  to  solve  every  problem  dealing  with  the  deafened 
that  comes  to  our  door  proves  a  positive  incentive  in  the  unfolding  of 
our  work. 

The  educational  and  social  activities  flourished  from  the  earliest  days 
of  the  organization  in  the  form  of  speech-reading  classes,  program  meet- 
ings, benefits  of  varied  kinds  such  as  the  annual  bazaar  and  bridge 
parties,  purposed  to  increase  our  accessible  funds.  Community  suppers 
and  other  friendly  gatherings  became  more  common  features  as  friend- 
ships grew  and  the  membership-body  increased. 

Of  the  more  serious  and  to  some  perhaps  more  worthwhile  activities 
stand  out  the  scholarships  in  speech  reading  offered  through  the  Educa- 
tional Committee.  The  social  service  department  gives  free  demonstra- 
tions and  advice  regarding  the  care  of  and  possibilities  awaiting  the 
deafened  through  the  use  of  hearing  aids:  also  keeping  itself  informed 
regarding  achievements  connected  with  hearing  instruments  of  varied 
kinds.  Consultation  and  advice  is  given  at  the  Guild  House  through  its 
several  departments  in  matters  relating  to  employment,  educational 
problems,  placement  and  rehabilitation  of  the  deafened  of  all  ages. 

The  Guild  is  rightly  proud  of  its  achievements  connected  with  spread- 
ing propaganda  of  measures  to  save  our  school  children  if  possible  from 
adventitious  deafness.  Scientists  have  stated  that  eighty  per  cent  of  our 
deafened  adults  might  have  had  their  hearing  saved  if  they  had  had 
timely  and  proper  treatment.  A  generation  ago  there  were  only  the 
most  primitive  methods  known  for  testing  the  hearing  of  school  children; 
many  of  these  little  ones  had  a  degree  of  subnormal  hearing  that  made  it 
a  physical  impossibility  for  them  to  keep  up  with  their  classmates. 
Grades  were  repeated  over  and  over.  Tears  were  shed  in  the  hushed 
darkness  of  the  bedtime  hour  as  the  phrase  rang  through  the  sensitive 
child's  memory,  that  had  been  reiterated  over  and  over  by  some 
"grownup",  "If  you  would  only  pay  attention!  Why  don't  you  listen  to 
what  is  said  to  you?"  Words  that  repeated  themselves  with  all  their 
varied  inflexions  of  impatience  and  irritability  expressed  by  one  who  had 


102 

never  thought  of  such  a  thing  as  subnormal  hearing.  How  weary  one 
grows  of  constant  listening  when  the  act  requires  intense  nerve  strain  in 
order  to  catch  the  sound  of  the  spoken  voice  and  all  its  complexity  of 
meaning ! 

Out  of  the  realization  of  many  of  these  difficulties  backed  by  a  knowl- 
edge born  of  experience  the  elder  generation  of  men  and  women  resolved 
that  coming  boys  and  girls  should  be  spared  the  sufferings  that  they  had 
known.  Through  their  persistence,  medicine,  science  and  invention  tackled 
the  problems  involved.  We  all  know  that  "an  ounce  of  prevention  is  worth 
a  pound  of  cure,"  so  the  problem  was  to  find  the  children  who  stood  on 
the  border  line  of  deafness.  Thus  the  phono-audiometers  were  brought 
forth  and  the  Guild  took  upon  itself  the  responsibility  of  spreading  the 
importance  of  this  group  testing  of  school  children  as  widely  and  as 
generously  as  time  and  circumstances  would  permit.  It  has  had  a  large 
part  in  selling  the  idea  of  the  phono-audiometer  to  school  boards  and 
authorities  in  southern  New  England. 

Beside  this  field  work  the  Guild  social  worker  gives  hearing  tests  with 
the  buzzer  type  of  audiometer  as  well  and  the  annual  report  shows  that 
many  of  the  five  hundred  and  forty-nine  persons  reported  as  having  been 
aided  by  the  social  service  department  came  for  a  hearing  test  and  the 
files  contain  careful  records  of  these. 

This  particular  test  is  helpful  in  giving  advice  regarding  hearing  aids 
for  when  the  social  worker  knows  the  degree  and  profundity  of  hearing 
loss  she  is  better  able  to  advise  regarding  hearing  aids.  The  loan  collec- 
tion of  these  hearing  aids  made  possible  through  the  courtesy  and  coopera- 
tion of  the  several  earphone  companies  represents  an  interesting  feature 
of  the  Guild  work.  Here  the  deafened  may  come  for  private  demonstra- 
tions of  the  several  makes  of  instruments,  learning  from  one  qualified  to 
give  the  information  something  of  its  care,  upkeep,  limitations  and  possi- 
bilities. In  this  way,  when  the  hearing  aid  giving  the  greatest  degree  of 
satisfaction  to  an  individual  has  been  found,  the  deafened  enquirer  is 
given  the  address  of  the  concern  and  advised  to  go  to  the  office  to  purchase 
a  device  that  he  or  she  has  reason  to  believe  will  give  the  maximum 
amount  of  satisfaction.  By  this  means  provided  for  the  deafened  irre- 
spective of  whether  they  be  members  of  the  Guild  or  not,  many  are  spared 
the  persistent  advances  of  eager  salesmen  whose  duty  it  is  to  sell  their 
goods  whether  or  not  their  instrument  meets  the  requirements  of  the 
particular  type  of  deafness. 

Some  persons  hear  best  and  easiest  with  instruments  making  use  of 
amplified  air  vibrations,  others  by  those  using  bone  conduction  vibrations. 
Again  one  likes  one  type  of  electric  amplification  while  another  prefers 
an  instrument  of  more  intense,  clearer,  harsher  or  lower  tone  pitch  with 
greater  resonance.  Of  these  varied  hearing  aids  it  may  well  be  said  that 
"One  man's  meat  is  another  man's  poison;"  one  type  of  hearing  aid  will 
give  satisfaction  to  one  type  of  deafened  person  while  the  same  instru- 
ment to  another  type  will  cause  the  most  unpleasant  reactions.  All  that 
are  approved  by  scientists  qualified  to  pass  on  their  acoustic  properties  are 
good.  The  best  one  in  each  case  varies,  for  the  best  is  always  that  which 
gives  the  deafened  individual  the  greatest  degree  of  satisfaction. 

Today  the  Guild  House  stands  as  an  educational,  rehabilitation  and 
social  centre  for  the  deafened  in  and  around  Boston.  Indeed  it  has  some- 
thing more  than  local  fame.  Visitors  come  from  all  parts  of  the  world 
particularly  from  the  United  States  and  Canada.  Our  bed  rooms  provide 
shelter  for  those  who  wish  to  avail  themselves  of  the  hospitality  we  have 
to  offer.  From  October  to  May  our  activities  are  in  full  operation.  Our 
workers  and  volunteers  are  busy  in  carrying  on  the  details  of  such 
activities  as  educational,  program,  entertainment,  friendship,  Green 
Twigs  (our  junior  members)  hospitality,  house,  library,  publicity,  round 
robin,  November  sale  and  such  like  committees;  while  the  staff  workers 
are  engrossed  with  matters  that  class  themselves   under  the   general 


103 

heading  of  social  service  work.  During  the  summer  months  the  social 
service  work  is  still  in  operation.  The  house  is  open  throughout  the  year 
from  9  a.  m.  to  5  p.  m.  except  Sundays  and  holidays. 

Besides  the  adult  problems  we  are  frequently  in  consultation  regard- 
ing child  problems,  both  from  the  medical  as  well  as  the  educational  view- 
point. As  a  member  of  the  Boston  Council  of  Social  Agencies  we  have 
an  opportunity  to  serve  and  to  be  served.  We  welcome  the  deafened  and 
all  problems  dealing  with  deafness.  Our  work  has  become  better  known 
perhaps  during  the  winter  just  passed  than  ever  before  for  our  publicity 
has  been  more  far  reaching.  Opportunities  for  radio  broadcasting  have 
been  offered  us  a  number  of  times  and  the  press  has  given  us  space  for 
varied  news  items  and  divers  information.  Our  officers  and  leaders  in  the 
work  have  made  public  and  private  addresses  as  well  as  encouraged  and 
helped  in  the  formation  of  other  local  community  centres  for  the  deafened 
in  other  cities. 

At  the  recent  convention  of  Social  Workers  held  in  Boston  the  American 
Federation  of  Organizations  for  the  Hard  of  Hearing  had  a  booth;  this 
was  managed  by  local  workers  and  the  members  of  the  Speech  Readers 
Guild  took  an  active  part  in  serving,  giving  out  information  pertaining 
to  the  problem  of  deafness  of  a  local  and  national  nature,  besides  loaning 
its  phono-audiometer  which  was  placed  on  exhibit  in  the  booth. 

The  sign  that  greets  the  member  or  visitor  who  mounts  the  steps 
leading  to  the  Guild  House  reads  "Please  Walk  In."  If  the  invitation  is 
accepted  a  cordial  greeting  will  meet  one  and  when  the  caller  has  made 
his  or  her  wishes  known,  as  promptly  as  possible  he  will  be  connected 
with  the  desired  department.  If  a  wait  is  necessary  owing  to  the 
pressure  of  work  a  comfortable  reception  room  offers  homelike  hospitality 
where  magazines  and  books  are  at  hand.  We  wish  our  service  to  and 
for  the  deafened,  to  be  known  as  available  to  all.  Should  you  feel  an 
interest  or  inclination  to  visit  the  Guild  House  at  339  Commonwealth 
Avenue  in  your  own  interest  or  in  the  interest  of  another — "Please 
Walk  in." 


104 


Editorial  Comment 


* Mental  Hygiene  and  the  Eye,  Ear,  In  the  light  of  recent  advances  in 
Nose  and  Throat  Specialist.  the  study  of  tonsillar  disease  and 

diseases  of  the  accessory  sinuses 
in  their  relation  to  nervous  and  mental  diseases,  the  specialists  covering 
these  fields  are  in  a  position  to  make  excellent  contributions  to  the  mental 
health  of  society. 

Primarily,  they  are  in  the  best  position  to  make  the  most  complete 
examination  of  these  parts,  to  evalue  the  pathology  present,  and  to 
advise  local  treatment  or  surgical  interference  as  indicated.  With  this 
new  knowledge  they  are  also  in  a  position  to  appreciate  the  necessity  of 
establishing  in  their  patients  the  proper  mental  attitude  toward  the  con- 
ditions from  which  they  suffer  and  to  distinguish  the  usual  apprehension 
and  concern  from  symptoms  of  more  grave  and  serious  nature,  such  as 
presented  by  the  psycho-neurotic  and  the  psychotic. 

In  the  treatment  of  the  first  group  of  patients,  the  specialist  is  in  his 
own  field  and  acts  accordingly.  In  those  cases  of  neuroses,  psycho- 
neuroses,  and  psychoses  showing  diseased  conditions  of  these  parts, 
psychiatric  counsel  and  advice  would  be  exceedingly  helpful  to  him  before 
instituting  any  radical  procedures;  such  counsel  removes  the  possibility 
of  any  other  underlying  causes  of  the  nervous  and  psychiatric  state. 

In  the  light  of  the  controversy  of  infected  teeth,  tonsils,  and  sinuses 
being  exciting  factors  in  the  cause  of  psychoneouroses  and  psychiatric 
states,  regardless  of  one's  point  of  view  that  these  infections  do  act  as 
causative  factors,  or  act  as  contributory  factors,  or  that  many  a  nervous 
patient  has  been  subjected  to  unnecessary  surgical  interference,  in  the 
last  analysis  whether  surgical  interference  should  be  instituted  is  a 
decision  to  be  rendered  by  the  specialist  in  these  diseases.  Such  a 
decision,  however,  should  be  based  on  criteria  of  his  experiences  in  his 
specialty  and  he  should  not  be  swayed  by  statements  that  removing  teeth, 
tonsils,  and  radical  sinus  operations  cure  nervous  and  mental  states. 

In  those  patients  suffering  from  conditions  of  the  eye  and  ear  that  will, 
regardless  of  all  known  therapeutic  procedures,  result  in  blindness  or 
complete  deafness,  the  specialists  in  these  fields  can  make  a  tremendous 
contribution  to  the  mental  health  of  these  patients  by  developing  in  them 
the  proper  mental  attitude  to  the  situation  in  which  they  will  eventually 
find  themselves.  Neuropsychiatrists  have  had  under  their  care  mental 
patients  in  whom  the  basic  cause  of  their  psychoses  was  an  inability  to 
make  such  an  adaptation  unaided  and  unguided. 


News  Notes 


THE  BEVERLY  SCHOOL  FOR  THE  DEAF  AS  AN  EDUCATIONAL 

INSTITUTION 

Helen  Wales 

Trustee  of  the  Beverly  School  for  the  Deaf 

The  first  and  foremost  aim  in  this  special  field  of  education  is  to  make 
these  deaf  children  as  near  like  normal  hearing  children  as  possible. 

The  average  deaf  child  when  he  comes  to  school  age  is  a  spoiled,  mis- 
understood, handicapped  little  piece  of  humanity.  He  must  learn  to 
express  himself  by  means  of  language  laboriously  acquired.  He  needs 
most  particularly  to  be  one  of  a  group,  to  be  treated  as  one  of  a  normal 
family  by  trained  individuals  who  can  understand  him. 

At  the  school  the  child  is  one  of  a  group  that  might  be  considered  as  a 

*  Taken  from  the  July  1930  issue  of  The  Pennsylvania  Medical  Journal.    Used  by  permission. 


105 

large  family.  Here  he  does  as  the  other  fellow  does.  He  learns  to  meet 
the  little  problems  of  every -day  life,  to  play,  to  share,  and  to  be  a  friend; 
and  as  language  and  speech  are  acquired,  to  use  them  as  a  means  of 
communication. 

The  oral  method  has  been  used  at  this  school  for  twenty  years  entirely 
as  a  means  of  instruction  and  communication,  and  the  general  progress 
and  development  has  been  great.  All  possible  means  are  employed  to 
promote  speech  and  lip  reading,  and  to  utilize  any  residual  hearing. 

The  Beverly  School  for  the  Deaf  is  located  in  Beverly  at  6  Echo  Avenue, 
corner  of  Elliott  Street.  This  educational  institution  which  has  now 
given  service  for  fifty  years  is  highly  commended  by  the  State  Board  of 
Education,  who  see  that  it  comes  up  to  the  standard.  The  State  makes 
an  appropriation  for  board  and  instruction. 

This  school  is  for  the  education  and  training  of  deaf  children  who  are 
capable  of  learning  and  for  children  who  are  too  hard  of  hearing  to 
attend  the  public  schools.  Many  of  the  latter  group  return  to  the  public 
schools  after  they  have  acquired  lip  reading. 

Deaf  children  whose  parents  live  in  Massachusetts  are  eligible  to  attend 
this  school.  Those  who  are  now  enrolled  come  mostly  from  the  eastern 
part  of  the  state. 

The  school  is  in  charge  of  a  trained  and  thoughtful  principal  and 
staff  of  officers  who  are  ever  on  the  watch  to  foresee  something  that 
may  be  done  for  the  welfare  of  the  individual  child  and  for  the  advance- 
ment of  the  school  as  a  whole. 

The  work  of  the  school  room  instruction  is  in  the  hands  of  earnest 
and  efficient  teachers,  especially  trained  for  the  teaching  of  the  deaf,  all 
of  whom  are  interested  in  securing  the  best  results  possible.  Special 
stress  is  placed  on  getting  more  intelligible  speech  and  straight  language 
as  well  as  on  the  subject  matter  in  hand. 

The  single  session  with  recess  lunches  proves  to  be  a  satisfactory 
arrangement.  This  leaves  the  afternoons  open  to  devote  to  recreation, 
rest  and  sleep  for  the  younger  ones  and  to  industries  for  the  older  ones. 
The  boys  have  shop  work,  chair  caning,  and  brush  making.  The  girls 
hook  rugs,  and  have  sewing  and  cooking.  Both  boys  and  girls  have  art, 
clay  modeling,  basketry  and  other  forms  of  hand  work. 

Playtime  is  as  carefully  planned  as  the  rest  of  the  daily  routine. 
Deaf  children  must  be  taught  to  play  for  it  is  characteristic  of  the 
untrained  deaf  to  be  inactive.  As  the  eye  performs  the  double  duty  of 
seeing  and  hearing,  these  children  must  be  taught  games  that  demand 
alertness  of  eye,  mind  and  body. 

When  not  in  the  class  room,  the  children  of  the  different  age  groups 
have  the  watchful  care  of  supervisors  who  understand  deaf  children  and 
oversee  them  at  all  times.  Personal  hygiene  'is  stressed  and  careful 
thought  is  given  to  the  establishment  of  good  food  habits. 

Each  child  has  a  definite  part  in  the  daily  tasks  that  must  be  done  here 
as  in  every  home.  Boys  and  girls  both  learn  to  do  their  duties  well  and 
to  be  thoughtful,  helpful  members  of  the  school  family  and  their  own. 

There  are  classes  for  religious  instruction  each  Sunday  for  Protestant 
and  Catholic  children  of  various  ages  and  the  older  ones  also  attend 
their  respective  churches. 

There  are  parties  for  special  occasions  throughout  the  year  and  all 
birthdays  are  observed.  Parlor  movies  are  enjoyed  as  well  as  the  worth 
while  pictures  at  the  regular  picture  houses. 

Outdoor  play  ground  apparatus  is  provided  and  games  enjoyed  through- 
out the  year,  with  winter  sports  taking  their  place  in  season.  The  local 
J¥\  M.  C.  A.  provides  training  once  a  week  until  we  shall  have  a  much 
needed  modern  school  house. 

Everybody  who  now  visits  this  institution  marvels  that  so  much  is 
accomplished  in  our  present  limited  quarters. 

Beverly  people  have  worked  for  and   carried  this   undertaking,   for 


106 

many  years.  The  school  now  serves  many  communities  and  has  proved 
its  value.  We  are  obliged  to  depend  upon  interested  and  public  spirited 
citizens  to  provide  the  buildings  and  other  necessary  equipment. 

We  feel  that  citizens  of  every  town  and  city  from  which  the  deaf 
children  come  will  feel  responsible  and  do  their  part  to  provide  adequate 
quarters  when  they  realize  the  great  need  for  a  modern  school  house. 

There  are  33  boys  and  37  girls  between  the  ages  of  six  and  sixteen  now 
enrolled  and  they  come  from  the  following  cities  and  towns  of  Massa- 
chusetts: Rockport,  Charlestown,  Worcester,  Lawrence,  Salem,  West 
Newbury,  Woburn,  Methuen,  Haverhill,  Beverly,  Newtonville,  Boston, 
Wakefield,  Peabody,  Revere,  New  Bedford,  Ludlow,  Maiden,  Middleboro, 
Lowell,  South  Sudbury,  East  Boston,  Reading,  Danvers,  Mattapan, 
Gloucester,  Vineyard  Haven,  Andover,  Hudson,  Rowley,  Everett,  Spring- 
field, South  Carver,  Waverly,  Maynard,  Newton,  Fall  River,  Waltham, 
Newburyport  and  Halifax.  The  new  school  house  should  include  at  least 
fourteen  classrooms,  a  gymnasium,  an  assembly  hall,  shops,  and  all  that 
is  necessary  to  make  possible  the  equipping  of  these  deaf  children  with 
an  education  that  will  fit  them  to  carry  on  as  useful  citizens  in  this  great 
country. 

It  might  be  interesting  at  this  time,  when  all  of  Massachusetts  is  look- 
ing back  to  see  what  is  of  interest  since  the  bringing  of  the  Massachusetts 
Bay  Charter  to  our  shores,  that  we  should  recall  to  the  attention  of  the 
thinking  people  of  Massachusetts  the  fact  that  the  Beverly  School  for 
the  Deaf  has  completed  fifty  years  of  service. 

The  idea  of  establishing  this  school  originated  with  Mr.  William  B. 
Swett  of  Marblehead  who  was  totally  deaf.  Mr.  Swett  believed  that  much 
might  be  done  whereby  the  adult  deaf  might  become  self-supporting. 
The  Reverend  Dr.  Thomas  Gallaudet,  manager  of  the  Church  Mission  to 
Deaf-mutes  of  New  York  city  became  interested  and  the  school  was  organ- 
ized in  1876  under  the  name  of  the  New  England  Industrial  School  for 
the  Deaf-mutes  which  name  was  changed  in  1922  to  the  Beverly  School 
for  the  Deaf. 

With  interest  and  support  of  others  Mr.  Swett  raised  the  necessary 
money  for  the  purchase  of  a  farm  and  the  erection  of  buildings.  The 
enterprise  succeeded  so  well  that  an  excellent  farm  of  57  acres  was  pur- 
chased in  Beverly  and  the  school  was  incorporated  in  1879  at  which  time 
the  industrial  department  was  opened  with  ten  deaf  adults. 

The  educational  department  was  opened  in  1880  with  seven  children. 

Following  is  a  list  of  trustees  as  appeared  in  the  first  annual  report: 
Rev.  Dr.  Thomas  Gallaudet  of  New  York,  president ;  Rev.  Julius  H.  Ward, 
Boston;  George  Roundy,  Hon.  John  I.  Baker,  William  C.  Boyden,  of 
Beverly;  Thomas  Appleton,  and' William  H.  Wormstead  of  Marblehead; 
Rev.  George  I.  Sanger,  Danvers;  Samuel  F.  Southwick,  Salem;  and 
Thomas  Brown,  West  Henniker,  N.  H.  Mr.  Swett  was  superintendent 
and  his  wife  matron;  Miss  Nellie  Swett,  a  daughter  who  had  hearing, 
was  teacher  under  Prof.  Ralph  H.  Atwood,  an  experienced  teacher  of 
the  deaf,  as  principal. 

In  1911  some  of  the  land  was  sold  as  the  farm  had  not  been  a  paying 
proposition  for  some  years  and  the  industrial  department  had  also  been 
given  up.  The  school  continued  to  grow  and  as  the  need  of  new  quarters 
was  felt  more  and  more  each  year  the  money  from  the  sale  of  the  land 
was  put  into  a  building  fund. 

Articulation  was  taught  more  each  year  and  after  Miss  Louise  Upham 
came  to  be  principal  in  1909  the  oral  method  was  used  entirely  as  the 
means  of  teaching  and  communication. 

The  Massachusetts  Legislature  made  the  first  appropriation  towards 
this  school  in  1886.  This  continued  in  different  amounts  almost  every 
year  until  1919 ;  since  which  time  the  state  has  made  a  per  capita  appro- 
priation for  board  and  education. 

Living  quarters  were  greatly  improved  by  the  erection  of  a  new  build- 


107 
ing  which  was  completed  early  in  the  fall  of  1924  during  the  time  Mrs. 
Ella  S.  Warner  was  principal. 

We  expect  to  add  another  chapter  to  this  school  history  by  the  erection 
of  a  new  modern  school  house. 

"DENTAL  CLINICS"* 

Frank  A.  Delabarre,  D.  D.  S. 

President,  Massachusetts  Dental  Society 

Dentistry  is  a  health  service  with  great  possibilities  of  prevention  of 
dental  lesions  and  their  sequalae,  which  latter  hold  a  serious  menace  to 
general  health. 

In  the  same  measure,  and  for  the  same  purpose  that  Medicine  is  asking 
Dentistry  to  eliminate  Oral  Focal  Infection,  which  is  often  a  causative 
factor  of  many  remote  diseases,  Dentistry,  spurred  on  by  recent  discover- 
ies, is  asking  Medical  aid  in  the  care  of  the  expectant  mother  and  infant 
to  insure  for  the  child  the  best  possible  physical  equipment,  including 
teeth  free  from  developmental  defects. 

These  enamel  defects,  called  pits  and  fissures,  are  the  areas  of  most 
frequent  decay. 

The  crowns  of  all  of  the  deciduous  teeth  and  the  first  permanent  molars 
begin  to  form  in  utero,  and,  so  far  as  these  areas  are  concerned,  are 
practically  completed  at  the  end  of  lactation.  Thus  the  mother  must 
provide  the  material  for  their  growth.  In  this  sense  the  Dental  problem 
is  really  a  Medical  one,  concerned  with  the  processes  of  metabolism, 
growth  and  development. 

Private  practice,  serving  the  individual,  has  proved  to  be  relatively 
inadequate  to  even  control  dental  decay  and  totally  lacking,  up  to  now, 
in  any  preventive  results. 

Dental  clinics  aim  at  community  health  but,  so  far,  have  been  only  one 
step  in  advance  of  private  practice,  in  that  the  work  is  centered  on 
children. 

This  is  due  to  a  lack  of  definite  policy  in  harmony  with  recently  estab- 
lished facts. 

The  success  of  any  children's  clinic  depends  more  on  the  policy  adopted 
than  on  any  other  factor. 

The  overwhelming  prevalence  of  dental  caries,  its  early  appearance, 
and  the  insidious  rapidity  of  its  development,  with  the  consequent  serious 
end  results,  are  governing  factors  in  determining  such  a  policy  . 

A  clinic  policy  developed  on  these  facts  should  include : 

1.  Medical  cooperation  in 

(a)  Prenatal  and  postnatal  care,  at  first  educational  and  later  on 
included  in  the  clinical  effort,  following  the  development  of  the 
preventive  idea  through  the  findings  of  research. 

(b)  Medical  care  of  the  older  children,  who  are  manifestly  bel6w  par 
physically,  to  develop  their  resistance  to  infection. 

2.  Direction  of  the  main  effort  for  control  of  caries  on  the  youngest  child 
available  with  a  positive  plan  of  follow-up  on  those  children  to  the 
period  of  adolescence,  and  a  definite  plan  of  extension  year  by  year. 

3.  A  schedule  of  regular,  frequent  examinations  for  the  patients  to 
anticipate  caries  by  filling  the  pits  and  fissures  soon  after  tooth  erup- 
tion or  to  control  it  in  its  earliest  appearance. 

4.  If  possible  a  service  for  any  older  child  for  the  relief  of  pain  and 
elimination  of  Foci  of  Infection.  This  service  would  be  automatically 
eliminated  by  the  extension  of  the  plan. 

5.  An  educational  program  for  the  parents  of  the  children  it  serves  on 
Dental  Health  propaganda. 

6.  Social  service  control  to  limit  attendance  to  those  unable  to  pay  for 
private  service. 

*  Read  before  the  New  England  Health  Institute,  April  1930. 


108 

Dental  service  in  conformity  with  such  a  policy,  with  directed  coopera- 
tion from  the  home,  will  make  it  possible  to  save  the  child  from  the 
dangers  of  the  results  of  Oral  Focal  Infection. 

Clinics  governed  by  previous  policies  which  allowed  service  for  any 
child  regardless  of  age  and  without  systematic  care  have  done  a  com- 
mendable good  but  have  not  made  any  headway  in  controlling  the  constant 
tide  of  caries,  toothache  and  infection. 

They  are  economically  unsound  and  comparatively  ineffective. 

It  can  be  positively  and  confidently  stated  that  it  will  cost  less  to  run 
a  clinic  on  a  sound,  logical  policy  than  it  would  to  take  care  of  an  equal 
number  of  children  in  the  old  way;  and  the  mouth  health  and  general 
health  of  the  two  groups  cannot  be  compared. 

No  other  plan  has  yet  been  devised  that  will  make  it  possible  to  serve 
the  entire  school  population  of  any  community,  within  a  reasonable  period, 
and  control  the  question  of  oral  disease. 

With  unlimited  money,  equipment  and  personnel  it  would  be  possible  to 
establish  a  clinic  at  once  to  care  for  the  entire  school  population  but  a 
much  larger  clinic  and  investment  would  be  required  than  eventually 
would  be  necessary. 

Inasmuch  as  the  majority  of  clinics  must  be  supported  by  public  funds, 
and  to  overcome  the  difficulties  of  securing  the  large  appropriations 
necessary  as  well  as  the  economic  waste  in  misguided  efforts,  the  following 
practical  plan  is  submitted  for  any  community  facing  the  problem  for  the 
first  time. 
1.    Make  a  survey  of  the  community  to  determine: 

(a)  School  population. 

(b)  Number  of  children  eligible  to  receive  the  free  service. 

(c)  Oral  examination  of  all  children  of  the  first  three  grades  to 
record  dental  defects  and  conditions;  this  is  to  be  filed  away  as  a 
control  for  future  comparison. 

(d)  Start  a  demonstration  clinic  with  an  appropriation  sufficient  for 
•a  three  year  effort. 

(e)  The  policy  of  the  clinic  to  be: 

1.  In  conformity  as  far  as  possible  with  the  policy  previously 
outlined  with  its  full  adoption  dependent  on  the  results 
obtained  in  the  first  three  years. 

2.  Only  the  first  grade  children  cared  for  the  first  year,  with 
careful  records  kept. 

3.  The  second  year,  take  care  of  these  same  children  (now  second 
graders)  and  also  the  new  first  grade  group. 

4.  Repeat  during  the  third  year  by  adding  the  new  first  grade. 

At  the  end  of  the  third  year  compare  the  records  with  the  original 
survey,  and  on  the  basis  of  improved  dental  and  general  health  shown, 
ask  for  a  graded  appropriation,  on  a  nine  year  plan,  for  the  further 
complete  extension  for  the  original  plan;  this  contemplated  the  inclusion 
of  a  prenatal  and  postnatal  medical  clinic,  a  dental  clinic  for  the  pre-school 
age  child  and  a  follow-up  extension  through  the  grades,  serving  the  same 
groups  originally  started  in  the  first  grade  by  adding  one  new  grade 
each  year. 

The  advantages  of  this  plan  are: 

(a)  A  definite  goal  of  complete  service  for  children  with  the  highest 
possible  preventive  results. 

(b)  The  increasing,  progressive  proof  of  its  technical  value  in  terms 
of  health. 

(c)  A  very  conservative  financial  plan  for  investment  and  main- 
tenance. 

The  Dental  Hygiene  Council  of  Massachusetts  will  be  very  glad  to 
confer  with  anyone  interested,  to  supply  the  details  for  such  a  plan 
necessarily  omitted  in  this  brief  outline. 


109 

THE  SCOPE  AND  AIM  OF  THE  COMMITTEE  ON  THE  COST  OF 

MEDICAL  CARE 

At  the  Spring  meeting  of  the  Committee  on  the  Cost  of  Medical  Care 
in  Washington  May  second  and  third,  1930,  a  special  committee  of  private 
practitioners  was  appointed  to  consider  the  relation  of  the  committee  to 
the  private  practitioners  of  the  country.  This  committee,  composed  of 
the  undersigned  members,  now  submits  the  following  statement  for  the 
information  of  these  practitioners  on  the  scope  and  aim  of  the  committee's 
work. 

It  was  clearly  recognized  by  all  present  at  the  Spring  meeting  that  the 
committee  has  undertaken  a  program  of  studies  which  in  its  scope  goes 
far  beyond  that  part  of  the  cost  of  medical  care  which  physicians  provide. 
The  expense  of  several  other  kinds  of  service  now  looms  large  in  the  total 
cost  of  many  illnesses.  In  addition,  special  emphasis  was  given  at  the 
meeting  to  the  question  of  the  adequacy  of  the  various  services  available 
in  a  community.  Finally,  the  committee  adopted  a  statement  of  three 
fundamental  principles  proposed  by  the  Chairman,  which  should  go  a  long 
way  toward  reassuring. those  who  have  been  apprehensive  regarding  the 
nature  of  the  committee's  ultimate  recommendations. 

I 

The  committee  is  interested  in  far  more  than  the  physician's  bill,  which, 
in  many  instances,  is  considerably  less  than  half  the  total  cost  of  illness. 
Hospital  care,  nursing,  dentistry,  laboratory  examinations,  and  medicines 
often  involve  considerable  expense,  as  is  clearly  shown  by  several  of  the 
committee's  studies  which  are  now  being  completed  or  have  already  been 
reported  upon.  In  one  mid-western  county  recently  surveyed,  the 
expenditures  for  various  kinds  of  medicines  constituted  over  one-third  of 
the  total  expense  for  medical  care,  and  were  20  per  cent  greater  than  the 
costs  of  physicians'  services.  It  is  also  becoming  apparent  that  a  great 
deal  of  money  is  being  spent  for  useless  medicines  and  for  various  irregu- 
lar forms  of  treatment  which  do  the  patient  no  good  or  which  may  result 
in  positive  harm. 

In  order  to  indicate  clearly  the  broad  scope  of  the  committee's  work, 
it  was  decided  at  the  spring  meeting  to  make  a  slight  change  in  its  name. 
The  word  "cost"  is  to  be  changed  to  "costs".  The  complete  name  of  the 
committee,  with  subtitle,  will  henceforth  be  "The  Committee  on  the  Costs 
of  Medical  Care — Organized  to  Study  the  Economic  Aspects  of  the  Pre- 
vention and  the  Care  of  Sickness,  including  the  Adequacy,  Availability  and 
Compensation  of  the  Persons  and  Agencies  Concerned." 

One  vital  problem  before  this  committee,  declared  a  prominent 
physician  member,  at  the  recent  meeting,  is  the  determination  of  what 
is  reasonably  adequate  care.  In  many  cases  of  obscure  disorders  and 
perious  illness,  expensive  facilities  are  essential.  Presumably,  there  must 
be  available  in  the  community  well  trained  general  practitioners,  certain 
specialists,  dentists,  nurses,  hospitals  and  health  agencies, — trained  and 
well  equipped  to  do  their  part  in  providing  all  the  care  that  the  individual 
may  need.  A  plan  of  the  executive  committee,  to  conduct  a  study  to 
determine  standards  of  adequate  medical  care,  under  the  general  direc- 
tion of  some  well  known  competent  physician  and  with  the  assistance  of 
a  committee  of  fifteen  or  twenty  other  physicians,  was  heartily  endorsed 
at  the  meeting  of  the  general  committee. 

The  aim  of  the  committee  is  to  study  the  problem  described  by  Dr. 
Olin  West,  the  Secretary  of  the  American  Medical  Association,  as  the  one 
great  outstanding  problem  before  the  medical  profession  today.  This  he 
says  is  that  involved  in  "the  delivery  of  adequate,  scientific  medical  care 
to  all  the  people,  rich  and  poor,  at  a  cost  which  can  be  reasonably  met  by 
them  in  their  respective  stations  in  life."  The  committee  is  endeavoring 
to  establish  a  foundation  of  facts  which  have  an  important  bearing  upon 


110 
this  problem.  On  the  basis  of  these  facts,  it  will  propose  recommenda- 
tions for  the  provision  of  adequate  and  efficient  therapeutic  and  preven- 
tive service  for  all  the  people  at  a  reasonable  cost  to  the  individual,  which, 
at  the  same  time,  will  provide  physicians,  dentists,  nurses,  hospitals  and 
other  agents  assurance  of  adequate  return.  This  is  not  a  new  statement 
of  aim.  Recent  discussion,  however,  has  given  new  emphasis  to  certain 
aspects  of  it.  There  are  important  items  in  the  cost  of  sickness  other 
than  the  physician's  bill;  and  the  adequacy  of  the  service  provided  must 
be  considered.  The  program  of  studies  is  a  comprehensive  one.  It  deals 
with  questions  of  supply,  demand,  distribution  and  costs  of  all  kinds  of 
services,  both  preventive  and  curative ;  the  relation  of  these  costs  to  other 
expenses;  the  return  accruing  to  the  practitioners  and  various  agents 
furnishing  medical  services ;  and  especially  will  it  seek  to  determine  what 
standards  of  adequacy  may  reasonably  be  expected. 

II 

Dr.  Ray  Lyman  Wilbur,  Chairman  of  the  Committee,  proposed  at  the 
meeting  May  2nd  a  statement  of  three  fundamental  principles  for  the 
consideration  of  the  committee.  This  statement  was  referred  to  each  of 
four  subcommittees  which  held  sessions  during  the  two  day  meeting. 
The  entire  committee,  at  its  last  session,  May  3rd,  adopted  with  a  few 
verbal  changes  the  three  principles.  These  will  be  of  special  interest 
to  the  physicians  and  dentists.    They  follow : 

1.  The  personal  relation  between  physician  and  patient  must  be  preserved 
in  any  effective  system  of  medical  service. 

Medical  service  is  and  doubtless,  by  its  very  nature,  must  remain  a 
distinctly  personal  service.  Even  in  this  age  of  standardized  commodities 
for  the  table,  ready-to-wear  clothing,  and  interchangeable  spare  parts 
for  all  types  of  machines,  there  has  been  no  plan  suggested  for  the 
reduction  of  medical  diagnosis  and  treatment  to  basic  units  which  can  be 
ordered  from  traveling  salesmen  or  acquired  through  correspondence 
courses.  The  physician  must  see  his  patient  and  see  him,  in  many  cases, 
over  an  extended  period  of  time  if  the  diagnosis  and  treatment  are  to 
achieve  the  greatest  possible  accuracy  and  efficiency.  There  is  no  sub- 
stitute for  personal  observation. 

Man  is  not  a  standardized  machine  and  each  individual  reacts  to  the 
conditions  of  life  in  a  manner  in  some  respects  unique.  In  the  treatment 
of  disease,  this  individual  variation  is  a  factor  of  great  significance  and 
can  receive  due  consideration  only  when  the  practitioner  has  known  the 
patient  for  a  considerable  time  and  maintains  a  personal  relation  with 
the  patient. 

2.  The  concept  of  medical  service  of  the  community  should  include  a 
systematic  and  intensive  use  of  preventive  measures  in  private 
practice  and  effective  support  of  preventive  measures  in  public  health 
work. 

The  cost  of  adequate  curative  treatment  is  now  high  and  may  continue 
to  increase  as  expensive  procedures  resulting  from  scientific  progress 
become  more  widely  used.  Sickness,  in  addition,  involves  other  personal 
and  social  costs,  some  of  which  cannot  be  measured  in  monetary  terms. 

The  outstanding  achievements  in  scientific  medicine  have  been  made  in 
the  preventive  rather  than  the  curative  field.  Knowledge  now  available 
for  the  control  of  malaria,  tuberculosis,  smallpox,  diphtheria,  pellagra, 
typhoid  fever,  hookworm  disease,  and  goiter,  if  effectively  applied,  would 
make  unnecessary  a  considerable  proportion  of  the  present  expense  for 
the  cure  of  sickness. 

3.  The  medical  service  of  a  community  should  include  the  necessary 
facilities  for  adequate  diagnosis  and  treatment. 

From  the  standpoint  of  effective  diagnosis,  many  diseases,  such  as 
tuberculosis,  cannot  be  recognized  promptly  in  their  early  stages  without 
the    aid  of  elaborate    technical  equipment.      From  the    standpoint    of 


Ill 

adequate  therapy,  if  the  best  of  modern  technique  is  not  immediately 
available,  complete  cures  are  either  delayed  or  rendered  impossible  of 
attainment.  To  cite  a  specific  illustration  of  the  improvement  of  modern 
therapeutic  procedures  over  those  of  ten  years  ago,  the  time  required 
for  treatment  of  fractures  of  the  hip,  and  the  percentage  of  permanent 
invalidity  resulting  from  that  injury  have  each  been  reduced  by  more 
than  half. 

We  cannot  be  content  with  anything  except  the  best  possible  service 
that  modern  science  can  provide  and  it  is  therefore  imperative  that 
modern  scientific  equipment  for  the  diagnosis  and  treatment  of  disease  be 
available  to  the  practitioners  of  medicine  in  every  community. 

Special  Committee  of  Private  Practitioners 
Stewart  R.  Roberts,  M.  D.,  Chairman 

Walter  P.  Bowers,  M.  D.  Kirby  S.  Howlett,  M.  D. 

A.  C.  Christie,  M.  D.  Arthur  C.  Morgan,  M.  D. 

Haven  Emerson,  M.  D.  Herbert  E.  Phillips,  D.  D.  S. 

George  E.  Follansbee,  M.  D.  C.  E.  Rudolph,  D.  D.  S. 

M.  L.  Harris,  M.  D.  Richard  M.  Smith,  M.  D. 

J.   Shelton   Horsley,   M.   D.  N.  B.  Van  Etten,  M.  D. 

SURVEY 

The  National  Tuberculosis  Association  and  the  Committee  on  the  Costs 
of  Medical  Care  are  engaged  in  a  survey  of  the  extent  and  character  of 
preventive  medical  services  in  industry  throughout  the  United  States 
with  particular  reference  to  physical  examinations. 

They  are  at  present  endeavoring  to  obtain  as  many  lists  as  possible  of 
plants  that  are  thought  to  have  physical  examinations  or  preventive 
medical  services  for  their  employees.  To  these  companies,  they  are 
sending  questionnaires  to  determine  the  nature  of  their  medical  service. 

They  ask  your  cooperation  in  this  survey.    They  will  be  grateful  for : 

1.  The  names  of  any  plants  where  workers  are  given  physical  exam- 
inations for  employment  or  periodically  thereafter. 

2.  The  names  of  physicians  or  medical  organizations  which  contract 
with  industrial  establishments  to  provide  physical  examinations 
for  employees. 

3.  Your  prompt  attention  and  cooperation  in  answering  any 
questionnaires  you  may  receive  from  them. 

Please  send  any  information  to:  Elisabeth  Dublin,  Research  Fellow, 
National  Tuberculosis  Association,  370  Seventh  Avenue,  New  York  City. 

HEARING  OF  SCHOOL  CHILDREN  AS  MEASURED  BY  THE 
AUDIOMETER  AND  AS  RELATED  TO  SCHOOL  WORK 

The  above  is  the  title  of  a  report  of  a  study  of  710  children  in  Washing- 
ton, D.  C.  and  1150  in  Hagerstown,  Maryland,  appearing  in  the  May  16, 
1930  issue  of  Public  Health  Reports,  published  by  the  United  States 
Public  Health  Service. 

Requests  for  copies  should  be  addressed  to  the  Surgeon  General,  United 
States  Public  Health  Service,  Washington,  D.  C. 


Book  Notes 


We  wish  to  call  your  attention  to  the  publication  of  THE  DIAGNOSIS 
OF  HEALTH  by  William  R.  P.  Emerson,  M.  D.  Medical  Consultant  in 
Physical  Fitness  at  Dartmouth  College;  President,  Nutrition  Clinics,  Inc. 
— D.  Appleton  and  Company.    New  York.     Price  $3.00. 

Believing  that  an  individual's  health  should  be  as  definitely  diagnosed 
as  his  illnesses,  Dr.  Emerson  issues  in  this  book  a  challenge  to  positive 
health  to  everyone.  He  shows  the  individual  how  to  rate  himself  in 
health  intelligence  and  health  habits,  and  then  provides  simple,  common- 
sense  rules  for  attaining  the  highest  possible  physical  fitness. 


112 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  January,  February,  and  March,  1930,  samples 
were  collected  in  165  cities  and  towns. 

There  were  2,021  samples  of  milk  examined,  of  which  373  were  below 
standard;  from  29  samples  the  cream  had  been  in  part  removed,  53 
samples  contained  added  water,  and  2  samples  were  skimmed  milk  above 
the  legal  standard.  There  were  27  samples  of  Grade  A.  Milk  examined, 
24  samples  of  which  were  above  the  legal  standard  of  4.00%  fat,  and  3 
samples  were  below  the  legal  standard. 

There  were  689  samples  of  food  examined,  of  which  152  were  adulter- 
ated or  misbranded.  These  consisted  of  5  samples  of  clams  which  con- 
tained added  water;  69  samples  of  eggs,  14  samples  of  which  were  sold 
as  fresh  eggs  but  were  not  fresh,  29  samples  of  cold  storage  eggs  not  so 
marked,  and  26  samples  were  decomposed;  43  samples  of  sausage,  4  of 
which  contained  a  compound  of  sulphur  dioxide  not  properly  labeled,  2 
contained  coloring  matter,  and  37  samples  contained  starch  in  excess  of 
2  per  cent,  1  sample  of  which  also  contained  a  compound  of  sulphur 
dioxide  not  properly  labeled,  and  1  sample  was  also  decomposed;  5  samples 
of  hamburg  steak,  2  of  which  contained  a  compound  of  sulphur  dioxide 
not  properly  labeled,  2  were  decomposed  and  1  sample  contained  starch  in 
excess  of  2  per  cent  and  was  also  decomposed;  1  sample  of  chicken  which 
was  decomposed ;  1  sample  of  vinegar  which  was  low  in  acid ;  1  sample  of 
dried  fruit  which  contained  sulphur  dioxide  not  properly  labeled;  25 
samples  of  cream  which  were  incorrectly  labeled  as  to  grade;  and  2 
samples  of  maple  syrup  which  contained  cane  sugar. 

There  were  40  samples  of  drugs  examined,  of  which  8  were  adulterated. 
These  consisted  of  4  samples  of  ether  for  anaesthesia,  all  of  which  con- 
tained aldehyde  and  2  samples  also  contained  peroxide ;  2  samples  of  head- 
ache powders  on  which  the  labels  were  of  too  small  type ;  and  2  samples  of 
spirit  of  nitrous  ether  which  were  deficient  in  the  active  ingredient. 

The  police  departments  submitted  1,388  samples  of  liquor  for  examina- 
tion, 1375  of  which  were  above  0.5%  in  alcohol.  The  police  departments 
also  submitted  15  samples  of  narcotics,  etc.,  for  examination,  12  of  which 
were  morphine,  1  cocaine,  1  medicine  which  contained  ergot,  and  a 
powder  in  capsule  form  which  was  examined  for  ergot  with  negative 
results. 

There  were  118  bacteriological  examinations  made  of  milk. 

There  101  bacteriological  examinations  made  of  soft  shell  clams,  30 
samples  in  the  shell  which  were  unpolluted,  and  71  samples  shucked,  47 
of  which  were  unpolluted,  and  24  were  polluted.  There  were  3  bacterio- 
logical examinations  made  of  hard  shell  clams,  in  the  shell,  which  were 
unpolluted;  and  there  were  4  bacteriological  examinations  made  of 
mussels,  in  the  shell,  1  of  which  was  unpolluted,  and  3  were  polluted. 

There  were  90  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  58  cities  and  towns  visited  for  the  inspection  of  pasteuriz- 
ing plants,  and  114  plants  were  inspected. 

There  were  95  convictions  for  violations  of  the  law,  $1,560  in  fines 
being  imposed. 

Edmond  Bellerose,  H.  Counoyer,  and  Spiro  Kollios  of  Southbridge; 
Florence  J.  Moriarty  of  Lowell ;  Ralph  Packard,  2  cases,  of  Northampton ; 
Joseph  Arruda  of  Tiverton,  R.  I. ;  Theodore  Photos  of  Salem ;  Brockelman 
Brothers,  Incorporated,  of  Worcester;  Parker  Gates  of  Leominster;  Han- 
ley's  Candy  Store,  Incorporated,  of  Cambridge;  Benjamin  M.  Hart  of 
Ipswich;  and  Thomas  McCarrier  of  Saugus,  were  all  convicted  for 
violations  of  the  milk  laws.  Parker  Gates  of  Leominster  appealed  his 
case. 

Eugene  Barthel  of  Gardner;  Michael  Sioufi,  Herbert  K.  Smaha,  and 
John  Kulik  of  Lawrence;  Joseph  Trytko  of  Easthampton;  Carl  A.  Weitz, 
Henry  Shapiro,  2  cases,  Betty  Alden,   Incorporated,  Vincent   Costanzo, 


113 
and  Samuel  Shore,  all  of  Boston;  Albert  A.  Smart  and  Adelard  Martel  of 
Lynn;  Fred  H.  Snow  of  Pine  Point,  Maine;  Samuel  Rudacevsky,  Samuel 
Goldstein,  Alfred  Larrivee,  Jacob  Tublin,  and  Louis  Zass,  3  cases,  all  of 
Fall  River;  Brockelman  Brothers,  Incorporated,  and  Benjamin  Lerner, 
of  Worcester;  Alexander  Cullen  of  Greenfield;  Elzear  Dionne  of  Lowell; 
Fein-Young  Incorporated,  of  Roxbury;  David  Foss,  Martin  Janik,  and 
Solin's  Market,  Incorporated,  of  Chicopee;  Joseph  Lenarcen,  Fernand 
Paradis,  and  Stanley  Sigda  of  Holyoke ;  Max  Suher  of  Springfield ;  Wilson 
&  Company  of  Providence,  R.  I.;  and  Victor  Albert  of  Cambridge,  were 
all  convicted  for  violations  of  the  food  laws.  Herbert  K.  Smaha  of 
Lawrence;  and  Vincent  Costanzo  and  Samuel  Shore  of  Boston,  all 
appealed  their  cases. 

Wilfred  Castonguay,  2  cases,  and  John  Gaucher,  2  counts,  of  New 
Bedford,  were  convicted  for  violations  of  the  oleomargarine  law. 

Raymond  Jansen  of  New  Bedford  was  convicted  for  violation  of  the 
drug  law. 

Joseph  Fram  of  Newburyport;  Massachusetts  Mohican  Company  of 
Waltham ;  Max  Smith,  H.  Winer  Company,  and  Samuel  Sheroff,  of  Boston ; 
James  Van  Dyk  Company  of  Fall  River ;  and  Brockelman  Brothers,  Incor- 
porated, of  Leominster,  were  all  convicted  for  violations  of  the  false 
advertising  law.  Joseph  Fram  of  Newburyport,  and  Samuel  Sheroff  of 
Boston  appealed  their  cases. 

Paiva  Almeido,  Alfonse  Sakovicz,  and  Spiros  A.  Thomas  of  Framing- 
ham,  Joseph  Cichon,  Peter  Ciejek,  William  Czelusniak,  and  John  Stisz,  all 
of  Easthampton;  Alfred  E.  Clemens  of  Allston;  Thomas  Granfield  of 
South  Hadley;  Harold  J.  Monahan  of  South  Hadley  Falls;  Frederick  E. 
Lyons  of  Greenfield;  Lewis  Pugatch  and  Walter  Bunshaft  of  Dorchester; 
Samuel  Sannartani  of  Natick;  Alberic  Surette  and  Palma  Palazini  of 
Holyoke;  George  Alarakos,  Louis  Gefteas,  Samuel  Kracun,  John 
Lawowicz,  and  Costas  Arris,  all  of  Lowell;  Jacob  Block,  Robert  Jinski, 
and  Frank  Skicus  of  Brighton;  Lawrence  Ciba,  Karzimierz  Feliks,  Aime 
Gamelin,  and  Jacob  Tublin,  all  of  Fall  River;  and  Aurille  J.  Filiault  and 
Samuel  Katz  of  Springfield,  were  all  convicted  for  violations  of  the  cold 
storage  law. 

James  Crane  of  Leominster;  and  Anthony  Konisky  of  Millbury,  were 
convicted  for  violations  of  the  pasteurization  law. 

Peter  Kusek  and  Wojciech  Stef anik  of  Chicopee ;  and  Henry  0.  Stevens 
of  Enfield,  were  convicted  of  violations  of  the  slaughtering  law. 

Samuel  Mover  of  Boston  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 :  7  samples 
each,  by  Parker  Gates  of  Leominster,  and  Henry  J.  Schultz  of  Salem, 
New  Hampshire;  3  samples,  by  J  Martin  of  Tiverton,  R.  I.;  and  2 
samples,  by  Octave  Boucher  of  Easthampton. 

Clams  which  contained  added  water  were  obtained  as  follows:  1 
sample  each,  from  Albert  Smart  of  Lynn,  and  F.  H.  Snow  of  Pine  Point, 
Maine. 

One  sample  of  dried  fruit  which  contained  sulphur  dioxide  not  properly 
labeled  was  obtained  from  First  National  Stores  of  Athol. 

One  sample  of  maple  syrup  which  contained  cane  sugar  was  obtained 
from  Martha  Kay  of  Needham. 

One  sample  of  vinegar  which  was  low  in  acid  was  obtained  from  Red 
Cross  Products  Company  of  Fall  River. 

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

Two  samples  each,  from  Ulrick  Rossle  of  New  Bedford;  Michael  Sioufi 
of  Lawrence;  The  Great  Atlantic  &  Pacific  Tea  Company  of  Greenfield; 


114 
Front  Street  Market  of  Worcester;  and  Adelard  Martel  of  Lynn.  1 
sample  each,  from  Solin's  Market,  Incorporated,  of  Chicopee;  John 
Moskel,  and  Pat's  Market  of  Holyoke ;  Frank  Przewonik  and  P.  Fugere  of 
Salem;  Brockelman  Brothers  of  Worcester;  Brockelman's  Market  of 
Fitchburg ;  Boston  Cash  Market  of  Pittsfield ;  Joseph  Charnas  of  Boston ; 
Fein  &  Young  Incorporated  of  Roxbury;  Peter  Reeves  &  Company  of 
Lawrence;  Joseph  Denley,  Henry  Brusseau,  M.  &  M.  Market,  and  Man- 
hattan Market,  all  of  Brockton;  Hall  Provision  Store  of  Maiden;  and 
Joseph  Therrien  and  Ernest  Lippe  of  Southbridge. 

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

One  sample  each,  from  United  Butchers  of  Haverhill ;  City  Cash  Market 
of  Chicopee ;  William  Tauscher  of  Chicopee  Falls ;  and  James  Lanarcen  of 
Holyoke. 

Sausage  which  contained  coloring  matter  was  obtained  as  follows:  1 
sample  each,  from  Bert  Mencis,  and  The  Great  Atlantic  &  Pacific  Tea 
Company  of  Haverhill. 

One  sample  of  sausage  which  contained  starch  in  excess  of  2  per  cent 
and  was  also  decomposed  was  obtained  from  Samuel  Goldstein  of  Fall 
River. 

One  sample  of  sausage  which  contained  starch  in  excess  of  2  per  cent 
and  also  contained  a  compound  of  sulphur  dioxide  and  was  not  properly 
labeled  was  obtained  from  New  York  Cash  Market  of  Chicopee. 

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

One  sample  each,  from  Central  Public  Market  of  Cambridge,  and  The 
Great  Atlantic  &  Pacific  Tea  Company  of  Boston. 

One  sample  of  hamburg  steak  which  contained  starch  in  excess  of  2 
per  cent  and  was  also  decomposed  was  obtained  from  Samuel  Rudacvsky 
of  Fall  River. 

Two  samples  of  hamburg  steak  which  were  decomposed  were  obtained 
from  Louis  Zass  of  Fall  River. 

There  were  eleven  confiscations,  consisting  of  42  pounds  of  decomposed 
chickens;  50  pounds  of  decomposed  fowls;  140  pounds  of  decomposed 
turkeys;  75  pounds  of  decomposed  poultry;  10  pounds  of  decomposed 
beef;  25  pounds  of  decomposed  beef  livers;  7  pounds  of  decomposed 
Hamburg  steak;  8  pounds  of  decomposed  lamb;  25  pounds  of  decomposed 
meat  products ;  and  10  pounds  of  decomposed  olives. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  December,  1929 : — 311,430 
dozens  of  case  eggs;  515,545  pounds  of  broken  out  eggs;  547,231  pounds 
of  butter;  2,930,087  pounds  of  poultry;  7,763,262  pounds  of  fresh  meat 
and  fresh  meat  products ;  and  2,573,444  pounds  of  fresh  food  fish. 

There  was  on  hand  January  1,  1930: — 1,253,370  dozens  of  case  eggs; 
1,487,039  pounds  of  broken  out  eggs;  6,665,349  pounds  of  butter;  8,402,- 
324%  pounds  of  poultry;  12,272,636%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  14,401,684  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  January,  1930: — 182,130 
dozens  of  case  eggs;  312,730  pounds  of  broken  out  eggs,  628,110  pounds 
of  butter;  2,371,328y2  pounds  of  poultry;  6,006,142  pounds  of  fresh 
meat  and  fresh  meat  products;  and  1,484,878  pounds  of  fresh  food  fish. 

There  was  on  hand  February  1,  1930: — 212,160  dozens  of  case  eggs; 
1,111,158  pounds  of  broken  out  eggs;  4,608,781  pounds  of  butter;  9,341,- 
499  pounds  of  poultry;  13,480,0141/4  pounds  of  fresh  meat  and  fresh 
meat  products;  and  10,055,842  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  February,  1930: — 148,500 
dozens  of  case  eggs;  367,530  pounds  of  broken  out  eggs;  503,253  pounds 
of  butter;  l,183,487y2  pounds  of  poultry;  5,224,704%  pounds  of  fresh 


115 
meat  and  fresh  meat  products ;  and  1,994,762  pounds  of  fresh  food  fish. 

There  was  on  hand  March  1,  1930: — 22,080  dozens  of  case  eggs;  793,- 
126  pounds  of  broken  out  eggs;  3,146,055  pounds  of  butter;  8,891,083 
pounds  of  poultry;  15,017,676%  pounds  of  fresh  meat  and  fresh  meat 
products;  and  6,660,071  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  Child  Hygiene     . 
Division  of  Tuberculosis 
Division  of  Adult  Hygiene     . 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


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,  M.  Luise  Diez,  M.D. 
Director,  Sumner  H.  Remick,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 

Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Frederick  S.  Leeder,  M.D.,  Pitts- 
field. 


Publication  of  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
5,500.     8-'30.     Order   9866. 


OCT  16  1530 


THE 
COMMONHEALTH 


Volume  17 
No.  3 


JULY-AUG.-SEPT. 
1930 


DIPHTHERIA 


MASSACHUSETTS 
DEPARTMENT   OF  PUBLIC  HEALTH 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 
Letter  of  the  Governor  to  Local  Health  Officials  .  .119 

To  the  Fellows  of  the  Massachusetts  Medical  Society  .  .     120 

Foreword,  by  George  H.  Bigelow,  M.D.         .....     121 

The     Diphtheria    Situation     in    Massachusetts,    by    Gaylord    W. 

Anderson,  M.D 121 

Diphtheria    Control  —  Active    Immunization    the    Only    Effective 

Method,  by  Clarence  L.  Scamman,  M.D.  .....      123 

The  Prevention  of  Diphtheria  —  Methods  of  Prevention,  by  Ben- 
jamin White,  Ph.D.  .  .124 
The  Laboratory  Diagnosis  of  Diphtheria  and  Release  of  Carriers, 

by  Francis  H.  Slack,  M.D 127 

Treatment  of  Diphtheria,  by  E.  H.  Place,  M.D 129 

The  Communicable  Disease  Nurse  in  Diphtheria  Control,  by  Sarah 

P.  Schneider,  R.N 133 

Control  of  Diphtheria  in  the  Schools,  by  Francis  G.  Curtis,  M.D.     .     134 
A      Diphtheria      Immunization      Campaign  —  Organization      and 

Methods,  by  the  State  District  Health  Officers  .  .138 

Results  of  Community  Immunization  Against  Diphtheria,  by  Ralph 

E.    Wheeler,    M.D.  .143 

American  Red  Cross  Roll  Call       .......     146 

Report  of  Division  of  Food  and  Drugs,  April,  May  and  June,  1930  .     147 





The  Commonwealth  of  Massachusetts 

Exectitive  Department 

State  House,  Boston 


The  Governor 

July  22,  1930 

To  Local  Health  Officials : 

There  is  far  too  much  diphtheria  in  the  Commonwealth  each 
year.  Through  the  Diagnostic  Laboratory  and  the  free  distri- 
bution of  antitoxin  and  toxin-antitoxin  the  State  is  aiding  you 
in  your  fight  against  this  disease.  However,  under  our  laws 
the  responsibility  for  control  rests  on  the  local  boards  of 
health.  In  this  number  of  "The  Commonhealth"  the  Depart- 
ment of  Public  Health  offers  you  much  information  of  value 
in  planning  your  diphtheria  control  campaign.  I  trust  you 
will  make  full  use  of  it  and  thus  help  in  the  reduction  of  sick- 
ness and  death  among  the  children  of  your  community. 

Sincerely, 

(Signed)  FRANK  G.  ALLEN. 


To  the  Fellows  of  the 

Massachusetts 

Medical 

Society: 


The  Commissioner  of  Public  Health  has  given  me  this  oppor- 
tunity to  remind  you  that  the  protection  of  the  health  of  the 
citizens  of  Massachusetts  rests  very  largely  in  your  hands. 
Without  your  active  co-operation  the  recent  advances  which 
medical  science  has  made  in  the  diagnosis  and  prevention  of 
the  communicable  diseases,  and  especially  of  diphtheria,  can- 
hot  be  made  available  to  the  whole  community.  Through  the 
State  government,  many  of  these  serological  and  diagnostic 
methods  are  made  available  without  expense,  and  yet  diph- 
theria is  still  one  of  the  most  prevalent  of  the  preventable 
diseases  in  childhood. 

Local  health  departments  and  school  authorities  offer  and 
urge  active  immunization,  but  this  is  work  which  should  really 
be  done  by  the  physicians  in  private  practice  throughout  the 
State.  Every  physician  who  has  children  under  his  care  should 
appreciate  these  facts  and  should  assume  his  proper  responsi- 
bilities. To  all  of  such  physicians  this  number  of  "The  Com- 
monhealth"  will  be  of  the  greatest  interest. 

Robert  B.  Greenough, 

President. 


August  7,  1930. 


121 

FOREWORD 

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

There  is  much  weeping  and  wailing  and  gnashing  of  teeth  among 
certain  simple  souls  that  in  the  realm  of  sickness  and  its  prevention  there 
is  so  much  ignorance.  But  after  the  tears  are  dried  and  the  damage 
from  the  gnashing  has  been  repaired,  it  is  frequently  found  that  these 
same  simple  souls  are  active  in  their  support  of  one  of  the  many  move- 
ments the  effect  of  which  is  to  prevent  the  effective  employment  of  some 
bit  of  knowledge  that  has  been  vouchsafed  us.  A  curious  type  of  think- 
ing which  seems  to  be  prevalent  these  days  when  life  is  largely  sheltered 
from  the  more  rude  and  wholesome  evidences  of  an  inexorable  nature ! 

The  thing  that  should  really  disturb  us  is  not  our  ignorance  in  matters 
pertaining  to  health  and  disease  since  this  ignorance  is  being  whittled 
away  slowly  but  steadily,  but  is  rather  the  wide  gap  which  exists  between 
our  knowledge  and  its  application.  The  function  of  health  officials  is 
not  primarily  to  chart  the  unknown  (our  betters  are  doing  this  for  us) 
but  it  is  to  bend  every  effort  to  more  and  more  effectively  bridge  the 
hideous  chasm  between  the  known  and  the  utilized.  In  this  chasm  are 
annually  many  thousands  sickened  and  dying,  and  among  them  are  all 
our  cases  and  deaths  from  diphtheria. 

It  is  because  of  the  utter  inexcusability  on  the  part  of  parents,  doc- 
tors, school  and  health  authorities  for  cases  and  deaths  from  diphtheria 
that  this  number  of  "The  Commonhealth"  is  devoted  to  this  subject.  We 
fear  infantile  paralysis,  shudder  at  influenza,  bemoan  the  common  cold, 
and  yet  are  rather  indifferent  to  diphtheria.  If  in  this  number  of  "The 
Commonhealth"  some  responsible  local  official  finds  something  that  may 
be  used  to  galvanize  the  public  out  of  its  lethargy  of  indifference  and 
into  support  of  an  active  diphtheria  campaign,  it  has  not  been  assembled 
in  vain. 

THE  DIPHTHERIA  SITUATION  IN  MASSACHUSETTS 

Gaylord  W.  Anderson,  M.D. 

Assistant  Director,  Division  of  Communicable   Diseases, 
Massachusetts  Department  of  Public  Health 

Last  year  Massachusetts  had  4,255  cases  of  diphtheria,  all  of  which 
might  have  been  prevented.  Of  these  4,255  cases,  256  died,  an  equally 
needless  loss  of  life.  Diphtheria  alone  claimed  more  lives  of  children 
under  ten  years  of  age  than  did  automobile  accidents  and  drowning  com- 
bined, and  yet  the  public,  and  at  times  the  medical  profession,  compla- 
cently accept  it  as  fate  while  waging  sensational  and  heated  campaigns 
against  the  loss  of  life  due  to  carelessness. 

Diphtheria  is  far  less  prevalent  today  than  in  previous  decades,  a 
downward  trend  in  both  cases  and  deaths  having  been  experienced 
throughout  the  country  for  several  years.  Massachusetts  has  kept  pace 
with  other  sections,  but  the  disease  has  become  a  distinctly  local  affair 
characteristic  of  certain  communities.  Some  cities  and  towns  which  have 
attacked  the  problem  vigorously  have  all  but  eliminated  the  disease  from 
within  their  borders.  Other  communities  of  similar  size  and  character  of 
population,  but  operating  under  health  practices  which  are  now  anti- 
quated, have  preferred  to  close  their  eyes  to  the  diphtheria  question  and 
are  now  suffering  from  as  many  or  more  diphtheria  cases  and  deaths  as 
they  did  fifteen  or  more  years  ago.  In  some  communities  diphtheria  is 
virtually  unknown ;  in  others  year  after  year  sees  a  heavy  toll  of  sickness 


122 

and  death,  all  among  the  children  who  are  too  young  to  take  any  steps  to 
protect  themselves. 


Brookline 
Unprotected 
city  of 
same  size 


1915-19 
214 
415 


Cases  • 
1920-24 

228 

457 


1925-29 
36 

749 


1915-19 
4 

28 


Deaths 
1920-24 
8 
60 


1925-29 

0 

60 


Massachusetts  has  not  the  worst  diphtheria  record  in  the  United  States, 
but  it  has  far  from  the  best.  Other  states  almost  as  densely  populated  as 
is  Massachusetts  have  diphtheria  rates  (both  cases  and  deaths)  which  are 
barely  half  those  in  this  state. 

Much  has  been  written  regarding  immunization  campaigns  in  cities  of 
other  states,  notably  New  York  City,  Auburn,  New  York;  New  Haven, 
Connecticut;    Sioux  City,  Iowa,    and  Middleton,    New  York,  who    have 

Massachusetts  Deaths  per  100,000  Population 


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demonstrated  conclusively  that  diphtheria  may  be  effectually  controlled 
and  virtually  eliminated  by  such  procedures.  In  Massachusetts,  Brook- 
line,  which  has  conducted  one  of  the  most  active  and  sustained  diphtheria 
control  programs,  is  the  only  community  above  30,000  population  which 
can  point  to  a  record  of  five  years  without  a  diphtheria  death.  During 
the  past  two  years  Lowell,  by  immunizing  over  25,000  children,  has  shown 
that  such  a  program  is  equally  feasible  for  larger  cities  and  has  set  a 
standard  for  other  Massachusetts  communities  to  strive  to  reach.  Several 
other  communities,  notably  Quincy  and  Northampton,  have  attacked  the 
problem  with  equal  vigor  and  are  already  reaping  the  fruits  of  their 
labors. 

The  darker  side  of  the  Massachusetts  diphtheria  situation  is  repre- 
sented by  certain  cities  and  towns,  better  not  named,  in  which  diphtheria 
is  today  as  prevalent  as  it  was  a  decade  or  more  ago.  These  communities 
rather  than  counting  their  diphtheria  on  the  fingers  of  one  hand  as  do 
their  more  energetic  neighbors,  still  count  diphtheria  in  the  hundreds 
simply  because  it  has  been  easier  to  side-step  the  issue. 

The  diphtheria  problem  in  Massachusetts  today  is  purely  a  local  one, 
for  diphtheria  has  become  a  local  disease.  Every  community  is  able  to 
determine  its  own  diphtheria  rate.  Communities  which  have  not  wanted 
diphtheria  have  virtually  eliminated  it  and  those  which  are  content  with 
an  annual  slaughter  still  have  as  much  diphtheria  as  in  previous  years. 


123 

DIPHTHERIA   CONTROL  —  ACTIVE   IMMUNIZATION   THE   ONLY 
EFFECTIVE  METHOD 

Clarence  L.  Scam  man,  M.D. 

Director,  Division  of  Communicable  Diseases 
Massachusetts  Department  of  Public  Health 

Responsibility  for  diphtheria  control  rests  primarily  on  the  shoulders 
of  the  local  board  of  health.  Until  such  time  as  communities  of  and  by 
themselves  organize  a  well  thought  out  diphtheria  prevention  program 
which  will  continue  from  year  to  year,  diphtheria  will  attack  four  to  five 
thousand  Massachusetts  children  every  year  and  will  kill  more  than  five 
out  of  every  one  hundred  sick. 

The  only  effective  method  of  prevention  is  active  immunization.  The 
New  York  State  Health  Department  is  convinced  that  active  immuniza- 
tion of  one-third  of  the  children  under  five  in  any  community  will  pre- 
vent an  epidemic  of  the  disease.  This  does  not  mean  that  diphtheria  will 
be  "stamped  out,"  since  no  child  can  be  considered  protected  from  diph- 
theria unless  immunized;  it  does  mean,  however,  that  there  will  be  no 
outbreak. 

Where  a  case  of  diphtheria  is  reported,  it  should  be  satisfactorily  iso- 
lated at  home  or  hospitalized,  and  an  immediate  investigation  started  to 
determine  the  source  of  infection,  if  possible.  A  case  history  card  *  will 
be  found  useful  in  recording  pertinent  information  in  such  an  investiga- 
tion. Susceptible  children,  particularly  those  in  the  pre-school  age, 
should  be  separated  from  the  patient  and  observed  daily  by  the  attend- 
ing physician  or  by  the  visiting  nurse  for  early  signs  of  the  disease. 
Release  from  quarantine  of  child  contacts  in  the  family  should  follow 
two  negative  cultures  from  both  nose  and  throat  taken  twenty-four  hours 
apart.  If  negative  cultures  are  secured  and  the  school  children  can  live 
away  from  home  they  should  be  allowed  to  continue  in  school.  If 
"carriers"  are  founcTthey  should  be  quarantined. 

If  at  all  practical,  Schick  tests  should  be  performed  on  the  family  group 
immediately.  Information  furnished  by  the  Schick  test  and  the  cultural 
history  of  the  contacts  will  greatly  facilitate  the  intelligent  handling  of 
the  situation.  This  is  an  excellent  psychological  time  to  urge,  through 
the  family  physician,  active  immunization  of  the  susceptible  children. 
It  is  important  to  explain  to  the  family  that  active  immunization  will  not 
prevent  the  contracting  of  diphtheria  from  the  present  case. 

So  long  as  the  family  physician  or  the  board  of  health  nurse  is  seeing 
the  family  contacts  every  twenty-four  hours,  passive  immunization  with 
diphtheria  antitoxin  is  not  advised. 

In  institutions,  asylums,  boarding  schools,  camps,  and  the  like,  wher- 
ever children  are  brought  together,  the  Schick  test  should  be  a  routine 
procedure,  performed  on  pupils,  patients  and  personnel  on  admission  or 
employment.  Those  found  "positive"  should  be  actively  immunized 
immediately.  A  record  of  the  immunization  history  of  each  individual 
should  be  kept  so  that  it  may  be  immediately  available  if  diphtheria 
appears,  for  after  a  case  appears  there  is  neither  time  nor  opportunity  to 
obtain  permission  for  such  tests. 

However  effective  isolation  and  quarantine  may  be  in  a  given  circum- 
stance, the  actual  control  of  diphtheria  is  entirely  dependent  on  the 
utilization  of  the  only  effective  preventive  measure — active  immunization. 


*  The  Department  will  be  glad  to  furnish  such  cards  to  local  boards  of  health  as  long  as  the 
supply    lasts. 


124 

THE  PREVENTION  OF  DIPHTHERIA  —  METHODS  OF 
PREVENTION 

Benjamin  White,  Ph.D. 

Director,  Division  of  Biologic  Laboratories 
Massachusetts  Department  of  Public  Health 

The  value  of  the  Schick  test  and  toxin-antitoxin  immunization  as 
agents  for  the  prevention  of  diphtheria  is  so  firmly  established  that  no 
general  discussion  seems  necessary.  In  order,  however,  that  physicians 
may  have  the  most  recent  information  concerning  these  procedures  it 
seems  desirable  to  present  their  more  important  details. 

I.     The  Schick  Test 

Strict  attention  should  be  paid  to  the  directions  accompanying  each 
outfit.  Outfits  from  various  manufacturers  differ  in  their  makeup  so, 
if  reliable  results  are  to  be  obtained,  the  special  directions  must  be  fol- 
lowed exactly. 

1.  The  Schick  Outfit: 

In  Massachusetts,  outfits  for  the  Schick  test  can  be  obtained  free 
from  local  Boards  of  Health, or  their  distributing  agencies  or  from  the 
Antitoxin  and  Vaccine  Laboratory,  375  South  Street,  Jamaica  Plain 
Station,  Boston.  They  should  be  obtained  just  prior  to  use  and  kept  con- 
tinuously in  an  ice  cold  place.  Immediately  after  use  discard  the  solu- 
tions, and  use  fresh  outfits  for  any  subsequent  tests. 

2.  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  centi- 
meter 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  grad- 
uated in  one-tenths  is  well  adapted  for  this  purpose.  On  the  right  arm 
exactly  one-tenth  of  a  cubic  centimeter  of  the  Diluted  Toxin  is  similarly 
injected  intracutaneously.  Measure  exactly  the  one-tenth  cubic  centi- 
meter injected  in  both  cases.  Do  not  guess  at  the  amount  from  the  size 
of  the  bleb  or  wheal  produced  by  the  injection.  If  the  point  of  the 
needle  has  been  properly  inserted,  with  the  lumen  uppermost  and  vis- 
ible through  the  skin,  the  injection  should  produce  a  small,  slightly 
raised  white  area  or  wheal,  which  should  move  with  the  skin  and  dis- 
appear 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  symptoms;  and  the  site  of  injection  requires  no  sub- 
sequent care. 

3.  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. 

4-.     The  Positive  Reaction: 

A  positive  reaction  begins  to  appear  on  the  right  arm  (Diluted  Toxin 
injection)  in  24  to  36  hours  and  is  characterized  by  a  circumscribed 
area  of  redness  and  slight  infiltration,  which  measures  1  to  2  centi- 
meters in  diameter.  It  develops  gradually,  reaches  its  greatest  intensity 


125 

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  antitoxin  in  the  blood,  and  therefore  may  contract  the  disease. 

5.  The  Pseudoreaction: 

In  some  individuals,  particularly  in  adults,  a  reaction  develops  which 
may  be  confused  with  a  positive  reaction.  Owing  to  a  hypersensitive- 
ness  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,  reach- 
ing a  maximum  of  intensity  on  the  third  day  and  then  fading,  the  re- 
action is  classed  as  a  pseudoreaction — the  individual  is  hypersensitive 
to  the  protein  of  the  diphtheria  bacillus  but  is  immune  to  diphtheria. 

6.  The  Combined  Reaction: 

If  a  combined  reaction  is  present,  the  redness  and  infiltration  at  the 
site  of  the  Diluted  Toxin  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 
representing  the  pseudoreaction  elements  of  the  test.  If  the  test  is  pos- 
itive, 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  pseudo- 
reactions  indicate  immunity,  the  positive  and  the  combined  reactions, 
susceptibility  to  diphtheria.  A  short  experience  in  reading  the  reac- 
tions 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 
positive. 

II.     Toxin-Antitoxin  Mixture 

1.  The   Material: 

The  preparation  now  supplied  by  the  State  Department  of  Public 
Health  is  the  one-tenth  L  plus  mixture.  It  is  supplied  in  boxes  contain- 
ing 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  Antitoxin  and  Vaccine  Laboratory,  375  South  Street,  Jamaica  Plain 
Station,  Boston.  Keep  the  package  at  a  temperature  between  40  to  50 °F. 
Do  not  permit  it  to  freeze.  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  is  the  usual  procedure 
although  the  intervals  between  injections  may  be  longer  if  more  con- 
venient. 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 
insertion  of  the  deltoid  muscle.  Paint  the  skin  at  the  site  of  the  injec- 
tion 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 
antitoxin  to  develop  to  inhibit  the  Schick  test.  Six  months  after  the  last 
injection  all  persons  should  be  retested  with  the  Schick  test,  because  a 


126 

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 
negative  reaction  shows  that  sufficient  antitoxin  is  present  in  the  body- 
to  render  that  person  immune  to  diphtheria. 

U.     Duration  of  Immunity: 

The  immunity  produced  by  the  proper  injection  of  toxin-antitoxin  mix- 
ture, as  a  rule,  lasts  for  more  than  10  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 
interferes  with  and  retards  the  development  of  active  immunity  follow- 
ing the  injection  of  toxin-antitoxin  mixture.  In  such  cases  wait  six 
weeks  before  giving  toxin-antitoxin  mixture. 

There  is  a  wide-spread  impression  that  the  toxin-antitoxin  mixture  in 
which  the  antitoxin  is  of  equine  origin  sensitizes  those  persons  injected 
with  it  to  such  a  degree  that  the  subsequent  injection  of  any  antitoxin 
or  serum  of  the  same  origin  presents  a  great  hazard.  This  impression 
is  erroneous  and  unfortunate.  Because  of  it  manufacturers  have  sub- 
stituted in  the  immunizing  mixture  antitoxin  made  from  goat  or  sheep 
serum  in  order  to  avoid  sensitization  to  horse  serum  protein.  The  older 
preparations  containing  horse-antitoxin  may,  it  is  true,  produce  some 
hypersensitiveness,  but  this  allergic  condition,  when  serums  of  equine 
origin  have  to  be  given,  is  rarely  responsible  for  any  reaction  more 
serious  than  a  somewhat  accelerated  or  aggravated  case  of  serum  sickness. 

III.     Toxoid 

Diphtheria  toxin  detoxified  with  formaldehyde — the  so-called  toxoid,  or 
anatoxine — is  an  excellent  immunizing  agent,  and  so  far  as  antigenic 
value  alone  is  concerned,  it  surpasses  toxin-antitoxin  mixture.  For 
children  under  six  years  of  age  it  is  the  ideal  immunizing  preparation, 
but  on  account  of  the  reactions  it  may  cause  in  older  children  it  must 
be  used  with  caution.  Some  children  above  the  age  of  six  and  many 
adults  are  hypersensitive  to  diphtheria  bacillus  protein  and  show  local 
and  general  reactions,  sometimes  of  considerable  severity,  when  injected 
with  toxoid.  Such  reactions  can  be  avoided  by  first  giving  an  intrader- 
mic  injection  of  diluted  toxoid — just  as  a  Schick  test  is  done — and  in  the 
case  of  those  persons  who  show  a  local  reaction  to  this  test,  the  toxoid  may 
be  given  in  a  longer  series  of  small  doses.  Where  the  greater  proportion 
of  children  to  be  immunized  are  of  school  age,  it  would  seem  better  to 
use  toxin-antitoxin  mixture  because  of  the  greater  inconvenience  of  the 
preliminary  test  required  before  toxoid  is  given  to  children  in  this  group. 

IV.     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  immun- 
ized 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  age  group  are  susceptible  and  therefore  the  Schick 
test  is  not  necessary. 

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  injections 
of  1  c.c.  each  of  diphtheria  toxin-antitoxin  mixture,  unless  they  show  a 
combined  reaction,  when  the  toxin-antitoxin  mixture  may  be  given  in 


127 

divided  doses  beginning  with  0.1  c.c,  then  0.2,  0.5,  1  c.c.  and  1  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  or  more  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  mixture  and 
be  again  retested  six  months  after  the  last  injection. 

The  percentage  of  children  immunized  by  one  series  of  three  injections 
of  toxin-antitoxin  mixture  will  vary  with  the  age  and  social  groups,  and 
will  also  depend  upon  the  previous  prevalence  of  diphtheria  in  the  com- 
munity 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  reliable 
results  and  to  immunize  the  highest  percentage  of  immune  persons  after 
toxin-antitoxin  treatment,  follow  precisely  all  the  directions  given  above 
and  contained  in  the  directions  furnished  with  every  package  of  these 
products. 

THE  LABORATORY  DIAGNOSIS  OF  DIPHTHERIA  AND  RELEASE 

OF  CARRIERS 

Francis  H.  Slack,  M.D. 

Assistant  Professor  of  Public  Health  Laboratory  Methods 

Massachusetts  Institute  of  Technology 

Director,  Sias  Laboratories,  Brookline,  Mass. 

When  diphtheria  occurs,  prompt  and  sufficient  dosage  with  antitoxin 
is  indicated  both  to  control  the  immediate  symptoms  and  to  lessen  the 
danger  of  post-diphtheritic  paralysis. 

The  clinical  symptoms  of  a  typical  case  of  the  disease  are  sufficiently 
diagnostic  to  warrant  antitoxin  treatment  without  delay  for  laboratory 
confirmation  of  the  diagnosis. 

Owing  to  variations  in  the  resistance  of  individuals  to  the  infection 
and  to  differences  in  virulence  of  the  diphtheria  bacilli,  all  grades  of  re- 
action occur  in  those  infected  from  the  most  severe  and  typical  lesions  to 
no  reaction  at  all. 

The  chief  values  of  the  diagnostic  laboratory  therefore  are: 

(1)  To  give  aid  in  diagnosis  of  non  typical  cases. 

(2)  For  examination  of  "release"  cultures. 

(3)  To  confirm  the  diagnosis  in  typical  cases. 

The  aim  of  the  laboratory  is  to  give  a  diagnosis  as  quickly  as  is 
possible.  In  the  ordinary  mixed  culture  from  a  case  of  diphtheria  the 
diphtheria  bacilli  will  develop  best  with  about  12  to  15  hours  incubation. 
This  is  taken  then  as  the  normal  time  before  a  report  is  made.  When  the 
culture  is  for  diagnosis,  examination  of  the  material  left  on  the  swabs 
will  be  made  on  request,  and,  in  some  laboratories  this  is  done  as  a  matter 
of  routine,  even  without  request.  This  examination  can  be  made  in  a 
few  minutes  and  if  the  diphtheria  bacilli  are  found  the  diagnosis  is  just 
as  accurate  as  with  a  full  grown  culture.  A  negative  finding,  however, 
is  not  conclusive  and  in  this  case  the  final  report  awaits  examination  of 
the  culture.    Where  a  culture  for  diagnosis  is  brought  to  the  laboratory 


128 

early  in  the  day  a  short  incubation  can  be  given  and  the  young  forms 
of  the  diphtheria  bacilli  recognized  if  present. 

These  extra  examinations  in  cultures  for  diagnosis  are  given  in  order 
that  if  the  case  is  one  of  diphtheria  proper  treatment  may  be  instituted 
as  quickly  as  possible.  It  cannot  be  too  strongly  impressed  on  the 
practising  physician,  however,  that  he  should  give  antitoxin  at  once  in 
typical  or  very  suspicious  cases  without  awaiting  laboratory  confirmation 
of  the  diagnosis. 

In  cases  of  release,  where  this  urgency  for  treatment  does  not  exist, 
reports  are  made  only  on  the  full  grown  cultures. 

One  cannot  be  engaged  for  long  in  diagnostic  laboratory  work  without 
having  the  conviction  that  some  physicians  rely  too  strongly  on  labora- 
tory aid  in  their  diagnoses,  even  to  the  extent  of  disregarding  clinical 
symptoms.  Treatment  is  withheld  from  typical  cases  of  diphtheria  until 
a  "positive"  report  is  received  from  the  laboratory,  or  a  "negative"  lab- 
oratory report  is  accepted  as  full  and  sufficient  evidence  of  the  absence 
of  diphtheria  despite  suspicious  symptoms. 

Laboratory  examinations  are  not  infallible  and  should  be  used  by  the 
physician  as  an  aid  in  diagnosis  but  not  to  the  exclusion  of  other  aids 
or  of  common  sense. 

A  "positive"  report  on  a  culture  sent  to  the  laboratory  for  diagnosis 
usually  indicates  the  presence  of  the  disease  and  taken  in  connection  with 
clinical  symptoms  is  a  reliable  confirmation  of  the  diagnosis. 

There  are,  however,  many  organisms  in  nature  which  resemble  the 
diphtheria  bacillus  and  there  are  also  true  diphtheria  bacilli  which  are 
non  virulent. 

One  per  cent,  at  least,  of  the  entire  population  of  healthy  people  are 
carriers  of  organisms  which  appear  typical  under  the  microscope  but 
which  in  most  instances  are  non  virulent.  It  may  happen  then,  in  a 
case  of  mild  sore  throat  from  some  other  cause,  that  some  of  these  forms 
may  be  present  and  lead  to  a  "positive"  report  from  the  laboratory. 

If  on  receipt  of  a  "positive"  report  a  visit  to  the  case  shows  apparent 
complete  recovery,  such  facts  should  be  reported  to  the  Health  Depart- 
ment. Other  cultures  should  be  taken.  If  cultures  continue  positive  and 
the  patient  shows  no  symptoms  the  organisms  may  be  tested  for  viru- 
lence:    If  negative  the  patient  should  be  released. 

A  "negative"  report  on  a  culture  for  diagnosis  should  never  be  accepted 
as  conclusive  if  the  symptoms  are  at  all  suspicious  of  diphtheria. 

If  a  false  membrane  is  present  or  if  the  case  is  laryngeal,  antitoxin 
should  be  given  without  waiting  laboratory  confirmation  of  the  diagnosis. 

There  are  several  reasons  why  negative  cultures  may  be  found  even 
though  diphtheria  is  present. 

(a)  The  swab  may  not  be  rubbed  over  the  infected  region,  this  is 
especially  apt  to  happen  in  laryngeal  cases. 

(b)  Other  fast-growing  organisms  may  overgrow  the  diphtheria 
bacilli;  this  is  especially  apt  to  take  place  in  summer  when  cultures 
planted  by  the  physician  are  incubating  during  the  time  before  they 
reach  the  laboratory  as  well  as  in  the  laboratory  incubator. 

(c)  Carelessness  in  allowing  the  swabs  to  touch  the  surface  of  a  table, 
chairs,  etc.,  before  the  culture  is  taken  may  introduce  spore  forms  from 
dust  which  contaminate  the  culture. 

In  cases  for  release,  the  chief  difficulty  is  with  those  who  remain 
"carriers"  of  typical  diphtheria  bacilli  although  fully  recovered  from  the 
symptoms  of  the  infection. 

_  In  such  cases  the  laboratory  offers  to  isolate  the  bacilli  and  to  test  for 
virulence.     If  not  virulent  the  patient  may  be  released. 

If  the  organism  is  virulent  the  patient  must  remain  in  quarantine 
until  negative  cultures  are  obtained.  Succeeding  tests  for  virulence  in 
the  same  case  have  usually  been  of  no  avail,  the  organism  remaining  viru- 
lent as  long  as  it  persists. 


129 

The  diagnosis  of  diphtheria  through  recognition  of  the  organism  in 
cultures  requires  long  and  careful  training  and  cannot  be  properly  done 
except  by  experts. 

Such  expert  diagnosticians  are  found  in  the  Health  Department  labora- 
tories and  their  services  should  be  freely  used  by  physicians. 

The  physician  should  also  consider  the  clinical  symptoms  of  the  case 
and  should  not  delay  antitoxin  treatment  for  laboratory  reports  when 
these  symptoms  are  typical  of  the  infection. 

TREATMENT  OF  DIPHTHERIA 

E.  H.  Place,  M.D. 

Physician-in-chief ,  South  Department,  Boston  City  Hospital 

In  the  present  knowledge  of  the  prevention  of  diphtheria,  consideration 
of  treatment  should  shrink  to  small  proportions.  To  require  treatment 
for  this  disease  today  is  to  acknowledge  health  ignorance  or  carelessness. 

Treatment  may  be  considered  mainly  under  three  headings:  (1)  anti- 
toxin treatment;  (2)  relief  of  obstruction  of  breathing  passages;  and 
(3)  prevention  and  treatment  of  complications. 

I.     Antitoxin  Treatment 

Earliness  of  treatment  is  of  prime  importance.  A  small  dose  of  anti- 
toxin on  the  first  day  is  of  more  value  than  very  large  doses  on  the  fourth 
to  fifth  day.  Toxin  acts  within  twenty-four  hours  and  antitoxin  is  only 
an  antidote,  having  no  effect  after  the  toxin  has  combined  with  the 
tissues.  Benefit  of  antitoxin  can  therefore  be  expected  only  on  toxin 
which  was  formed  within  about  twenty-four  hours  previous  to  treatment. 

Reaction  of  the  tissues  locally  to  toxin,  as  swelling  and  membrane, 
may  continue  to  increase  up  to  thirty-six  hours  after  adequate  antitoxin 
has  reached  the  blood  stream. 

Dosage.  It  is  thus  clear  that  the  dose  of  antitoxin  must  be  estimated 
from  the  severity  of  the  diphtheritic  local  reaction  and  given  at  once, 
and  the  effectiveness  of  the  dose  cannot  be  clinically  told  until  too  late  to 
remedy  by  further  dosage.  In  any  case,  however,  where  antitoxin  has 
been  given  and  the  progress  of  the  disease  seems  unusually  rapid  or 
severe,  a  second  dose  may  be  given  at  the  earliest  possible  time  and  should 
be  maximum.  There  is  no  need  of  balancing  the  antitoxin  dose  to  the 
toxin.  A  sufficient  amount  to  neutralize  the  toxin  is  needed  and  an  excess 
is  harmless  and  indeed  inevitable.  The  principle  is  simple, — all  that  can 
be  needed  as  soon  as  possible. 

The  exact  requirements  cannot  be  determined  by  any  method,  but 
experimental  studies  and  clinical  experience  show  that  this  often  is  as 
small  as  5,000  to  10,000  units.  In  virulent  and  rapidly  increasing  cases 
there  is  reason  to  doubt  that  this  is  adequate,  and  much  larger  amounts 
should  be  given.  Variation  in  the  amount  according  to  the  severity  of 
the  case  is  justified  by  clinical  experience,  but  as  too  large  a  dose  cannot 
be  given  and  too  small  may  jeopardize  the  patient,  the  physician  should 
give  the  maximum  dose  indicated  for  the  case. 

Variation  of  the  dose  with  the  size  of  the  patient,  to  secure  correspond- 
ing concentrations  of  antitoxin,  is  often  followed,  but  as  the  concentra- 
tion of  toxin,  other  things  being  equal,  also  increases  with  decrease  in 
size  of  patient,  the  chief  indication  for  dose  must  be  the  severity  of  the 
disease.  This  is  indicated  not  by  general  reactions,  fever,  malaise,  pros- 
tration, etc.,  but  by  the  extent  and  rapidity  of  increase  of  the  local  in- 
flammation. Oedema  of  the  throat  tissues  or  neck  is  always  an  indication 
of  great  severity  and  maximum  dose. 

Laryngeal  location  of  the  infection  is  often  taken  as  an  indication  for 
maximum  dosage.  While  it  is  true  that  the  mortality  of  this  type  is  the 
highest,  this  is  not  due  to  toxemia  as  in  the  faucial  cases,  but  to  mechani- 


130 

cal  obstruction  and  to  secondary  infection,  especially  of  the  lungs.  In 
these  cases  earliness  of  treatment  is  especially  important  but  dosage  of 
over  10,000  units  is  rarely  needed. 

Table  of  Suggested  Dosage 
Mild  Cases  2,000—     5,000  units 

Moderate  Cases  5,000—  10,000  units 

Severe  Cases  10,000—  50,000  units 

Malignant  Cases  50,000—100,000  units 

Mode  of  Administration.  Preliminary  tests  for  sensitiveness,  as  dis- 
cussed later,  should  always  be  done. 

The  intravenous  route  is  the  most  effective  and  should  be  used,  if 
possible,  in  all  severe  cases.  The  intramuscular  route,  to  be  equally  effec- 
tive within  a  reasonable  time,  requires  four  times  larger  dose.  The  usual 
precautions  for  intravenous  therapy  should  be  followed.  Slow  adminis- 
tration is  desirable. 

For  intramuscular  injection,  the  buttocks  offer  the  best  site,  a  long 
needle  being  used  (three  inches,  19-20  guage).  Large  amounts  may  be 
given,  if  slowly,  with  little  pain  or  after  tenderness,  and  absorption  is 
rapid.  The  upper  glutei  should  be  used  to  avoid  the  sciatic  notch.  Com- 
plete aseptic  precautions  should  be  taken,  of  course. 

Anaphylaxis  and  Serum  Disease.  Sensitization  tests  should  always  be 
done  either  by  the  intracutaneous  or  the  skin  scratch  method,  the  former 
being  more  delicate.     Some  prefer  the  conjunctival  test. 

Very  small  amounts  should  be  used,  preferably  about  1/100  c.c.  Care 
should  be  taken,  if  the  test  syringe  (Schick  test  type)  has  been  filled 
from  the  barrel  end,  to  expel  the  water  from  the  hub  and  the  needle 
before  testing.  Keactions  within  fifteen  minutes  of  more  than  0.5  c.c. 
indicate  the  desirability  of  desensitizing,  as  shown  in  the  table. 

Table  for  Desensitizing 

(Doses  at  Fifteen  Minute  Intervals  or  more — 

Subcutaneously) 

1st   —  0.01     c.c.  4th  —  0.5     c.c. 

2nd  —  0.1       c.c.  5th  —  1.0     c.c. 

3rd  —  0.25     c.c.  6th  —  2.0     c.c. 

If  the  intravenous  route  is  to  be  used  a  second  series,  intravenously, 
of  0.1,  0.2,  0.5  and  1  c.c.  should  be  done. 

Any  general  reaction  during  the  series  should  lead  to  abandoning  the 
dosage  and  giving  smaller  dosage  at  an  even  slower  rate.  If  no  reaction 
has  appeared  at  the  end  of  the  series,  the  treatment  dose  may  be  given 
intramuscularly.  We  have  seen  no  dangerous  reaction  in  any  case  where 
the  above  procedure  was  followed.  The  usual  late  reactions,  so-called 
serum  disease — urticaria,  arthralgia,  erythema  multiforme,  Arthus  re- 
action, fever,  adenopathy,  angio-neurotic  oedema,  cannot  be  foretold  by 
these  tests  nor  prevented  by  desensitization. 

Serum  disease  can  be  reduced  about  fifty  per  cent  by  treatment  started 
at  the  time  of  serum  administration  and  continued  for  ten  days. 

(Calcium  lactate        —  gr.  V 
(Ephedrine  sulfate  —  gr.  2/3  t.i.d. 

Urticaria  is  readily  relieved  for  a  period  of  one  to  three  hours  by 
subcutaneous  injections  of  epinephrine  M  V  to  M  XV.  Quiet,  keeping 
the  skin  cool,  and  antipruritic  lotions  give  some  relief.  Urticaria  lasts 
from  a  few  hours  to  about  seven  days,  averaging  four  days. 

Arthralgia  is  usually  relieved  by  immobilization  of  the  affected  joints. 
Even  the  most  severe  arthralgia  cases  can  be  changed  to  any  desired 
position  by  passively  moving  at  an  extremely  slow  rate  if  the  patient  can 


131 

be  led  to  relax.  There  is  no  need  of  keeping  patients  in  one  position  for 
a  long  time,  nor  of  withholding  bed  pans,  etc.  Small  doses  of  hypnotics  or 
analgesics  may  be  indicated.  Allonal  gr.  2  2/3  every  four  hours  is 
valuable. 

Angio-neurotic  oedema  responds  to  no  treatment  but  is  apt  to  fluctuate 
and  rarely  lasts  over  three  to  four  days.  Oedema  of  the  glottis,  causing 
breathing  obstruction,  is  reported  but  no  case  of  actual  oedema  as  viewed 
by  laryngoscope  has  come  under  my  observation. 

Vomiting  and  nausea  when  they  occur  are  controlled  by  abstinence  of 
anything  by  mouth,  and  supplying  fluid  and  glucose  by  rectum  or  under 
the  skin. 

Arthus  reaction,  consisting  of  often  severe  local  cellulitis,  cannot  be 
foretold  by  skin  tests.  It  appears  usually  in  twenty-four  hours  and  lasts 
three  to  four  days.  Cold  or  hot  applications  and  immobilization  of  the 
part  usually  give  relief  but  do  not  materially  affect  the  course. 

Anaphylactic  shock  is  the  bete  noir  of  antitoxin  administration.  Pre- 
liminary testing  and  proper  desensitization  remove  this  danger  almost 
wholly.  Slow  administration  reduces  the  danger.  Epinephrine  subcutan- 
eously  or  intravenously  in  doses  of  M  XX  to  LV  give  prompt  relief  if 
asphyxia  is  not  complete. 

II.     Obstruction  of  Breathing  Passages 

Nasal  obstruction  requires  no  special  treatment.  Obstruction  of  the 
throat,  if  sufficiently  severe,  requires  tracheotomy.  This  may  be  post- 
poned until  the  breathing  is  difficult  and  labored  or  the  patient  moderately 
tired  if  there  is  good  hope  that  antitoxin  relief  may  soon  be  secured. 
However,  every  faucial  case  with  obstruction  should  be  kept  under  con- 
stant observation  with  facilities  for  tracheotomy  at  hand,  as  sudden 
complete  asphyxia  is  not  rare.  Tracheotomy,  if  no  laryngeal  and  tracheal 
involvement  is  present,  gives  instant  relief  and  adds  little  if  at  all  to  the 
danger  of  the  patient.  Tracheotomy  may  be  technically  difficult  because 
of  the  attending  great  oedema  of  the  neck,  especially  in  fat  patients. 

Oedema  of  the  glottis  from  faucial  diphtheria  may  occur  rapidly  and 
requires  tracheotomy. 

Laryngeal  obstruction  may  best  be  relieved  by  intubation.  If  this  should 
fail  or  be  unavailable,  tracheotomy  must  be  done.  Relief  should  be 
secured  early  enough  to  prevent  marked  fatigue.  The  very  gradual  onset 
of  obstruction  in  these  cases  and  the  ability  of  the  patient  to  secure  in- 
creased pulmonary  aeration  by  extra  muscular  effort  often  leads  the 
unwary  to,  wait  too  long  for  relief. 

Laryngeal  cases  should  always,  if  possible,  be  sent  to  a  hospital  because 
of  the  sudden  and  dangerous  changes  that  occur  and  the  need  of  all  the 
facilities  for  laryngoscopy,  suction,  bronchioscopy  and  tracheotomy.  Re- 
moval of  the  obstructing  membrane  by  forceps,  swabs  or  suction  is 
effective  and  safe  but  requires  instrumental  facilities.  In  a  majority  of 
cases  swelling  of  the  mucous  membrane  causes  obstruction  requiring 
relief,  and  suction  is  valueless  here. 

Chronic  laryngeal  stenosis  from  scars  or  infiltration  may  result  from 
destruction  from  secondary  infection,  from  faulty  technique  in  intuba- 
tion, or  from  too  large  an  intubation  tube.  In  our  clinic  this  occurs  in 
0.5  per  cent  of  the  intubation  cases.  There  is  usually  infection  of  the 
laryngeal  cartilages,  especially  the  cricoid,  perichondritis,  or  pretracheal 
abscess.  The  pretracheal  region  should  be  palpated  daily  in  intubed 
cases  and  any  oedema  here  should  indicate  tracheotomy.  Continued  ob- 
struction without  progressive  relief  for  three  weeks  is  accepted  also  as 
indication  for  tracheotomy. 

The  first  essential  treatment  of  chronic  obstruction  is  to  remove  all 
irritation  or  trauma  from  mechanical  manipulation  or  pressure  by  aband- 
oning intubation  and  resorting  to  low  tracheotomy.  At  this  stage  the 
operation  is  practically  without  danger.     Following  tracheotomy,  com- 


132 

plete  rest  of  the  larynx  and  general  treatment  to  raise  the  general  resist- 
ance,— outdoors,  sunlight,  good  diet — is  indicated.  Only  after  complete 
recovery  from  the  infection  locally  should  any  treatment  to  restore  the 
laryngeal  opening,  if  needed,  be  undertaken. 

III.     Complications 

Prevention  of  complications  is  possible  to  a  greater  degree  than  in  most 
diseases  by  early  antitoxin  treatment.  The  most  frequent  and  danger- 
ous of  complications  are  due  to  toxin. 

Paralysis.  True  diphtheritic  paralysis  is  prevented  by  correct  anti- 
toxin treatment  if  the  patient  is  seen  in  time.  The  more  extensive 
paralyses  are  practically  always  seen  in  cases  treated  late, — three  to 
five  days.  However,  serious  toxic  neuritis  may  occur  in  patients  where 
antitoxin  is  delayed  only  twenty-four  to  forty-eight  hours  after  onset 
of  the  diphtheria.  Treatment  has  little  if  any  effect  on  the  course  of 
the  paralysis.  Deformity  does  not  result  and  the  paralysis  is  never  per- 
manent, nor  crippling.  Strychnia  in  full  doses  seems  to  hasten  repair 
once  it  has  appeared.  During  the  progress  of  the  paralysis — from  the 
fourth  week  to  the  tenth  week — involvement  of  the  respiratory  muscles 
may  threaten  life  by  asphyxia  or  secondary  (static)  pneumonia.  The 
Drinker  respiratory  chamber  is  undoubtedly  the  best  means  of  treatment 
of  such  cases.  Postural  treatment  may  materially  assist  such  cases  if 
the  chamber  is  not  at  hand;  and  other  artificial  respiratory  means  may 
also  assist  some.  The  need  of  such  efforts  is  usually  short — for  about 
one  to  two  weeks  and  usually  at  about  the  sixth  to  eighth  week  of  con- 
valescence. Massage  and  electricity  have  little  appreciable  effect  and 
seem  harmful  during  the  progressive  stage.* 

Cardiac  Involvement.  Toxic  injury  to  the  myocardium  and  conducting 
mechanism  is  the  most  dangerous  of  the  toxic  complications — fifty  per 
cent  of  the  patients  dying.  This  appears  usually  in  the  second  and  third 
week  of  convalescence.  As  complete  cardiac  rest  as  possible  should 
be  secured — horizontal  position,  removal  of  all  psychic  stimuli,  abstinence 
of  everything  by  mouth  if  nausea  or  vomiting  are  present.  Fluid  may 
be  given  by  rectum.  Small  repeated  doses  of  luminal,  allonal  or  morphia 
are  usually  helpful. 

Digitalis  does  not  help  and  may  increase  the  block.  Caffeine  sodium 
benzoate  in  doses  gr.  I — III  may  be  of  slight  assistance.  The  urgency 
of  the  cardiac  damage  will  subside  in  from  four  days  to  two  weeks  (if 
fatality  does  not  occur)  and  recovery  is  ultimately  complete. 

Pneumonia.  Broncho-penumonia  threatens  in  laryngeal  and  tracheal 
cases  but  is  rare  in  involvements  above  the  larynx.  Prompt  antitoxin 
treatment  at  onset  of  symptoms  and  early  relief  of  obstruction  offer  the 
best  chances  of  escaping  it.  Guarding  such  cases  from  other  respiratory 
infections  in  other  patients  or  in  attendants  is  important  and  frequently 
neglected. 

Cervical  adenitis  and  abscess,  otitis  media  and  mastoiditis  present 
relatively  unimportant  problems  in  the  after  care.  Endocarditis  and 
septicemia  are  extremely  rare.  True  nephritis  occurs  also  with  great 
infrequency  under  modern  treatment.  All  cases  of  diphtheria  after 
adequate  antitoxin  treatment  and  relief  of  breathing  obstruction  should 
be  kept  at  rest,  under  the  best  of  hygienic  conditions,  for  a  period  of 
from  three  to  six  weeks,  unless  the  physician  is  convinced  that  paralysis 
and  cardiac  complications  cannot  occur. 


*  Paralysis  of  the  swallowing  muscles  may  require  gavage.  Saliva  in  these  cases  is  often 
the  cause  of  distressing  coughing  and  strangling.  This  may  be  relieved  by  extreme  Trendelen- 
burg position,  by  turning  on  the  side  and  by  small  doses  of  atropine. 


133 

THE  COMMUNICABLE  DISEASE   NURSE   IN  DIPHTHERIA 

CONTROL 

Sarah  P.  Schneider,  R.N. 

Communicable  Disease  Nurse 
Providence  Health  Department 

In  diphtheria,  as  well  as  the  other  communicable  diseases,  the  well- 
trained  and  intelligent  public  health  nurse  may  be  a  much  more  valuable 
visitor  than  the  male  inspector.  She  is  not  only  able  to  give  the  neces- 
sary instructions  but,  since  the  mother  feels  more  at  ease  with  the  nurse 
and  will  give  her  her  confidence,  is  often  much  more  successful  in  gather- 
ing the  epidemiological  data.  Her  value  as  a  friendly,  sympathetic  inter- 
preter of  the  Health  Department  cannot  be  overestimated. 

She  must  be  alert,  conscientious  and  tactful.  Her  whole  attitude  and 
every  action  must  exemplify  the  meticulous  care  and  attention  to  details 
which  she  is  urging  upon  the  household.  The  day's  work  may  take  her 
to  the  homes  of  the  wealthy  as  well  as  the  poverty-stricken.  In  the 
former  she  may  find  a  graduate  nurse  in  charge  of  the  patient;  while  in 
the  latter,  the  mother  in  addition  to  her  duties  as  nurse  and  house- 
keeper has  the  care  of  the  well  children.  Both  homes  may  have  diphtheria 
yet  their  problems  are  different.  In  either  case  the  nurse  must  be 
able  to  interpret  to  the  family  the  importance  and  methods  of  com- 
municable disease  technic,  but  always  in  terms  of  what  is  particularly 
adaptable  to  the  peculiar  economic  and  domestic  situation. 

The  case  should  be  visited  as  soon  as  possible  after  the  report.  Her 
first  visit  should  be  given  over  to  gathering  data,  instructing  the 
mother  and  placarding  the  home,  if  that  is  part  of  her  program.  The  case 
should  be  revisited  the  following  day  and  then  at  least  once  a  week,  pref- 
erably oftener.  It  is  unnecessary  for  her  to  become  contaminated  when 
taking  the  history.  She  should  remain  standing  throughout  the  visit, 
taking  care  not  to  brush  against  the  furniture.  It  is  well  for  the  nurse 
to  ask  a  member  of  the  family  to  open  the  door  for  her  when  she  leaves. 
She  must  carry  instructive  literature,  placards,  tacks,  small  hammer, 
culture  tubes,  thermometers,  dressings,  bandages,  scissors  and  forceps, 
paper  towels,  and  soap,  which  should  be  carried  in  a  soap  box,  unless 
liquid  soap  is  used.  If  it  is  necessary  for  the  nurse  to  contaminate  her 
hands,  before  doing  so,  she  should  place  a  paper  towel  upon  the  table,  on 
this  place  the  open  soap  box,  paper  towels  and  any  other  articles  she  may 
need  to  use.  If  the  temperature  is  to  be  taken,  she  should  remove  the 
thermometer  from  the  case  while  her  hands  are  clean  and  so  place  the 
case  that  the  thermometer  may  be  easily  inserted  after  it  has  been  thor- 
oughly washed  with  soap  and  water.  She  should  then  thoroughly  wash 
her  hands  with  soap  under  running  water.  The  thermometer  and  case 
should  be  sterilized  in  a  1-20  carbolic  solution  or  some  other  solution 
approved  by  the  health  department  before  using  again. 

The  epidemiological  data  should  consist  of  exposure,  date  of  attack, 
any  previous  attack,  date  of  antitoxin — curative  or  prophylactic — any 
attempt  at  toxin-antitoxin  immunization,  age,  school  or  business  affilia- 
tions, the  family  census,  the  milk  supply  and  contacts.  The  exposure 
may  not  always  be  known  to  the  family,  yet  careful  questioning  may 
reveal  that  a  member  has  had,  what  was  thought  to  have  been  a  "plain 
sore  throat,"  a  week  or  so  before,  which  responded  to  home  treatment. 
This  member  should  be  cultured.  He  may  be  the  primary  case.  This  is 
especially  true  where  the  reported  case  is  that  of  a  pre-school  child  with 
no  contact  outside  of  the  family.  In  regard  to  immunization,  the  nurse 
may  find  that  the  patient  has  received  as  many  as  three  treatments  of 
toxin-antitoxin.  This  is  no  evidence  of  immunity.  A  re-Schick  only,  is 
the  deciding  factor.  This  should  be  explained  to  the  family  who  may  be 
prejudiced  against  further  immunization  unless  the  matter  is  clearly 
understood. 


134 

The  instructions  regarding  the  care  of  the  patient  and  the  prevention 
of  the  spread  of  the  disease  should  be  simple  and  easily  understood,  since 
the  majority  of  mothers  are  too  busy  to  follow  any  elaborate  technique. 
Printed  directions  should  be  left  to  supplement  the  nurse's  instructions. 
It  must  be  impressed  upon  the  mother  that  the  patient  is  a  source  of 
danger  to  others  from  the  beginning  of  illness  until  at  least  two  con- 
secutive negative  cultures  have  been  obtained,  that  the  mild  case  is  as 
great  a  source  of  danger  as  the  severe  case  and  that  other  cases  develop- 
ing in  the  family  may  not  be  as  mild  as  the  first.  There  seems  to  be  a 
common  belief  among  mothers  that  it  is  not  necessary  to  take  special 
precautions  with  the  mild  cases  and  the  convalescents. 

The  patient  is  the  source  of  danger  and  must  be  isolated.  No  one  but 
the  mother,  nurse  and  doctor  should  be  permitted  to  enter  the  patient's 
room.  The  mother  should  wear  a  gown  to  completely  cover  her  dress 
when  caring  for  the  patient.  Her  hands  should  be  washed  with  soap 
under  running  water  both  before  and  after  removing  the  gown,  care  to 
be  taken  to  fold  the  gown  so  that  the  side  that  comes  in  contact  with  her 
dress  is  inside  and  remains  uncontaminated.  The  gown  should  be  hung 
in  the  patient's  room.  The  writer  has  found  that  a  great  many  of  the 
mothers  will  follow  out  this  technique  even  in  the  poorer  localities, 
"strange  as  it  may  seem."  The  mother  may  give  the  patient  a  drink  or 
tray  without  coming  in  contact  with  the  patient  or  any  article  of  furni- 
ture in  the  room — it  is  then  not  necessary  for  her  to  wear  a  gown.  She 
should,  however,  carefully  wash  her  hands  upon  leaving  the  room. 

A  paper  bag  should  be  kept  at  patient's  bedside  in  which  soiled  cloths 
which  are  used  for  handkerchiefs  may  be  put  and  later  burned.  The 
dishes  should  be  boiled  for  ten  or  fifteen  minutes.  The  soiled  linen 
should  be  rolled  in  a  small  package,  placed  in  a  tub  of  hot,  soapy  water, 
thoroughly  washed,  rinsed  and  hung  in  the  sunshine.  Contaminated 
faucets  and  door  knobs  should  be  washed  with  soap  and  water. 

The  nurse  should  instruct  the  mother  to  notify  the  physician  at  once 
if  the  patient  has  any  difficulty  in  breathing  or  if  any  other  illness 
develops  in  the  family.  Child  contacts  should  be  cultured.  Carriers 
should  be  kept  apart  from  well  children.  Though  the  writer  firmly 
believes  in  this  teaching,  she  recognizes  the  difficulty  of  putting  it  into 
practice. 

When  the  patient  has  had  two  consecutive  negative  cultures  and  is 
ready  to  be  discharged,  he  should  be  given  a  tub  bath,  shampoo,  dressed 
in  clean  clothing  and  placed  in  another  room. 

Everything  in  the  patient's  room  liable  to  any  contamination  should  be 
either  thoroughly  washed  or  exposed  to  sunlight.  The  blankets,  com- 
forters, pillows  and  mattress  should  be  turned  so  that  the  sun  reaches 
both  sides.  After  this  has  been  done  and  the  room  has  been  thoroughly 
aired  for  a  day,  it  may  be  safely  used. 

On  every  convenient  occasion,  the  nurse  should  preach  the  gospel  of 
prevention  by  proper  isolation  of  diphtheria  cases  and  virulent  carriers 
and  the  administering  of  toxin-antitoxin  to  all  susceptibles. 

The  writer  knows  from  years  of  experience  that  often  people  may  be 
careless  without  dire  results,  still  she  believes  in,  and  feels  it  her  duty 
to  urge,  these  teachings. 

CONTROL  OF  DIPHTHERIA  IN  THE  SCHOOLS 

Francis  George  Curtis,  M.D. 
Chairman,  Neivton  Board  of  Health 

It  goes  without  saying  that  the  ideal  way  of  controlling  diphtheria  in 
the  schools  consists  in  having  the  entire  school  population  immunized 
against  the  disease. 

As  it  is  manifestly  impossible  to  do  this,  partly  because  of  the  passive 
indifference  of  a  large  number  of  parents  and  partly  because  of  the  active 


135 

opposition  of  others  who  object  to  having  their  own  children  immun- 
ized and,  not  content  with  this,  carry  on  an  active  campaign  to  influence 
others  to  take  the  same  position,  it  follows  that  there  will  always  be  a 
certain  percentage  of  susceptible  children  attending  school. 

The  schools,  nevertheless,  offer  the  most  fertile  field  for  mass  immun- 
ization of  children,  and  it  is  here  that  the  best  results  of  the  procedure 
can  be  obtained. 

For  several  years  immunization  of  children  in  the  kindergartens  and 
of  new  entrants  in  the  first  and  second  grades  has  been  part  of  the 
routine  work  of  the  Newton  Health  Department.  Our  results  have  been 
most  satisfactory  and  accomplished  with  so  little  disturbance  of  the 
regular  school  exercises  that  it  seems  worth  while  to  describe  our  method 
for  the  benefit  of  others  who  may  wish  to  do  similar  work. 

It  should  be  understood  that  in  Newton  the  medical  inspection  of 
school  children  is  under  the  control  of  the  Health  Department  but  there  is 
no  reason  why  a  similar  method  cannot  be  carried  out  by  the  School 
Department. 

It  was  finally  decided  that  it  would  be  best  to  take  the  children  as 
they  entered  school  and  immunize  all  whose  parents  wished  to  have  it 
done,  and  in  this  way,  gradually  build  up  as  large  an  immune  population 
as  possible.  We  also  felt  that  by  showing  the  difference  in  the  incidence 
of  diphtheria  among  immune  and  non-immune  children  we  could  show  the 
value  of  the  procedure. 

Our  belief  has  been  justified  by  the  fact  that  during  the  past  five  years 
no  child  who  has  been  immunized  has  developed  diphtheria. 

We  limited  our  activities  to  the  children  in  the  kindergartens  and  new- 
comers in  the  first  and  second  grades.  This  enabled  us  to  complete  the 
work  more  quickly  and  with  less  disturbance  of  the  routine  school  work 
and  gave  the  protection  to  the  younger  and  presumably  more  susceptible 
children. 

We  also  recognized  that  to  be  successful  it  would  require  cooperation 
between  the  physicians,  the  nurses,  and  the  teachers. 

Every  year  before  the  opening  of  the  schools  in  the  autumn,  a  sched- 
ule of  the  special  work  to  be  done  in  the  schools  during  the  coming  school 
year  by  the  Health  Department  is  drawn  up  and  submitted  to  the  Super- 
intendent of  Schools  for  his  approval. 

When  this  has  been  received,  copies  of  the  schedule  are  distributed  to 
the  physicians,  the  nurses  and,  by  the  School  Department,  to  the  teachers. 
In  this  way  all  interested  know  when  any  special  work  is  to  be  started 
and  are  prepared.  This  schedule,  among  other  things,  shows  the  dates 
upon  which  immunization  against  diphtheria  will  be  done  in  each  of 
the  various  schools. 

Six  weeks  or  a  month  before  the  date  set  for  starting  the  immuniza- 
tion, depending  somewhat  upon  the  number  of  children  who  are  eligible 
for  immunization,  circulars,  explaining  what  it  is  proposed  to  do  and 
urging  mothers  to  have  their  children  immunized,  are  distributed  to  the 
nurses.  These  circulars  have  a  consent  slip  attached  which  can  be 
signed  by  the  mother,  torn  off  and  returned. 

These  consent  slips  are  filled  in  by  the  teachers  and  nurses  with  the 
names  of  each  child  who  has  entered  school  for  the  first  time  and  given 
to  the  children  to  take  home  for  signature. 

The  returned  signed  consent  slips  are  kept  by  the  teacher  and  the 
nurses  visit  those  mothers  who  have  not  returned  the  slips  in  order  to 
find  out  why  they  have  not  been  signed  and  perhaps  persuade  the  mother 
to  sign. 

By  the  time  the  date  fixed  for  the  beginning  of  the  work  has  arrived 
every  mother  has  been  seen  and  talked  with  by  the  nurses. 

We  consider  these  visits  very  necessary  as  it  is  often  found  that  the 
slip  has  not  been  returned  because  of  carelessness  or  because  the  mother 
does  not  quite  understand  what  is  to  be  done  and  a  short  explanation  by 


136 

the  nurse  will  convince  her  of  its  value  and  she  will  sign.  Again  children 
of  pre-school  age  are  often  found,  whom  the  mother  wishes  to  have  pro- 
tected and  arrangements  are  made  to  have  her  bring  these  for  treatment. 
The  next  step  is  the  actual  immunization.  No  preliminary  Schick  is 
done,  the  children  being  so  young  that  we  consider  it  a  waste  of  time. 

The  staff  consists  of  three  physicians,  the  nurse  in  whose  district  the 
school  is  situated,  the  teacher  and  an  assistant.  The  children,  each  carry- 
ing his  consent  slip,  are  formed  in  line  with  the  arm  bared  to  the  shoulder. 
The  arm  is  iodinized  and  the  children  move  on  to  the  physicians,  who 
take  the  signed  slip,  give  the  injection,  wipe  off  the  site  with  alcohol  and 
are  ready  for  the  next  child. 

When  all  the  children  on  the  list  have  been  treated,  the  signed  slips 
are  gathered  up  and  the  staff  moves  on  to  the  next  school  where  the  pro- 
cess is  repeated.  No  child  is  immunized  who  has  not  a  signed  consent 
slip.  In  this  way  150  to  200  children  are  immunized  in  from  2  to  2% 
hours,  including  the  time  spent  in  driving  from  school  to  school. 

The  whole  process  of  giving  the  required  three  injections  takes  three 
weeks,  working  from  2  to  2%  hours  a  morning  on  four  days  of  the  week. 
We  usually  make  a  fourth  visit  for  the  purpose  of  giving  the  final  injection 
to  any  children  who  have  been  absent  at  any  of  our  regular  visits  and  any 
others  whose  mothers  may  have  asked  to  have  them  immunized  after  the 
work  has  begun.  As  our  object  is  to  immunize  as  many  children  as  pos- 
sible we  will  take  new  children  on  the  second  visit  but,  as  a  rule,  not  later. 
A  list  is  prepared  showing  how  many  are  to  be  done  at  each  school  and 
the  staff  drives  rapidly  from  school  to  school,  giving  the  necessary  injec- 
tions at  each.     It  takes  about  one  hour  a  day  to  do  this. 

After  a  morning's  work  is  finished,  the  consent  slips  are  taken  to  the 
office,  arranged  alphabetically  by  schools,  a  record  card  for  filing  made 
out  and  the  names  transcribed  into  a  field  book  for  checking  the  second 
and  third  injection.    The  consent  slips,  by  schools  are  filed  and  preserved. 

As  a  matter  of  convenience,  at  the  second  and  third  visits  each  child 
has  a  typewritten  slip  bearing  his  or  her  name,  either  pinned  on  his 
clothing  or  carried  in  his  hand.  By  so  doing  the  recorder  can  easily 
identify  the  child  and  check  the  name  as  present.  For  purposes  of 
accuracy  of  records,  the  recorder  should  check  his  field  book  with  the 
nurse  in  order  to  be  sure  that  any  who  are  absent  have  been  properly 
recorded,  so  that  they  may  be  added  to  the  list  for  the  last  visit. 

Now  as  to  the  technic: — We  use  the  toxin-antitoxin  furnished  by  the 
Massachusetts  Department  of  Public  Health  in  20  c.c.  bottles.  Ten  c.c. 
glass  syringes  are  used. 

The  arms  are  touched  with  iodine,  either  with  the  so-called  iodine  pens 
or  with  a  brush,  usually  the  former.  Each  physician  has  a  dish  filled 
with  alcohol  and  a  small  roll  of  absorbent  cotton. 

Fresh  needles  are  not  used  for  each  child  as  we  have  felt  that  it  is  not 
necessary.  After  each  injection  the  physician  immerses  his  needle  in  the 
alcohol  and  then  wipes  it  off  with  a  wad  of  absorbent  cotton  dripping 
with  alcohol. 

All  syringes  and  needles  are  boiled  in  an  instrument  sterilizer,  before 
starting  the  morning's  work  and  fresh  needles  are  available  at  any  time. 
The  rubber  cork  of  the  20  c.c.  containers  is  immersed  in  alcohol  before  the 
needle  is  pushed  through  to  fill  the  syringes. 

There  have  been  no  untoward  results  among  the  2500  children  that  we 
have  immunized :  one  child  fainted  while  standing  in  line  but  it  was  found 
that  fainting  was  a  personal  idiosyncrasy.  Reports  of  sore  arms  have 
been  received  but  investigation  has  failed  to  verify  such  reports. 

The  best  proof  that  the  children  do  not  have  sore  arms  is  found  in 
the  fact  that  they  come  up  cheerfully  for  the  second  and  third  injection 
and  do  not  cringe  from  the  needle. 

In  beginning  the  immunization  in  any  school  a  certain  amount  of  care 
should  be  exercised  to  pick  out  for  the  first  to  be  injected,  children  who 


137 

are  not  liable  to  be  nervous,  as  a  child  who  begins  to  cry,  will  often  start 
the  whole  line  crying,  whereas  one  who  takes  the  prick  of  the  needle 
quietly  is  not  so  apt  to  start  a  disturbance  among  the  others.  Sometimes 
an  obviously  nervous  child  is  asked  to  stand  aside  and  come  up  later. 
Very  seldom  have  we  found  a  child  who  makes  so  much  trouble  that  he 
has  to  be  sent  out  of  the  room.  The  whole  procedure  being  voluntary, 
we  have  felt  it  wiser  not  to  inject  any  child  who  absolutely  refuses  to 
submit,  although  we  have  the  signed  consent  slips. 

In  such  cases,  the  mother  usually  comes  at  the  next  session  or  sends  a 
note  requesting  to  have  the  treatment  given  in  any  event.  When  this 
happens  the  child  is  told  to  stand  aside  until  all  the  others  have  been 
treated  and  is  then  given  his  injection. 

Many  of  such  cases  are  due  to  unreasoning  dread  of  physical  pain  and 
the  child,  seeing  that  his  school  mates  do  not  object  and  are  not  hurt, 
takes  the  injection  with  little  objection.  Then  having  found  by  personal 
experience  that  it  doesn't  hurt,  he  makes  no  objection  to  the  subsequent 
injections. 

The  children  who  have  been  immunized  should  be  given  the  Schick 
Test  later  in  order  to.  make  sure  that  immunity  has  been  established. 
Although  this  has  not  been  done  in  every  case  in  Newton,  it  has  been 
found,  as  has  already  been  said,  that  during  the  past  five  years  no  child 
who  is  on  our  records  as  having  been  immunized  has  subsequently  been 
reported  with  diphtheria. 

One  weak  point  in  this  method  of  immunization  is  that  it  does  not 
take  care  of  the  pre-school  child  but  it  is  the  policy  of  the  Health  Depart- 
ment to  encourage  mothers  with  pre-school  children  to  bring  them  to 
the  schools  for  immunization;  a  practice  which  is  being  increasingly 
followed  each  year. 

By  immunizing  a  majority  of  the  children  in  the  kindergartens  and  the 
newcomers  in  the  first  and  second  grades  the  Department  is  gradually 
establishing  a  fairly  large  immune  population  in  the  schools  and  has 
reduced  the  incidence  of  diphtheria  among  the  children  in  the  public  and 
parochial  schools. 

Another  result  has  been  a  marked  increase  in  the  number  of  children 
both  of  school  and  pre-school  age,  who  have  been  immunized  by  their 
own  physicians,  as  shown  by  the  increased  number  of  calls  for  toxin-anti- 
toxin by  private  physicians  since  this  policy  went  into  effect. 

We  do  not  claim  that  our  method  is  ideal  and  cannot  be  improved,  but 
we  believe  that  it  is  efficient  and  know  that  it  is  done  with  very  little  dis- 
turbance of  the  regular  routine  of  the  schools,  which  is  always  to  be 
desired. 

By  this  method  incoming  children  are  immunized  quietly  and  almost 
as  a  matter  of  routine.  Parents  are  beginning  to  realize  that  immuniza- 
tion against  diphtheria  is  of  value,  that  it  can  be  done  without  physical 
discomfort  to  the  children  and  are  ready  and  willing  to  have  it  done. 

Immunization  against  diphtheria  is  unending.  New  children  are  enter- 
ing the  schools  every  year  and  must  be  immunized,  if  the  occurrence  of 
diphtheria  is  to  be  controlled. 

The  advantages  of  using  the  schools  are  that  the  children  are  there  so 
that  there  is  no  delay  or  confusion  in  getting  them  to  the  place  where  the 
work  is  to  be  done — the  children  are  used  to  doing  things  in  school  and  so 
make  less  objection  and  are  often  anxious  and  willing  to  do  what  the 
others  are  doing. 

All  of  these  elements  go  to  make  the  work  run  smoothly. 


138 

A  DIPHTHERIA  IMMUNIZATION  CAMPAIGN 
ORGANIZATION  AND  METHODS  * 

Until  such  time  as  communities  of  and  by  themselves  organize  a  well 
thought  out  diphtheria  prevention  program  which  will  continue  from  year 
to  year,  diphtheria  will  attack  four  to  five  thousand  Massachusetts  chil- 
dren every  year  and  will  kill  more  than  five  out  of  every  one  hundred  sick. 

The  successful  issue  of  any  public  health  campaign  depends  upon  arous- 
ing the  intelligent  interest  of  the  community  so  as  to  obtain  the  greatest 
possible  cooperation. 

It  is  necessary  to  awaken  civic  consciousness  in  the  individual  to  public 
health.  Too  frequently  the  citizen  regards  the  Board  of  Health  as  respon- 
sible for  the  health  conditions  of  a  city  or  town  and  fails  to  recognize  his 
responsibility,  likewise  his  possibilities  for  public  service  when  engaged 
in  an  organized  crusade. 

An  intensive  campaign  is  designed  to  create  a  substantial  foundation 
for  future  immunization  building.  It  is  of  distinct  value  to  the  commun- 
ity that  has  not  had  a  diphtheria  immunization  program  in  the  past  as 
well  as  to  those  communities  who  are  conducting  yearly  clinics  and  have 
failed  to  reach  all  members  of  the  pre-school  and  school  population. 

Patronage Sponsorship 

The  local  board  of  health  may  find  it  advantageous  to  solicit  the  aid 
of  well-recognized  and  progressive  citizens  to  sponsor  a  diphtheria  im- 
munization program. 

Every  community  has  its  civic  organizations  such  as  the  various  lunch- 
eon clubs,  women's  organization,  chamber  of  commerce,  etc.,  who  are 
always  interested  and  alert  to  feature  a  movement  of  local  benefit.  Fre- 
quently these  organizations  are  in  search  of  a  worth  while  endeavor.  No 
appeal  should  be  stronger  or  add  more  credit  to  the  efforts  of  an  organ- 
ization than  that  of  life  conservation,  particularly  in  relation  to  the  child. 

Campaign 

Does  your  health  department  wish  to  take  advantage  of  this  sponsor- 
ship by  an  already  well-organized  and  substantial  community  group  to 
institute  a  special  campaign  to  promote  the  necessary  publicity  and  inter- 
est or  is  the  work  to  be  undertaken  by  the  board  of  health,  with  or  with- 
out the  aid  of  a  sponsoring  committee  of  prominent  citizens  ? 

The  principle  of  cooperation,  the  active  enlistment  of  the  greatest 
number  of  citizens,  will  determine  the  advisability  of  selection  and  pro- 
cedure. 

The  outline  as  given  can  be  adopted  in  part  or  as  a  whole.  It  is  recog- 
nized that  a  program  suitable  for  a  large  city  with  a  varied  population 
will  require  a  greater  intensive  effort  than  the  same  endeavor  for  a 
small  community,  nevertheless,  the  fundamental  principles  presented  can 
be  applied  in  either  circumstance. 

In  any  working  scheme  undertaken  the  board  of  health  will  furnish 

actual    and   technical    guidance    and    will   conduct    the     immunization 

procedure.  „,  .     ,. 

Objective 

To  immunize  all  pre-school  and  school  children  under  ten  years. 

Activity 

All  activity  is  primarily  designed  to  arouse  and  sustain  community 
interest. 

The  Publicity  Director  will  centralize  the  activity  and  will  be  essen- 
tially responsible  for  the  success  of  the  campaign. 

The  publicity  campaign  and  its  duration  will  depend  largely  upon  the 

*  Massachusetts  Department  of  Public  Health,  contributed  by  the  following  State  District  Health 
Officers: — Doctors  R.  E.  Archibald,  O.  A.  Dudley,  F.  S.  Leeder,  C.  B.  Mack,  R.  P.  MacKnight, 
and   H.   E.   Miner. 


139 

size  and  homogeneity  of  the  population.  Where  the  foreign  element  is 
large,  more  and  varied  efforts  will  be  required.  The  duration  accordingly 
will  vary  from  ten  days  to  three  weeks.  Preliminary  preparation,  creat- 
ing a  working  program,  assembling  literature,  etc.,  should  be  started 
several  weeks  in  advance. 

Cooperating  Groups 

In  populous  communities  a  list  of  all  organizations  should  be  made  and 
they  should  be  invited  to  participate. 
Such  a  list  should  include: — 

Schools — public,  private,  parochial,  nursery  and  kindergarten. 
Churches. 

Social,  Welfare  and  Business  Groups. 
Medical  Group.  , 

Groups 
Social,  Business  and  Welfare: 

American  Legion  Nurses'  Organizations 

Boy  scouts  Orphan  Asylums 

Fraternal  and  Benevolent  Organ-  Parent  Teachers'  Association 

izations  Grange 

Girl  Scouts  Public  Utility  Corporations 

Labor  Organizations  Industries 

Life  Underwriters  Association  Relief  and   Welfare   Organizations 
Local  Hygiene  Societies  devoted  to  child  care 

Luncheon  Clubs  Representatives  from  Hospitals 

Milk  Companies  Women's  Organizations 

Neighborhood  Societies  Salvation  Army 

Red  Cross  Vacation  Societies 

The  issues  of  the  campaign  can  be  sustained  by  preparation  of  indi- 
vidual prgorams  on  the  campaign  subject  matter  presented  at  meetings 
of  these  organizations. 

Mailing  Lists  —  All  members  can  be  furnished  with  descriptive 
material  through  their  respective  mailing  lists.  Mailing  lists  of  electric, 
gas  and  telephone  companies  can  be  utilized  to  furnish  leaflets,  health 
publications,  etc.  The  home  delivery  of  milk  companies  can  be  utilized 
for  the  same  purpose. 

Boy  Scouts,  Girl  Scouts  —  Yeoman  service  can  be  furnished.  They  can 
escort  children  to  private  physicians  and  clinics.  They  can  disseminate 
knowledge  and  instruct  their  elders. 

Nurses'  Associations  and  Visiting  Nursing  Groups  —  Volunteer  service 
can  be  offered,  social  and  technical  guidance  furnished.  The  Visiting 
Nurses'  Association  occupies  a  position  of  trust  and  confidence  and  is 
invaluable  in  securing  the  pre-school  child's  attendance  at  a  clinic. 

Propose  to  the  respective  boards  of  management  of  welfare  and  aid 
groups  that  all  pre-school  and  school  children  making  application  for 
their  consideration  be  immunized  against  diphtheria  before  being  ad- 
mitted to  camps,  etc. 

Obtain  donations  of  advertising  space  in  street  cars,  busses  and  on 
billboards,  etc.  Also  from  local  business  concerns  with  daily  advertising 
space.  Local  transportation  companies  by  offering  free  rides  to  and 
from  the  clinic  may  materially  assist  in  the  success  of  the  program  both 
by  the  service  rendered  and  the  resulting  publicity.  Insurance  agents 
and  collectors  of  small  insurance  payments  make  intimate  personal  con- 
tact, are  particularly  interested  and  have  an  unusual  opportunity  to 
obtain  attendance  of  children  at  a  conservation  clinic. 

Foreign  committees  have  proven  particularly  effective  in  cities  having 
a  large  foreign  population.  Select  doctors,  clergymen,  and  other  prom- 
inent representatives  of  these  individual  national  groups  having  the 
confidence  of  their  people. 


140 

The  municipal  government  should  be  encouraged  to  give  moral  and 
other  support  for  a  comprehensive  and  effective  campaign. 

The  response  to  an  intensive  campaign  may  make  it  necessary  that 
the  hospitals  supply  temporary  clinic  accommodation. 

Schools 

Parents  of  school  and  pre-school  children  can  be  circularized  and  pro- 
vided with  informative  literature. 

The  assistance  of  the  Parent  Teachers'  Association  will  prove  invalu- 
able. By  example  they  can  set  the  pace  and  by  making  contact  with  less 
enlightened  parents  they  can  educate. 

Churches 

Pastoral  letters  by  eminent  church  dignitaries  have  proven  particu- 
larly effective,  notably  in  church  groups  having  a  large  foreign 
population. 

Church  publications  afford  a  good  vehicle  for  educational  purposes. 

Talks  by  the  clergy  upon  life  conservation,  etc. 

Formal  opening  of  the  campaign  from  the  pulpit. 

Medical  Group 

A  policy  to  protect  the  legitimate  interests  of  the  local  physicians 
should  be  determined  upon  by  consulting  the  local  or  county  medical 
organization.  Public  clinics  are  created  for  those  who  are  unable  to 
pay  the  usual  medical  fee. 

Through  cooperation  of  the  board  of  health  and  the  local  medical 
organization  endeavor  to  establish  a  special  reasonable  charge  during 
the  period  of  this  campaign  for  private  immunizing  service  in  the 
physician's  office.  Specify  certain  hours  on  stated  days  of  the  week  for 
this  private  attention.  By  publication  advise  the  public  of  this  special 
consideration. 

Joint  sponsorship  by  the  county  or  local  medical  organization  and  the 
board  of  health  of  a  circularizing  letter  and  poster  card  for  the 
physician's  waiting  room  will  enable  the  local  physician  to  resort  to  his 
private  mailing  list  and  to  display  the  poster. 

Publicity 

Press  —  Get  all  publicity  possible  well  in  advance  of  immunization  day. 

Interest  editorial  writers. 

Get  donations  of  space  from  leading  advertisers  in  local  papers. 

Publish  actual  picture  illustrations  in  newspapers,  etc. 

Publish  human  interest  stories  in  relation  to  work. 

Radio  —  In  large  cities  frequent  talks  by  recognized  men  and  women. 

Movies  —  Snappy  notes  on  campaign  purpose  and  progress. 

Posters  —  Secure  billboard  donation  and  display  appropriate  posters. 

Window  Displays  —  Space  should  be  reserved  in  all  store  windows  for 
posters,  exhibits,  etc. 

Show  window  decorations  should  be  appropriate. 

One  hundred  per  cent  cards  could  be  displayed  in  windows  of  private 
residences. 

Churches  —  Special  talks  on  individual  and  community  value  of  diph- 
theria immunization.    Two  Sundays  will  intervene  in  a  ten-day  program. 

Speakers  —  Organize  all  speakers  and  speaking  programs. 

Program  —  Demonstration  —  Awards 

Program  —  Should  be  devised  to  create  and  sustain  interest  during 
period  of  activity. 

Preliminary  Opening  —  Pulpit  announcement  and  talk  on  life  conser- 
vation. 


141 

Formal  Opening  —  Mayor's  office  or  Health  Officers'  Headquarters. 
General  gathering  of  sponsors  and  invited  guests,  conduct  same  so  as  to 
be  of  news  value. 

Public  Meetings  — ■  Secure  representative  citizens  for  speaking  pur- 
poses. Health  pageant,  playlets  or  tableaus  can  be  staged  —  appropriate 
films  can  be  secured. 

Demonstrations  —  Enabling  school  children  to  play  a  part.  Health 
pageants,  etc.     Foreign  group  children  in  native  costumes,  etc. 

Gala  Aspect  —  Appropriate  window  dressings  in  shops,  health  pen- 
nants, street  banners,  etc. 

Awards 

Awards  —  Medals,  certificates,  merit  marks,  window  cards  for  private 
residences,  special  merit  designation  for  Boy  Scouts  and  Girl  Scouts,  etc., 
to  encourage  and  stimulate  effective  individual  and  group  activity. 

Awarding  —  Under  proper  auspices  and  with  appropriate  ceremony. 

Budget 

If  the  campaign  is  actively  sponsored  by  an  organized  community 
group  it  is  assumed  that  the  expense  incident  to  the  publicity  campaign 
will  be  a  direct  contribution  of  that  organization  to  community  better- 
ment and  life  conservation. 

Toxin-antitoxin  will  be  furnished  by  the  State  Department  of  Public 
Health.  The  State  Department  of  Public  Health,  the  various  life  insur- 
ance companies,  and  other  national  organizations  will  furnish  literature 
without  charge  and  in  some  instances  films. 

Past  experience  and  the  prospective  number  of  children  to  be  immun- 
ized by  an  intensive  campaign  will  furnish  figures  upon  which  to  base 
the  cost  of  medical  service. 

If  the  board  of  health  conducts  the  campaign  and  is  unable  to  find  a 
suitably  equipped  person  in  its  personnel  to  act  as  Publicity  Director 
provision  must  be  made  for  such  position. 

Clinic  Organization 

The  Medical  or  Clinical  Director  and  the  Publicity  Director  are  fre- 
quently the  two  positions  of  greatest  importance  in  an  intensive  campaign. 

Asepsis,  accuracy  of  dosage,  efficient  organization  and  cooperation  are 
the  cardinal  principles  recognized  from  an  administrative  viewpoint. 

The  number  of  clinic  stations  will  be  regulated  by  geographical  dis- 
tribution, general  accessibility  and  the  presence  of  suitable  public  meeting 
places.  It  may  be  advisable  to  hold  one  central  clinic  in  towns  and  cities 
of  average  size.  Frequently  public  school  buildings  are  used  especially 
if  clinics  are  to  be  held  in  various  sections  of  the  community. 

The  number  of  clinics  and  size  of  personnel  will  naturally  depend  upon 
the  prospective  number  of  children  to  be  treated  on  any  one  day.  When 
a  great  number  of  children  are  to  be  treated  and  several  clinic  stations 
are  provided,  a  morning  is  given  per  station  each  week,  the  average  not 
to  exceed  four  stations.  A  fourth  week  should  be  reserved  for  late  appli- 
cants and  irregulars,  afterward  a  few  hours  in  a  central  clinic  on  a 
stated  day  each  week  until  the  full  complement  of  children  are  immunized. 

Not  less  than  three  rooms  should  be  provided  for  each  clinic — when  a 
large  hall  is  used  it  should  be  roped  so  that  adequate  space  is  provided 
for  reception,  for  immunizing  and  for  dressing  purposes.  The  reception 
room  should  be  sufficiently  large  to  accommodate  the  expected  number  of 
children.  This  is  especially  important  during  inclement  weather.  The 
rooms  or  spaces  should  be  in  series,  with  entrance  and  exit  so  arranged 
that  the  normal  clinic  flow  will  not  be  impeded. 

Care  should  be  exercised  to  insure  a  sufficient  supply  of  toxin-anti- 
toxin from  the  State  Antitoxin  and  Vaccine  Laboratory,  375  South 
Street,  Jamaica  Plain,  Boston.  Due  allowance  must  be  made  for  wastage. 
For  the  immunization  of  a  large  group,  the  Vim-Forsbeck  automatic 


142 
syringe  with  needle  rack  and  holder  assure  accuracy  of  dosage  and  will 
greatly  facilitate  the  clinic  work. 

Celerity  in  action  and  continuity  in  performance  is  the  prime  con- 
sideration in  conducting  a  clinic  of  this  character;  the  personnel  must  be 
adequate  to  assure  such  service.  Physicians,  nurses,  aides  and  record 
keepers  should  be  selected  in  such  numbers  as  the  anticipated  attendance 
indicates. 

The  aides  are  frequently  recruited  from  the  nurses'  training  school  of 
a  local  hospital  or  by  volunteers  from  one  of  the  local  women's  organiza- 
tions. Aides  are  responsible  for  an  uninterrupted  flow  of  the  clinic  and 
for  the  maintenance  of  order  during  the  clinic  period.  They  are  stationed 
in  the  reception  and  exit  rooms  and  assist  in  removal  and  final  adjust- 
ment of  coats  and  wraps;  the  children  are  marshalled  into  line  after 
checking  the  list  presented  by  the  record  keeper.  The  aide  also  assists  in 
the  preparatory  arrangements,  under  direction  of  the  physician  or  nurse. 

The  nurse's  station  is  in  the  immediate  vicinity  of  the  physician.  She 
is  charged  with  the  maintenance  of  recognized  aseptic  procedure  as 
applied  to  clinic  practice,  and  prepares  the  physician's  working  table, 
sterilizes  syringes  and  needles,  refills  syringes,  if  directed  to  do  so,  and 
attends  to  such  professional  duty  as  is  consistent  with  the  best  recognized 
clinic  procedure.  Where  the  automatic  syringe  is  used,  only  one 
physician  is  necessary  but  one  or  two  additional  nurses  may  be  required 
to  care  for  the  additional  numbers  served. 

Records 

Request  slips  are  usually  issued  through  the  schools  and  through 
cooperating  agencies  to  the  pre-school  child.  In  this  manner  the  per- 
mission of  the  parent  by  signature  is  obtained  to  proceed  with  the 
immunization  and  to  perform  such  tests  as  are  indicated.  One  week  or 
less  is  allowed  for  their  return  to  the  teacher  who  transmits  them  to  the 
school  nurse.  This  will  afford  the  school  nurse  ample  time  to  make 
personal  contact  with  the  parents  who  have  failed  to  return  the  slip. 
Record  sheets  are  then  made  for  each  individual  clinic  and  the  same  are 
placed  at  designated  stations.  In  an  intensive  campaign  the  signed 
requests  for  pre-school  children  and  the  children  not  attending  school 
are  usually  given  at  the  time  treatment  is  sought. 

During  a  campaign  it  is  well  to  give  each  child  filing  a  request  slip, 
a  printed  slip  designating  the  child's  name,  the  clinic  station,  the  day 
and  hour.  The  child  is  given  another  slip  of  like  character  in  each  suc- 
ceeding clinic.  A  slip  color  scheme  differentiating  each  immunizing  week 
will  frequently  avoid  difficulty  in  the  final  record  assembly. 

The  name  and  address  of  each  child  is  recorded  at  each  clinic  period 
immediately  before  treatment.  This  data  is  finally  transferred  to  a  per- 
manent record  card  not  less  than  three  by  five  inches.  The  State  De- 
partment of  Public  Health  will  distribute  printed  form  cards  upon 
request.  The  final  record  should  include:  serial  number,  name,  sex,  age,, 
school  and  grade,  previous  history  of  diphtheria,  date  and  result  of 
preliminary  test,  date  of  each  immunizing  dose,  date  and  result  of 
final  test,  space  for  remarks. 

The  record  keeper  is  primarily  responsible  for  completeness  of  data 
and  neatness  of  work.  The  record  of  every  child  should  be  carefully 
checked  to  be  certain  that  all  previous  injections  are  recorded  as  well  as 
the  dates  of  all  tests. 

Not  earlier  than  six  months  after  the  final  immunization  injection 
all  children  should  be  Schick  tested  to  determine  whether  or  not 
immunity  is  complete  in  every  child. 


143 

Suggestions  for  Supplies  and  Equipment  for  Use  in  Diphtheria 
Immunization  Programs 

1  Sterno  heater  with  extra  can  of  Sterno  (wood  alcohol  may  be  sub- 
stituted for  fuel  instead  of  Sterno) 

1  Saucepan  with  cover  (a  small  sterilizer  may  be  used) 

2  Small  enamel  basins 

1  Bottle  alcohol  for  cleaning  syringes 
1  Bottle  of  15%  lysol  for  needles 
Rubber  bands 

3  Straight  forceps 

Jl  Bottle  tincture  of  iodine  U.  S.  P.  or  acetone  or  70%  alcohol   (for 
sterilizing  arm) 
Cotton 
6  Envelopes  sterile  gauze  squares 
1  4  oz.  bottle  aromatic  spirits  of  ammonia 
1  Square  yard  white  oilcloth 
24  2  c.c.  or  5  c.c.  syringes 
36  Needles  y2",  24  gauge 
32  Sets  Schick  syringes 
3  Dozen  special  Schick  needles  %",  27  gauge 

Individual  tastes  may  differ  as  to  equipment  and  supplies  necessary 
for  this  work. 

The  State  Department  of  Public  Health,  through  its  District  Health 
Officers,  is  ready  at  all  times  to  advise  and  assist  local  Boards  of  Health  in 
the  organization  and  execution  of  a  sustained  diphtheria  immunization 
program. 

THE   RESULTS   OF   COMMUNITY   IMMUNIZATION   AGAINST 

DIPHTHERIA 

Ralph  E.  Wheeler,  M.D. 

Epidemiologist,  Massachusetts  Department  of  Public  Health 

Control  of  diphtheria  through  a  reduction  of  the  susceptibility  of  the 
community,  viz.  by  active  immunization,  has  been  tried  on  an  extensive 
scale  for  a  period  of  several  years  in  many  cities  of  varying  sizes.  The 
mode  of  attack  has  been  varied  according  to  the  special  local  conditions 
but  the  underlying  principle,  immunization  of  the  susceptible,  has  been 
the  same.  There  are  brought  together  herewith  the  results  obtained  in 
several  of  these  communities  in  an  attempt  to  evaluate  the  feasibility  and 
effect  of  such  methods  of  control. 

In  Sioux  City,  Iowa,  (Population  80,000)  one  of  the  first  to  institute 
diphtheria  control  measures,  the  campaign  has  been  directed  toward 
getting  the  parents  to  take  their  children  to  the  family  doctor  for 
immunization.  We  can,  therefore,  have  no  accurate  data  on  the  number 
of  children  actually  given  toxin-antitoxin,  but  the  Health  Department 
reports  that  a  high  percentage,  both  of  school  and  of  pre-school  children, 
have  been  protected.  The  progressive  decline  in  the  prevalence  of  diph- 
theria would  seem  to  bear  out  this  statement,  for  the  number  of  cases 
per  100,000  in  Sioux  City,  as  shown  in  Table  I,  has  fallen  very  markedly 
since  the  beginning  of  the  campaign  in  1922. 

Auburn,  New  York,  (Population  35,000)  began  immunization  in  the 
same  year.  They  report  the  singularly  favorable  proportion  of  55%  of 
the  pre-school  and  90%  of  the  school  children  immunized.  Here  too, 
the  prevalence  of  diphtheria  has  decreased  greatly,  the  decline  following 
soon  after  the  beginning  of  the  toxin-antitoxin  campaign. 


1  Iodine  to  be  used  for  T.  A.   T.  only.     Use  alcohol  or  acetone  for  the  Schick  test. 

2  For    T.    A.    T.    clinic. 

3  For  Schick  clinic. 


144 

Brookline,  Massachusetts,  (Population  45,000)  began  an  active  cam- 
paign m  1923.  The  proportion  of  children  immunized  is  not  definitely- 
known  as  private  doctors  did  no  small  share  of  the  total,  but  diphtheria 
has  become  much  less  prevalent  in  Brookline  since  the  start  of  the  cam- 
paign and  it  is  particularly  gratifying  to  note  that  there  have  been  no 
deaths  from  diphtheria  in  this  community  of  45,000  for  the  past  six 
years. 

New  Haven,  Connecticut,  (Population  190,000)  the  largest  of  the  cities 
studied,  has  protected  its  children  against  diphtheria  with  toxin-anti- 
toxin since  1923,  when  a  consistent  Health  Department  program  was 
begun.  A  survey  of  four  of  the  city  blocks  showed  that  88%  of  the 
children  of  school  age  and  30%  of  the  pre-school  children  were  immune. 
The  disease,  as  shown  by  the  rates  quoted  below,  has  been  much  reduced 
in  prevalence  following  the  administration  of  toxin-antitoxin. 

Middletown,  New  York,  (Population  20,000)  began  its  campaign  of 
immunization  in  1924  with  such  singular  thoroughness  that  99%  of  the 
school  children  and  73%  of  the  children  below  school  age  were  reached  by 
the  program.  That  these  are  not  merely  sanguine  estimates  is  shown  by 
the  course  of  the  diphtheria  rates  of  the  City  since  the  inauguration  of 
the  campaign. 

The  following  Table  shows  the  rates,  over  the  past  decade,  of  diphtheria 
in  the  five  communities  under  consideration.  The  rates  for  the  years 
following  the  year  in  which  immunization  measures  were  begun  are 
printed  in  heavy  type. 

Table  I  —  Effect  on  the  Case  Rate  per  100,000  of  T oxin- Antitoxin  Ad- 
ministration in  Five  Cities  of  the  United  States 

Sioux 
Year  City  Auburn  Brookline     New  Haven     Middletown 

1920  -  248  96  284  313 

1921  290  361  126  287  170 


1922 

389 

270 

200 

123 

58 

1923 

277 

118 

115 

64 

31 

1924 

124 

61 

36 

38 

51 

1925 

63 

50 

26 

15 

55 

1926 

99 

19 

18 

16 

5 

1927 

34 

28 

18 

29 

0 

1928 

10 

39 

9 

26 

14 

"!929 

27 

6 

11 

25 

0 

In  order  further  to  show  the  significance  of  toxin-antitoxin  adminis- 
tration in  the  lowering  of  the  death  and  case  rates  of  diphtheria,  the 
rates  of  the  five  cities  were  weighted  and  averaged.  The  resulting 
figures  showed  a  nearly  progressive  decline  in  rates  following  the  begin- 
ning of  the  use  of  toxin-antitoxin,  as  in  the  case  of  the  individual  cities. 
If,  now,  the  rates  of  communities  in  which  little  or  nothing  is  done  in 
the  way  of  protection  against  diphtheria,  but  which  in  other  ways  are 
comparable  to  the  above  cities,  are  averaged  in  the  same  manner  and 
compared  with  the  others,  the  following  striking  contrast  is  obtained: 


145 

Table  II  —  Average  Diphtheria  Case  Rate  of  Five  Communities  Where 
Immunization  is  Employed  Compared  with  Average  of  Other- 
wise Comparable  Communities  Which  Do  Not  Immunize 
Against  Diphtheria. 


Towns  Immunizing 
Year  (Average  *  Rate 

per  100,000) 


Towns     Not  Immun- 
izing     (Average  "x" 
Rate  per  100,000) 


1920 

246 

1921 

284 

1922 

189 

1923 

92 

1924 

48 

1925 

48 

1926 

21 

1927 

20 

1928 

25 

1929 

14 

214 
230 
214 
168 
143 
128 
107 
171 
170 
188 


*  Weighted  average  used  in  determining  the   rates. 

Diphtheria  in  "Immunized"  Communities  Contrasted  with  Diphtheria 
Where  Extensive  Immunization  Has  Not  Been  Practiced 

Average  Case  Rate  Per  100,000  Population 


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1928 


It  will  be  noted  that  about  1922  diphtheria  tended  to  decrease  in  both 
the  immunized  and  non-immunized  communities.  This  was  part  of  a 
country-wide  falling  off  in  the  prevalence  of  diphtheria  subsequent  to 
an  epidemic  wave.  The  important  fact  is  that  in  the  communities  where 
immunization  was  employed,  the  decrease  in  diphtheria  has  been  both 
more  pronounced  and  more  permanent,  whereas  in  the  unprotected  com- 
munities the  disease,  after  the  initial  fall,  begins  rapidly  to  increase  again 
and  has  now  almost  reached  its  former  heights. 

The  conclusion  is  unavoidable,  therefore,  that  in  communities  where 


146 

the  use  of  toxin-antitoxin  is  pushed  among  both  pre-school  children  and 
those  of  school  age,  the  resulting  effect  on  the  incidence  of  diphtheria  is 
a  very  favorable  one.  It  has  been  remarked  elsewhere,  in  this  issue  of 
The  Commonhealth,  that  communities  can  practically  control  the  amount 
of  diphtheria  prevailing  within  their  limits.  The  purpose  of  this  note  is 
to  show  that  many  communities  have  actually  done  this. 

AMERICAN  RED  CROSS 

The  Roll  Call  this  year,  to  enroll  members  for  1931, 

will  be  held  as  usual  from  Armistice  Day  to 

Thanksgiving,  November  11  to  27. 


147 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  April,  May,  and  June,  1930,  samples  were 
collected  in  206  cities  and  towns. 

There  were  2,438  samples  of  milk  examined,  of  which  646  were  below 
standard;  from  29  samples  the  cream  had  been  in  part  removed,  74 
samples  contained  added  water,  and  1  sample  of  skimmed  milk  below  the 
legal  standard.  There  were  24  samples  of  Grade  A  milk  examined,  19 
samples  of  which  were  above  the  legal  standard  of  4.00%  fat,  and  5 
samples  were  below  the  legal  standard. 

There  were  169  samples  of  food  examined,  of  which  38  were  adulter- 
ated. These  consisted  of  2  samples  of  oleomargarine  intended  for  use 
on  pop  corn  to  be  sold  as  buttered  pop  corn,  2  samples  sold  as  butter 
which  proved  to  be  oleomargarine,  1  of  which  also  contained  coloring 
matter;  4  samples  of  clams  which  contained  added  water;  4  samples  of 
confectionery,  2  of  which  had  too  much  menthol  and  2  had  terpenes 
present;  9  samples  of  cream,  2  of  which  were  low  standard,  and  7  were 
not  labeled  in  accordance  with  the  law;  2  samples  of  maple  syrup  which 
contained  cane  sugar;  2  samples  of  hamburg,  1  sample  contained  a  com- 
pound of  sulphur  dioxide  not  properly  labeled,  and  1  sample  was  decom- 
posed; 1  sample  of  caustic  poison  which  did  not  bear  a  poison  label;  5 
samples  of  soft  drinks  which  bore  labels  printed  in  too  small  type;  1 
sample  of  chocolate  drink  which  was  incorrectly  labeled ;  2  samples  of  egg 
noodles  which  were  artificially  colored;  1  sample  of  extract  of  ginger  in 
which  acetone  and  pyridine  were  present;  1  sample  of  bread  which  was 
moldy;  and  2  samples  of  mattress  filling  which  were  secondhand  material 
and  not  so  labeled. 

There  were  28  samples  of  drugs  examined,  of  which  12  were  adulter- 
ated. These  consisted  of  2  prescriptions,  1  of  which  was  concentrated, 
and  the  other  sample  was  too  dilute;  and  10  samples  of  spirit  of  nitrous 
ether,  all  of  which  were  deficient  in  the  active  ingredient.  One  sample 
of  liquor,  submitted  by  the  Maiden  Hospital,  was  examined  for  added 
poisons  with  negative  results. 

The  police  departments  submitted  1,545  samples  of  liquor  for  examin- 
ation, 1,527  of  which  were  above  0.5%  in  alcohol.  The  police  depart- 
ments also  submitted  17  samples  of  narcotics,  etc.,  for  examination,  10 
of  which  were  morphine  or  morphine  derivatives,  1  opium,  1  sample  of 
Jamaica  ginger  which  contained  methyl  alcohol,  1  sample  of  alcohol 
examined  for  poisons  with  negative  results,  and  2  samples  of  oranges, 
1  sandwich,  and  1  letter,  all  of  which  contained  morphine. 

There  were  92  bacteriological  examinations  made  of  milk. 

There  were  135  bacteriological  examinations  made  of  soft  shell  clams, 
91  samples  in  the  shell,  68  of  which  were  unpolluted,  and  23  were 
polluted,  and  44  samples  shucked,  29  of  which  were  unpolluted,  and  15 
were  polluted.  There  were  5  bacteriological  examinations  made  of  hard 
shell  clams,  in  the  shell,  all  of  which  were  unpolluted. 

There  were  161  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  121  cities  and  towns  visited  for  the  inspection  of  pasteur- 
izing plants,  and  436  plants  were  inspected. 

There  were  38  convictions  for  violations  of  the  law,  $1,315  in  fines 
being  imposed. 

Mathias  Dakos  of  Peabody;  Francis  Grout  of  Sherborn;  George  Hen- 
richon  of  Brimfield;  John  Schultz  of  Salem,  New  Hampshire;  Thomas 
J.  Welch  of  Newburyport;  Octave  Boucher  and  Herman  Samuel  of  East- 
hampton;  Joseph  Delgnio  of  West  Medway;  Louis  Guertin  and  Joseph 
Pilch  of  Ware ;  Norman  H.  Hudson  of  Wareham ;  Milo  Ingalls  of  Dracut ; 
Samuel  Terzian  of  Whitman;  Simon  Dastague  of  Sudbury;  Alfred 
Heilman  of  Templeton;  and  Michael  Kapatoes  of  Milford,  were  all  con- 
victed for  violations  of  the  milk  laws.  Octave  Boucher  of  Easthampton, 
Samuel  Terzian  of  Whitman,  and  Alfred  Heilman  of  Templeton,  all 
appealed  their  cases. 


148 

Mah  Sing  and  Donat  L'Heureux  of  Salem;  Kuechler  Brothers,  Incor- 
porated, of  New  Bedford;  Brockelman  Brothers,  Incorporated,  and  Fred 
Davis  of  Lowell;  Lewis  Handler  of  Brookline;  and  Nicholas  Boulos  of 
Stoughton,  were  all  convicted  for  violations  of  the  food  laws.  Brockel- 
man Brothers,  Incorporated,  of  Lowell  appealed  their  case. 

Cape  Ann  Dairy,  Incorporated,  5  counts,  of  Essex;  John  W.  Pratt  of 
Peabody;  James  B.  Crane  of  Leominster;  Everett  Freeman  and  Joseph 
B.  and  Walter  C.  Smith  of  Whitman;  Ashley  Stoddard  of  Rockland; 
George  Moore  of  Weymouth;  Frank  H.  Bassett  of  Greenfield;  and  Lester 
E.  Avery,  2  cases,  of  Plymouth,  were  all  convicted  for  violations  of  the 
pasteurization  law.  Joseph  B.  and  Walter  C.  Smith  of  Whitman  appealed 
their  case. 

Jacob  Wineberg  of  Adams ;  and  Emilio  Balzarini  of  Rockport,  were  con- 
victed for  violations  of  the  slaughtering  law. 

Max  Blass  and  Julius  Shapiro  of  Chelsea  were  convicted  for  violations 
of  the  mattress  law. 

James  B.  Crane  of  Leominster  was  convicted  for  obstruction  of  an 
inspector. 

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 :  9  samples, 
by  George  Henrichon  of  Brimfield;  8  samples,  by  Alfred  Heilman  of 
Templeton;  6  samples,  by  John  Schultz  of  Salem  Depot,  New  Hampshire; 
4  samples,  by  John  Andre  of  Ludlow;  2  samples,  by  William  Borkosky  of 
West  Springfield;  and  1  sample,  by  Simon  Dastague  of  North  Sudbury. 

Milk  which  had  the  cream  removed  was  produced  as  follows ;  2  samples, 
by  Antonio  Rodrigue  of  Palmer;  and  1  sample,  by  Ephraim  Manning  of 
East  Brookfield. 

Four  samples  of  milk  which  contained  added  water,  3  of  which  also 
had  the  cream  removed  were  produced  by  Walter  Kopinos  of  West 
Springfield. 

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

One  sample  each  from  First  National  Stores,  Incorporated,  of  Black- 
stone,  and  Herlihy  Brothers  Company  of  Somerville. 

Cream  which  was  not  labeled  in  accordance  with  the  law  was  obtained 
as  follows:  3  samples  from  Hazen  K.  Richardson  of  Middleton;  1  sample 
each,  from  William  F.  Marshall  of  West  Gloucester,  Robert  Catherwood 
&  Son  of  Lowell,  and  Floyd  Verrill  of  Concord. 

One  sample  sold  as  butter  which  proved  to  be  oleomargarine  was 
obtained  from  the  Central  House  of  North  Brookfield. 

One  sample  sold  as  butter  which  proved  to  be  oleomargarine  and  also 
contained  coloring  matter  was  obtained  from  Albert  Delisle  of  New 
Bedford. 

Two  samples  of  oleomargarine  intended  for  use  on  pop  corn  to  be  sold 
as  buttered  pop  corn  were  obtained  from  Everett  E.  Nichols  of  Lynn. 

One  sample  of  clams  which  contained  added  water  was  obtained  from 
Fred  H.  Snow  of  Pine  Point,  Maine. 

Two  samples  of  egg  noodles  which  were  artificially  colored  were  ob- 
tained from  the  Plymouth  Macaroni  Company  of  Plymouth. 

Five  samples  of  soft  drinks  which  bore  labels  printed  in  too  small 
type  were  obtained  from  Nehi  Bottling  Company,  Incorporated,  of 
Springfield. 

One  sample  of  maple  syrup  which  contained  cane  sugar  was  obtained 
from  Nicholas  Boulos  of  Stoughton. 

One  sample  of  hamburg  steak  which  was  decomposed  was  obtained 
from  Donant  L'Heureux  of  Salem. 

One  sample  of  hamburg  steak  which  contained  a  compound  of  sulphur 


143 
dioxide  and  was  not  properly  labeled  was  obtained  from  Louis  Handler 
of  Brookline. 

One  sample  of  extract  of  ginger  in  which  acetone  and  pyridine  were 
present  was  obtained  from  Steve  Savicka  of  Lowell. 

One  bottle  of  ammonia  which  did  not  bear  a  poison  label  was  obtained 
from  the  Jersey  Creamery  of  Maynard. 

Mattress  filling  which  was  secondhand  material  and  not  so  labeled 
was  obtained  as  follows :  1  sample  each,  from  Julius  Shapiro  of  the  New 
England  Bed  &  Springs  Company  of  Chelsea,  and  Max  Blass  of  the 
Liberty  Mattress  Company  of  Chelsea. 

There  were  ten  confiscations,  as  follows:  3  pounds  of  decomposed 
chicken;  25  pounds  of  decomposed  ducks;  314  pounds  of  decomposed 
fowl;  16  pounds  of  decomposed  turkeys;  300  pounds  of  beef  afflicted  with 
generalized  tuberculosis;  80  pounds  of  tainted  pork;  50  pounds  of  tainted 
pork  loins;  20  pounds  of  tainted  pork  sausage;  20  pounds  of  decomposed 
sausage  meat;  and  20  pounds  of  tainted  frankforts. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  March,  1930:  2,389,860 
dozens  of  case  eggs;  672,571  pounds  of  broken  out  eggs;  578,718  pounds 
of  butter;  1,046,601  pounds  of  poultry;  4,523,681  pounds  of  fresh  meat 
and  fresh  meat  products;  and  1,396,124  pounds  of  fresh  food  fish. 

There  was  on  hand  April  1,  1930:  2,207,385  dozens  of  case  eggs;  861,- 
388  pounds  of  broken  out  eggs;  1,878,995  pounds  of  butter;  7,479, 145y2 
pounds  of  poultry;  14,228,3181/4  pounds  of  fresh  meat  and  fresh  meat 
products;  and  3,430,654  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  April,  1930:  3,664,980 
dozens  of  case  eggs;  1,248,011  pounds  of  broken  out  eggs;  591,161  pounds 
of  butter;  841,636%  pounds  of  poultry;  4,295,1621/4  pounds  of  fresh 
meat  and  fresh  meat  products;  and  5,149,913  pounds  of  fresh  food  fish. 

There  was  an  hand  May  1,  1930:  5,579,970  dozens  of  case  eggs;  1,585,- 
631  pounds  of  broken  out  eggs;  1,285,437  pounds  of  butter;  5,712,124 
pounds  of  poultry;  13,058,914  pounds  of  fresh  meat  and  fresh  meat 
products;  and  6,695,465  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  May,  1930:  3,370,470 
dozens  of  case  eggs;  1,169,396  pounds  of  broken  out  eggs;  3,586,542 
pounds  of  butter;  l,060,0991/2  pounds  of  poultry;  3,167,5151/2  pounds 
of  fresh  meat  and  fresh  meat  products;  and  8,705,976  pounds  of  fresh 
food  fish. 

There  was  on  hand  June  1,  1930:  8,718,000  dozens  of  case  eggs;  2,258,- 
411  pounds  of  broken  out  eggs;  4,011,417  pounds  of  butter;  4,781,995 
pounds  of  poultry;  ll,721,599y2  pounds  of  fresh  meat  and  fresh  meat 
products;  and  13,794,933  pounds  of  fresh  food  fish. 


150 

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  Under  direction  of  Commissioner. 

Division  of  Sanitary  Engineering  .     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   .....     Director  and  Chemist,  H.  W.  Clark 
Division  of  Biologic  Laboratories         Director  and  Pathologist, 

Benjamin  White,  Ph.D. 
Division  of  Food  and  Drugs  .  Director  and  Analyst, 

Hermann  C.  Lythgoe,  S.B. 
Division  of  Child  Hygiene  Director,  M.  Luise  Diez,  M.D. 

Division  of  Tuberculosis  Director,  Sumner  H.  Remick,  M.D. 

Division  of  Adult  Hygiene  Director, 

Herbert  L.  Lombard,  M.D. 

State  District  Health  Officers 

The  Southeastern  District  Richard     P.     MacKnight,     M.D., 

New  Bedford. 

The  Metropolitan  District  Charles  B.  Mack,  M.D.,  Boston. 

The  Northeastern  District  Robert  E.  Archibald,  M.D.,  Lynn. 

The  Worcester  County  District  Oscar  A.  Dudley,  M.D.,  Worcester. 

The  Connecticut  Valley  District  Harold   E.   Miner,   M.D.,   Spring- 

field. 

The   Berkshire   District  .  Frederick  S.  Leeder,  M.D.  Pitts- 

field. 


Publication  op  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
5000.     8-.30.     Order   9893. 


_ 

I 


' 


THE 
COMMONHEALTH 


Volume  17 

No.  4 


OCT. -NOV. -DEC. 
1930 


Public  Health  Nursing 


MASSACHUSETTS 
DEPARTMENT  OF  PUBLIC  HEALTH 


^ 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

In  Memory  of  Mary  E.  Ayer  .          .          .          .          .          .                   .          .          .  153 

The  Public  Health  Nurse  in  the  Community,  by  Dorothy  Deming,  R.N.       .          .  154 

Relationships,  by  Sophie  C.  Nelson,  R.N. 155 

The  Relationship  of  Board  Members  to  Public  Health  Nurses,  by  Gertrude  W. 

Peabody,  R.N.                     157 

Education  and  the  Public  Health  Nurse,  by  Ada  Boone  Coffey,  R.N.  .          .          .  159 

Staff  Education,  by  Elsie  Brehaut,  R.N .          .          .  162 

Group  Education  in  Small  Communities,  by  Katherine  C.  Taft  ....  163 

Post-Graduate  Education,  by  Helen  M.  Hackett,  R.N 165 

Parental  Education  in  a  Public  Health  Program,  by  Frances  H.  Benjamin   .          .  169 

The  Specialist  versus  the  Generalist,  by  George  H.  Bigelow,  M.D.        .          .          .  170 
How  the  Nurse  Can  Contribute  the  Service  the  Public  Expects,  by  Annie  W. 

Goodrich,  R.N 171 

The  Relationship  of  the  Nurse  to  the  Health  Officer  Group,  by  Francis  P.  Denny, 

M.D .  175 

Physicians'  Report  on  Nursing  Supply 178 

The  Nurse  the  Doctor  Wants 180 

Maternal  and  Infancy  Nursing  Service,  by  Nora  M.  McQuade,  R.N.   .                   .  181 
A  Few  High  Spots  in  Vital  Statistics,  by  Mary  P.  Billmeyer,  A.B.,  R.N.,  and 

Angeline  D.  Hamblen,  A.B.         ........  184 

Where  Are  We  Going  in  Tuberculosis  Control?    By  Kendall  Emerson,  M.D.         .  188 
The  Problem  of  the  Undernourished  School  Child — How  It  May  Be  Solved, 

by  John  A.  Ceconi,  M.D.    .          .__ 193 

The  Average  Day  of  an  Industrial  Nurse  in  a  Modern,  Busy  Factory  Employing 

Between  Two  and  Three  Thousand  People,  by  Louise  G.  Fiske,  R.N.       .  196 

Social  Work  and  the  School,  by  Mary  P.  Billmeyer,  A.B.,  R.N 197 

The  Scientific  Research  Work  of  the  U.  S.  Public  Health  Service,  by  Surgeon- 
General  H.  S.  Cumming      .........  204 

Address  of  President  Hoover  at  the  Opening  Session  of  the  White  House  Confer- 
ence on  Child  Health  and  Protection    .......  207 

The  White  House  Conference  on  Child  Health,  and  Protection     .  .  .  .211 

"Health  Forum" 213 

Porto  Rican  Diet - 213 

Necrology: 

Dr.  John  A.  Ceconi            ..........  214 

Miss  Catherine  A.  Bowen           .........  214 

Book  Notes: 

American  Red  Cross  Disaster  Relief  Handbook   ......  214 

Children  of  the  Covered  Wagon          ........  214 

Cross-Sections  of  Rural  Health  Progress      .......  215 

A  Chapter  in  Child  Health 215 

Recording  and  Reporting  for  Child  Guidance  Clinics    .  .  .  .  .216 

Medical  Care  for  15,000  Workers  and  Their  Families 216 

Editorial  Comment: 

Preparation  for  the  Summer  Round-Up       .......  217 

Getting  Ready  for  May  Day— Child  Health  Day 217 

News  Note: 

Maternal  Deaths  in  Massachusetts  in  1929           ......  218 

Report  of  the  Division  of  Food  and  Drugs,  July,  August  and  September,  1930       .  218 

Index    .          .          .          .          .          .          .          .          .          .                   .          .          .  221 


THIS  SPECIAL  NUMBER 
PUBLIC    HEALTH    NURSING 

IS    DEDICATED 

To   the  Memory   of 
MARY  E.  AYER 

After  protracted  illness  and  suffering  Mary  E.  Ayer  died  at 
Northampton  on  September  19,  1930.  Following  a  diversified 
nursing  experience  she  had  been  on  the  staff  of  the  Department 
of  Public  Health  for  twelve  years,  first  in  the  Division  of  Com- 
municable Diseases  and  more  lately  in  the  Division  of  Child 
Hygiene.  At  first  her  district  was  the  Connecticut  Valley  but 
was  then  extended  to  include  the  Berkshires.  In  spite  of 
increasing  physical  handicaps  she  gave  to  this  much  larger 
area  the  same  quality  of  nice  personal  attention  which  char- 
acterized all  her  doings,  for  her  spirit  was  never  handicapped. 
It  may  be  asked  whether  under  the  pressure  of  many  things 
the  volume  of  burden  placed  on  her  was  not  unreasonable. 
This  is  hard  for  anyone  to  answer  but  of  this  we  are  certain, 
that  a  necessarily  limited  service  from  her  was  richer  in 
accomplishment  than  would  have  been  more  service  by  most  of 
the  rest  of  us. 

For  such  as  she,  description  is  a  poor  thing.  Her  devotion, 
her  standards,  her  sincerity,  her  wise  judgment,  were  apparent 
to  those  fortunate  to  know  her.  No  blighting  negativeness 
impaired  the  value  of  her  experience.  We  talk  of  and  devote 
much  time  to  professional  and  technical  training.  Essential 
as  they  are,  they  become  a  hollow  mockery  without  wise  and 
pleasing  adventurousness  and  without  those  ineffable  personal 
characteristics  which  when  present  as  in  Miss  Ayer  are  very 
much  akin  to  religion.  The  older  professions  have  now  and 
then  had  such  personalities  among  their  ranks,  and  their  pres- 
ence has  built  up  a  precedent  that  has  helped  to  keep  ideals 
bright  even  in  a  tarnishing  world.  The  newer  professions, 
such  as  public  health,  need  vastly  such  precedents  and  through 
all  who  knew  Miss  Ayer  this  is  perhaps  her  permanent  contri- 
bution. For  probably  but  few  of  us  will  ever  be  privileged  to 
meet,  and  much  less  work  with,  her  like  again. 


154 
THE  PUBLIC  HEALTH  NURSE  IN  THE  COMMUNITY 

Dorothy  Deming,  r.n. 

Assistant  Director 
National  Organization  for  Public  Health  Nursing 

The  term  public  health  nurse  has  been  defined  as  applying  to  "any 
graduate  nurse  who  is  taking  part  in  an  organized  community  service  to 
individuals  and  families,  including  the  interpretation  and  application  of 
medical,  sanitary  and  social  procedures  for  the  correction  of  defects,  pre- 
vention of  disease,  and  the  promotion  of  health,  and  may  include  skilled 
care  of  the  sick  in  their  homes."*  Formerly,  the  term  "visiting  nurse" 
referred  to  the  nurse  whose  chief  activity  was  bedside  care,  and  "public 
health  nurse"  to  the  nurse  whose  principal  efforts  were  educational.  Now, 
however,  the  term  has  come  to  include  both  groups  of  nurses,  and  is  so 
used  in  this  paper. 

The  feature  of  the  public  health  nurse's  work  which  distinguishes  her 
service  from  that  rendered  by  nurses  in  other  fields  is  that  she  is  engaged 
in  organized  community  service. 

The  public  health  nurse  is  part  nurse,  part  teacher,  part  social  worker, 
but  in  anp.of  these  three  capacities  she  is  primarily  a  member  of  the 
community,  and  is  therefore  closely  related  to  many  organizations  con- 
cerned with  the  public  welfare.  She  cannot  carry  on  her  program  suc- 
cessfully or  productively  as  an  isolated  actor.  She  is  merely  one  spoke  in 
a  very  large  wheel.  The  more  closely  she  is  in  touch  with  the  activities  of 
others  with  a  constant  sharing  and  interchange  of  ideas  and  methods,  the 
more  soundly,  fully,  and  satisfactorily  will  she  fulfill  her  purpose,  the 
more  efficiently  and  constructively  will  her  whole  program  advance.  She 
can  proceed  no  faster  than  the  rate  of  community  thinking.  It  is  her 
responsibility  to  see  that  the  average  citizen  grasps  the  significance  of 
her  work,  and  that  the  groups  of  organized  non-professional  people, 
boards  of  directors,  and  the  like,  hear  her  message,  understand  how  they 
can  help,  and  are  given  opportunities  to  share  in  her  program.  We 
may  make  these  statements  concrete  and  practicable  by  reducing  them  to 
a  few  rules  of  procedure: 

1.  The  public  health  nurse  knows  her  community  resources  thor- 
oughly. 

2.  The  public  health  nurse  establishes  working  relationships  with  all 
other  social  and  health  agencies  in  the  town,  county,  and  state, 
including  non-professional  groups  such  as  Parent-Teacher  As- 
sociations and  church  societies. 

3.  The  public  health  nurse  recognizes  the  official  authorities — the 
local  board  of  health,  the  county  board  of  supervisors,  the  state 
department  of  health  as  the  leaders  in  health  work  and  follows  no 
policies  contrary  to  theirs,  and  initiates  no  new  program  without 
consultation  with  them.  This  relationship  is  strengthened  be- 
tween official  and  non-official  groups,  if  the  non-official  agency 
invites  official  representation  on  its  board  of  directors,  or  medical 
advisory  committee. 

4.  The  public  health  nurse  initiates  a  new  program  only  after  a 
study  of  the  community  need,  the  existing  agencies  who  are  try- 
ing to  meet  the  need,  and  consultation  with  the  organizations  in- 
volved. This  includes  consultation  with  the  council  of  social 
agencies,  if  one  has  been  organized. 

5.  The  public  health  nurse  considers  herself  a  citizen  of  the  com- 
munity which  she  serves,  taking  pride  in  civic  progress  and 
developing  a  civic  conscience  toward  undesirable  conditions.  This 
implies  that  she  will  register  as  a  voter,  read  her  local  newspaper, 

*  Board  Members'  Manual — page   4 —  published   by   the   Macmillan   Co.,    1930.     $1.25. 


155 

take  such  part  as  time  allows  in  community  activities.    She  never 

uses  her  position  for  political  ends. 
6.    The  public  health  nurse  owes  it  to  her  community  to  render  the 

best  professional  service  possible.     To  this  end  she  keeps  up  to 

date  by 

Attending  local  nurses'  meetings 
Attending  state  and  national  nursing  conventions 
Reading  professional  journals 

Using  the  advisory  service  of  her  state  and  the  National 
Organization  for  Public  Health  Nursing.  Through  member- 
ship in  the  latter,  she  allies  herself  with  those  of  her  profes- 
sion who  have  done  and  are  doing  most  for  public  health 
nursing  as  a  national  body. 

RELATIONSHIPS 

Sophie  C.  Nelson,  r.n. 

Director,  Visiting  Nurse  Service 

John  Hancock  Mutual  Life  Insurance  Co. 

and 

President,  National  Organization  for  Public  Health  Nursing 

The  National  Organization  for  Public  Health  Nursing  tells  us  that 
public  health  nursing  is  an  organized  service  (not  for  profit)  rendered  by 
.graduate  nurses  to  the  individual,  family  and  community.  This  service 
includes  the  interpretation  and  application  of  medical,  sanitary  and 
social  procedures  for  the  correction  of  defects,  prevention  of  disease  and 
the  promotion  of  health  and  may  include  skilled  care  of  the  sick  in  their 
homes. 

According  to  this  definition,  the  work  of  the  public  health  nurse  has 
three  aspects — educational,  preventive  and  curative.  Although  this  is  the 
general  explanation  of  public  health  nursing,  specifically  the  public  health 
nurse  does  many  things.  Her  services  are  rendered  according  to  the 
nature  of  the  problems,  both  functionally  and  by  age  groups.  Function- 
ally, public  health  nursing  service  is  rendered  in  relation  to  the  following 
things : 

Health  Supervision 

This  relates  to  instruction  in  relation  to  the  aspects  of  health,  such  as 
habits  or  personal  hygiene,  clothing,  exercise,  rest,  nutrition,  social  and 
mental  adjustments,  the  observing  of  physical  defects  and  seeing  to  their 
correction. 

Maternity  Service 

This  includes  supervision  during  pregnancy  and  nursing  care  given  to 
the  mother  during  pregnancy,  delivery  and  after  delivery;  service  to  the 
baby  after  delivery;  instruction  to  the  mother  about  health  habits,  nutri- 
tion, personal  hygiene,  etc.,  and  the  interpretation  of  the  physician's 
instructions. 

Morbidity  Service 

This  relates  to  care  of  the  sick,  including  communicable  diseases,  with 
health  instruction  coincidental  with  the  care  of  the  sick  and  particularly 
rendered  during  convalescence. 

Special  Activities 

Nursing  service  is  rendered  in  relation  to  activities  which  might  be 
considered  special,  such  as  industrial  hygiene,  mental  hygiene  and  social 
welfare.  Activities  in  relation  to  industrial  welfare  activities  are  ren- 
dered in  behalf  of  the  health  of  the  employees  within  the  plant  and  out- 
side the  establishment. 


156 

In  relation  to  age  groups,  nurses  render  service  to  infants,  pre-school 
children  and  school  children,  which  again  includes  the  supervision  of 
children  within  and  without  their  homes  and  the  school  building.  Service 
is  rendered  to  adults  in  relation  to  general  health  supervision  and  par- 
ticularly in  relation  to  special  activities,  such  as  the  prevention  of  cancer 
and  the  retardation  of  certain  heart  conditions. 

Administratively,  public  health  nursing  service  is  usually  rendered  by 
agencies  engaged  specifically  in  public  health  nursing,  and  it  may  be 
administered  through  non-official  agencies  or  official  agencies  either 
independently  or  jointly.  Although  public  health  nursing  may  be  an 
independent  service,  any  consideration  to  program  must  be  considered  in 
conjunction  with  the  service  rendered  by  other  workers  and  other  groups, 
and  the  work  of  the  public  health  nurse  in  relation  to  her  various  activ- 
ities must  be  integrated  into  the  whole  health  program. 

By  virtue  of  nursing  activities  and  their  potential  contribution,  we  find 
the  nursing  personnel  constituting  the  largest  single  group  of  workers. 
In  most  communities  from  which  information  has  been  gathered,  over 
half  the  expenditure  for  official  health  work  is  expended  in  relation  to  pub- 
lic health  nursing  service.  The  problem  consequently  arises  how  best  we 
may  utilize  the  services  of  this  large  group  of  public  health  workers,  and 
when  we  talk  about  "how,"  we  immediately  have  to  consider  what  shall 
be  their  scope  and  qualifications  for  performance  and  what  shall  be  their 
relationship  with  other  workers  and  departments  so  that  their  service  can 
be  best  utilized  and  integrated  into  the  whole  program.  We  must  sub- 
sequently give  consideration  to  the  methods  best  known  to  have  been 
effective. 

Before  considering  relationships,  we  must  consider  the  qualifications 
requisite  to  good  public  health  nursing,  and  certain  principles  have  been 
evolved  which  by  experience  and  use  have  been  found  to  be  effective. 
These  principles  are  that  graduate  trained  nurses  should  be  used  because 
they  guarantee  a  known  type  of  service;  that  nurses  with  post-graduate 
courses  should  be  employed  where  possible,  appreciating  the  need  of 
further  instruction  outside  the  walls  of  a  hospital;  that  methods  be 
evolved  of  securing  and  maintaining  adequate  technique  for  a  high  stand- 
ard of  performance  (among  other  things,  this  means  continued  super- 
vision and  instruction) ;  that  a  continued  program  of  education  be  main- 
tained for  the  nurse  or  by  the  nurse  in  order  that  she  may  be  familiar 
with  new  methods  of  prevention  of  disease  and  new  methods  of  teaching 
health.  It  is  essential  in  order  to  have  effective  performance  in  any  one 
group  that  certain  basic  fundamentals  be  adhered  to  in  the  employment 
of  certain  types  of  people. 

No  single  group  of  people  has  the  necessary  information  requisite  to 
the  maintenance  of  health  of  every  individual  in  relation  to  every  function 
in  the  community.  Consequently  we  have  several  kinds  of  personnel  used 
in  relation  to  one  function.  For  instance,  consider  communicable  disease 
control.  There  is  the  laboratory  worker,  the  physician,  the  inspector  and 
the  public  health  nurse.  All  of  these  people  have  certain  responsibility 
for  the  control  of  communicable  disease.  It  is  subsequently  essential  that 
each  consider  the  other  in  relation  to  the  project  and  that  each  be  cog- 
nizant of  what  the  other  may  be  doing  and  is  expected  to  do. 

If  this  is  true  of  the  individual,  it  is  equally  true  of  the  organization 
employing  the  individual.  No  single  organization  responsible  for  a  cer- 
tain functional  performance  in  any  given  community  is  in  a  position  to 
outline  its  own  program  except  in  relation  to  and  in  consideration  of  the 
functions  and  programs  of  other  groups.  Programs  are  naturally  based 
on  the  specific  needs  in  the  community,  and  they  should  be  determined  in 
relation  to  the  scope  and  contributions  of  all  the  agencies  involved. 

All  of  these  lead  us  very  definitely  to  relationships.  It  is  important  in 
any  community  that  a  program  be  evolved  for  that  community  which  shall 
take  into  consideration  the  contribution  of  each  group  of  health  workers ; 
that  the  program  shall  be  outlined  jointly  and  not  singly  by  the  individual 


157 
organizations,  and  that  each  organization  shall  be  cognizant  of  and  take 
into  consideration  what  is  being  done  by  others.  This  leads  us  very 
definitely  into  knowing  what  is  necessary  in  the  community  to  be  done, 
how  it  is  being  done  and  by  whom.  Consequently  each  group  needs  cer- 
tain assistance  from  other  groups  in  relation  to  their  specific  program. 
There  are  certain  very  definite  aids  that  the  individual  worker  or  organ- 
ization has  at  hand  in  any  given  situation.  We  must  first  take  cognizance 
of  the  aid  that  may  be  given  locally  through  other  individual  workers  or 
other  organizations,  and  a  definite  relationship  in  relation  to  each  set  of 
workers  must  be  outlined. 

Outside  of  local  aid,  one  naturally  thinks  next  of  the  state.  State  de- 
partments of  health  are  in  a  position  to  give  specific  information  to  the 
individual  public  health  nurse  in  relation  to  technique  and  standards  of 
performance  and  administrative  assistance  in  relation  to  how  best  to  work 
out  the  specific  problems  which  she  has  at  hand.  All  types  of  personnel 
employed  by  the  state  departments  of  health  should  be  considered  as  being 
specific  consultants  for  the  individual  organization  or  worker  in  a  local 
community. 

Next  we  consider  the  relationship  and  assistance  that  may  be  gotten 
from  our  national  organizations.  We  have  organizations  in  relation  to 
function  such  as  the  National  Organization  for  the  Prevention  of  Blind- 
ness, the  American  Child  Health  Association,  the  National  Committee  for 
Mental  Hygiene  and  the  National  Tuberculosis  Association.  All  these 
associations  are  prepared  to  act  as  consultant  specialists  in  their  given 
field  and  are  also  prepared  to  help  in  outlining  programs.  The  organiza- 
tion in  which  public  health  nursing  is  most  naturally  considered  is  the 
National  Organization  for  Public  Health  Nursing  which  is  prepared  to 
assist  both  the  individual  and  the  local  organization  in  their  specific  tech- 
nical problems  and  in  their  community  problems  as  far  as  public  health 
nursing  is  concerned.  All  of  these  agencies  should  be  considered  in  defin- 
ite relationship  and  having  a  specific  contribution  to  make  to  the  indi- 
vidual worker  and  organization,  and  relationships  should  be  worked  out 
very  definitely  with  each  and  all  of  them. 

Any  consideration  of  administration  or  relationship  is  based  only  on 
opinion  and  the  objective  must  necessarily  be  to  consider  what  is  likely 
to  be  the  most  harmonious  way  of  working  out  a  problem  and  then  going 
to  it. 

It  is  most  important  in  any  situation  to  define  quite  carefully  the  func- 
tion of  each  person  technically  and  in  relation  to  other  people  and  the 
scope  of  any  agency  activity  in  relation  to  the  scope  of  other  agency  activ- 
ities. This  involves  knowing  what  the  community  needs  in  total  and  how 
much  the  given  organization  is  prepared  to  do.  Consequently  it  involves 
knowing  what  you  want  done,  whom  you  want  to  do  it  and  how  you  want 
it  done.  In  other  words,  each  individual  and  organization  in  order  to  be 
most  effective  must  be  cognizant  of  the  services  and  contributions  of  other 
types  of  individuals  and  organizations  in  order  that  jointly  utilizing  the 
talents  of  all  they  may  work  out  a  program  that  shall  be  most  productive 
for  the  community  as  a  whole. 

THE  RELATIONSHIP  OF  BOARD  MEMBERS  TO 
PUBLIC  HEALTH  NURSES 

Gertrude  W.  Peabody,  R.N. 

President,  Massachusetts  Organization  for  Public  Health  Nursing 

Public  Health  Nursing,  as  it  is  called  today,  had  its  origin  in  this  coun- 
try in  the  Visiting  Nurse  Associations  that  were  first  organized  about 
forty  years  ago.  These  associations  were  started  not  by  nurses  but  by 
intelligent,  conscientious,  public-spirited  citizens  who,  in  various  cities, 
formed  themselves  into  committees,  and  employed  nurses  who  had  been 
trained  to  nurse  the  sick,  but  who  had  no  more  experience  than  their  com- 


158 
mittees  in  adapting  this  knowledge  to  meeting  the  needs  of  the  com- 
munity. Every  step  of  the  way  was  worked  out  jointly  by  the  nurse  and 
her  board  of  directors ;  and  very  remarkable  it  is  that  many  of  the  policies 
arrived  at  under  those  pioneer  conditions  are  accepted  today  as  the  under- 
lying principles  of  the  modern  public  health  nursing  association. 

The  developments  in  public  health  have  imposed  upon  the  nurse,  in  addi- 
tion to  nursing  the  sick,  the  responsibilities  of  a  teacher  of  health  and  of 
the  prevention  of  disease.  Post-graduate  courses  have  been  established 
to  train  her,  and  many  opportunities  are  available  for  professional  help 
and  guidance;  so  that  the  Board  of  today  is  able  to  employ  a  nurse  ade- 
quately equipped  to  conduct  a  community  health  program  according  to 
recognized  standards. 

More  and  more  public  health  nurses  are  employed  by  public  officials; 
but  in  Massachusetts  there  are  160  privately  administered  nursing 
associations  employing  about  450  nurses,  or  nearly  half  of  all  the  public 
health  nurses  in  the  State.  Why  is  it  that  the  privately  supported  and 
administered  association  holds  is  place  in  this  great  professional  move- 
ment? What  special  contribution  may  its  board  of  directors  make?  The 
first  contribution  of  the  board  is  that  it  is  a  permanent  representative 
body.  The  nurses  come  and  go,  identifying  themselves  in  varying  degrees 
with  the  community,  while  the  board  is  selected  from  permanent  resi- 
dents, and  is  the  guaranty  to  the  community  and  nurses  of  the  continu- 
ance and  growth  of  the  service.  The  board  is  therefore  responsible  for 
securing  the  money  to  conduct  the  work,  and  to  do  so  must  be  able  to 
interpret  to  the  community,  in  a  convincing  way,  its  value.  The  board 
appoints  the  nurse  or  superintendent  of  a  staff  of  nurses,  and  to  do  that 
must  know  not  only  what  the  association  is  doing,  and  what  to  expect  of 
the  nurse,  but  what  it  can  look  forward  to  contributing  to  the  community 
welfare.  Further,  the  board,  in  consultation  with  the  nurse,  must  decide 
the  policies  that  govern  the  association.  These  are  serious  responsibil- 
ities to  place  on  untrained  volunteer  citizens,  especially  in  connection  with 
the  maintenance  of  an  organization  which  is  concerned  with  anything 
so  precious  to  the  community  as  its  health.  If  the  board  places  complete 
reliance  upon  a  nurse  who  is  very  capable  and  full  of  initiative,  there  is 
danger  of  its  becoming  perfunctory,  and  blindly  endorsing  her  recommen- 
dations, but  this  is  a  short  view  policy.  Such  superficial  knowledge  of 
the  work  does  not  produce  the  enthusiasm  needed  to  raise  money,  and 
when  a  new  nurse  has  to  be  secured  it  finds  the  board  ignorant  of  the 
necessary  qualifications  for  her  successor.  A  board,  on  the  other  hand, 
which  is  working  closely  with  the  nurse  can  do  much  to  supplement  her 
by  suggesting  new  lines  of  development  to  the  well  trained,  plodding, 
though  unimaginative,  nurse  or  by  holding  back  the  ambitious,  over- 
zealous  and  perhaps  unpractical  nurse.  The  board  which  thus  shares  in 
the  work  has  the  faith  and  enthusiasm  to  win  the  confidence  of  the  com- 
munity, and  from  it  the  support  which  will  enable  the  work  to  expand  and 
meet  new  conditions. 

A  second  contribution  which  the  board  may  make,  and  which  offers 
peculiar  opportunity  for  the  exercise  of  its  knowledge  and  judgment,  is 
in  the  relationship  of  the  association  to  the  community  and  to  other  agen- 
cies in  the  community.  The  nurse  may  be  a  stranger  and  may  need  to 
have  the  interrelationship  and  personnel  of  other  associations  interpreted 
to  her.  The  problems  of  co-operation  and  adjustment  in  a  community  are 
often  difficult  and  trying,  and  may  be  more  easily  solved  by  board  mem- 
bers than  by  professional  workers.  In  such  problems,  the  nurse  needs 
at  least  to  be  fortified  by  the  wisest  thought,  and  sometimes  even  the 
courageous  action  of  the  board. 

A  third  contribution  of  the  board  comes  with  a  knowledge  of  public 
health  nursing  in  its  broader  meaning  and  its  modern  development.  The 
board  stands  before  the  community  as  a  group  which  commands  confi- 
dence. It  must  be  able  to  answer  the  questions:  Are  you  offering  your 
community  an  adequate,  up-to-date  public  health  program?     If  not,  why 


159 
not?  Are  the  children  of  our  community  being  given  the  best  health 
supervision  that  modern  science  has  decreed  practicable?  If  your  reason 
for  not  having  done  so  is  lack  of  money,  is  that  lack  due  to  the  refusal 
of  the  community  to  meet  your  demands,  or  to  your  neglect  to  interpret 
to  the  community  the  meaning  and  value  of  these  newer  developments  in 
public  health  nursing? 

In  these  few  suggestions  lie  some  of  the  contributions  that  are  essen- 
tial for  a  board  to  make  in  a  well  administered  nursing  association.  But 
it  is  impossible  to  separate  the  duties  of  the  board  and  of  the  nurse;  for 
the  success  of  the  privately  administered  nursing  association  rests,  as  it 
did  forty  years  ago,  on  the  sharing  by  the  professional  and  non-profes- 
sional in  the  solution  of  every  problem.  The  board  certainly  cannot  raise 
the  money,  or  interpret  the  work,  so  as  to  secure  the  co-operation  of  the 
community  unless  it  thoroughly  understands  what  the  nurse  is  doing,  and 
what  together  it  may  look  forward  to  developing;  nor  can  the  nurse  plan 
and  conduct  her  work  unless  she  is  assured  of  the  confidence  and  financial 
backing  of  the  board.  Furthermore,  the  nurse  looks  to  her  board  for  a 
fresh,  spontaneous,  diversified  point  of  view  to  offset  her  somewhat 
studied  routine,  standardized  way  of  looking  at  the  work,  and  she  tests 
her  own  plans  and  judgment  on  her  board  and  having  their  approval  gains 
confidence  to  present  them  to  the  public.  But  the  opinion  of  a  board,  no 
matter  how  able  the  individuals  may  be,  is  worth  very  little,  unless  it  is 
based  upon  a  thorough  knowledge  of  the  work  of  its  own  associa- 
tion and  enough  knowledge  of  the  recognized  standards  for  public 
health  nursing  as  a  whole  to  measure  the  value  of  its  own  work.  To  fulfil 
these  responsibilities,  the  board  must  meet  regularly  with  the  nurse,  both 
in  board  and  in  small  committee  meetings.  To  get  the  best  results,  it  is 
essential  that  the  nurse  be  present  at  all  meetings,  to  avoid  any  possibil- 
ity of  misrepresentation.  No  matter  what  subject  is  under  discussion, 
the  professional  nursing  point  of  view  is  bound  to  enter  into  it  at  one 
point  or  another.  Whether  a  discussion  develops  into  praise  or  criticism 
of  the  work,  it  needs  a  professional  explanation ;  whether  it  is  budget  or 
publicity  that  absorbs  the  committee's  attention,  the  nursing  point  of 
view  is  a  necessary  contribution.  Beyond  the  time  given  to  the  local 
work  lies  the  further  obligation  of  the  board  to  read  and  learn  by  personal 
contact  what  other  associations  are  doing,  that  they  may  judge  for  them- 
selves what  is  applicable  to  their  own  needs. 

The  privately  supported  association  has  the  great  advantage  of  being 
free  from  the  public  and  political  limitations  which  are  attached  to  nurs- 
ing work  under  public  control,  and  therefore  owes  to  itself,  to  the  com- 
munity it  serves,  and  to  the  cause  of  progress,  that  it  initiate  new  lines 
of  experimental  work.  Visiting  nursing  itself — and  indeed  every  step  in 
its  phenomenal  growth — prenatal,  school,  tuberculosis,  mental  hygiene, 
to  mention  only  a  few — all  were  started  and  proved  by  privately  supported 
associations,  and  no  one  knows  how  many  more  opportunities  lie  ahead  of 
them. 

The  freedom  to  expand  and  the  flexibility  and  enthusiasm  which  a 
board  of  directors  may  contribute  to  it,  are  the  present  advantages  which 
the  private  associations  have.  A  board  which  administers  its  association 
with  such  ideals  in  mind  has  an  unlimited  opportunity  in  the  development 
of  public  health  nursing. 

EDUCATION  AND  THE  PUBLIC  HEALTH  NURSE 

Ada  Boone  Coffey,  R.N., 

Extension  Secretary,  Public  Health  Nursing 
State  Department  of  Health,  Albany,  N.  Y. 

The  interest  in  adult  education  has  increased  greatly  in  the  last  few 
years.  This  interest  has  been  widespread  and  has  included  all  strata  of 
society  from  the  foreign  born  and  illiterate  native  American  to  the  col- 


160 
lege  graduate.  Classes  for  adults  in  elementary  subjects  are  commonly 
found  in  most  cities,  sometimes  fostered  by  the  public  school  system  and 
other  times  as  a  private  enterprise.  Women's  clubs,  parent-teacher 
associations  and  many  other  agencies  are  contributing  their  leadership 
to  the  advancement  of  organized  study. 

The  great  universities  have  enlarged  their  extension  services  and  are 
offering  courses  which  are  open  to  those  beyond  the  school  age.  These 
courses  cover  a  wide  range  of  subjects  all  the  way  from  home  economics 
to  astronomy.  The  University  of  California  alone  has  13,500  adults  en- 
rolled in  extension  courses. 

The  National  Education  Association  has  recently  published  the  figures 
that  421,000  teachers,  or  45  per  cent  of  the  total  number  employed,  took 
special  courses  last  summer. 

Public  health  nurses  have  been  rather  backward  in  recognizing  the  fact 
that  theirs  is  a  teaching  profession  and  that  a  sound  educational  founda- 
tion and  continued  study  are  essential  to  advancement  in  this  field.  Only  a 
small  per  cent  of  the  public  health  nurses  have  had  special  training  in 
teaching  methods  and  the  large  majority  entered  public  health  nursing 
without  post-graduate  study  and  often-times  without  a  period  of  super- 
vised experience.  Some  of  these  "self-made"  public  health  nurses  have 
shown  real  genius  in  working  out  the  problems  which  confronted  them 
and  deserve  much  credit. 

Public  health  is  a  hybrid  made  up  from  an  admixture  of  many  sciences. 
Medicine,  chemistry,  bacteriology,  sanitation,  sociology,  psychology  and 
pedagogy  all  share  in  the  composition:  Public  health  nursing  as  an  integ- 
ral part  of  public  health  makes  use  of  this  accumulated  scientific  knowl- 
edge and  combines  it  with  the  art  of  nursing.  The  great  demand  for  pub- 
lic health  nurses  following  the  war  is  probably  the  reason  why  so  many 
went  into  this  field  without  adequate  preparation.  Today  the  situation  is 
changing  rapidly  and  official  and  non-official  organizations  are  asking  for 
trained  workers.  New  legislation  is  enacted  every  year  raising  the  edu- 
cational standards  and  requiring  special  training.  A  full  high  school 
course,  good  hospital  training,  post-graduate  study,  and  supervised  staff 
experience  are  the  aims. 

The  public  health  nurse  without  these  qualifications  must  take  stock  of 
her  assets  and  be  on  the  alert  to  find  ways  and  means  of  adding  to  the 
credit  side  of  her  record.  Many  ways  of  doing  this  are  available.  Special 
summer  courses,  institutes,  home  study  and  group  conferences  are  pos- 
sible for  the  majority  if  they  are  carefully  planned. 

Is  there  not  some  way  that  the  acquired  skill  of  the  experienced  but 
untrained  public  health  nurse  and  the  theoretical  knowledge  of  the  trained 
worker  can  be  pooled  to  the  mutual  advantage  of  both? 

The  most  practical  leven  thus  far  applied  to  this  problem  is  some  form 
of  staff  education  and  group  discussion. 

Staff  education  is  a  term  which  has  been  used  to  mean  various  things. 
Oftentimes  it  has  meant  the  regular — or  irregular — conferences  of  the 
nurses  of  one  organization  for  the  purpose  of  discussing  procedures  and 
routines  that  the  work  of  the  whole  group  might  be  systematic  and  run 
smoothly  or  it  has  been  used  to  mean  the  introductory  preparation  of  new 
workers  to  the  field.  Oftentimes  a  series  of  lectures  with  discussion  fol- 
lowing has  been  the  program  of  staff  education.  All  of  these  forms  are 
important  but  are  apt  to  be  more  or  less  passive  in  nature  and  learning 
requires  an  active  effort  on  the  part  of  the  learner.  Lectures  and  casual 
reading  are  not  enough. 

Outlined  study  with  some  measurement  of  the  result  of  study  is  the 
better  method  of  increasing  knowledge.  When  this  newly  acquired  knowl- 
edge can  be  immediately  applied  to  practice  the  chance  of  forgetting  is  de- 
creased. The  sooner  the  application  follows  the  study  the  more  readily  does 
it  become  a  part  of  the  equipment  of  the  learner.  With  each  repeated 
application  it  becomes  more  firmly  fixed  until  that  particular  knowledge  is 
over-learned  to  the  extent  that  forgetting  does  not  readily  occur. 


161 

The  New  York  State  Department  of  Health  in  co-operation  with  the 
Extension  Division  and  Medical  College  of  the  New  York  University 
tried  out  an  experiment  in  state-wide  Staff  Education  last  year.  This 
experiment  was  summarized  in  the  Public  Health  Nurse  magazine  for 
June  1930. 

A  point  of  great  significance  in  this  experiment  was  the  response  of 
public  health  nurses  and  their  interest  in  continued  study.  Most  of  those 
who  completed  the  first  year's  course  enrolled  again  for  further  study. 

The  plan  of  this  Extension  Course  for  Nurses  is  outlined  home  study 
combined  with  conference  discussion.  The  outline  is  divided  into  nine 
sections,  one  section  assigned  for  each  month  of  the  nine  months'  school 
year  from  October  through  June. 

The  enrollment  was  open  until  September  1,  and  the  conference  centers 
were  determined  from  the  residence  of  the  applicants.  Ten  was  set  as 
the  minimum  enrollment  for  a  conference  group. 

After  the  place  of  conference  had  been  determined  a  well  qualified 
public  health  nurse  was  selected  as  the  group  leader.  These  leaders  have 
had  approved  courses  in  public  health  nursing  and  are  holding  executive 
or  supervisory  positions. 

An  institute  for  the  group  leaders  was  held  the  week  of  September  22 
before  classes  started  that  the  conferences  might  be  as  uniform  as  pos- 
sible. Thirty-four  groups  are  meeting  monthly  in  New  York  State  and 
one  in  Worcester,  Massachusetts.  Thirty-one  public  health  nurses  are 
enrolled  in  the  Worcester  class  and  Miss  Mary  P.  Billmeyer,  Department 
Consultant  of  the  Massachusetts  Department  of  Public  Health  is  the 
group  leader. 

The  titles  of  nine  sections  of  this  year's  outline  are  as  follows : 

Month  Section  Subject 

October  I  History  of  Public  Health  and  Public  Health 

Nursing 
Theory  and  Application  of  Vital  Statistics 
Infection  and  Immunity 
Tuberculosis 

Mother  and  Child  Welfare 
The  Young  Child 
The  School  Child 

Adult  Hygiene  and  Health  Hazards 
Team  Work 

The  required  reading  includes  three  booklets  published  by  the  New 
York  State  Department  of  Health: 

1.  Collected  Papers,  containing  a  collection  of  papers  by  leading 
authorities,  either  reprinted  from  other  publications,  or  especially  pre- 
pared for  this  course. 

2.  Outlines  and  Tests,  a  booklet  especially  prepared  as  the  study 
manual  for  the  Extension  Course. 

3.  Handbook  of  Standard  Methods,  published  by  the  Division  of 
Maternity,  Infancy  and  Child  Hygiene. 

Three  textbooks  are  required: 

Public  Health  Nursing  by  Mary  Gardner,  R.N. — Macmillan. 
Public  Health  and  Hygiene  by  Charles  Bolduan,  M.D. — Saunders. 
Mental  Hygiene  and  the  Public  Health  Nurse  by  V.  May  MacDonald, 
R.N. — Lippincott. 
The  Public  Health  Nurse,  the  official  magazine  of  the  National  Organ- 
ization for  Public  Health  Nursing  is  also  required  reading. 

The  test  of  study  for  each  section  is  written  and  brought  to  class.  The 
two  hour  conference  period  is  devoted  to  discussion  of  the  problems  pre- 
sented in  the  required  reading  with  an  effort  made  by  the  group  leader  to 
apply  these  problems  to  the  local  situation. 


November 

II 

December 

III 

January 

IV 

February 

V 

March 

VI 

April 

VII 

May 

VIII 

June 

IX 

162 

Over  800  nurses  are  carrying  the  course  this  year — twice  the  number 
who  carried  it  last  year. 

This  Extension  Course  has  apparently  filled  a  definite  need  as  means  of 
stimulating  public  health  nurses  to  study.  Many  have  expressed  their 
determination  to  take  up  resident  post  graduate  study  because  of  the 
course.  Several  have  been  stimulated  to  complete  their  high  school  work 
so  that  they  can  take  up  post-graduate  courses. 

It  is  the  common  experience  that  once  systematic  study  is  undertaken 
it  creates  an  appetite  for  further  study.  There  are  so  many  new  and 
interesting  facts  to  be  learned  and  so  many  new  methods  of  learning  that 
study  becomes  a  source  of  real  pleasure  as  well  as  one  of  practical  value. 

Has  this  scheme  of  outlined  home  study  and  conference  discussion 
opened  up  a  practical  means  by  which  public  health  nurses  can  acquire 
some  measure  of  theory  along  with  their  daily  work? 

In  New  York  State  we  know  it  has. 

STAFF  EDUCATION 

Elsie  Brehaut,  R.N., 
Superintendent,  Lowell  Visiting  Nurse  Association 

The  request  for  an  educational  program  for  the  nurses  of  the  Lowell 
Visiting  Nurse  Association  came  from  its  Board  of  Managers.  It  was 
their  thought  that  such  a  program  would  keep  the  nurses  informed  of  the 
latest  developments  in  Public  Health  Nursing  as  well  as  provide  an  oppor- 
tunity for  the  expression  of  the  nurses'  ideas  about  their  own  work.  They 
also  thought  that  this  education  would  supplement  the  supervision  pro- 
vided by  the  association. 

Sometimes  the  nurses  feel  the  stress  and  strain  of  putting  such  a  pro- 
gram over  because  we  carry  an  hourly  service  and  a  delivery  service.  We 
must  always  scan  the  group  in  the  morning  to  see  how  many  nurses  were 
out  on  delivery  service  the  night  before  and  we  must  answer  delivery  calls 
while  staff  education  is  in  progress.  Perhaps  the  best  answer  as  to 
whether  the  effort  is  worth  while  or  not  comes  from  the  summary  of  staff 
education  given  by  one  of  our  nurses,  "Staff  education  helps  to  solve  the 
many  problems  arising  in  the  course  of  the  day's  work.  There  is  also  the 
getting  together  through  group  discussion  which  helps  to  acquaint  the 
nurses  with  each  other's  viewpoints.  Staff  education  stimulates  keener 
interest  in  the  nursing  periodicals  which  the  individual  might  never  read. 
Demonstrations  by  individual  nurses  before  the  group  keep  the  nursing 
technique  uniform.  The  reticent  and  timid  nurse  gains  poise.  She  be- 
comes accustomed  to  hearing  her  own  voice  in  public  thus  learning  to 
address  a  group  confidently."  Occasionally  nurses'  comments  are  not  so 
favorable  as  the  above  statement  but  the  concensus  of  opinion  is  in  favor 
of  staff  education. 

The  program  is  planned  by  a  committee  elected  by  the  staff  with  the 
Superintendent  a  member  ex-officio.  This  committee  plans  the  program 
and  assigns  to  each  of  the  nineteen  nurses  her  share  in  it,  giving  due  con- 
sideration to  the  capabilities  of  each  nurse.  The  committee's  general 
basis  for  building  the  program  is  as  follows:  The  American  Journal  of 
Nursing  and  the  Public  Health  Nurse  are  always  reviewed  each  month, 
and  the  Journal  of  Social  Hygiene  occasionally.  An  outside  speaker  is 
secured  each  month,  usually  a  local  person  representing  a  co-operating 
agency  or  a  doctor  who  speaks  to  the  group  on  some  medical  phase  of  our 
work.  In  addition  one  demonstration  of  nursing  procedure  is  given  each 
month.  A  period  of  forty-five  to  fifty  minutes  is  usually  required  for  this 
type  of  education.  Book  reviews,  reports  on  meetings  attended  by  the 
staff  and  reports  of  our  own  work  provide  material  for  the  second  and 
shorter  period  of  staff  education  given  each  week. 

During  the  past  winter  we  were  so  fortunate  as  to  be  invited  to  a 
course  of  lectures  on  syphilis  and  gonorrhea  given  to  the  student  nurses 


163 

of  a  local  hospital.  We  were  also  invited  to  a  meeting  of  the  medical 
association  to  hear  a  lecture  on  obstetrics. 

Each  nurse  is  expected  to  ask  questions  and  state  her  views;  this  pro- 
duces some  difference  of  opinion.  Pertinent  matters  such  as  uniforms 
and  records  are  brought  to  the  group  for  discussion. 

The  Chairman  of  the  Program  Committee  is  responsible  for  the  carry- 
ing out  of  each  program.  This  is  necessary  because  the  Superintendent 
is  responsible  for  assigning  the  daily  work. 

We  are  not  advocating  our  plan  as  an  ideal  one  for  carrying  on  this 
education,  but  the  staff  and  the  Board  of  Managers  agree  that  it  is  the 
only  way  it  can  function  at  present.  The  group  meets  at  8  a.m.  except 
when  we  have  an  outside  speaker  when  it  meets  at  4  p.m.  It  does  not  seem 
practical  to  have  too  many  afternoon  meetings  because  we  have  much 
extra  time  to  make  up  in  afternoons  on  account  of  our  delivery  program 
and  our  rather  heavy  Sunday  service.  We  give  fewer  afternoons  off  on 
staff  education  days  so  that  our  nursing  work  is  cared  for.  We  are  also 
permitted  to  use  our  relief  nurse  on  those  days,  if  it  is  necessary. 

Occasionally  recreation  is  substituted  for  education.  Our  evening 
parties  have  given  us  much  pleasure  through  the  discovery  of  the  hitherto 
unknown  dramatic  talent  of  our  daily  associates. 

GROUP  EDUCATION  IN  SMALL  COMMUNITIES 

Katherine  C.  Taft, 
Oxford,  Mass. 

The  opportunity  for  education  and  help  which  the  Commonwealth  of 
Massachusetts  offers  in  its  Child  Hygiene  program  adds  another  thrill  to 
being  a  resident  of  this  state.  To  the  women  who  came  to  our  town  last 
winter,  in  gratitude  is  this  article  dedicated. 

One  year  and  a  half  ago  it  became  apparent  among  members  of  a  once 
flourishing  Girls  Club  that  a  common  interest  had  appeared,  namely, 
their  homes  and  children.  Diet,  teeth,  discipline  and  physical  defects 
were  problems  confronting  so  many  young  mothers,  but  to  whom  should 
they  turn?  To  the  State  Department  of  Child  Hygiene,  of  course,  for 
had  not  Mrs.  Helen  M.  Hackett  and  Dr.  Susan  M.  Coffin  and  Miss  Esther 
Erickson  conducted  two  Summer  Round-Ups  with  success?  To  this  num- 
ber of  ex-club  members  were  added  all  the  interested  women  throughout 
the  town. 

Ours  was  in  every  way  a  very  normal  group  of  young  women,  some 
with  eagerness  to  learn,  others  reticent.  The  Public  Library  proved  a 
happy  choice  for  a  meeting  place,  with  the  warm,  hospitable  atmosphere 
adding  an  informal  touch  to  our  pleasant  winter  afternoon  lectures. 
From  the  start  we  were  known  as  the  "Child  Hygiene  Study  Group"  with 
no  officers,  no  dues  and  no  by-laws.  There  was  a  leader  responsible  for 
everything,  and  aiding  her  were  ten  of  the  most  enthusiastic  members. 
Advertising,  without  a  doubt,  comes  next  in  importance  to  the  speaker. 
Through  the  three  daily  newspapers,  postal  cards,  telephones  and  personal 
calls,  every  woman  who  had  shown  the  slightest  interest  was  reached  not 
more  than  two  days  before  the  meeting.  Experience  taught  us  that 
notices,  even  a  week  in  advance  were  forgotten  and  our  attendance 
suffered. 

To  Mrs.  Helen  M.  Hackett  goes  all  the  praise  for  our  wonderful  winter, 
in  that  she  planned  the  program  without  a  slip  and  asked  only  an  audi- 
ence in  return.  During  the  six  months,  four  teas  were  given  which  helped 
in  blending  the  new  residents  with  the  native  born  and  drawing  out  the 
more  reserved  personalities. 

Dr.  M.  Luise  Diez,  herself,  came  and  delivered  the  first  lecture  on  "Pre- 
natal Care."  Her  talk  evoked  wide  discussion  and  her  wise  counsel  can 
still  be  heard  this  fall  among  the  prospective  mothers.  Throughout  the 
talks,  the  speakers  followed  Dr.  Diez'  example  in  omitting  "dont's",  arous- 


164 

ing  no  antagonism,  and  leaving  a  clearly  defined  picture  of  herself  and 
her  subject  in  the  minds  of  her  listeners.  Dr.  Diez  laid  the  foundation 
and,  with  perfect  tact,  she  presented  her  difficult  subject.  We  need  many 
more  meetings  with  Dr.  Diez  to  bring  permanently  into  her  fold  the  many 
mothers  in  our  community. 

Dr.  Susan  M.  Coffin,  in  her  understanding  and  sympathetic  manner 
talked  on  the  "Pre-school  Child",  later  answering  the  scores  of  questions 
coming  from  every  side.  Somehow,  because  we  had  known  her  previously 
we  felt  nearer  to  Dr.  Coffin  and  I  feel  sure  many  a  toddler  has  been 
spared  an  unwise  spanking  because  of  her  suggestions  for  a  more 
thoughtful  handling  of  his  misdemeanor.  Perhaps  the  most  enthusiastic 
meeting  was  with  Dr.  Olive  Cooper  on  "Mental  Hygiene  of  the  Pre-School 
Child."  Secrets  fhat  seldom  before  had  seen  the  light  of  day,  such  as 
thumb-sucking,  tantrums,  and  other  bad  habits,  were  allowed  their  free- 
dom that  day  and  have  never  again  been  so  closely  guarded,  for  we  all 
know  now  that  our  child  is  not  the  first  nor  yet  the  only  offender  in  these 
vices. 

Dr.  Fredrika  Moore  on  "School  Hygiene"  and  Mrs.  Eleanor  McCarthy 
on  "Dental  Hygiene"  were  talks  full  of  information  and  interest.  It  is 
nearly  one  year  since  these  women  so  ably  presented  their  facts  and  with 
great  enthusiasm  did  our  dentist  report  "There  has  been  a  marked 
improvement  in  the  mouths  of  all  the  children  coming  to  my  clinic.  But 
especially  pleased  am  I  in  the  number  of  pre-school  children  who  are 
brought  to  my  office  for  examination  and  care  of  the  first  teeth.  I  con- 
sider the  first  grade  have  the  best  and  cleanest  mouths  of  any  entering 
class  I  have  examined."  And  the  dentist  gives  most  of  the  credit  to  our 
state  advisers  for  this  improvement. 

After  hearing  Mrs.  Albertine  McKellar  on  "Child  Health  Day"  and 
Miss  Alma  Porter  on  "Posture,"  Gym-Sets  and  other  playground  equip- 
ment were  made  or  purchased  and  adorned  many  back  yards,  that  our 
children  may  have  as  straight  backs — with  no  "wings" — and  as  much 
fun  as  in  other  communities. 

Our  Public  Health  Nurse  gives  to  Miss  Mildred  Thomas  of  the 
Worcester  County  Extension  Service  and  to  Miss  Esther  Erickson,  who 
spoke  on  "Nutrition"  great  credit  for  the  improvement  in  the  interest 
she  is  finding  in  diets,  baby  formulas,  longer  rest  periods  and  attendance 
at  her  Well  Baby  Clinic.  She  reports  too  that  with  the  deeper  under- 
standing of  the  above  problems  by  mothers,  her  work  is  greatly  facilitated. 

Lastly,  Dr.  Lila  Burbank,  a  doctor,  a  wife  and  a  mother,  made  a  strong 
appeal  to  every  mother  to  care  for  herself  that  she  might  better  care  for 
her  family.  "Annual  Physical  Examinations"  was  her  text  and  splendid 
sound  common  sense  did  she  bring  to  us.  Interviewing  the  local  physi- 
cians, they  could  recall  no  direct  results  from  the  winter's  work  with  but 
one  exception — a  greater  understanding  on  the  part  of  mothers  to  grasp 
the  medical  directions.  However,  another  winter  with  the  state's  help 
through  Mrs.  Hackett,  they  feel  results  will  come  to  their  notice. 

The  librarian  has  added  many  books  and  magazines  to  her  shelves  and 
reports  that  the  increased  demand  for  this  literature  is  most  gratifying. 

I  cannot  refrain  from  adding  another  benefit  derived  and  this  is  in 
adult  mental  hygiene,  though  we  had  no  lecture  on  the  subject.  We  have 
mingled  together  in  this  common  search  for  a  way  to  make  citizens 
mentally  and  physically  better  than  their  parents.  There  has  come  a 
very  good  excuse  for  an  afternoon  to  ourselves.  We  leave  our  kiddies 
with  high  school  girls  or  neighbors,  don  our  better  clothes  and  sit  quietly 
while  a  very  pleasing,  well-dressed,  educated  woman  addresses  us  on  the 
literally  hundreds  of  problems  we  thought  peculiar  to  ourselves,  and 
listening,  find  that  we  are  one  of  thousands  with  the  same  thoughts  and 
fears.  What  a  comfort  and  actual  refuge  in  which  to  study  our  seem- 
ingly increasing  problems  and,  with  conceit  perhaps,  find  that  our  ways 
were  not  entirely  wrong!  During  our  neighborly  discussions  over  the 
fence,  or  a  cup  of  tea,  we  are  thrilled  when  putting  one  of  the  suggested 


165 
methods  to  test.     Our  four  year  old  has  gone  through  the  night  with  a 
dry  bed,  and  we  just  can't  wait  to  hear  about  next  door  Mary's  thumb. 
The  secrets  are  out  for  we  all  have  some  habits  to  make  or  break  in  our 
household,  and  with  these  to  hold  our  attention,  gossip  is  neglected. 

And  now  to  those  who  are  forming  a  group  for  this  wonderful  Child 
Hygiene  Education.  Don't  let  yourselves  be  discouraged  if  the  audience 
dwindles.  At  our  largest  gathering  there  were  forty-six  mothers  and 
grandmothers,  and  during  an  interval  when  whooping  cough  and  measles 
were  with  us,  we  had  but  ten  who  could  attend.  Everywhere  there  are 
people  endowed  with  special  intuition  as  to  just  how  to  bring  up  children 
and  they  soon  leave  for  other  fields.  A  few  found  their  bridge  club  fell 
upon  that  day.  In  making  calls  upon  those  present  at  our  smallest  meet- 
ing I  found  enough  had  been  absorbed  to  well  repay  the  lecturer  for  her 
effort.  These  conditions  arise  where  women  have  paid  well  for  their 
admission — many  of  our  sex  lose  the  power  of  concentration  through  lack 
of  exercise,  but  those  who  remain  loyal  often  sow  quantities  of  seed 
among  their  sisters  long  after  the  lecturer  has  forgotten  the  group. 

Invitations  to  teachers  are  important,  there  is  so  much  for  them  to 
imbibe. 

Before  long  Mrs.  Hackett  is  coming  to  us  again  with  this  winter's  pro- 
gram which  she  promises  will  be  most  interesting.  To  you  who  are  enter- 
ing another  Helpful  Winter  and  to  you  who  have  your  first  treat  to  enjoy 
with  the  Child  Hygiene  Department  of  Public  Health,  our  group  wishes 
all  success. 

POST-GRADUATE  EDUCATION 
Helen  M.  Hackett,  R.N., 

Public  Health  Nursing  Consultant, 
State  Department  of  Public  Health 

At  times  during  the  year  we  usually  plan  for  physical  refreshment.  Is 
it  not  logical  to  assume  that  occasionally  it  becomes  necessary  to  arrange 
for  mental  refreshment,  to  review  our  previous  knowledge  and  to  lay  in 
provisions  for  the  future? 

One  means  of  obtaining  such  mental  refreshment  is  afforded  to  public 
health  nurses  by  the  East  Harlem  Nursing  and  Health  Service  in  New 
York  City.  This  is  a  co-operative  health  unit  of  the  following  organiza- 
tions: The  Henry  Street  Visiting  Nurse  Service,  The  Association  for 
Improving  the  Condition  of  the  Poor,  The  Maternity  Center  Association, 
and  St.  Timothy's  League.  It  is  a  teaching  center  affording  opportunity 
for  field  training  in  community  nursing  service  of  every  type — in  other 
words,  a  generalized  nursing  program — covering  the  entire  family. 

It  was  the  rare  privilege  of  the  writer  to  have  had  a  refresher  course 
under  this  organization  recently.  The  organization  plans  its  program  so 
that  each  student  is  able  to  learn  how  a  program  which  considers  the 
family  as  a  unit  actually  functions  in  the  home,  in  the  clinics,  and  in  the 
classes,  as  well  as  in  individual  conferences.  Their  entire  program  re- 
volves around  the  necessity  of  bringing  to  the  mother  the  need  of  safe- 
guarding her  own  personal  health  and  that  of  her  entire  family.  Every 
nurse  connected  with  East  Harlem  Service  is  in  uniform.  Her  schedule 
is  arranged  by  the  Supervisor  of  Student  Activities  who  introduces  her 
to  a  senior  staff  nurse  who  is  held  responsible  for  the  student  nurse's 
field  training.  Observation  visits  are  arranged  to  acquaint  the  new 
student  with  the  technique  required  by  the  Service.  Under  this  plan  she 
can  observe  antepartum  care  in  the  home,  postpartum  care,  care  of  the 
newborn,  and  child  health  supervision.  She  is  also  instructed  in  the 
management  of  social  problems  in  the  home  as  they  arise.  All  cases  are 
cleared  through  the  Social  Service  Exchange.  Classes  and  clinics  are 
held  daily,  except  Saturday. 


r  166 

Prenatal  Class — Antepartum 

Mothers  are  referred  to  this  class  by  the  Berwind  Clinic  and  the 
Bellevue  Hospital  School  for  Midwives,  as  well  as  those  found  by  the 
nurses  in  their  visits  to  the  home.  The  nurses  are  reaching  mothers  very 
early  in  pregnancy  as  a  rule.  Registration  on  entrance  is  in  charge  of 
one  of  the  mothers. 

Urinalysis  is  made,  blood  pressure  taken,  and  a  personal  conference 
held  with  each  individual,  very  carefully  taking  into  consideration  food, 
exercise,  rest,  etc.  Special  emphasis  is  placed  upon  the  need  for  the 
mother  who  is  having  her  first  baby,  to  begin  her  schedule  early.  Regu- 
larity in  arising,  eating  and  going  to  bed  are  stressed  in  order  that  the 
adjustment  will  not  be  difficult  when  the  baby  arrives. 

Pre-activity  is  planned  so  that  every  mother  attending  the  class  may 
have  an  opportunity  to  help — in  making  pads,  the  preparation  of  sand- 
wiches and  cocoa,  and  similar  activities — the  nurse  explaining  why  as 
they  went  along. 

The  lesson  of  the  day  was  very  carefully  planned  and  yet  was  not  too 
formal.    Following  are  the  subjects  taken  up  during  the  series : 

The  Home — what  constitutes  the  home,  etc. 

Food  for  the  Family 

Growth  and  Development 

Clothes  and  Shoes,  for  the  Mother  Should  be  Attractive  and  Com- 
fortable. 

Clothing  for  the  Baby 

Demonstration  of  Bath 

Preparation  for  Delivery. 

Each  lesson  was  so  arranged  that  it  tied  up  with  the  one  that  had  gone 
before  and  the  one  to  follow  thus  assuring  continuity.  The  mothers 
were  made  to  feel  all  during  the  afternoon  that  it  was  their  class  and 
that  they  had  a  great  deal  to  contribute.  Much  discussion  followed  at 
the  end  of  the  class  and  it  was  obvious  that  the  mothers  had  gained  a 
great  deal  because  of  previous  contact  with  the  Center. 

Reading  is  taken  into  consideration  and  the  librarian  co-operates  by 
putting  into  the  library  books  which  would  be  of  interest  to  the  mothers 
during  pregnancy.  The  mothers  are  urged  to  discuss  what  they  are 
reading,  what  they  are  planning  in  the  way  of  clothing  for  themselves 
and  their,  babies,  and  a  place  is  allotted  so  that  they  may  have  on  display 
some  of  the  clothing  that  they  make.  All  exhibits  are  spotless  and  very 
attractively  arranged. 

At  the  end  of  the  class  refreshments  are  served  by  the  mothers. 

Some  mothers  are  obliged  to  bring  along  their  small  children  and  for 
these  children  a  special  room  is  arranged,  fitted  up  with  small  tables  and 
chairs  and  supplied  with  toys.  This  room  is  in  charge  of  an  aide  who 
has  a  wonderful  insight  into  the  needs  of  children.  She  observes  the 
attitude  of  the  children  toward  each  other,  the  sharing  of  toys,  putting 
away  toys,  feeding  themselves,  and  putting  away  the  dishes.  It  was  inter- 
esting to  observe  the  children  coming  for  the  first  time,  their  difficulty 
in  leaving  their  mothers,  and  how  quickly  they  made  the  adjustment 
under  the  careful  management  of  the  aide.  This  arrangement  gave  the 
mothers  opportunity  to  attend  the  classes  unhampered. 

At  the  end  of  the  class  the  workers  all  meet  for  discussion  of  good  and 
poor  points  in  teaching. 

Cradle  Class 

Children  are  eligible  to  attend  this  class  if  they  are  under  the  care  of 
a  private  physician  or  a  clinic.  They  are  weighed  and  measured,  strip- 
ped; temperature  is  taken,  and  they  are  observed  for  skin  affections, 
pediculosis,  etc.  The  mother  is  taught  to  weigh  the  baby  and  take 
temperature. 

Individual  conferences  are  held  with  the  mother  concerning  food,  and 
its   relation   to   growth   and   development   is   carefully   discussed.     The 


167 

mother  outlines  her  plan  and  the  worker  very  tactfully  and  carefully  sug- 
gests rearrangements  where  indicated. 

Food  and  clothing  exhibits,  very  attractively  arranged,  add  to  the 
interest  of  these  classes. 

Prenatal  Clinic 

At  this  clinic  held  at  the  East  Harlem  Nursing  and  Health  Center 
weekly,  there  is  always  a  physician  in  attendance.  A  complete  physical 
examination  is  made  including  urinalysis  and  blood  pressure,  and  a  con- 
ference is  held  with  the  mother  relative  to  general  health  habits. 

Infant  and  Preschool  Clinics 

The  same  procedure  is  carried  out  here  as  in  the  Cradle  Class,  with 
regard  to  weighing  and  measuring,  taking  of  temperatures,  and  indi- 
vidual conferences  with  the  mothers. 

The  conference  with  the  mother  is  very  carefully  recorded  so  that  when 
the  child  reaches  the  doctor  the  record  gives  him  a  clear  picture  of  home 
conditions. 

After  the  child  is  examined  he  is  vaccinated  and  given  immunization 
against  diphtheria.  Schick  testing  six  months  following  immunization 
is  a  routine  procedure  at  these  clinics.  It  was  interesting  to  note  here, 
too,  that  they  are  reaching  the  children  at  a  very  early  age. 

Preschool  Mothers'  Club 

This  Club  includes  mothers  of  preschool  children  who  meet  once  a  week 
to  discuss  matters  pertaining  to  child  care.  As  in  the  other  groups, 
interesting  exhibits  of  food  and  clothing  are  prepared.  The  same  plan  is 
followed  here  as  in  the  Prenatal  Class. 

Detailed  records  are  kept  both  of  the  classes  and  home  visits  resulting 
from  the  clinics,  and  these  are  frequently  evaluated.  Any  worker  reading 
a  record  at  the  Health  Center  can  get  a  very  clear  idea  of  the  family  situa- 
tion as  a  whole  from  these  records. 

School  102 

Under  a  co-operative  plan  between  the  City  Health  Department  and  the 
East  Harlem  Nursing  and  Health  Center,  one  school  in  the  demonstra- 
tion area  is  selected  for  teaching  purposes — School  102.  The  nurse  is  a 
member  of  the  East  Harlem  Service  staff.  At  this  school  the  mothers  are 
urged  to  come  to  the  school  for  personal  conferences  regarding  their 
children. 

Student  Conferences 

The  students  connected  with  the  Service  have  an  opportunity  to  attend 
staff  meeting  every  other  Thursday,  where  Miss  Anderson,  the  Director 
of  the  Service,  presides.  At  these  meetings  subjects  of  special  interest 
to  all  are  brought  up  for  discussion. 

Every  Monday  student  conferences  are  held.  During  the  writer's  stay 
at  East  Harlem  such  timely  subjects  as  the  following  were  placed  before 
the  students  for  discussion:  nutrition,  budgeting,  tuberculosis,  child 
hygiene  and  mental  hygiene. 

Contacts  were  made  with  students  from  foreign  countries  and  it  was  of 
particular  interest  to  hear  of  their  programs  and  methods  of  procedure. 
In  this  group  were  represented  Syria,  China,  England  and  Armenia,  and 
the  interchange  of  ideas  meant  much  to  the  entire  group. 

Special  Field  Visits 

Much  valuable  information  was  obtained  through  field  visits  to  the 
Maternity  Center,  the  Norwegian  Hospital,  the  National  Organization 
for  Public  Health  Nursing,  the  National  Mental  Hygiene  Association,  the 
American  Nurses  Association  and  the  Mothers  Milk  Bureau. 

A  day  was  spent  at  the  conference  of  the  Child  Study  Association  of 
America,  at  which  the  speakers  were  Dr.  Arnold  Gesell  of  Yale  Univer- 


168 

sity,  Dr.  Mandel  Sherman  of  Washington,  D.  C,  and  Dr.  George  D.  Stod- 
dard of  Iowa. 

Summary 

As  the  family  as  a  unit  is  the  keynote  of  the  entire  program  of  this 
organization,  it  was  stressed  in  every  class,  clinic  and  conference  held 
under  its  direction. 

This  is  decidedly  a  teaching  center  where  all  methods  of  procedure  and 
technique  are  most  efficiently  carried  out.  In  the  classes,  the  clinics  and 
the  home  visits  one  gets  the  reaction  that  the  family  has  received  a  great 
deal  of  benefit  from  this  contact  with  the  Center  and  it  is  stressed  in 
every  teaching  point  that  the  family  should  be  considered  as  a  unit 
always. 

The  writer,  too,  received  a  great  deal  of  benefit  from  this  contact  with 
the  East  Harlem  Health  and  Nursing  Service.  She  considers  its  teaching 
methods  excellent  and  feels  that  while  no  program  can  always  be  taken 
in  toto  for  every  community,  many  of  the  fundamental  principles  taught 
at  the  Service  can  be  applied  to  any  program. 

Visit  to  Mount  Vernon 

Following  the  completion  of  the  above  course  a  field  trip  was  made  to 
Mount  Vernon,  New  York,  to  observe  the  school  nursing  procedure 
carried  on  under  the  Department  of  Public  Instruction  in  its  medical 
division.  With  a  population  of  over  50,000,  there  are  approximately 
10,000  school  children  under  their  supervision.  One  full  time  medical 
director  is  in  charge  of  this  work,  with  three  assistant  physicians,  a 
supervising  nurse  and  seven  assistant  nurses,  two  part  time  dentists  and 
a  dental  hygienist  completing  the  personnel. 

A  great  deal  of  attention  is  paid  to  the  child  entering  industry.  A 
complete  physical  examination  is  made  of  such  children  which  includes 
eye  and  ear  tests  and  dental  examination.  All  defects  found  must  be 
corrected  before  the  child  is  permitted  to  go  to  work. 

The  children  in  all  grades  are  given  a  complete  physical  examination. 
Much  stress  is  laid  upon  the  toxin-antitoxin  program.  A  cardiac  clinic 
is  held  under  the  direction  of  the  board  of  health  to  which  children  are 
referred  from  the  schools.  Intensive  follow-up  work  is  done  in  connection 
with  these  to  see  that  they  are  getting  proper  rest,  etc. 

A  tuberculosis  clinic  is  also  conducted  by  the  health  department  co- 
operating closely  with  the  schools. 

The  Department  of  Public  Instruction  carries  on  an  eyesight  conserva- 
tion clinic. 

In  the  Junior  High  Schools  pupils  showing  any  personality  difficulty 
are  referred  to  a  guidance  teacher.  The  principal  of  the  Junior  High 
School  feels  that  this  service  has  been  of  marked  benefit  to  the  children 
as  well  as  the  school  staff. 

There  are  twenty-one  physical  education  teachers  in  the  Department 
of  Physical  Education  to  whom  children  may  be  referred  for  the  detec- 
tion and  correction  of  postural  defects. 

They  are  working  under  the  platoon  system  and  the  children  them- 
selves are  held  responsible  for  order  in  passing.  This  works  out  very 
well  in  Mount  Vernon.  Their  classrooms  are  splendidly  equipped  as  to 
lighting,  ventilation  and  seating  arrangements. 

Mount  Vernon  has  an  excellent  school  medical  and  nursing  program 
with  an  interested  superintendent  of  schools  who  feels  that  the  health 
of  the  school  child  reacts  upon  the  entire  community.  One  gets  the  im- 
pression that  the  children  coming  under  this  service  are  fortunate  indeed 
because  all  connected  with  the  service  have  the  interest  of  the  individual 
child  foremost  in  mind. 

The  writer  was  impressed  with  the  cordial  relations  existing  between 
all  the  workers  in  this  school  program  and  feels  that  it  would  be  of 
benefit  if  every  nurse  in  this  state  were  able  to  see  this  program  in 


169 

operation.  If  time  and  opportunity  would  permit  any  nurse  to  visit 
Mount  Vernon  to  see  their  school  medical  work  in  action  she  would 
receive  a  cordial  welcome  and  would  be  amply  repaid  for  such  a  visit. 

PARENTAL  EDUCATION  IN  A  PUBLIC  HEALTH  PROGRAM 

Frances  H.  Benjamin, 

Supervisor  of  Health  Education 
East  Harlem  Nursing  and  Health  Service 

Little  has  been  said  about  the  possibilities  for — Parental  Education  in 
a  Public  Health  Program. 

Modern  community  health  programs  plan  to  expend  a  generous  portion 
of  their  budgets  in  carrying  on  a  Prenatal  and  Child  Care  program, 
since  these  safeguard  the  family  and  both  protect  and  make  possible  for 
the  child  a  good  start  during  the  formative  years  when  growth  and 
learning  are  most  rapid  and  significant. 

Since  it  is  possible  to  start  working  with  young  home  makers  when 
they  are  at  the  beginning  of  their  careers  as  parents,  and  because  the 
public  health  worker  can  know  intimately  the  home  into  which  the  baby 
is  to  come,  the  Public  Health  Program  provides  opportunities  for  Par- 
ental Education  which  other  organizations,  as  the  school,  and  even  the 
nursery  school,  cannot  claim. 

What,  then,  are  the  advantages  of  early  contact  with  young  parents  in 
the  home?  First,  it  is  possible  to  learn  what  in  the  family  life  are  posi- 
tive factors  to  build  upon,  and  what  things  will  make  for  difficulty. 
Second,  it  is  possible  to  gain  the  confidence  and  interest  of  these  young 
parents  and  so  help  them  to  view  this  period  as  a  preparation  for  parent- 
hood, emphasizing  understanding  each  other,  a  common  sharing  of 
responsibility  for  the  coming  baby  and  the  reorganization  of  habits  of 
living,  all  of  which  should  make  for  a  happier  personal  adjustment  and 
provide  for  a  more  desirable  environment  for  the  child. 

This  early  contact  with  the  family  may  bring  about  a  desire  on  the 
part  of  the  parents  to  budget  their  ideas,  time,  energy  and  money  and 
so  give  a  new  point  of  view  and  a  workable  family  plan,  whereby  the 
children  may  have  a  better  chance  to  grow  and  develop. 

Parallel  with  the  work  in  the  homes  the  Public  Health  Program  has  at 
its  command  clinics  where  for  both  parents  and  children  it  is  possible  to 
connect  up  the  home  teaching  with  the  necessity  for  a  sound  physical 
basis  for  health.  The  medical  examination  by  the  physician  serves  to 
give  parents  a  standard  for  growth  and  well  being  and  a  means  to  know 
where  help  is  needed. 

Besides  knowing  the  parents  during  the  prenatal  period,  it  is  possible 
to  continue  the  contact  with  the  family  during  the  infant  and  preschool 
years,  thus  observing  the  child  as  he  grows  and  gradually  makes  his 
adjustment  to  his  family,  his  playmates  and  to  the  school.  The  parents 
and  the  public  health  worker  share  in  the  plan  for  the  child's  care  and 
training.  In  this  way  community  resources  are  brought  to  the  attention 
of  the  parents  and  made  use  of,  the  library,  the  schools,  facilities  for  recre- 
ation and  child  guidance  and  the  like.  Public  opinion  is  created  around 
what  the  community  offers  for  the  child's  adjustment. 

Study  groups  for  parents  are  effective  means  for  Parental  Education 
in  a  Public  Health  Program,  particularly  so  since  this  is  the  activity 
which  completes  the  circle,  the  home,  the  clinic  and  the  class  or  group. 
As  an  adjunct  from  the  beginning  of  the  contact  with  the  family  the  class 
or  group  gives  the  expectant  mother  opportunity  for  membership.  This 
experience  in  which  she  may  participate  in  class  discussion  and  activity 
helps  to  give  her  a  basis  for  child  care  and  training  for  this  child  and 
succeeding  children.  Among  other  things,  she  gains  an  understanding 
of  the  function  of  her  own  body  in  relation  to  the  developing  fetus,  she 
builds  up  a  vocabulary  which  frees  her  from  possible  prejudices  and 


170 

which  will  serve  her  well  later  in  dealing  sensibly  and  wisely  with  her 
children.  She  receives  first  hand  information  concerning  the  nourish- 
ment of  her  baby  in  utero,  and  learns  to  tie  this  knowledge  up  with  her 
own  nourishment  at  this  time  and  its  relation  to  the  food  that  she  as  home 
maker  selects  and  prepares  for  her  husband  and  children. 

There  is  opportunity  for  parents  to  continue  group  study  during  the 
infant  and  preschool  years,  thus  helping  them  to  locate  and  deal  with 
their  problems,  think  and  read  for  themselves  and  to  know  where  to  go 
for  help. 

Therefore,  the  Public  Health  Program  offers  unusual  opportunities  for 
Parental  Education  because  it  is  possible  to  reach  parents  early  and  in 
the  home,  thus  giving  them  a  good  start  in  thinking  and  practice,  to  work 
with  them  over  a  period  of  time,  utilizing  the  clinic  and  the  class  or 
group,  and  so  covering  the  most  important  years  of  the  child's  growth  and 
development  and  building  up  an  understanding  approach  to  the  school 
which  will  make  for  desirable  adjustment  there. 

THE  SPECIALIST  VERSUS  THE  GENERALIST 

George  H.  Bigelow,  M.D. 

State  Commissioner  of  Public  Health 

It  is  unfortunate  that  Mr.  Sales'  best  seller  has  introduced  such  a 
sanitary  connotation  to  the  word  "specialist."  But  if  it  causes  us  to 
pause  and  evaluate  what  the  specialist  and  the  generalist  have  to  offer  in 
all  of  the  professional  fields  it  has,  perhaps,  not  been  amiss.  Not  only  in 
the  field  of  curative  medicine,  but  also  in  the  field  of  preventive  medicine 
and,  for  that  matter,  in  almost  all  fields  of  human  endeavor,  there  is  con- 
fusion as  to  precisely  the  proper  use  of  the  generalist  and  the  specialist. 

No  one  will  question  that  in  medicine  and  the  other  professions,  in  the 
sciences,  industry  and  the  arts,  enormous  advances  in  our  knowledge  of 
its  application  have  been  made  which  would  have  been  quite  impossible 
without  high  degrees  of  very  exacting  specialization.  But  as  with  every- 
thing else  that  is  new,  there  is  danger  that  the  field  has  or  will  become 
glutted,  that  the  end  will  become  lost  in  the  intricacy  of  the  means,  that 
the  form  will  be  mistaken  for  the  substance;  in  short,  that  we  will  have 
builded  a  Frankenstein  monster  which  will  consume  us.  Not  a  little  of  the 
popular  dissatisfaction  with  medicine  as  it  is  today  is  due  to  the  layman's 
bewilderment  in  the  presence  of  and  his  improper  utilization  of  the  sur- 
geon, internist,  urologist,  gynecologist,  dermatologist,  orthopedist,  pedia- 
trician, obstetrician,  laryngologist,  otologist,  rhinologist,  ophthalmologist, 
gastro-urologist,  proctologist,  pharyngologist,  cardiologist,  neurologist, 
phychologist,  psychiatrist,  immunologist,  serologist,  pharmacologist, 
physiological-chemist,  pathologist  and  what  you  will!  (They  sound  like 
the  names  of  Pullman  cars  twenty  years  ago  when  there  was  still  romance 
in  travel). 

But  the  confusion  in  other  fields  is  becoming  just  as  bad.  Who  should 
put  the  synthetic  ceiling  in  place?  The  plasterer,  bricklayer,  paper 
hanger,  steamfitter,  mortitian  (or  whoever  applies  mortar  nowadays), 
the  plumber's  assistant,  or  who?  It's  all  right  to  laugh  but  if  you  make 
a  mistake  there  may  be  no  home  fire  burning  in  the  new  house  by 
Christmas!  So  the  health  administrator,  if  he  takes  any  thought  of  the 
morrow,  is  dizzy  as  to  precisely  the  proper  field  of  usefulness  of  the 
epidemiologist,  the  vital  statistician,  the  dentist,  dental  hygienist,  nutri- 
tionist, dietitian,  chef  (where  does  one  end  and  the  other  begin),  health 
educator,  physical  educator,  public  health  social  worker,  psychiatrist, 
psychiatric  social  worker,  occupational  therapist,  vocational  guider,  and 
the  whole  keyboard  of  specialized  public  health  nurses  including  general 
communicable  disease,  tuberculosis,  venereal  disease,  maternal  and  infant, 
preschool  and  school.  We  all  realize  that  each  one  has  something  to  con- 
tribute.   Otherwise  they  would  have  made  no  dent  in  the  sands  of  time, 


171 

but  just  how,  where,  and  when?  I  learned  recently  of  a  plan  to  put  one 
full-time  dentist  in  the  schools  for  every  2,000  otherwise  innocent  school 
children!  But  suffering  budgets,  that's  the  figure  we  use  for  a  school 
nurse  and  we  cannot  get  money  enough  for  them !  But  even  if  it  was  not 
a  question  of  money,  why  a  dentist  instead  of  a  doctor,  a  nutritionist,  a 
physical  educator,  or  even  a  dental  hygienist.  The  heavens  rock  and  the 
stars  fall,  and  if  they  would  only  fall  selectively  it  might  not  be  so  bad. 

It  is  natural  that  the  recoil  from  this  should  be  a  feeling  of  to  perdition 
with  all  specialists,  give  me  only  a  generalist.  But  before  being  lulled 
to  sleep  by  this  analgesic  let  me  make  two  points : 

(1)  It  takes  vastly  more  background,  experience,  training  and  judg- 
ment to  be  a  competent  generalist  than  to  be  a  competent  specialist. 

(2)  It  is  much  easier  to  supervise  adequately  the  work  of  a  specialist 
than  that  of  a  generalist. 

I  could  elaborate  on  these  two  points  ad  nauseam  but  I  think  any  ad- 
ministrator after  a  little  thought  must  agree  to  both.  Thus  because  of 
the  general  mediocrity  of  personnel  available  to  us  today  at  what  we  can 
pay  (or  at  any  price  for  that  matter)  we  will  frequently  have  to  continue 
specialization  when  our  souls  cry  out  for  generalization. 

The  moral  of  this  all,  then,  is  that  in  any  given  set-up  the  allocation  of 
work  between  generalists  and  specialists  must  depend  on  such  variables 
as  the  temper  of  the  community  and  what  it  will  stand,  the  size  of  the 
budget,  the  character  and  density  (both  mental  and  physical)  of  the 
population,  the  job  to  be  done,  and  the  personnel  available.  And  what- 
ever you  do  there  will  be  times  when  you  wish  profoundly  you  had  done 
differently ! 

HOW  THE  NURSE  CAN  CONTRIBUTE  THE  SERVICE 
THE  PUBLIC  EXPECTS* 

Annie  W.  Goodrich,  R.N. 

Dean,  Yale  University  School  of  Nursing 

The  subject  assigned  me  has  recalled  so  vividly  an  episode  in  the  early 
history  of  the  trained  nurse  that  although  repetition  has  worn  it  thread- 
bare, I  am  constrained  to  repeat  it  as  a  brief  summation  of  the  tradition- 
ally required  historical  review. 

Approximately  a  quarter  of  a  century  ago  a  clergyman  came  to  the 
office  of  the  school  of  nursing  of  which  I  was  then  superintendent  seek- 
ing a  nurse  capable  of  developing  a  visiting  nursing  organization  in  his 
town,  presenting  the  required  qualifications  as  follows:  "You  are,  I 
believe,  from  New  England.  You  will  therefore  I  am  sure  understand 
the  type  of  committee  interested  in  forwarding  such  a  project, — culti- 
vated, refined,  conservative,  intellectual  persons.  It  would  be  important 
for  this  young  woman  to  be  a  socially  acceptable  guest,  one  who  could 
attend  their  dinners,  contribute  to  the  conversation  and  secure  their 
interest,  for  upon  her  personality  would  greatly  depend  the  raising  of 
the  required  funds  for  the  undertaking."  The  hospital  facilities  of  the 
town  were  not  great  and  the  dispensary  facilities  almost  lacking.  "It 
would  seem  advisable  therefore  for  her  to  be  familiar  with  minor  surgical 
conditions  so  that  she  could  treat,  before  leaving  in  the  morning,  any 
cases  that  might  come  in  to  her.  Drugs,  as  you  know,  are  expensive.  A 
well-trained  graduate  would  I  suppose  have  sufficient  knowledge  to  per- 
haps put  up  the  less  important  prescriptions  and  prepare  ointments, 
solutions,  etc.  Busy  workers  were  not  only  unable  to  take  time  to  go  to 
the  drugstore,  but  neither  had  they  the  money,  and  it  would  seem  that 
she  might  greatly  decrease  their  expenses  by  this  contribution.  She 
would,  of  course,  be  so  thoroughly  versed  in  her  knowledge  of  medical  and 
surgical  conditions  as  to  easily  secure  the  confidence  of  the  physicians, 

*  Given  before  the  Institute  for  Board  Members  of  the  Directors  of  Visiting  Nursing  Associa- 
tions under  the  auspices  of  the  Henry  Street  Visiting  Nurse  Service. 


172 
so  that  upon  arriving  at  the  house,  should  the  doctor  not  be  able  to  make 
frequent  visits,  or  indeed  should  he  not  be  able  to  come  at  all,  he  could 
depend  upon  her  to  differentiate  between  serious  and  minor  sickness 
conditions  and  save  his  visits  or  lessen  them.  She  should  be  the  type  of 
woman  who  was  not  afraid  to  render  any  needed  service,  but  finding  the 
mother  ill  would  give  the  needed  care,  roll  up  her  sleeves,  bathe  the  baby, 
wash  the  dishes,  scrub  the  floor, — the  hungry,  tired  husband  returning 
to  find  his  house  in  order,  his  sick  wife  looked  after,  the  children  fed  and 
clean,  and  dinner  awaiting  him.  He,  too,  was  a  busy  man.  He  should 
hope  she  would  be  familiar  with  the  ritual  of  the  church,  and  in  case  he 
could  not  reach  the  patient  that  she  could  be  depended  upon  to  minister 
even  to  the  end.  Ah,  yes,  salary."  The  salary  would  indeed  be  moderate, 
but  his  face  brightening,  he  was  sure  to  the  type  of  woman  he  was 
describing  the  salary  would  be  of  small  importance. 

The  required  personality  was  found.  Somewhat  over  a  year  later  he 
sought  a  successor  with  the  encouraging  statement  that  the  appointee 
had  measured  up  in  every  particular  he  thought  but  one.  She  did  not 
seem  to  have  sufficient  endurance.  She  had  broken  down, — yes,  quite  com- 
pletely broken  down,  and  he  would  like  someone  like  her  to  fill  her  place. 

Whatever  changes  have  taken  place  since  this  episode  occurred,  (and 
let  me  add  in  parenthesis  this  is  the  type  of  service  to  a  far  greater 
extent  still  than  is  imagined  that  the  public  pictures  the  nurse  as  render- 
ing) both  qualitatively  and  quantitatively  the  demand  for  nursing  service 
has  increased  rather  than  decreased. 

Quantitatively  we  appear  to  have  reached  the  saturation  point.  I  do 
not  believe  this  to  be  the  case  except  in  its  bearing  upon  one  aspect  of 
nursing  activity,  as  I  will  explain  shortly. 

Qualitatively  we  are  distinctly  failing.  Upon  the  profession  itself  the 
burden  must  necessarily  fall  of  determining  the  means  through  which  the 
nursing  needs  of  the  community  can  most  adequately  (using  the  term  in 
its  fullest  sense)  be  met.  To  the  community,  however,  the  nursing  pro- 
fession must  turn  for  the  means.  This  audience  is  too  fully  informed  as 
to  the  rapid  growth  and  development  of  function  in  the  field  of  nursing 
to  require  or  desire  a  detailed  presentation  of  present  day  demands. 
Rather  is  the  question  before  us,  how  are  the  demands,  ever-increasing 
in  scope  and  number,  to  be  met.  Concretely  speaking,  by  community 
understanding,  organization  and  support. 

Community  Understanding 

For  enlightenment  concerning  any  given  project  the  method  of  proced- 
ure is  now  fairly  well  established.  It  provides  for  a  survey  of  the  field 
within  a  given  and  usually  limited  area,  an  analysis  of  the  findings  in 
relation  to  the  variety,  quantity  and  quality  of  service  rendered  and 
required  and  a  program  based  on  the  findings  through  which  increased 
satisfaction  of  the  public  may  be  predicated. 

Community  Organization 

The  complexity  and  multiplicity  of  health  and  welfare  organizations 
and  institutions  presents  a  confusing  picture  rather  than  an  ordered 
scheme  of  physical  and  social  relief,  and  the  part  of  the  nurse  in  this  maze 
of  humanitarian  activities  is  varied,  demanding  and  wholly  unrelated. 
Again  to  this  audience  a  detailed  enumeration  of  the  various  types  of 
nursing  service  would  be  an  inexcusable  imposition.  Suffice  it  to  say 
there  are  today  between  seventy-five  and  a  hundred,  each  demanding  of 
the  worker,  if  a  rich  interpretation  of  function  is  to  be  ensured,  some- 
thing more  than  the  undergraduate  course  does  or  should  provide. 

The  recommendations  based  on  the  findings  of  the  survey  would  inevit- 
ably provide  for  that  integration  of  nursing  activities  through  which 
alone  can  be  ensured  a  balanced  and  adequate  nursing  service  for  the 
community.  Again  in  concrete  terms  this  implies  a  central  nursing 
council  advisory  to  a  bureau  under  exceedingly  able  and  adequate  direc- 


173 

tion  to  which  could  be  referred  the  arising  nursing  needs  of  all  varieties 
and  through  which  accurate  information  relating  to  supply  and  demand 
could  be  obtained.  This  integration  of  activities  is  entirely  in  accord 
with  the  trend  of  the  times.  Familiar  are  we,  as  has  been  well  expressed 
by  an  English  historian,  with  the  present  day  clash  between  the  increas- 
ing tendency  to  specialization  and  the  integration  of  such  specialization 
from  which,  he  adds,  the  future  has  most  to  gain.  Abundant  illustrations 
from  the  chain  stores  to  the  Institute  of  Human  Relations  bear  witness 
to  this  fact. 

Community  Support 

As  a  believer  in  socialized  education,  I  am  naturally  a  believer  in  social- 
ized medicine  and  nursing,  since  health,  physical,  mental  and  emotional, 
is  as  important  for  effective  citizenship  as  education,  or  indeed  funda- 
mental to  it.  For  the  State  to  assume  the  responsibility  for  one  and  not 
the  other  seems  inconsistent.  "To  cure  the  body  and  to  save  the  soul" 
is  the  legend  inscribed  on  the  seal  of  St.  Lukes,  a  well-known  hospital. 
"To  cure  the  body  and  to  save  the  State"  might  well  be  a  governmental 
inscription.  Pending  the  assuming  of  health  and  sickness  responsibility 
by  the  State,  and  contributary  to  it,  would  be  the  voluntary  coming  to- 
gether of  those  citizens  best  fitted  through  knowledge  and  function  to 
develop  a  program  whereby,  through  an  integrated  service,  a  community's 
needs  can  increasingly,  efficiently  and  at  the  least  possible  cost,  be  met. 

The  responsibility  of  the  community  in  relation  to  its  nursing  service 
strikes  deeper  than  the  selection  of  personnel,  raising  of  budget,  deter- 
mination of  function  for  any  given  project.  I  should  like  to  add  to  the 
story  with  which  I  opened  my  remarks  that  the  nurse  who  so  ably  meas- 
ured up  to  the  requirements  as  outlined  was  not  the  young  woman  of 
limited  environment  inured  to  hardships  and  forced  by  circumstance  to 
the  performance  of  humble  tasks.  Cultured,  charming,  orthodox,  she  has 
moved  from  one  important  post  to  another,  has  written  a  book  on  nurs- 
ing, and  is  now  holding  a  position  of  uniquqe  and  great  distinction. 

However  inconspicuous  a  part  the  nurse  may  take  in  any  given  health 
project,  almost  without  exception  it  is  a  part  of  fundamental  importance. 
If  a  survey  with  a  resulting  plan  for  the  integration  of  the  nursing 
service  of  a  given  community  is  demanded  in  order  that  the  arising  needs 
can  be  effectively  met,  it  is  not  less  important  that  similar  consideration 
should  be  given  to  the  subject  of  nursing  education.  I  stated  that  we  had 
come  to  the  saturation  point  quantitatively  speaking,  now  may  I  add  only 
in  so  far  as  private  duty  is  concerned  and  mainly  in  large  cities,  but  the 
situation  in  such  localities  is  of  a  most  serious  nature.  Not  tens  but  in 
some  places  hundreds  of  women  are  barely  able  or  even  unable  to  earn 
their  daily  bread,  while  the  call  on  the  other  hand  by  institutions  and 
organizations  for  qualified  women  cannot  be  met. 

One  of  the  oft  repeated  assertions  of  the  women  who  brought  the  first 
school  of  nursing  into  existence  was  the  importance  of  the  selection  of 
students  on  the  basis  of  ability,  maturity  and  culture. 

Within  half  a  century  there  has  been  an  immense  change  in  the  educa- 
tional program  of  the  women  of  all  classes.  I  refer  to  the  great  increase 
in  the  women  graduating  from  high  school  and  college.  Of  no  less 
importance  is  the  change  in  the  subject  matter.  College  after  college, 
year  after  year,  is  increasingly  including  and  expanding  the  science 
courses.  If  parents  who  are  giving  their  children  the  benefit  of  higher 
education  are  unwilling  to  have  them  turn  to  the  field  of  nursing,  the 
reasons  for  such  unwillingness  should  be  sought  and  changes  made  which 
would  make  a  field  pre-eminently  a  woman's  and  of  such  creative  im- 
portance, one  which  they  would  eagerly  seek  as  a  life  expression  for  their 
daughters. 

Not  less  important  is  the  rapid  immediate  relating  of  nursing  educa- 
tion to  the  educational  system  which  will  ensure  to  every  student  in  the 
field  a  professional  preparation  which  will  enable  her  to  function  effec- 


174 
tively  in  her  chosen  branch  and  to  co-operate  with  the  ever-increasing 
group  of  social  and  health  workers. 

As  we  turn  the  pages  of  the  history  of  nursing  and  nursing  education, 
we  cannot  but  be  impressed  with  the  important  part  that  women  played  in 
bringing  into  existence  this  now  great  army  of  health  workers.  As  the 
women  of  the  past  conceived  and  carried  out  this  reformation  (for  so  may 
be  termed  the  change  in  the  nursing  care  of  the  sick  whether  in  the  hospi- 
tal, dispensary  or  through  extra-mural  branches)  surely  even  greater  re- 
sults will  be  achieved  by  the  women  of  today  through  the  new  freedom 
with  all  it  implies,  scientific  knowledge  broadening  the  vision,  enriching 
the  imagination,  deepening  the  sense  of  social  responsibility,  through  an 
ever-increasing  understanding  of  the  possibilities  of  change.  It  does  not 
seem  possible  that  the  contribution  of  the  descendants  of  women,  who, 
though  handicapped  by  the  restrictions  of  the  Victorian  era  worked  such 
marvels,  should  not  be  equally  great. 

I  vision  a  similar  influence  upon  the  institutions  and  conditions  which 
are  the  disgrace  of  our  civilization  today.  "Democracy,"  says  Dean  Inge, 
"disintegrates  society  into  individuals  and  only  collects  them  again  into 
mobs."  "Democracy,"  says  Pasteur,  "is  that  order  in  the  State  which 
permits  each  individual  to  put  forth  his  utmost  effort."  Interpret 
democracy  in  the  terms  of  whomsoever's  philosophy  of  the  good  life  you 
will,  but  let  us  remember  we  are  only  in  the  process  of  creating  demo- 
cracy, not  of  experiencing  it. 

Present  day  science,  which  is  the  best  light  we  have  bearing  upon  nature 
in  general  and  human  nature  in  particular,  is  increasingly  insistent, 
whether  speaking  as  a  behaviorist,  a  psychologist,  an  educator  or  a  phil- 
osopher, upon  the  influence  of  environment  upon  individuality  not  as  a 
gift  but  as  an  achievement  created,  I  am  quoting,  "under  the  influence  of 
the  associated  life." 

The  most  superficial  knowledge  of  the  relationship  of  the  nurse  to 
human  growth  and  development,  to  say  nothing  of  her  contribution  to  the 
field  of  remedial  or  curative  medicine,  a  service  through  which  incident- 
ally her  wider  services  have  arisen,  presents  her  as  a  strategic  factor  in 
a  social  order  designed  to  aid  the  individual  in  functioning  to  his  highest 
capacity. 

We  have  a  long  way  to  travel  before  a  satisfying,  even  endurable,  life 
can  be  assured  future  generations.  The  saving  grace  of  the  past,  present 
and  future  struggle  is  a  reasonable  hope  that  the  efforts  of  each  succeed- 
ing generation  are  of  some  avail.  Fortunately  it  is  a  reasonable  hope. 
Whatever  may  be  the  forces  involved,  change  of  heart,  economic  per- 
spicacity, higher  levels  of  mass  intelligence,  social  changes  of  profound 
significance  are  taking  place,  steadily,  unremittingly  and  throughout  the 
world. 

Whether  it  be  the  experimental  health  center  in  China,  socialized  medi- 
cine in  Russia,  a  maternity  project  in  the  Kentucky  mountains  or  the 
White  House  Conference  on  Child  Care  and  Protection  in  Washington, 
seeds  have  not  only  been  sown,  but  have  taken  root  that  presage  the  social 
order  dreamed  of  through  the  ages,  a  social  order  made  possible  through 
that  greatest  of  gifts  to  groping,  bewildered,  complex  humanity,  the  pene- 
trating, revealing,  directing  and  inspiring  light  we  choose  to  designate  as 
Science.  No  worker  needs  that  torch  more  than  the  nurse,  that  miner 
as  it  were  digging  through  the  long  hours  for  coal  and  often,  often 
finding  diamonds. 

To  such  members  of  society  as  are  here  assembled,  the  nursing  pro- 
fession must  turn  for  a  concerted  and  persistent  demand  that  even  as  the 
extra-mural  nursing  activities  are  staffed  with  graduate  nurses  with 
only  such  number  of  students  enrolled  as  can  be  assimilated  so  must  the 
hospitals  be  staffed  throughout  their  various  departments,  opening  the 
clinical  experience  to  students  in  such  numbers  only  and  of  such  educa- 
tional qualifications  as  a  study  of  community  needs  and  resources  indi- 
cates as  required  and  advisable.     Further  there  should  be  demanded  an 


175 
educational  content  based  on  the  needs  of  the  community,  with  hours  of 
study  and  practice  that  accord  with  those  of  other  professional  schools, 
and  that  the  leisure  and  diversion  be  assured  for  both  graduate  staff  and 
students  through  which  alone  effort  and  interest  in  the  life  activity  will 
be  sustained.  Under  such  circumstances,  and  only  such,  will  the  nurs- 
ing profession  be  equipped,  mentally,  physically  and  emotionally,  to  meet 
the  community  needs. 

Scientific  discoveries  have  created  a  new  universe,  through  transporta- 
tion from  the  covered  wagon  to  the  aeroplane;  through  communication 
from  the  written  word  to  the  radio;  through  new  interpretations  of  the 
old  sciences  and  the  development  of  new  sciences  bearing  upon  nature 
and  human  nature,  from  the  change  in  flower,  plant  and  animal,  to  the 
discovery  of  the  latent  powers  of  man  and  the  latent  powers  of  woman. 
What  of  all  this  should  the  nurse  be  required  to  study?  Herself,  the 
community  and  her  subject.     Age  old  philosophy  with  new  implications. 

THE  RELATIONSHIP  OF  THE  NURSE  TO  THE 
HEALTH  OFFICER  GROUP 

Francis  P.  Denny,  M.D. 

Health  Officer,  Brookline,  Mass. 

It  is  very  difficult  to  discuss  the  relationship  of  the  public  health  nurse 
to  any  other  group  without  qualifying  almost  every  statement  that  is 
made  because  there  are  so  many  different  kinds  of  public  health  nurses 
and  they  are  organized  so  differently  in  different  places.  The  particular 
type  of  public  health  nurse  with  which  we  are  familiar  is  apt  to  come  to 
our  minds  in  discussing  the  subject.  We  are  much  in  the  same  situation 
as  the  blind  men  who  were  asked  to  describe  the  elephant.  Each  des- 
cribed him  by  the  particular  part  he  happened  to  touch.  One  felt  of  his 
sides  and  said  he  was  like  a  wall,  another  his  leg  and  said  he  was  like  a 
tree,  another  his  tail  and  said  he  was  like  a  rope,  etc.,  etc. 

I  have  a  suspicion  that  it  was  intended  that  I  should  discuss  the  rela- 
tionship of  the  nurse  that  is  employed  by  a  visiting  nurse  association — 
that  is  a  private  agency — to  the  health  officer,  but  it  is  so  important  that 
all  the  nurses  of  a  community,  whether  working  for  the  private  agency 
or  the  municipality,  should  be  considered  as  one  group,  all  working  for 
the  health  of  that  community,  that  it  seems  undesirable  to  discriminate 
and  therefore  most  of  what  I  shall  have  to  say  will  apply  to  all  kinds  of 
public  health  nurses,  regardless  of  their  affiliations. 

We  see  the  ideal  relationship  in  the  small  community  where  one  nurse 
only  is  required  to  do  all  the  work.  There,  usually  part  of  her  salary  is 
paid  by  the  Board  of  Health  and  part  by  the  local  Visiting  Nursing 
Association.  The  partof  the  nurse  that  is  working  for  the  town  will  not 
quarrel  with  the  part  of  her  that  is  working  for  the  Visiting  Nursing 
Association.  There  is  perfect  co-operation.  This  situation  of  the  single 
nurse  in  the  small  town  working  for  her  community  is  the  ideal  for  which 
we  should  all  strive.  We  may  have  one  group  of  nurses  working  for  the 
Visiting  Nursing  Association,  another  for  the  Board  of  Health,  another 
for  the  school  department,  but  if  each  nurse  feels  herself  part  of  the 
larger  group  working  for  the  whole  community,  then  the  problem  of  the 
relationship  of  the  different  groups  to  each  other  and  to  the  health  depart- 
ment is  solved. 

There  has  been  a  great  improvement  during  the  past  ten  years  in  the 
relationship  of  the  private  agencies  and  the  Board  of  Health.  The  health 
officer  now  takes  pride  in  the  health  work  of  the  private  agencies  and 
considers  it  part  of  the  health  assets  of  his  community.  In  the  Boston 
Health  Centers  we  have  excellent  examples  of  the  co-operation  which 
now  exists. 

It  is  very  important  where  there  are  two  or  more  groups  of  nurses 
that  they  should  meet  together  frequently  to  talk  over  their  problems  and 


176 
in  this  way  become  familiar  with  each  other's  work.  Every  nurse  needs 
to  feel,  when  she  visits  a  home,  that  her  responsibility  does  not  end  when 
she  has  performed  the  special  service  for  which  she  visited  that  home. 
It  is  her  job  to  discover  the  special  health  needs  of  that  particular  house- 
hold and  see  that  they  are  taken  care  of. 

There  are,  of  course,  many  very  obvious  ways  in  which  she  can  help  the 
health  department.  When  she  discovers  children  with  rashes  or  suspic- 
ious throats,  she  will  try  to  have  a  physician  call,  or  failing  in  this,  notify 
the  health  department. 

Every  nurse  should  feel  that  she  has  a  very  definite  responsibility  in 
regard  to  tuberculosis.  Tuberculosis  is  still  one  of  our  most  serious 
problems.  It  is  shocking  how  far  advanced  the  disease  usually  is  before 
it  is  recognized.  We  have  come  to  realize  how  essential  the  X-Ray  is  for 
early  diagnosis  and  how  little  reliance  is  to  be  placed  on  the  examination 
of  the  ordinary  physician.  Even  the  expert — the  specialist — occasionally 
slips  up  on  the  diagnosis  because  he  relies  too  much  on  his  stethescope 
and,  neglecting  a  perfectly  typical  history,  fails  to  get  an  X-Ray. 

The  nurse  should  always  have  tuberculosis  in  the  back  of  her  mind  and 
be  on  the  watch  for  persons  with  a  persistent  cough,  constant  fatigue,  loss 
of  appetite  and  weight,  who  have  spit  blood  at  any  time,  or  who  have 
had  pleurisy.  When  a  nurse  discovers  an  individual  with  any  of  these 
suspicious  symptoms,  I  believe  she  should  disregard  the  general  rule  of 
referring  a  patient  to  his  own  physician  and  should  endeaver  to  steer  him 
to  some  tuberculosis  clinic  if  such  is  available.  There  is  so  much  at 
stake !  It  is  often  a  matter  of  life  and  death.  The  family  physician  may 
take  months  of  precious  time  to  make  the  diagnosis.  If  the  patient  has 
not  tuberculosis  the  clinic  will  not  continue  to  treat  him,  so  the  doctor 
loses  nothing  of  his  practice  unless  the  patient  has  tuberculosis  and  if  he 
has,  then  the  doctor  ought  to  lose  him  because  he  ought  to  go  to  a 
sanatorium. 

The  Nurse  As  a  Health  Teacher 

Every  health  officer  is  conscious  of  the  fact  that  he  often  fails  to  get 
satisfactory  results  from  his  health  measures  because  of  the  ignorance  of 
those  whose  health  he  is  trying  to  improve.  Preventive  medicine  is,  so  to 
speak,  marking  time,  waiting  for  health  education  to  make  possible  the 
application  of  the  advances  in  science  which  have  been  made.  Health  edu- 
cation is  a  very  large  and  important  field  where  I  am  sure  much  more 
can  be  done  by  the  nurse  than  is  now  the  case. 

Health  teaching  is  the  function  of  every  public  health  nurse  of  what- 
ever type.  The  nurse  who  is  efficient  as  a  teacher  renders  in  this  way  a 
service  worth  her  whole  salary  irrespective  of  the  special  object  of  her 
visits. 

Nurses  vary  very  much  in  their  ability  as  health  teachers,  and  they 
may  at  times  loose  sight  of  this  important  part  of  their  work.  It  should, 
perhaps,  be  given  more  attention  in  their  training  and  should  be  more 
frequently  emphasized  by  their  supervisors. 

Of  course,  the  nurse  will  try  to  correct  the  very  obvious  errors  of 
personal  hygiene  which  she  sees — the  child  who  is  eating  some  improper 
food,  the  baby  reeking  with  perspiration,  wrapped  up  with  excessive 
clothing  and  close  to  the  kitchen  stove,  the  children  swapping  their  lolly- 
pops  and  coughing  and  sneezing  in  each  other's  faces. 

In  addition  to  calling  attention  to  hygienic  errors  just  at  the  time  that 
they  are  being  committed,  I  feel  that  the  nurses  in  a  community  should 
always  be  carrying  on  some  definite  plan  for  health  education.  There 
should  always  be  a  few  important  principles  or  health  lessons  which  all 
the  nurses  are  trying  to  put  across. 

The  word  which  best  describes  this  form  of  activity  is  propaganda. 
This  word  has  come  to  have  a  somewhat  sinister  suggestion  because  it 
has  been  used  for  improper  purposes,  but  its  meaning,  according  to  the 
dictionary,  is  "a  careful  plan  to  spread  certain  particular  principles,"  and 


177 
that  is  just  what  we  need  to  develop — a  carefully  worked  out  plan  for 
teaching  certain  important  health  lessons  or  principles. 

Propaganda  may  be  carried  on  in  such  a  way  that  the  persons  to  be 
influenced  are  not  aware  of  the  fact  that  an  effort  is  being  made  to 
change  their  ideas  or  habits,  and  this  is  an  important  feature.  The 
particular  type  of  person  we  most  need  to  reach  is  the  one  who  will  make 
no  effort  to  acquire  health  knowledge, — the  mother,  for  example,  who  will 
not  go  to  any  mothers'  classes  or  clubs,  will  sureiy  resent  any  too  obvious 
effort  to  instruct  her  in  health  matters. 

What  is  needed  with  such  a  person  is  an  apparently  casual  suggestion 
which  will  be  followed  up  by  similar  suggestions  at  later  visits  either  by 
the  same  nurse  or  by  another  of  the  same  group.  There  is  an  old  Latin 
proverb — "Repetitio  Mater  studiorum  est." — Repetition  is  the  mother 
of  learning.  It  is  only  by  repetition  of  our  health  lessons  that  we  can 
accomplish  anything  in  changing  people's  habits.  At  the  present  time 
the  health  teaching  of  our  public  health  nurses  is  too  desultory,  it  is 
spread  too  thin,  we  are  not  getting  enough  repetition.  To  get  this  the 
nurse's  teaching  must  be  deliberately  planned  and  all  the  nurses  must  be 
teaching  the  same  thing  at  the  same  time. 

The  first  thing  to  do  is  to  decide  on  what  special  phases  of  health  work 
to  concentrate.  There  probably  should  not  be  more  than  three  or  four 
different  lines  of  health  propaganda  to  be  carried  on  at  any  one  time  and 
these  might  be  changed  from  time  to  time.  These  could  best  be  decided 
on  by  the  whole  nursing  group  in  conference  with  the  health  officer  and 
others  familiar  with  conditions  in  that  community  and  would  vary  in 
different  places. 

At  the  present  time  it  would  be  wise  almost  everywhere  to  work  at 
diphtheria  immunization.  If  this  were  to  be  done,  I  would  suggest  some 
such  procedure  as  this:  Each  and  every  nurse  on  her  visits  should 
inquire  whether  all  the  children  have  been  protected.  If  they  have  been, 
a  word  of  commendation  is  in  order.  If  they  have  not  been,  and  there  is 
a  marked  attitude  of  hostility,  it  is  probably  best  at  first  not  to  say  much 
more  than  enough  to  show  that  the  nurse  and  the  organization  she  repre- 
sents think  favorably  of  it.  Above  all,  the  nurse  should  not  start  an 
argument  and  force  the  parent  to  take  a  position  she  will  continue  to 
try  to  defend.  At  the  next  visit  tell  how  many  children  have  been  treated 
at  the  school  her  children  attend  or  at  the  nearby  health  center.  Most 
people  hate  to  be  with  the  minority.  They  follow  like  sheep  what  most 
of  the  flock  are  doing.  At  a  subsequent  visit,  if  still  resistant,  it  is  well 
to  speak  of  some  definite  case  of  diphtheria,  preferably  in  the  neighbor- 
hood, and  some  family  that  the  mother  knows  about,  where  the  parents 
had  been  meaning  to  protect  the  child  but  had  neglected  to  do  so  and  now 
are  full  of  regrets.  It  is. very  uncomfortable  for  us  parents  to  think  how 
we  are  going  to  feel  if  our  child  gets  a  serious  disease  which  we  might 
have  prevented. 

A  carefully  planned  procedure  like  this  just  outlined  gradually  over- 
comes what  is  called  in  the  commercial  world  "the  sales  resistance"  and 
you  finally  sell  your  proposition.  The  important  thing  is  not  to  fire  all 
your  guns  at  once  but  by  subtle  repetition  and  by  different  methods  of 
approach  to  gradually  get  the  lesson  across.  With  all  the  nurses  in  the 
community,  working  at  the  same  time  for  the  same  object,  I  am  convinced 
that  an  astonishing  amount  could  be  accomplished. 

It  might  be  well  in  some  communities  during  the  winter  to  concentrate 
on  the  prevention  of  rickets — sunshine  and  cod  liver  oil — instead  of  leav- 
ing it  all  to  the  infant  welfare  nurses. 

As  broncho-pneumonia  is  now  our  most  serious  preventable  disease  of 
early  life,  since  gastro-enteritis  has  become  so  rare,  it  would  seem  that 
there  is  an  important  field. 

The  yearly  health  examination  and  the  early  recognition  of  cancer,  the 
dangers  of  overweight,  are  subjects  which  might  very  properly  be  taken 
up  in  an  intensive  educational  campaign. 


178 

I  should  like  to  carry  out  this  idea  of  organized  health  propaganda  one 
step  further  and  especially  to  get  Dr.  Bigelow's  reaction  to  it. 

Why  should  not  this  be  carried  out  on  a  larger  scale  than  in  just  one 
community.  Why,  for  example,  should  it  not  be  tried  on  a  state-wide 
scale. 

Let  us  suppose  that  all  the  public  health  nurses  in  the  state  should 
agree  to  talk  to  their  families  about  the  early  signs  of  cancer,  taking,  for 
that  purpose,  perhaps,  the  time  while  they  are  washing  and  drying  their 
hands.  Such  a  campaign  as  this  should  not  be  done  quietly  but  with 
some  publicity.  At  the  outset  the  nurses  could  tell  their  families  their 
reason  for  bringing  up  the  subject.  There  were  so  many  people  dying 
unnecessarily  from  cancer  because  they  did  not  consult  a  doctor  soon 
enough,  that  all  the  nurses  in  the  state  had  decided  to  make  sure  that 
their  patients  knew  the  early  symptoms  of  cancer  and  so  none  need  die 
unnecessarily.  Breast  and  uterine  cancer  would  naturally  be  stressed 
with  the  women  but  it  would  be  well  for  a  woman  to  know  that  if  her 
old  man  who  works  all  day  with  a  pipe  in  his  mouth  gets  a  sore  lip  or 
tongue,  he  should  see  a  doctor  right  away. 

Very  soon  after  such  a  campaign  was  started  the  nurses  would  begin  to 
get  this  reaction:  "Oh  yes,  the  other  nurse  who  was  here  spoke  to  me 
about  that."  Here  you  are  getting  the  needed  repetition.  A  few  ques- 
tions asked  in  a  casual  way  would  show  when  the  lesson  was  really 
learned. 

There  is  a  splendid  campaign  of  education  for  the  early  recognition 
of  cancer  going  on  now  in  this  state  under  Dr.  Bigelow's  leadership  but 
if  all  the  public  health  nurses  would  take  hold  of  this  problem,  supple- 
menting what  is  now  being  done,  I  believe  much  more  would  be  accom- 
plished. 

The  public  health  nurse  has  the  best  entrance  of  any  outsider  into 
most  homes.  She  is  the  only  person  of  education  and  refinement  who 
enters  some  of  them.  She  comes  for  a  purpose  which  the  people  can 
understand  and  appreciate.  I  doubt  if  the  nurses  themselves  realize  what 
an  event  their  visits  are  and  how  much  of  an  influence  they  exert. 

What  is  most  needed  now  is  to  capitalize  this  unusual  relationship  for 
the  purpose  of  health  education  even  more  than  has  been  done  in  the 
past.  There  would  seem  to  be  great  possibilities  of  increasing  the  effec- 
tiveness of  this  feature  of  the  nurses'  work  by  more  careful  planning 
and  by  having  a  whole  group  of  nurses  working  to  put  across  a  few 
important  health  principles. 

PHYSICIANS'  REPORT  ON  NURSING  SUPPLY 

On  a  typical  day  in  a  period  of  heavy  sickness  load,  only  two  per  cent 
of  those  patients  who  needed  a  special  or  private  duty  nurse  were 
unable  to  get  one,  it  was  shown  by  the  answers  of  4,000  physicians  to 
questionnaires  on  the  demand  for  nurses  in  their  own  practice. 

This  case  check-up  by  the  physicians  substantially  agrees  with  the 
growing  evidence  from  other  sources,  such  as  the  registries,  that  there 
is  at  present  no  shortage  in  the  general  supply  of  nurses,  and  that  it  is, 
indeed,  closely  approaching  the  saturation  point,  as  far  as  actual,  econ- 
omic demand  is  concerned.  These  studies  of  the  nursing  situation  were 
made  by  the  Committee  on  the  Grading  of  Nursing  Schools. 

Informal  comments  from  the  doctors  corroborated  statistical  findings 
that,  while  it  is  sometimes  hard  to  get  a  nurse  for  Sundays,  out-of-town 
cases,  or  twenty-four  hour  duty,  it  is  almost  never  impossible  to  find 
any  special  nurses  at  all. 

The  physicians  questioned  represent  those  who  minister  to  the  most 
heavily  nursed  portions  of  the  community,  in  cities  and  towns  of  all  sizes. 
The  months  studied  were  January  and  March,  two  peak  months  of  illness. 
It  was  found  that,  on  the  day  of  his  answer,  the  typical  physician  had 
three  patients  who  needed  special  nurses  and  two  who  got  them.    But  of 


179 
all  the  patients  who  in  the  estimation  of  the  attending  doctor,  needed  a 
nurse,  only  two  in  each  100  were  unable  to  find  one. 

Of  the  patients  who  did  not  have  the  special  nurse  recommended  as 
necessary,  it  was  found  that: 

45%  could  not  afford  a  nurse 
29%  were  cared  for  by  relatives  or  friends 
13%  did  not  want  a  nurse 
7%  were  cared  for  by  a  visiting  nurse 

Only  6%  of  these  patients,  or  2%  of  the  total  number,  wanted  a  nurse 
but  could  not  find  one. 

These  findings  are  especially  interesting  from  the  standpoint  of  actual 
economic  demand  and  willingness  to  pay  for  nursing  service  on  the  part  of 
patients.  More  than  500  patients,  for  example,  did  not  want  a  nurse  and 
did  not  engage  one,  though,  in  the  opinions  of  their  physicians,  they 
needed  her  skilled  nursing  care. 

In  the  period  of  a  month,  the  typical  physicians  in  this  group  had  five 
patients  who  employed  nurses.  They  estimated  that,  given  adequate  floor 
service  in  the  hospital,  two  of  the  five  would  not  have  needed  "specials." 
Twenty-six  per  cent  of  the  physicians  felt  that  some  of  their  patients 
could  have  been  cared  for  by  a  visiting  nurse  or  hourly  service,  and  27 
per  cent  felt  the  services  of  relatives  or  competent  servants  would  have 
been  adequate. 

Since  the  physicians  reporting  were  a  selected  group,  caring  for  the 
most  heavily  nursed  members  of  the  community,  it  would  seem,  from 
the  foregoing  facts,  that  for  the  profession  as  a  whole  the  daily  average 
of  patients  per  physician  actually  needing  skilled  nursing  care  is  much 
less  than  three. 

Half  the  physicians  in  this  heavily  nursed  group  declared  that  every 
one  of  their  patients  who  needed  private  duty  nurses  had  thern.  There 
is,  therefore,  reason  to  believe,  the  study  states,  that  the  lack  of  a  nurse 
is  often  due  not  to  a  shortage,  either  in  the  general  or  local  supply,  but  to 
the  patient's  decision  that  he  did  not  want  or  could  not  afford  a  nurse. 

Since,  in  the  opinion  of  the  doctors,  two  of  every  five  patients  employ- 
ing special  nurses  could  have  been  cared  for  by  the  floor  service  of  a 
well-run  hospital,  the  increase  of  adequacy  of  such  floor  service  would 
mean  a  decrease  in  the  employment  of  "specials"  and  additional  employ- 
ment of  full-time  graduates  in  the  hospitals  instead. 

Many  hospitals  are  already  studying  the  problem  of  increasing  the 
supply  of  graduate  nurses  on  their  staff  so  as  to  lessen  the  cost  of  nurs- 
ing care  for  the  patient  and  yet  add  little  additional  expense  to  the 
hospital's  budget. 

Seventy-three  per  cent,  or  almost  three-fourths,  of  the  physicians  said 
they  feel  it  is  harder  for  their  patients  to  pay  the  nurse's  fee  than  to 
obtain  her  services.  Those  in  the  North  Central  and  Western  states  were 
more  emphatic  on  this  point.  Paying  the  fee  is  slightly  less  of  a  problem 
in  the  larger  cities  than  in  the  smaller  ones. 

Of  23,500  physicians  who  answered  questions  as  to  the  general  need 
for  private  duty  nurses  in  their  practice,  87  per  cent  of  the  general  prac- 
titioners said  they  need  them  often;  5  per  cent,  occasionally;  and  8  per 
cent,  practically  never. 

The  specialists,  who  make  up  two-fifths  of  the  total  number  reporting, 
showed  somewhat  less  demand  for  the  special  nurse,  with  79  per  cent 
requiring  them  frequently  for  their  cases  and  17  per  cent  practically 
never.  The  private  duty  nurse  is  most  in  demand  by  the  surgeon  and 
obstetrician,  98  and  94  per  cent,  respectively,  saying  they  often  need  her 
for  their  patients.  The  percentages  of  need  in  the  other  specialities  were : 

Internal  medicine,  89% 
Orthopedic  surgery,  86% 
Pediatrics,  85% 
Urology,  85% 


180 
Ophthalmology,  75% 
Neurology,  57% 
Tuberculosis,  47% 
Industrial  medicine,  47% 
Dermatology,  33% 
Roentgenology,  25% 
Public  health,  9% 

Though  physicians  sometimes  have  to  call  two  or  three  registries  to  get 
nurses  for  certain  types  of  cases,  their  comments  show  much  more  fre- 
quently an  inability  to  get  the  kind  of  nurse  they  feel  is  particularly 
needed  for  the  case,  rather  than  a  total  unavailability  of  nurses. 

About  two  calls  per  physician  were  refused  during  a  one-month  period. 
The  doctors  find  that  nurses  are  most  apt  to  turn  down  calls  for  twenty- 
four  hour  duty,  night  duty,  cases  in  the  home,  Sunday  or  holiday  cases, 
and  those  requiring  the  nurse  to  go  out  of  town. 

In  fifty-two  per  cent  of  cases,  the  source  of  supply  for  nurses  was  the 
hospital  registries;  21  per  cent  of  the  physicians  got  nurses  through 
their  own  lists;  17  per  cent,  through  the  central  registries;  5  per  cent, 
from  the  commercial  registries;  and  5  per  cent  from  unspecified  sources. 

Not  unnaturally,  the  physician  finds  the  nurse  he  gets  from  his  own 
private  list  the  most  satisfactory.  Nine  out  of  ten  of  all  the  physicians 
said  they  would  like  to  have  the  nurse  on  their  last  case  back  again. 

THE  NURSE  THE  DOCTOR  WANTS 

The  ideal  nurse  for  the  present-day  physician  is  one  who  has  good 
breeding  and  an  attractive  personality,  skill  in  giving  general  care  and 
making  patients  comfortable,  who  can  observe  and  report  symptoms  well, 
takes  care  to  follow  medical  orders  and  is  adept  at  handling  people. 

This  picture  of  the  perfect  nurse  was  ascertained  from  questionnaires 
sent  to  doctors  in  many  branches  of  medicine,  by  the  Committee  on  the 
Grading  of  Nursing  Schools,  which  is  conducting  a  five-year  study  of 
nursing  and  its  problems.  The  above  qualifications  were  the  five  most 
stressed  by  the  more  than  4,000  physicians  from  all  parts  of  the  country 
who  answered  the  queries. 

Just  how  the  various  requirements  for  a  good  nurse  rank  in  the  minds 
of  the  physicians  as  a  whole,  may  be  seen  from  the  following: 

65%  want  the  nurse  to  have  skill  in  general  care 

65%  want  the  nurse  to  have  skill  in  making  the  patient  comfortable 

45%  want  the  nurse  to  have  skill  in  observing  and  reporting  symptoms 

43%  want  the  nurse  to  have  care  in  following  medical  orders 

34%  want  the  nurse  to  have  good  breeding  and  attractive  personality 

30%  want  the  nurse  to  have  skill  in  handling  people 

28%  want  the  nurse  to  have  skill  in  asepsis 

27%  want  the  nurse  to  have  familiarity  with  hospital  routine 

22%  want  the  nurse  to  have  experience  and  background 

21%  want  the  nurse  to  have  familiarity  with  their  personal  methods 

15%  want  the  nurse  to  have  ability  to  work  under  a  heavy  strain 

15%  want  the  nurse  to  have  familiarity  with  a  particular  disease 

3%  want  the  nurse  to  be  a  responsible   adult  to   take   charge  of  the 

family 

3%  want  the  nurse  to  be  a  mother's  helper  and  houseworker 

The  modern  physician  thus  places  the  old-fashioned  concept  of  a  nurse 
as  "a  pair  of  hands  and  feet"  at  the  bottom  of  the  list.  His  demand  now 
is  for  a  woman  of  good  background,  of  high  professional  principles,  with 
thorough  training  and  experience  in  the  actual  care  of  the  patient,  as 
nurse  for  his  cases. 

The  study  shows  that  the  demand  for  practical  nurses  by  physicians  is 
steadily  dropping,  with  84%  preferring  the  graduate,  registered,  trained 


181 

nurse  at  all  times  for  their  own  cases,  and  an  additional  8%  preferring 
them  always  for  certain  types  of  cases. 

The  general  practitioner  and  the  internist  are  most  interested  in  the 
ability  of  the  nurse  to  give  general  care,  69%  and  70%,  respectively, 
registering  for  this  quality,  as  compared  with  the  average  percentage  of 
65.  The  neurologist  is  least  interested  in  it,  though  more  than  half  of 
those  questioned  checked  for  it. 

Skill  in  observing  symptoms  is  most  desired  from  the  nurse  by  the 
surgeon,  neurologist,  obstetrician  and  pediatrician.  The  three  last-named 
groups  also  had  a  more  than  average  interest  in  the  qualification  of  good 
breeding  and  personality.  The  surgeons  emphasized  skill  in  asepsis  and 
care  in  following  medical  orders  as  well. 

The  neurologists  are  by  far  the  most  interested  in  having  for  their 
patients  nurses  who  can  handle  people,  61%  checking  this,  as  compared 
with  an  average  of  30%. 

Nurses  who  take  particular  care  to  follow  orders  shine  brightest  in  the 
eyes  of  the  pediatricians,  57%  of  them  desiring  this  qualification,  while 
the  average  demand  is  43  % .  The  surgeons  and  the  obstetricians  are  most 
interested  in  having  nurses  familiar  with  hospital  routine  and  their 
personal  methods. 

Nine  out  of  ten  physicians  reported  they  are  getting  the  nurses  they 
want  and  would  be  glad  to  take  the  nurse  on  their  last  case  back  again. 
The  surgeons  were  the  group  most  satisfied,  63%  of  them  marking  their 
nurses  with  the  highest  rating. 

Some  of  the  typical  comments  made  by  the  physicians,  that  show  what 
they  appreciate  in  nursing  care  specifically,  were: 

"A  good  observer,  gentle,  thorough.  She  follows  orders  explicity  and 
reports  changes  promptly."  "My  nurse  has  a  sense  of  humor,  which 
helps  a  lot."  "She  kept  hordes  of  anxious  relatives  and  friends  out  of 
the  room."  "She  has  always  been  cheerful."  "She  combined  a  good 
technical  training  with  common  sense."  "She  carried  out  orders  but 
modified  them  when  the  need  was  obvious."  "She  had  a  proper  sense  of 
the  dignity  of  the  position."  "She  is  intelligent,  observing,  not  afraid 
to  take  a  severe  case  twelve  miles  in  the  country."  "She  was  a  good  cook 
and  knew  how  to  handle  people."  "There  has  been  a  very  distinct  im- 
provement in  the  patient's  mental  condition  during  her  stay  in  the 
hospital." 

"Her  asepsis  was  perfect."  "She  was  of  great  value  in  preventing  a 
psychosis  from  developing."  "One  of  the  nurses  was  exceptionally  good- 
natured  and  tolerant."  "Anyone  who  can  feed  a  patient  a  half-pound  of 
cooked  liver  daily  for  four  or  five  months  deserves  credit  for  being  a 
good  cook  and  knowing  how  to  handle  people."  "She  sees  to  it  that  even 
the  family  are  happy." 

MATERNAL  AND  INFANCY  NURSING  SERVICE 

Nora  M.  McQuade,  R.N. 
State  Department  of  Public  Health 

The  evolution  of  Infant  Hygiene  work  since  the  day  of  the  old  "Milk 
Station"  where  the  nurses  dispensed  bottles  of  "certified  milk"  in  iced 
containers  to  mothers  who  used  it  as  they  saw  fit,  to  the  present  time 
when  it  is  called  a  Maternity  and  Infancy  Nursing  Service,  with  prenatal 
nursing,  medical  and  nursing  supervision  of  the  well  child,  and  the  teach- 
ing of  health  habits  as  some  of  the  high  lights,  indicates  the  change  of 
emphasis  in  the  Maternal  and  Infant  Hygiene  movement  in  the  last 
twenty-five  years. 

To  define  the  present  day  nursing  service  for  mothers  and  infants  is  to 
say  there  shall  be  available  for  all  women  in  a  community,  nursing  care 
during  the  entire  prenatal  period;  the  service  of  a  graduate  nurse  at 
delivery  for  women  delivered  at  home;  bedside  care  after  the  birth  of 


182 
the  child  and  medical  and  nursing  supervision  of  infants  to  their  first 
birthday.     Supervision  should  not  stop  with  this  first  birthday  but  a 
discussion  of  it  for  the  pre-school  child  is  beyond  the  purpose  of  this 
paper. 

This  complete  nursing  service  may  be  given  by  one  or  two  groups  of 
nurses.  Usually  it  is  divided  between  the  governmental  nursing  group 
and  the  bedside  nurses  sponsored  by  private  agencies. 

If  this  latter  situation  holds,  the  planning  of  the  program  should  be 
entered  into  by  both  agencies.  Each  should  know  exactly  what  it  is 
expected  to  do,  so  there  will  be  no  gaps  in  the  service.  Each  organization 
should  have  a  definite  policy  and  these  policies  should  be  mutually 
respected.  It  must  be  kept  in  mind  that  this  work  is  a  part  of  a  com- 
munity health  program  and  is  not  done  for  the  exaltation  of  any  group. 

The  prenatal  nursing  service  may  be  undertaken  by  either  agency.  It 
offers  a  wide  field  for  health  education  as  well  as  an  opportunity  for  help- 
ing to  preserve  the  life,  health  and  happiness  of  mothers  and  children. 
It  requires  a  higher  order  of  salesmanship  than  some  of  the  other  ser- 
vices because  it  is  not  as  well  understood  nor  is  its  value  as  well  recog- 
nized. This  attitude  is  easily  understood,  when  one  considers  that  women 
have  always  borne  children  by  the  working  of  one  of  the  laws  of  nature 
and  have  gotten  on  usually  quite  well.  With  our  present  knowledge  we 
know  motherhood  should  be  natural  and  normal  but  it  is  not  always. 

Prenatal  care  may  consist  of  medical  supervision  only;  usually  a  nurse 
is  asked  to  assist  with  the  care  and  observation  of  the  patient  whether 
she  sees  the  doctor  in  his  private  office  or  in  a  clinic.  Often  the  nurse  is 
the  first  person  outside  the  family  to  be  told  a  baby  is  coming  and  the 
patient  looks  to  her  for  advice  and  encouragement.  The  nurse's  first 
duty  in  this  situation  is  to  persuade  the  woman  to  put  herself  under  the 
care  of  a  physician — not  always  an  easy  thing  to  do. 

The  routine  of  a  prenatal  nursing  visit  has  a  well-developed  technique 
which  is  often  described.  The  content  of  the  visit  should  be  as  full  as 
the  local  medical  society  will  permit.  It  varies  from  a  complete  visit 
which  includes  urinalysis  and  the  taking  of  blood  pressure  to  the  giving 
of  simple  advice  on  personal  hygiene  and  preparation  of  the  layette.  The 
technique  should  be  carefully  carried  out  as  it  is  less  confusing  for  the 
patient  to  have  the  visit  made  in  the  same  way  by  all  nurses. 

Because  medical  supervision  is  an  unknown  quantity  to  many  mothers, 
they  know  little  or  nothing  about  the  care  they  should  receive  from 
physicians  during  pregnancy.  It  is  the  nurse's  duty  to  teach  them  what 
this  care  consists  of  so  they  can  ask  for  it  if  it  is  not  offered  to  them. 
They  must  be  taught  also  to  value  good  obstetrical  work  and  to  be  willing 
to  pay  for  it.  The  prenatal  nurse  must  be  sure  of  her  knowledge  and 
must  be  able  to  impart  it  in  an  understandable  and  practical  way. 

The  care  a  mother  will  give  her  baby  and  whether  or  not  he  will  be 
breast  fed  is  often  determined  in  the  prenatal  period.  Maternal  attitudes 
may  be  fostered  by  the  clever  nurse  which  will  make  for  the  health  of 
the  infant  and  the  happiness  of  the  mother  during  the  trying  first  year 
of  the  baby's  life. 

Included  in  prenatal  nursing  care  should  be  plans  for  the  mother  dur- 
ing the  lying-in  period.  This  should  include  care  of  the  home  and  other 
children  as  well  as  care  for  the  mother  and  new  babe.  Relatives,  neigh- 
bors and  community  resources  should  be  called  on,  if  necessary,  to  make 
the  mother  comfortable  and  free  from  worry.  Often  it  is  the  only  time 
in  the  year  an  over-burdened  woman  has  a  chance  to  rest. 

In  order  to  have  prenatal  nursing  care  a  factor  in  a  health  program  it 
should  reach  a  large  percentage  of  the  pregnant  women  in  a  community. 

A  monthly  check-up  on  the  work  can  be  made  by  comparing  the  number 
of  patients  carried  to  delivery  during  the  month  with  the  number  of 
births  occurring  in  that  month.  A  list  of  current  births  can  be  obtained 
from  the  city  or  town  clerk.  This  comparison  shows  the  strong  and  the 
weak  points  in  the  service. 


183 

Next  in  sequence  in  the  definition  of  a  Maternity  and  Infancy  Nursing 
Program  is  the  Nurse  at  Delivery  Service.  This  is  unquestionably  a 
function  of  the  private  organizations.  There  are  problems  of  administra- 
tion occurring  in  this  service  which  can  be  more  easily  handled  by  such 
an  agency. 

The  demand  for  this  service  has  not  been  as  great  as  the  necessity  for 
it  appears  to  the  nurse.  In  no  other  way  can  the  care  given  in  hospitals 
be  approximated  in  the  homes.  There  are  still  a  large  number  of  women 
who  for  very  good  reasons  must  be  delivered  at  home.  The  obstetrician 
occasionally  encounters  difficulties  which  spell  disaster  for  the  mother  or 
babe  or  both  if  he  is  working  alone  or  with  an  incompetent  assistant. 
The  very  best  prenatal  care  cannot  prevent  these  accidents. 

This  service  must  be  constant  to  be  effective.  A  nurse  must  be  avail- 
able at  all  hours.  The  entire  staff  may  participate  in  rotation  or  a  special 
staff  doing  part-time  routine  work  may  be  employed.  A  technique  must 
be  worked  out  and  supervision  given  as  in  other  services. 

The  extension  of  this  service  offers  a  challenge  to  nurses  working  with 
mothers  and  babies. 

Postpartum  care  as  given  by  visiting  nurse  societies  is  the  best  under- 
stood of  all  nursing  services;  no  doubt  because  it  is  one  of  the  oldest. 

The  situation  presented  for  health  teaching  in  this  service  is  perfect. 
The  nurse  is  invited  into  the  home ;  she  works  with  her  hands ;  she  brings 
physical  comfort  to  the  individual  served.  If  she  fails  to  take  advantage 
of  this  situation  to  drive  home  a  lesson  of  personal  hygiene,  child  care, 
nutrition,  etc.,  she  fails  as  surely  as  if  she  neglects  to  give  the  physical 
care  which  is  required  of  her. 

Supervision  of  the  well  baby  has  long  been  conceded  the  duty  of  the 
governmental  agency.  It  is  usually  carried  on  through  the  medium  of 
Well  Baby  Conferences  and  by  home  visiting  by  the  nurses. 

It  is  very  important  that  there  shall  be  no  gap  between  this  service  and 
the  bedside  care  of  the  mothers.  There  should  be  a  reference  system  by 
which  the  nurse  who  is  to  carry  on  the  supervision  of  the  baby  will  know 
at  once  of  his  discharge  from  the  hospital  or  from  bedside  care.  Young 
mothers  particularly,  find  it  very  hard  to  adjust  themselves  to  their  new 
duties  and  responsibilities  when  the  entire  care  of  the  baby  falls  on  their 
hands.  At  this  time  the  supply  of  breast  milk  often  diminishes  and  there 
is  danger  of  the  baby  being  weaned.  A  wise,  sympathetic  baby  welfare 
nurse  can  give  invaluable  assistance  by  teaching  the  technique  of  nurs- 
ing and  giving  encouragement  to  the  mother  during  this  trying  time. 

Training  in  good  mental  and  physical  habits  should  be  started  at  once 
and  often  the  nurse  is  the  only  person  who  knows  this.  She  must  pass  on 
her  knowledge  in  such  a  way  that  it  will  be  understood  and  acted  on. 

This  first  visit  may  determine  the  relations  of  the  nurse  with  the 
mother  for  all  time  so  its  content  must  be  adapted  to  her  need.  Advice 
given  in  a  perfunctory  manner  has  no  value. 

Supervision  of  well  babies  to  be  effective  must  be  continuous.  Each 
visit  must  be  planned  and  the  advice  given  must  fit  each  case.  There  can 
be  no  hard  and  fast  rule  in  timing  these  visits;  each  mother  and  babe 
presents  a  separate  problem. 

The  nurse  doing  this  type  of  work  should  know  practical  teaching 
methods  which  will  enable  her  to  explain  procedures  in  such  a  way  that 
they  will  be  understood  and  remembered.  She  should  know  the  normal 
mental  and  physical  development  of  babies  and  the  principles  and  practi- 
cal application  of  infant  feeding. 

A  maternal  and  infancy  nursing  service,  well  developed  and  well 
executed,  plays  an  important  part  in  maintaining  family  health. 


184 
A  FEW  HIGH  SPOTS  IN  VITAL  STATISTICS 

Mary  P.  Billmeyer,  A.B.,  R.N. 

Department  Consultant  in  Public  Health  Nursing 

and 

Angeline  D.  Hamblen,  A.B. 

Department  of  Public  Health 

Vital  statistics  have  been  called  the  bookkeeping  of  human  life.  A 
more  detailed  definition  would  be  the  "numerical  registration  and  tabula- 
tion of  population,  marriages,  births,  diseases  and  deaths,  coupled  with 
the  analysis  of  the  resulting  numerical  phenomena." 

Vital  statistics  are  used  to  gauge  progress  and  any  sound  public  health 
program  must  be  based  on  them.  No  one  can  guess  at  a  progressive  pro- 
gram—  there  must  be  reasoning  behind  plans.  Keeping  accurate 
records  of  cases  with  analysis  of  the  information  collected  will  show  the 
strength  or  weakness  of  a  program.    In  other  words  they  will  show : 

1.  The  quality  and  quantity  of  work. 

2.  Trend  of  activities 

3.  Fields  undeveloped. 

4.  Fields  of  activity  needing  greater  emphasis. 

In  studying  vital  statistics  the  following  processes  are  used :  * 

"1.  Collection  of  facts. 

2.  Classification  of  the  facts. 

3.  Generalization  from  the  facts. 

4.  Comparison  of  the  facts. 

5.  Drawing  conclusions  from  the  study  of  the  facts. 

6.  Display  of  the  facts  and  the  results." 

The  basis  of  vital  statistics  is  population  which  is  obtained  from  a  cen- 
sus. The  federal  government  takes  a  census  every  ten  years,  the  last 
being  taken  in  1930.  The  state  takes  one  every  ten  years,  the  last  being 
taken  in  1925,  which  means  there  is  always  a  five-year  period  between 
the  federal  and  the  state  census.  Unfortunately  the  last  state  census 
does  not  give  the  population  by  age  or  sex  so  if  one  is  making  any  cal- 
culations where  these  items  are  required  the  federal  census  must  be  used. 
As  most  rates  are  computed  on  the  number  of  the  population  at  the 
middle  of  the  year  (July  1),  and  the  census  is  taken  at  ten-year  intervals 
and  may  be  in  different  months,  one  often  needs  to  estimate  the  popula- 
tion for  the  intercensal  years.  This  may  be  done  in  one  of  two  ways — 
the  geometrical  method,  which  is  based  on  the  law  of  compound  interest, 
or  the  arithmetical  method.  The  latter  method  is  simpler  and  the  one 
more  commonly  used.  The  following  estimation  of  the  population  of 
Worcester  on  July  1,  1928  is  an  example  of  this  method : 

190,757— March  31,  1925  (state  census) 
179,754 — January  1,  1920   (federal  census) 
11,003 — Gain  in  63  months  (5  yrs.  3  mos.) 

63)11003   (  174.6  gain  in  1  month 

63  3 

470  "523.8  gain  in  3  months  (Mar.  31  to  July  1) 

441  4 

293  2095.2  gain  in  1  year. 

252_  3^ 

410  6285.6  gain  in  3  years. 

190,757— March  31,  1925 

524— (523.8  or  524— gain  Mar.  31  to  July  1) 


191,281— July  1,  1925 

6,286— (6285.6  or  6286— gain  in  3  years— 1925  to  1928) 


197,567— July  1,  1928 


*  Whipple — Vital   Statistics. 


185 
Registration 

In  Massachusetts,  births,  marriages  and  deaths  are  recorded  with  the 
local  registrar  who  sends  certified  copies  to  the  state  registrar.  Phy- 
sicians are  required  to  give  notice  of  a  birth  within  forty-eight  hours  and 
to  return  a  complete  record  within  fifteen  days.  Parents  are  required  to 
notify  the  local  registrar  within  forty  days.  In  addition  to  the  above, 
persons  in  charge  of  a  hospital,  almshouse  or  other  institution,  public  or 
private,  are  required  to  give  on  or  before  the  fifth  day  of  each  month, 
notice  of  every  birth  occurring  among  the  persons  in  such  institution 
during  the  preceding  month.  The  law  also  requires  the  clerk  of  each  town 
annually  in  January  to  ascertain  the  facts  for  record  of  all  children  born 
in  his  town  during  the  preceding  year  and  resident  therein. 

Birth  certificates  are  often  used  for  the  following  purposes: 

1.  To  prove  heritage. 

2.  To  prove  parentage  and  legitimacy. 

3.  To  prove  right  of  admission  to  professions  and  public  offices. 

4.  As  evidence  to  establish  age  for 

(a)  Voting 

(b)  Legal  age  to  marry 

(c)  Pensions 

(d)  Liability  of  parents  for  debts  of  minor 

(e)  Administration  of  estates  and  settlements  of  insurance 

(f )  Enforcement  of  laws  relating  to  education  and  child  labor 

(g)  Determining  relationship  of  guardians  and  wards 
(h)   Proof  of  citizenship  to  obtain  a  passport 

(i)   Claim  for  exemption  from  jury  or  military  duty 
Records  of  marriages  are  made  in  the  cities  and  towns  where  the  con- 
tracting parties  dwell  and  where  the  ceremony  is  performed.     Copies  of 
these  records  are  forwarded  annually  to  the  state  registrar. 
The  practical  purposes  of  marriage  records  are : 

1.  As  evidence  to  establish  dower  and  courtesy  rights  of  husband 
and  wife. 

2.  To  prove  legality  as  to  claims  of  inheritance. 

3.  As  evidence  upon  which  to  base  subsequent  records  concerning 
the  parties. 

4.  For  insurance  pension  and  retirement. 

5.  To  establish  legal  settlement  for  the  public  aid  and  the  settlement 
of  dependent  children. 

6.  Naturalization  and  passports. 

7.  To  prove  legitimacy  of  children. 

Undertakers  are  required  to  file  death  certificates  with  the  local  board 
of  health  which  in  turn  is  required  to  transmit  the  death  certificate  to 
the  local  registrar.  The  local  registrar  is  required  to  send  a  certified 
copy  to  the  state  registrar  on  or  before  the  tenth  day  of  the  month  follow- 
ing that  in  which  the  death  occurred. 

Some  of  the  purposes  of  death  registration  are: 

1.  To  give  early  intimation  of  pestilential  or  epidemic  disease. 

2.  Evidence  in  inheritance  of  property  or  settlement  of  life  insur- 
ance. 

3.  Prevent  crime  through  the  restriction  of  the  disposal  of  dead 
human  bodies. 

4.  Insure  permanent  and  uniform  record  of  death  of  each  individual 
for  both  sentimental  and  legal  reasons. 

Rates 

The  birth  rate  is  the  ratio  of  the  number  of  live  births  to  1,000  of  the 
population  and  is  found  by  dividing  the  number  of  births  by  the  number 
of  thousands  in  the  population.  For  example,  if  the  population  of  a  given 
area  were  10,000  and  the  number  of  births  170,  the  birth  rate  would  be 


186 
170  divided  by  10  (number  of  thousands  in  the  population)  which  equals 
17.    This  means  that  for  every  1,000  people  in  the  population  there  were 
17  births. 

Cases 
The  morbidity  rate  is  the  ratio  of  cases  to  the  population.  It  is  gen- 
erally computed  per  100,000  population.  If  there  were  50  cases  of  diph- 
theria in  an  area  whose  population  was  10,000  the  morbidity  rate  for 
diphtheria  would  be  50  divided  by  10  (number  of  thousands  in  popula- 
tion) which  equals  5,  the  rate  per  1,000.  Multiply  by  100  to  obtain  the 
rate  per  100,000  which  would  equal  500. 

Deaths 

General 
The  mortality  rate  is  the  ratio  of  deaths  to  the  population.  The  general 
or  crude  death  rate  is  the  ratio  of  the  total  number  of  deaths  to  1,000  of 
the  total  population.  If  there  were  120  deaths  in  an  area  whose  popula- 
tion was  10,000  the  crude  death  rate  would  be  120  divided  by  10  (the 
number  of  thousands  in  the  population)  which  equals  12  per  1,000. 

Mortality  Rates  in  Age  Groups:  Per  100,000  Population 
Massachusetts :     1 929 


Under  1   1-4     5-9   10-14    15-19         20-23  30-39  40-49  50-59  60-S9  70+ 

You  will  notice  that  the  death  rate  is  very  high  for  the  very  young  and 
the  very  old.  It  therefore  stands  to  reason  that  if  a  population  group  con- 
sists of  large  numbers  of  babies  (foundling  homes)  or  old  people 
(homes  for  the  aged)  the  crude  death  rate  is  bound  to  be  high  regardless 
of  the  health  conditions. 

Specific 

Specific  rates  are  confined  to  specific  groups  of  population  such  as  age, 
sex,  color,  or  nativity.  They  are  usually  computed  per  100,000  population 
rather  than  1,000  so  that  the  answer  may  be  expressed  in  whole  numbers 
rather  than  in  decimals.  To  obtain  specific  rates  divide  the  number  of 
cases  or  deaths  in  the  specific  group  by  the  population  in  the  specific 
group.  If  there  were  25  cases  of  diphtheria  among  5,000  girls  the  mor- 
bidity rate  for  females  would  be  25  divided  by  5  (number  of  thousands 
in  the  population)  which  would  equal  5,  the  rate  per  1,000.  Multiply 
by  100  to  obtain  the  morbidity  rate  per  100,000  which  would  equal  500. 

The  infant  mortality  rate  is  an  age  specific  death  rate.  It  is  the  num- 
ber of  deaths  of  infants  under  1  year  of  age  per  1,000  live  births.  The 
number  of  live  births  is  used  as  the  best  estimate  of  the  population  in 
the  age  group  under  1.     If  there  were  310  deaths  under  1  year  of  age 


187 

and  5,000  live  births  in  a  community  the  infant  mortality  rate  would  be 
310  divided  by  5,  which  would  equal  62  per  1,000  live  births. 

The  maternal  mortality  rate  is  another  specific  death  rate.  Usually 
it  is  the  number  of  deaths  of  women  from  diseases  caused  by  pregnancy 
and  confinement  per  1,000  live  births.  In  some  states  the  rate  is  based 
upon  10,000  live  births.  Occasionally  the  rate  is  based  on  the  number  of 
live  births  and  stillbirths  combined.  The  number  of  births  is  used  be- 
cause it  is  the  best  estimate  of  the  female  population  which  might  die 
from  diseases  caused  by  pregnancy  and  confinement. 

Fatality 

If  in  the  study  of  some  particular  disease  such  as  diphtheria,  tuber- 
culosis, etc.,  the  relationship  between  the  number  of  cases  and  the  number 
of  deaths  is  desired,  the  rate  to  be  used  is  called  the  fatality  rate.  This 
is  best  expressed  in  percentage.  If  there  were  50  cases  and  2  deaths  from 
diphtheria  in  a  community  the  fatality  rate  would  be 
2  (number  of  deaths)  ,.„.„., 

^0   (number  of  cases)   X  100  (percentage)  =4.0. 

After  all  the  data  have  been  collected  and  the  rates  computed  they 
should  be  analyzed  or  interpreted.  In  general  one  cannot  draw  true  con- 
clusions from  very  small  numbers.  The  larger  the  experience  the  smaller 
the  possibility  of  variations.  If  one  baby  died  in  a  town  where  there  were 
only  2  live  births  the  infant  mortality  rate  would  be  500,  while  if  1  baby 
more  or  less  died  in  any  large  city  which  has  many  live  births  the  infant 
mortality  rate  would  not  be  affected. 

It  is  also  very  important  to  try  to  form  some  idea  of  the  normal  hap- 
pening of  events — to  see  how  a  certain  group  has  acted  over  a  period  of 
years  or  to  have  a  control  group  as  nearly  as  possible  identical  with  the! 
one  used. 

Graphs 

It  is  wise  to  include  graphs  with  an  analysis.  The  following  are  the 
more  common  types: 

1.  One  scale — comparison  on  basis  of  single  magnitude. 

2.  Two  scale — comparison  on  basis  of  two  magnitudes,  horizontal 
and  vertical. 

3.  Component  part — a  single  quantity  shown  in  sub-divisions. 

4.  Pictorial — for  display;  e.g.,  a  large  and  small  sheaf  of  wheat  to 
show  increase  in  export  of  wheat. 

5.  Maps — spots  to  show  where  high  or  low  rates  prevail,  etc. 
Graphs  should  always  have  a  title,  should  always  be  self-explanatory, 

the  scales  should  be  clearly  marked  and  the  zero  line  plainly  indicated. 

Quoting  from  Miss  Ada  Boone  Coffey,  Extension  Secretary,  Public 
Health  Nursing,  New  York  State  Department  of  Health  "The  mental  atti- 
tude with  which  a  public  health  nurse  approaches  the  study  of  vital  stat- 
istics is  of  great  significance.  Records  and  reports  will  be  either  a 
burdensome  task  or  a  thrilling  experience,  depending  entirely  upon  the 
use  made  of  the  facts  collected  on  them.  If  no  use  is  made  of  the  facts 
collected  and  the  records  are  never  analyzed  then  records  are  only  a  means 
of  serving  the  individual  case,  and  important  as  this  aspect  is,  very  little 
progress  will  be  made  without  studying  the  individual  case  record  as 
related  to  the  whole  program. 

"A  study  of  the  monthly  and  annual  vital  statistics  reports  prepared  by 
the  state  and  a  study  of  local  rates  are  of  great  interest  and  value  to  the 
public  health  nurse.  She  should  be  able  to  figure  rates  having  been  given 
the  number  of  deaths  and  the  population  of  the  groups  concerned. 

"Only  by  an  analysis  of  the  needs  and  problems  in  a  community  and  a 
comparison  of  these  with  the  actual  accomplishments  can  the  service  be 
evaluated  and  only  by  evaluation  and  a  knowledge  of  the  value  of  a  service 
as  a  means  of  life  saving  and  of  health  promotion  will  sufficient  funds  be 
supplied  to  allow  a  universal  health  service." 


188 
WHERE  ARE  WE  GOING  IN  TUBERCULOSIS  CONTROL* 

Kendall  Emerson,  M.D. 
Managing  Director,  National  Tuberculosis  Association 

Prophecies  are  based  on  retrospect.  It  would  be  idle  to  attempt  to 
forecast  the  future  in  tuberculosis  control  save  in  the  light  of  past  experi- 
ence. It  is  an  easy  matter  to  assemble  a  catalog  of  the  policies  and  prac- 
tices pursued  by  the  National  Tuberculosis  Association  since  its  inaug- 
uration in  1904.  It  is  a  very  different  matter,  however,  to  appraise  their 
effectiveness. 

We  started  twenty-five  years  ago  when  the  death  rate  from  tuberculosis 
in  the  United  States  was  200  per  100,000.  Today  it  is  79.2  (1928  Reg- 
istration Area) .  But  just  what  contribution  preventive  measures  have 
made,  considered  as  a  whole  or  taking  each  project  separately  into 
account,  is  a  question  the  answer  to  which  lies  in  the  realm  of  pure  specu- 
lation. It  would  be  quite  idle  to  attempt  too  accurate  a  prophecy  regard- 
ing the  fate  of  any  single  phase  of  our  work.  It  will  be  more  profitable 
to  discuss  the  subject  from  the  broader  point  of  view  of  general  tenden- 
cies rather  than  the  details  of  specific  projects. 

1.  What  are  the  probable  changes  in  plans  for  the  treatment  of  the 
active  case? 

2.  What  preventive  measures  will  probably  be  stressed? 

3.  What  program  of  health  education  should  we  advocate  and  what 
is  our  contribution? 

4.  How  are  we  co-operating  in  the  general  public  health  field? 

5.  Whither  are  we  tending  in  matters  of  after-care  and  social  re- 
habilitation? 

Treatment  of  Active  Case 
Regarding  the  first  of  these  questions,  it  is  of  interest  to  recall  that  a 
quarter  of  a  century  ago  there  were  113  sanatoria  in  the  United  States 
with  9,000  beds.  Today  there  are  over  618  sanatoria  with  73,695  beds  and 
almost  daily  we  are  hearing  of  newly  projected  institutions  scattered 
over  all  parts  of  the  country.  The  conclusion  from  these  contrasting 
observations  supports  overwhelmingly  the  practice  of  caring  for  our 
active  cases  in  adequately  equipped  sanatoria.  In  view  of  the  undeniable 
advantages  of  institutional  training  for  the  tuberculous  sick,  as  well  as 
their  acknowledged  role  in  effective  treatment,  we  may  assume  that  the 
sanatorium  is  a  permanent  institution. 

Sanatoria 

What  changes,  if  any,  may  we  expect  in  our  present  sanatorium  system  ? 
In  the  early  days  and  even  up  to  the  present  time,  isolated  localities  have 
been  chosen  for  their  establishment,  for  several  apparently  adequate 
reasons.  There  are  serious  disadvantages  in  this  plan.  In  the  first  place, 
patients  frequently  object  to  going  so  far  away  from  home,  thereby  de- 
feating our  purpose  to  remove  active  cases  from  a  community  where  they 
may  be  a  menace  to  those  with  whom  they  are  in  contact.  For  the  same 
reason,  the  number  of  patients  who  leave  sanatoria  against  advice  is  dis- 
proportionately large,  homesickness  undoubtedly  playing  an  important 
part. 

Secondly,  an  important  consideration  is  that  of  economy.  For  a  good 
many  years  the  National  Tuberculosis  Association  has  advocated  tuber- 
culosis wards  in  general  hospitals,  especially  those  located  in  smaller  cities 
or  rural  areas.  Much  economy  in  their  administration  could  be  effected 
thereby,  particularly  in  these  days  when  surgery  is  playing  so  consider- 
able a  part  in  the  treatmeant  of  pulmonary  disease. 

The  third  and  most  important  argument  against  isolated  sanatoria  is 
the  fact  that  by  their  distance  from  teaching  centers  the  vast  opportun- 

*  Presented  at  the  New  England  Health  Institute  at  Boston,  Mass,,  April,  1930. 


189 
ities  which  they  afford  for  instruction  to  medical  students  and  physicians 
is  largely  missed.  This  lack  is  now  being  recognized  by  medical  schools 
and  opportunities  are  being  sought  for  bringing  clinical  material  within 
reach  of  students.  Chicago  University  is  adding  tuberculosis  beds  to  the 
hospital  of  its  medical  school.  Syracuse  is  putting  internes  in  the  Muni- 
cipal Hospital  and  Yale  has  arranged  with  the  William  Wirt  Winchester 
Hospital  to  have  all  its  undergraduate  students  receive  instruction  at  the 
institution  which  is  located  within  the  city  limits  of  New  Haven. 

These  are  some  of  the  arguments  that  point  toward  a  change  in  policy 
of  the  sanatorium  of  the  future.  These  changes  are  in  line  with  our 
advocated  policies  and  the  writer  believes  that  they  will  form  a  notice- 
able modification  of  our  present  practice  in  the  matter  of  hospitalization 
of  cases. 

Preventive  Measure 

The  second  broad  trend  for  consideration  is  that  of  general  preventive 
measures  now  employed,  which  include  case-finding,  breaking  contacts, 
preventoria  open-air  schools  and  many  other  projects.  Any  forecast  for 
change  in  present  methods  of  prevention  can  only  be  based  on  research. 
With  this  principle  in  mind,  the  National  Tuberculosis  Association  has 
devoted  an  increasing  share  of  its  resources  to  studies  along  various 
lines  which  may  be  roughly  grouped  under  social,  laboratory  and  clinical 
research,  all  of  which  forms  part  of  the  broad  epidemiological  study  of  the 
disease. 

Future  Program  Committee 

In  spite  of  the  enormous  amount  of  work  already  done,  a  review  of  our 
actual  knowledge  of  the  life  cycle  of  the  bacillus  itself,  of  the  effect  of 
economic  influence  on  the  prevalence  of  the  disease,  of  the  methods  of  its 
propagation  and  transmission  and  of  its  varying  specificity  for  different 
races,  is  sadly  limited.  Facing  this  discouraging  fact,  the  National 
Association  has  established  a  Future  Program  Committee,  serving  as 
members  of  which  are  a  number  of  the  leading  tuberculosis  experts  of 
the  country.  This  Committee  has  had  the  advantage  of  the  advice  of  dis- 
tinguished statisticians,  students  of  public  health  and  administrators  and 
is  beginning  to  formulate  definite  lines  of  epidemiological  study  which 
must  occupy  an  increasing  amount  of  our  attention  in  the  future. 

One  of  the  recommendations  of  this  Committee  is  that,  when  possible, 
the  National  Association  shall  add  to  its  staff  a  skilled  epidemiologist  and 
at  the  same  time  make  provision  for  more  satisfactory  training  of  men 
equipped  to  carry  on  an  increasing  amount  of  scientific  research  along 
the  above  lines. 

Problems 

Among  many  students  of  tuberculosis  the  opinion  is  widespread  that 
our  economic  prosperity  during  the  past  generation  has  been  an  impor- 
tant factor  in  lowering  our  mortality  rate,  but  that  it  has  not  affected  to 
an  equal  degree  the  widespread  infection  from  the  disease.  Natural  fear 
arises  that  if  we  should  suffer  a  general  economic  depression  with  the 
return  of  less  prosperous  living  conditions,  the  mortality  might  again 
show  an  alarming  increase.  Such  a  catastrophe  did  occur  in  Germany 
under  conditions  of  privation  engendered  by  the  recent  war.  It  is  a 
logical  objective  to  determine  more  scientifically  the  method  whereby  the 
disease  maintains  its  endemic  proportions  and  the  epidemiological  ques- 
tions involved  have  by  no  means  received  a  satisfactory  answer. 

The  racial  incidence  of  tuberculosis  is  another  unsolved  problem. 
While  the  Negro  death  rate  has  decreased  at  a  pace  somewhat  resembling 
that  of  the  White,  actual  Negro  mortality  is  still  from  two  to  four  times 
higher,  and  the  same  appears  to  be  true  among  Mexicans  and  certain 
other  fractions  of  our  population. 

No  one  can  as  yet  appraise  with  accuracy  what  we  speak  of  as  resist- 
ance against  the  disease  assumed  to  be  produced  by  the  initial  or  child- 
hood type  of  infection.    Until  studies  of  the  antigenetic  properties  of  the 


190 
blood  are  farther  advanced  than  at  present,  such  questions  will  remain 
as  indeterminate  factors  in  our  future  program. 

Enough  has  been  said  to  indicate  the  lines  of  thought  along  which  the 
Future  Program  Committee  is  working.  While  it  is  not  likely  that  any- 
revolutionary  recommendations  will  grow  out  of  this  study,  some  of  the 
conclusions  reached  may  profoundly  modify  our  present  day  practices. 

Protection  of  the  Child 

Until  such  time  it  is  probable  that  far  more  work  will  be  done  on  the 
development  of  the  preventorium  type  of  care  applied  to  children.  This 
does  not  mean  necessarily  the  establishment  of  any  enormous  number  of 
actual  institutions,  but  it  does  mean  a  vastly  increased  protection  for 
babies  and  young  children  against  contact  with  cases  of  active  disease. 
Whether  or  not  Dr.  Calmette's  vaccine,  popularly  known  as  B.  C.  G.,  will 
figure  as  an  important  element  in  this  part  of  our  future  program  is  still 
a  matter  of  uncertainty.  It  would  be  idle  to  ignore  the  reports  now  reach- 
ing us  from  France  as  to  the  success  of  its  use;  on  the  other  hand  there 
is  considerable  improbability  that  the  same  need  for  infant  protection 
will  arise  in  this  country  and  for  that  reason  it  is  doubtful  whether  there 
will  be  any  advocacy  of  its  generalized  use.  It  undoubtedly  might  prove 
of  real  service  in  individual  cases,  or  under  certain  crowded  conditions, 
or  where  the  epidemic  existence  of  the  disease  was  most  marked. 

By  the  preventorium  type  of  care  is  meant  all  means  that  can  be  rea- 
sonably employed  to  break  contact  between  a  child  and  an  infected  adult. 
To  a  considerable  extent  this  would  have  to  be  done  by  isolating  the  child, 
for  which  purpose  institutional  preventoria  may  be  required  for  an  in- 
definite period  in  the  future.  There  are  many  disadvantages  in  taking  a 
child  out  of  its  home  and  it  is  possible  that  more  economical  solutions  of 
the  problem  may  arise.  There  can  be  no  doubt  that  the  future  is  to  see 
a  vast  increase  in  the  so-called  open-air  schools.  This  does  not  mean  the 
extreme  type  of  school  where  very  low  temperatures  are  maintained  with 
their  resulting  discomfort  to  scholars.  It  does  mean  in  the  long  run  a 
vastly  different  attitude  on  the  part  of  the  public  toward  minimal  require- 
ments for  all  schools. 

If  the  open-air  school  is  good  for  the  contact  children  or  the  subnormal 
or  handicapped  scholar,  it  is  certainly  not  harmful  for  the  robust  indi- 
vidual. Ideally,  the  school  of  the  future  should  be  a  one  hundred  per  cent 
open-air  school,  affording  opportunities  for  the  specialized  treatment  of 
each  individual  scholar  which  may  be  indicated  by  his  particular  needs. 
True,  the  expense  involved  is  a  bit  staggering,  but  we  are  never  going  to 
approach  a  one  hundred  per  cent  health  standard  for  our  school  children 
until  the  best  protective  methods  are  available  to  each  and  every  one  of 
them. 

Case-Finding 

Pausing  only  a  moment  for  a  consideration  of  future  means  for  detect- 
ing existing  infectious  cases,  one  can  only  remark  that  up  to  the  present 
the  theoretical  measures,  such  as  reporting  of  cases,  adequate  public 
health  nursing,  proper  housing  regulations  and  the  supervision  of  health 
in  industry,  have  as  yet  scarcely  been  tried.  It  would  be  rather  begging 
the  question  in  any  future  phophecy  of  control  methods  of  tuberculosis 
to  invent  new  devices  before  testing  out  thoroughly  such  rational  pre- 
ventive measures  as  these.  How  this  ideal  is  to  be  achieved  is  one  of  the 
big  problems  of  the  future  and  that  brings  us  to  our  third  topic  of  discus- 
sion, namely,  health  education. 

Health  Education 

The  methods  employed  by  the  National  Association  and  at  present  advo- 
cated may  be  divided  into  two  broad  classes;  first,  general  publicity 
directed  primarily  toward  the  adult  public;  and  second,  child  health  edu- 
cation, which  is  a  part  of  the  school  curriculum.  It  does  not  seem  probable 


191 

that  many  new  devices  for  improving  the  dissemination  of  information 
through  publicity  will  be  found.  Existing  channels  should  be  deepened 
and  broadened.  The  public  health  service  itself  has  in  the  last  few  years 
taken  this  matter  with  increasing  seriousness  and  all  of  the  more  active 
state  and  many  local  departments  are  issuing  pamphlets  and  publications 
on  the  subject  of  preventive  medicine  which  have  an  increasing  wide 
distribution. 

The  volunteer  agencies  are  at  the  same  time  enlarging  their  contribu- 
tions and  the  radio  will  without  doubt  play  an  increasing  part  in  this 
general  program.  Its  effectiveness  generally  will  grow  as  more  children 
with  a  health  education  program  are  graduated  from  our  schools,  since 
they,  in  contrast  to  their  parents  will  have  had  the  soil  cultivated  to  a 
greater  extent  for  the  reception  of  the  seeds  of  preventive  medical 
instruction. 

Child  health  education  began  as  a  part  of  the  public  school  system  only 
about  a  dozen  years  ago.  It  has  developed  with  very  striking  rapidity 
and  like  most  such  rapid  growth  is  now  in  a  state  of  considerable  chaos. 
The  subject  matter  is  medical  and  the  channels  through  which  the 
instruction  must  come  is  educational.  Complications  have  been  and  are 
inevitable,  and  the  future  must  find  a  way  of  smoothing  out  the  tangles. 
Fortunately,  the  National  Education  Association  has  recognized  the 
fundamental  importance  of  health  education  and  is  more  than  ready  to 
co-operate  in  giving  it  an  established  and  appropriate  position  in  the 
curriculum. 

The  question  of  whence  the  necessary  material  for  instruction  shall 
come  and  how  it  shall  be  administered  is  not  an  easy  one  to  solve  in  view 
of  the  fact  that  so  highly  technical  a  subject  must  be  entrusted  to  the 
hands  of  lay  teachers  to  interpret.  By  patient  effort  this  will  be  accomp- 
lished, but  it  is  one  of  the  hard  tasks  of  the  future  and  one  in  which  the 
National  Association  and  all  its  branches  have  a  profound  interest.  It  is 
proposed  to  enlarge  the  scope  of  the  Nation's  child  health  education  de- 
partment in  an  effort  to  help  more  effective^  toward  a  solution  of  this 
problem.  I  believe  that  more  practical  developments  will  result  along 
this  particular  line  of  work  than  along  any  other  of  our  enterprises  for 
perhaps  the  next  decade  or  two. 

Co-operation  in  the  General  Public  Health  Field 

In  the  inauguration  of  the  work  of  the  National  Tuberculosis  Associa- 
tion it  was  desirable,  as  well  as  inevitable,  to  place  chief  emphasis  on 
actual  preventive  work  in  tuberculosis  itself.  From  the  first,  however, 
it  was  recognized  that  any  attempt  to  control  the  disease  involved  all 
fields  of  public  health  enterprises,  such  as  sanitation,  food  protection, 
housing,  conditions  of  labor,  as  well  as  the  health  of  the  community  and 
the  prevention  of  communicable  diseases. 

Subsequent  to  the  formation  of  the  National  Tuberculosis  Association, 
other  volunteer  health  organizations  have  grown  up,  each  devoting  its 
primary  attention  to  one  of  the  various  branches  into  which  health  work 
and  the  control  of  communicable  diseases  may  be  divided.  In  view  of  the 
characteristics  of  tuberculosis,  it  is  evident  that  the  preventive  work  of 
such  organization  bears  a  close  relationship  to  the  objectives  at  which 
we  have  aimed,  namely,  improvement  in  health  standards  and  economic 
conditions. 

Through  the  formation  of  the  National  Health  Council  an  attempt 
was  made  to  co-ordinate  the  work  of  all  such  volunteer  health  associa- 
tions. This  has  been  partially  successful,  but  the  future  should  see  a 
far  closer  community  of  effort  between  all  associations  having  as  their 
main  objective  public  education  in  preventive  medical  principles.  Some 
progress  can  be  reported  during  the  past  year. 

It  is  believed  that  there  are  influences  at  work  which  may  accelerate 
this  progress.  Among  others  it  is  fair  to  allude  to  the  White  House  Con- 
ference on   Child   Health   and   Protection   which   has   aroused   national 


192 
interest  in  President  Hoover's  familiar  doctrine  that  the  future  health 
of  the  race  depends  on  the  protection  of  the  child.  The  fact  that  all 
health  organizations  have  been  asked  to  participate  in  this  Conference 
and  that  most  of  us  are  making  special  studies  which  shall  serve  as  a 
basis  for  discussion  will  undoubtedly  have  an  important  influence  in 
showing  us  the  close  inter-relationship  of  our  several  activities. 

Through  its  nation-wide  organization  of  state  and  local  associations 
our  Society  is  in  a  position  to  extend  its  co-operative  aid  in  the  broader 
fields  of  public  health  work.  While  this  should  mean  no  lessening  of  our 
primary  duty  to  stress  the  importance  of  tuberculosis  as  a  continuing 
public  menace,  we  must  still  not  lose  sight  of  our  opportunity  to  contrib- 
ute to  a  more  generalized  program.  Among  the  future  trends  of  our 
organization,  it  is  the  writer's  opinion  that  our  opportunity,  as  well  as 
our  obligation,  toward  closer  co-operation  with  the  public  health  service 
itself  and  with  other  health  organizations  will  be  increasingly  stressed. 

After-Care  and  Rehabilitation 

Finally,  we  must  refer  to  the  matter  of  after-care  and  rehabilitation. 
This  has  been  called  the  third  stage  of  treatment,  the  first  stage  being 
rest  in  bed,  the  second,  rest  with  graduated  exercise,  and  the  third,  the 
arrested  stage  or  period  of  rehabilitation  when  the  patient  may  be 
restored  to  his  maximum  economic  efficiency.  Until  very  lately  sana- 
toria have  paid  only  the  scantiest  attention  to  this  really  vast  problem. 
Public  health  departments  have  shown  indifference.  Society  in  general 
and  industry  in  particular  have  given  no  considerable  amount  of  co- 
operation. 

One  means  of  meeting  the  need  is  by  the  sheltered  workshop,  such  as 
the  Altro  Shop,  or  Potts  Memorial  in  this  country,  and  the  Papworth 
Industrial  Village  in  England.  At  best  such  enterprises  are  in  the  nature 
of  experiments  or  demonstrations.  The  vast  bulk  of  arrested  cases  must 
be  absorbed  by  communities  from  which  they  come.  It  is  an  expensive 
matter  to  cure  or  arrest  a  case  of  tuberculosis.  It  is  an  economic  fallacy 
not  to  protect  the  investment  so  made  by  preventing  future  breakdowns. 
The  difficulties  and  expense  of  this  undertaking  have  appalled  us  and  we 
have  at  best  only  marked  time  in  attempting  a  solution  of  this  problem  up 
to  the  present.  The  future  must  see  us  adopt  an  aggressive  policy.  A 
hurried  outline  of  the  procedure  may  be  stated  as  follows: 

In  the  first  place,  patients  should  be  kept  in  sanatoria  until  their  cases 
are  arrested  to  a  point  where  they  can  safely  be  allowed  to  go  back  into 
their  respective  communities  and  undertake  some  sort  of  work.  If  their 
previous  employment  was  of  a  nature  to  which  they  may  return  without 
danger,  the  problem  is  greatly  simplified.  If  their  subsequent  career 
involved  vocational  rehabilitation  and  sheltered  employment  for  a  con- 
siderable period  or  perhaps  permanently,  the  economic  burden  is  greatly 
increased.  Society's  responsibility,  is,  however,  nonetheless  clear  because 
of  the  difficulties  in  the  way. 

Of  course,  the  cases  which  have  not  benefited  by  sanatorium  treatment 
must  be  looked  upon  as  unproductive,  chronic  invalids  and  except  for 
their  medical  supervision  do  not  enter  into  this  discussion. 

Every  discharged  case  should  be  transferred  to  the  public  health 
service  records  in  the  community  to  which  he  returns.  This  should  not 
be  a  perfunctory  matter  but  should  be  done  with  such  thoroughness  as  to 
insure  a  one  hundred  per  cent  supervision  of  all  discharged  cases.  It 
does  not  mean  an  undue  burden  on  the  public  health  service.  It  does 
mean  that  that  service  should  be  responsible  for  seeing  to  it  that  each 
case  is  placed  under  the  supervisory  direction  which  it  requires. 

The  burden  of  the  arrested  industrial  case  must  come  on  industry. 
If  we  examine  the  records  of  the  employees  of  any  large  factory,  we  will 
find  that  only  in  exceptional  cases  do  we  have  more  than  one  or  two  per 
cent  affected  with  tuberculosis.  It  does  not  seem  unjust  to  expect  such 
industries  to  absorb  their  sanatorium  graduates,  adjusting  each  to  the 


193 
specific  job  which  he  is  safely  capable  of  undertaking.    This  rule  cannot 
have  universal  application  since  it  is  probable  that  certain  hazardous 
trades  would  have  a  disproportionate  number  of  breakdowns,  but  the 
rule  still  has  a  wide  application. 

If  vocational  rehabilitation  is  necessary,  the  state  rehabilitation  bur- 
eaus, subsidized  as  they  are  by  Federal  grants,  should  be  encouraged  to 
handle  this  problem.  Already  such  co-operation  has  been  secured  in 
various  states  and  there  is  a  promise  that  the  work  will  extend  rapidly 
in  the  years  to  come. 

Underlying  all  discussions  of  future  program  in  tuberculosis  work  is 
a  substratum  of  research,  without  which  there  is  no  reliable  guidance. 
The  work  of  the  Medical  Research  Committee  of  the  National  Tuber- 
culosis Association  is  already  familiar.  Our  work  in  social  research  is 
not  so  widely  known,  but  it  is  progressing  in  many  productive  directions. 
In  spite  of  its  existence  throughout  the  history  of  mankind,  tuberculosis 
is  in  some  respects  as  much  of  a  mystery  as  it  was  in  the  days  of 
Hippocrates. 

The  intensive  laboratory  and  epidemiological  study  must  be  continued 
and  extended.  There  is  always  the  possibility  that  this  may  lead  to  some 
abrupt  discovery  which  will  alter  the  picture  and  modify  our  whole 
program  of  work.  Pending  that  hoped  for  discovery,  we  must  admit 
that  the  future  of  our  work  varies  rather  in  intensity  than  in  kind  and 
that  for  the  most  part  we  must  continue  to  build  more  solidly  a  structure 
on  the  same  foundations  and  along  similar  lines  as  those  upon  which  we 
have  built  for  the  past  quarter  century. 

THE  PROBLEM  OF  THE  UNDERNOURISHED  SCHOOL  CHILD 
HOW  IT  MAY  BE  SOLVED 

John  A.  Ceconi,  M.D., 
Director  of  School  Hygiene,  Boston  Public  Schools 

Tuberculosis  has  been  a  menace  to  every  community  and  it  has  been 
felt  for  years  that  this  disease  in  a  great  many  instances,  although  con- 
sidered a  communicable  disease,  is,  in  reality,  preventable.  So  Massa- 
chusetts health  authorities,  tuberculosis  experts,  and  others  interested 
in  the  conservation  of  health  and  life  determined  on  a  policy  which  had 
for  its  end  the  elimination,  so  far  as  possible,  from  the  community  of  the 
so-called  "white  plague".  The  Massachusetts  Department  of  Public 
Health  conceived  the  so-called  Ten  Year  Underweight  Program  alluded 
to  in  this  paper  and  it  was  introduced  into  the  Boston  public  schools 
and  special  physical  examinations  of  children  have  been  made  through- 
out the  entire  city.  Preliminary  to  these  special  physical  examinations 
by  the  specialists  of  the  Massachusetts  Department  of  Public  Health, 
the  entire  elementary  and  intermediate  school  population  (exclusive  of 
kindergartens)  was  weighed  and  measured — approximately  94,000  pupils. 
Of  this  number  a  selected  group  which  consisted  of  children  who  were 
ten  per  cent  or  more  underweight,  also  all  children  who  were  tuberculous 
contacts,  or  children  who  were  habitually  absent  on  account  of  colds  or 
other  reasons  were  grouped  and  given  the  special  examination  by  the 
State  experts.  Reactors  to  the  tuberculin  test  were  given  intensive 
X-Ray  examination. 

Of  the  94,000  children  weighed  and  measured  9,150  children  were 
examined  with  the  following  results: 

Number  of  cases  of  malnutrition      ......  1,240 

Number  of  cases  of  pulmonary   tuberculosis      ....  7 

Number  of  cases  of  hilum  tuberculosis     .....  173 

Number  of  cases  of  latent  hilum  tuberculosis   ....  45 

Number  classified  as  suspects   .........  456 

Number  X-Rayed  and  classified  as  negative                lrJ                  .  1,423 


194 

Invitations  were  extended  to  the  parents  and  guardians  of  the  children 
to  be  present  at  the  examinations.  Approximately  75%  of  the  parents 
accepted  this  invitation,  and  every  parent  who  attended  the  examination 
of  his  or  her  child  not  only  gave  consent  for  the  examination  but  his 
individual  support.  This  was  indeed  a  wonderful  manifestation  of  the 
interest  and  co-operation  of  the  parents  and  guardians  of  our  school 
children.  I  earnestly  believe  that  the  attendance  of  the  parents  at  these 
examinations  is  definite  evidence  to  show  the  eagerness  on  the  part  of 
the  home  to  work  with  the  school  in  new  departures  in  health  education. 
Out  of  the  total  number  of  children  found  to  be  underweight,  90%  of  the 
parents  gave  written  consent  for  the  examination. 

Just  a  word  concerning  the  type  of  examination  and  the  type  of  indi- 
viduals performing  the  examinations.  The  chance  of  embarrassment 
from  an  examination  such  as  this  was  most  carefully  guarded  against. 
No  child  was  examined  without  the  nurse  and,  in  75%  of  the  cases,  in 
the  presence  of  the  parent.  No  child  was  exhibited  and  each  child  was 
covered  with  a  special  cape  for  the  occasion. 

These  examinations  were  conducted  by  a  skilled  group  of  tuberculosis 
experts  selected  by  the  Massachusetts  Department  of  Public  Health,  and 
it  is  impossible  for  me  to  express  by  mere  words  my  gratitude  and 
appreciation  for  the  wonderful  work  and  help  that  they  have  given  in 
the  Boston  public  schools. 

It  is  estimated  by  the  Massachusetts  Department  of  Public  Health  that 
approximately  $100,000.00  has  been  expended  by  that  department  for 
these  examinations  of  the  children  in  the  Boston  public  schools.  This  is 
a  startling  figure  but  it  is  thought  that  it  would  be  just  as  well  to  bring 
this  fact  out  for  two  reasons,  first,  that  health  authorities  and  officials 
are  one  in  their  belief  that  health  is  purchasable,  and  secondly,  that  the 
conduct  of  this  valuable  program  in  the  Boston  public  schools  was 
absolutely  without  expense  to  either  the  City  of  Boston  or  to  the  pupils. 

From  the  moment  of  its  conception,  the  Director  of  School  Hygiene 
was  sold  to  the  Ten  Year  Underweight  Program,  and  here  and  now  he 
emphatically  states  that  the  work  done  by  the  Massachusetts  Department 
of  Public  Health  in  the  Boston  public  schools  has  far  exceeded  his  expec- 
tations. It  has  been  demonstrated  that  it  is  one  of  the  most  important 
public  health  functions  in  disease  prevention  campaigns,  and  lack  of 
success  spells  just  this — lack  of  co-operation  and  nothing  else. 

After  all,  what  the  Department  of  School  Hygiene  is  advocating  and 
doing  is  nothing  more  or  less  than  an  endeavor  to  pay  a  debt  to  the 
school  child — the  debt,  the  giving  to  him  the  best  possible  chance  for  a 
long  and  useful  life.  To  do  this  we  cannot  allow  him  to  go  blindly  on  his 
way  trusting  to  luck  that  he  will  escape  the  common  pitfalls.  He  has 
to  be  helped  and  the  least  we  can  do  for  him  is  to  see  that  his  physical  and 
mental  armamentarium  is  such  that  when  he  leaves  our  educational  juris- 
diction he  will  be  a  credit  physically,  mentally  and  morally  to  his  Alma 
Mater,— THE  BOSTON  PUBLIC  SCHOOLS. 

It  might  be  well  to  state  that  since  the  findings  of  the  pulmonary 
experts  of  the  Massachusetts  Department  of  Public  Health  were  reported, 
the  Department  of  School  Hygiene  has  placed  each  summer  in  the  Salva- 
tion Army  Fresh  Air  Camp  at  Sharon,  Mass.,  about  three  hundred  of 
these  children  for  whom,  under  ordinary  circumstances,  no  vacation 
would  be  available.  The  average  gain  in  weight  in  each  child  at  this 
camp  has  been  seven  to  ten  pounds.  The  Federated  Jewish  Charities  has 
provided  excellent  camps  for  their  children  who  came  in  this  group — 
approximately  250  each  summer.  The  various  settlement  houses  and 
social  agencies  throughout  the  City  provided  vacations  for  an  additional 
two  hundred  children  in  this  group  each  summer.  The  heartfelt  gratitude 
of  the  Department  of  School  Hygiene  goes  out  to  these  agencies  for  the 
wonderful  co-operative  spirit  shown  in  helping  us  conserve  the  health  of 
these  children. 


195 

From  the  Ten  Year  Underweight  Program  it  was  sharply  drawn  to  the 
attention  of  the  Department  of  School  Hygiene  that  rest  and  proper 
nutrition  of  the  child  were  paramount  issues  in  defeating  the  inroads  of 
tuberculosis  and  a  nutrition  specialist  was  appointed  and  has  made  a 
study  of  the  nutrition  requisites  for  the  correction  and  prevention  of 
malnutrition. 

The  open-air  classes  were  first  visited  and  conferences  held  with 
masters,  teachers,  school  nurses,  and  school  physicians.  The  purpose  of 
this  open-air  class  survey  was  to  determine  the  adequacy  of  these  classes 
and  to  care  for  the  malnourished  and  pre-tuberculous  children.  The 
types  of  programs  conducted  and  the  needs  of  the  locality  were  con- 
sidered. It  was  found  that  the  old  type  open-air  classes  were  not  suited 
to  care  for  the  needs  of  these  children  because  of  the  fact  principally  that 
the  personnel  of  these  classes  was  restricted  to  children  of  not  more 
than  two  grades. 

The  children  requiring  the  nutritional  care  and  supervision  come  from 
all  grades  from  the  first  to  the  eighth.  The  rest  and  nutrition  classes, 
therefore,  were  established  in  September  1926  to  care  for  the  needs  of 
the  pupils  and  to  give  the  needed  medical  and  nutritional  care  with  a 
minimum  loss  in  educational  activity.  Twenty-five  of  these  classes  are 
now  being  conducted  caring  for  about  815  children.  Twenty-two  of  these 
classes  are  carrying  on  a  full-time  program  and  three  a  part-time  pro- 
gram.    Preparations  are  under  way  for  additional  classes. 

The  full-time  program  is  as  follows: 

9.00  a.m.  to  10.00  a.m.  regular  classes 
10.00  a.m.  to  10.30  a.m.  rest  on  cots 
10.30  a.m.  to  10.45  a.m.  midmorning  lunch  and  recess 
10.45  a.m.  to  11.50  a.m.  regular  classes 
11.50  a.m.  to  12.45  p.m.  rest  on  cots 
12.45  p.m.  to     1.20  p.m.  dinner  and  outdoor  play 
1.20  p.m.  to     3.30  p.m.  regular  classes. 

In  the  part-time  program  the  noonday  rest  and  the  dinner  are  omitted. 

The  rest  periods  in  the  morning  are  scheduled  at  a  time  when  a  minor 
subject  is  taught  and  in  this  way,  although  the  children  devote  two  and 
one-half  hours  to  the  rest  and  nutrition  program,  they  lose  but  twenty 
minutes  in  educational  activity.  The  teachers  feel  that  the  children  in 
this  group  improve  physically  to  such  a  degree  that  this  improvement 
more  than  compensates  for  the  twenty  minutes  a  day  devoted  to  the  rest 
class  program. 

Just  a  few  figures  to  give  an  idea  of  the  gain  in  weight  of  these 
children  in  one  of  the  rest  and  nutrition  classes.  One  child  gained  21 
pounds,  one  16  pounds,  one  &%  pounds,  one  6  pounds,  and  four  5  pounds, 
all  of  this  in  less  than  six  months.  This  is  typical  of  all  other  classes. 
Losses  in  weight  were  noted  in  these  children  after  vacation  periods. 
The  school  attendance  of  this  group  of  children  has  been  excellent,  the 
only  absences  having  been  for  children  who  had  tonsillectomies  per- 
formed or  who  were  in  hospitals  for  correction  of  other  physical  defects. 

The  midmorning  lunches  consist  of  a  one-half  pint  bottle  of  milk  with 
bread  and  butter.  The  average  noonday  meal  is  beef  stew  with  vegetables 
or  macaroni  with  tomato  sauce,  bread  and  butter,  baked  apple  or  pudding, 
and  cocoa.  The  afternoon  luncheon  at  3.30  o'clock  generally  consists  of 
a  sandwich  and  milk  or  cocoa.  The  average  daily  cost  per  pupil  for  this 
food  is  eleven  cents. 

The  menus  are  prescribed  by  the  Supervisor  of  Nutrition  Classes  and 
the  food  is  purchased,  prepared  and  served  by  nutrition  class  attendants 
and  assistant  nutrition  class  attendants.  These  attendants  also  super- 
vise the  rest  periods. 

The  Supervisor  of  Nutrition  Classes  meets  these  children  and  their 
parents  at  regular  intervals  in  order  to  secure  and  obtain  their  interest 
and  co-operation  in  carrying  out  the  health  program  at  home.     The 


196 
probable  cause  for  the  malnutrition  is  explained  and  health  and  food 
habits  are  discus"sed.  Menus  are  suggested  and  the  method  of  prepara- 
tion is  explained.  These  meetings  favor  study  and  correction  of  home 
difficulties  under  friendly  circumstances,  utilize  the  experiences  of  all 
families  for  the  benefit  of  each,  and  economize  time  by  bringing  the 
parents  to  the  class.  By  health  talks,  games,  etc.,  the  children's  own 
interest  is  aroused  and  they  are  stimulated  to  enter  the  game  of  health. 

The  health  and  nutrition  program  as  outlined  in  this  paper  has  the 
following  advantages: 

1.  It  includes   all  the  pre-tuberculous   and  malnourished   children, 
irrespective  of  grades. 

2.  As  soon  as  a  child  attains  normal  weight  and  health  he  returns 
to  the  regular  school  program. 

3.  Convalescing  children  may  be  included  temporarily  and  are  thus 
often  enabled  to  return  to  school  earlier  than  otherwise. 

4.  It  obviates  the  necessity  of  special  open-air  class  teachers. 

5.  It  maintains   continuous  close   contact  between   the   school   and 
the  home. 

THE  AVERAGE  DAY  OF  AN  INDUSTRIAL  NURSE  IN  A  MODERN, 

BUSY  FACTORY  EMPLOYING  BETWEEN  TWO  AND 

THREE  THOUSAND  PEOPLE 

Louise  G.  Fiske,  R.N., 

Dennison  Manufacturing  Company 

The  plant  opens  at  7:45  a.m.  and  the  nurses  are  ready  for  work  at 
that  time  in  a  spick  and  span  all  white  uniform  from  head  to  toe.  We 
have  a  day  of  8%  hours  excepting  on  Saturday  when  we  close  at  noon. 

The  waiting  room  is  usually  occupied  with  one  or  more  patients,  some 
to  see  the  doctor,  others  to  see  the  nurses.  There  are  minor  dressings 
to  be  changed;  maybe  some  injury  received  at  home  the  night  before,  or 
before  starting  to  work;  perhaps  a  sick  headache,  indigestion  or  cold,  or 
some  other  ailment  common  to  a  large  group  of  people. 

The  filling  of  our  three  surgical  units  (tables)  takes  time.  We  have 
bandages  and  band-aid  dressings  to  cut  and  pill  bottles  to  fill. 

In  the  meantime  the  patients  are  coming  in,  we  must  stamp  their 
"permission  to  visit  the  Clinic"  cards  as  they  come  and  go,  on  our  auto- 
matic time  clock,  which  records  the  time  they  arrive  at  the  Clinic  and  the 
time  they  leave.  This  prevents  any  wasting  of  time  by  the  employee 
from  his  department  to  ours,  as  the  "permission"  card  is  given  him  from 
his  clerk  in  his  particular  room.  Then  after  each  patient  leaves,  we  have 
forms  to  fill  out,  surgical,  medical  and  accident  forms  that  are  part  of  the 
daily  records,  and  later  these  are  typed  by  the  typist  and  filed  in  our 
permanent  records. 

All  new  employees  are  required  to  have  a  physical  examination.  The 
examination  covers  eyes,  teeth,  nose,  ears,  throat,  temperature,  haemo- 
globin, color  test,  weight,  height,  blood  pressure,  pulse  rate,  heart,  lungs, 
abdomen,  spine,  inguinal  region,  feet  and  chemical  urinalysis.  This 
examination  is  offered  yearly  to  all  employees  and  most  of  the  employees 
welcome  the  examination  and  ask  for  it  if  by  any  chance  they  are  over- 
looked in  our  yearly  checkup. 

We  have  a  small  X-Ray  machine  and  we  take  pictures  of  all  injuries 
where  we  think  there  might  possibly  be  a  fracture.  We  X-Ray  teeth, 
chests  and  sinuses.  We  have  a  dark  room  and  develop  our  films  in  a  few 
minutes  after  taking  the  pictures.  One  day  a  week  an  outside  X-Ray 
specialist  comes  in  and  reads  these  films. 

At  ten  and  three  o'clock  milk  is  served  in  the  rest  room  to  girls  who  are 
ten  pounds  or  more  underweight  and  those  returning  from  sickness. 
Each  girl  is  weighed  once  a  month,  and  disappointing  as  it  may  seem,  we 
have  found  only  an  average  gain  of  two  pounds  per  person;  yet  the  lost 


197 

time  from  these  usually  below  par  girls  has  been  found  lessened  by  their 
taking  milk  during  the  working  period.  Every  employee  is  allowed 
half-an-hour  sick-rest,  if  it  is  necessary,  during  our  morning  and  after- 
noon working  periods,  without  loss  of  pay. 

An  oculist  from  the  Massachusetts  Eye  and  Ear  Infirmary  comes  to 
our  plant  on  an  average  of  two  days  a  month  to  examine  and  give  pre- 
scriptions to  those  needing  glasses. 

We  encourage  employees  to  come  to  us  and  talk  over  their  problems 
and  thus  act  as  a  clearing  house  for  employees  to  air  their  minds  of 
troubling  thoughts,  which  thoughts  may  be  most  anything  from  trouble 
at  home  to  working  conditions  in  the  factory.  We  urge  them  to  talk, 
realizing  that  one-half  of  their  inhibitions  are  over  when  they  have  had 
an  opportunity  to  talk  things  over  with  someone  in  a  confidential  manner. 
It  is  most  important  to  be  friendly  and  courteous  to  everyone  who  comes 
to  the  Clinic.  The  idea  that  they  receive  these  many  services  without 
payment  produces  a  queer  psychological  reaction  and  the  nurse  must 
show  the  uttermost  tact  to  offset  this  feeling  by  being  ready  to  compre- 
hend and  readily  read  the  thoughts  of  these  patients.  Now  and  then  we 
are  called  to  an  employee's  home,  but  only  when  that  particular  employee 
wishes  us  to  go. 

In  an  effort  to  prevent  or  lessen  the  number  of  colds,  this  Fall  we  gave 
to  over  two  hundred  employees,  a  catarrhal  vaccine  in  five  graduated 
doses,  three  or  four  days  apart.  This  has  been  done  the  past  five  years 
and  we  have  found  that  over  three-fourths  of  these  patients  have  been 
benefited  by  this  vaccine  treatment. 

Monthly  inspections  are  done  throughout  the  plant  by  the  nurses. 
Dressing  rooms,  toilets,  floors,  lights,  crowding  of  runways  and  aisles  are 
inspected.  In  fact,  we  try  to  have  good  housekeeping  in  a  factory.  The 
reports  are  sent  to  the  respective  department  heads  for  correction  of 
defects  found  in  their  departments. 

Our  days  are  busy  ones  and  average  through  the  colder  months  from 
85  to  125  patients  daily.  In  the  summer  the  attendance  drops  off  about 
twenty  per  cent  due  to  vacations  and  healthier  outdoor  living. 

Our  work  is  interesting  and  varied,  no  two  days  alike.  We  are  mingl- 
ing with  business  executives  and  up-to-the-minute  industrial  problems,  so 
that  our  minds  cannot  help  being  stimulated  and  kept  wide  awake  with 
what  is  going  on  in  the  industrial  world. 

SOCIAL  WORK  AND  THE  SCHOOL*  L 

Mary  P.  Billmeyer,  A.B.,  R.N., 
Department  Consultant  in  Public  Health  Nursing 

What  is  social  work?  As  you  go  out  from  your  home  in  your  town, 
your  life  is  influenced  by  social  conditions  over  which  you  as  an  indi- 
vidual have  little  or  no  control.  The  very  house  in  which  you  live  may 
be  good  or  bad;  the  streets  may  be  dangerous  or  safe;  the  water  and 
milk  supply  may  give  you  typhoid  fever  or  keep  you  healthy;  the  school 
houses  may  be  sanitary  or  may  be  unfit  for  any  child,  according  to  the 
extent  to  which  the  social  consciousness  of  the  people  of  your  community 
has  been  awakened. 

You  have  then  lived  in  a  community.  Perhaps  in  your  school  was  a 
child  who  was  not  promoted  because  of  mental  incapacity  or  some  other 
cause;  perhaps  you  know  of  a  family  where  there  was  want  because  the 
father  had  deserted  or  was  ill,  or  for  some  reason  could  not  earn  enough 
to  support  his  family;  perhaps  even  in  your  own  family  difficult  problems 
arose,  such  as  sickness,  discouragement,  the  choice  of  a  vocation.  Per- 
haps you  were  even  a  member  of  a  gang  which  became  a  boy  scout 
troop,  or  you  learned  games  in  a  playground  transformed  from  a  vacant 
lot;   or  knew  of  efforts  to  fight  tuberculosis.     Perchance  a  place  was 

*  Talk  given  at  the  School  Hygiene  Conference December  1930. 


198 
opened  by  the  Red  Cross  or  some  other  group  where  people  could  be 
examined  and  where  information  on  health  matters  was  given  out.  You 
may  have  seen  a  nurse  in  uniform  making  visits  either  in  the  city  homes 
or  distant  farm  houses.  If  you  lived  in  the  city  you  may  have  gone  to 
the  Y.  M.  C.  A.,  the  K.  of  C.  or  the  Y.  W.  C.  A.,  or  a  settlement ;  or  have 
been  a  member  of  an  organized  club  in  your  church.  Back  of  all  this 
activity  lies  a  framework  of  skilled  effort  which  has  come  to  be  con- 
sidered a  profession. 

In  discussing  social  work  as  a  profession  it  is  necessary  to  clarify 
certain  conceptions  which  are  popularly  confused  with  it.  As  is  the  case 
with  any  activity  that  has  emerged  into  professional  status  and  differ- 
entiated itself  from  the  kind  of  activity  in  which  any  one  of  ordinary 
intelligence  might  participate,  social  work  must  live  down  a  variety  of 
names  and  conceptions  which  were  common  to  it  in  its  early  and  unpro- 
fessional forms. 

Much  of  social  work  had  its  origin  in  religious  almsgiving  and 
"charity"  and  the  latter  words  persist  in  many  combinations.  "Phil- 
anthropy," too,  is  much  used,  particularly  by  those  who  wish  to  avoid  a 
narrowly  religious  flavor  of  "charity."  "Social  Service"  is  becoming  a 
popular  term  as  "social  reform"  once  was. 

There  is  no  intention  here  to  give  an  authoritative  definition  of  these 
terms  or  of  "social  work."  It  is  necessary  only  to  interpret  their  usual 
meanings  in  relation  to  social  work  as  a  profession.  "Social  service" 
must  be  accepted  with  the  connatation  of  its  literal  meaning  "service 
to  society."  This  prevents  any  single  profession  laying  exclusive 
claim  to  it,  for  it  is  hard  to  say  what  profession  is  not,  in  some  of  its 
aspects  at  least,  a  service  to  society.  "Philanthropy,"  if  accepted  in  its 
literal  meaning  of  "love  of  man,"  denotes,  like  charity,  a  motive  or  state 
of  mind  rather  than  an  activity.  In  a  somewhat  perverted  use  these 
terms  imply  the  giving  of  material  things  from  one  who  has  to  one  who 
has  not.  A  process  so  largely  composed  of  motive  and  the  mere  act  of 
giving,  is  not  to  be  granted  the  status  of  professional  activity. 

So  we  come  to  the  term  "social  work"  for  a  connotation  which  at  least 
has  implications  of  a  process  requiring  specialized  knowledge  and  skill 
sufficient  to  be  called  professional.  It  is  well  also  to  point  out  here  that 
emphasis  must  be  placed  on  "process"  as  an  aid  to  keeping  in  mind  the 
fact  that  not  what  is  done,  but  how  it  is  done,  is  what  constitutes  the 
test  of  professional  activity.  To  the  uninitiated  onlooker  the  activity 
may  look  like  social  work,  but  only  the  way  the  thing  is  being  done  and 
the  actual  achievement  will  determine  the  presence  or  absence  of  profes- 
sional skill.  A  building  in  construction  shows  a  variety  of  trades  at 
work,  but  only  a  knowledge  of  the  process  reveals  the  professional  archi- 
tect at  its  heart.  It  may  not  seem  difficult  on  the  face  of  it,  to  take  an 
orphan  child  and  turn  it  over  to  a  family,  but  only  the  skilled  process  of 
the  professional  social  worker  guarantees  the  reasonable  adjustment 
between  the  child  and  the  foster  family  which  will  make  possible  normal 
life  for  that  child " 

What  then  are  the  processes  of  professional  social  work?  "From  time 
immemorial  and  especially  since  the  beginning  of  the  Christian  era, 
charitable  and  philanthropic  motives  have  led  to  activity  in  behalf  of 
the  sick,  the  unfortunate  and  the  uncared  for.  The  advent  of  the  present 
civilization,  based  so  largely  upon  machinery  and  the  industrial  system, 
brought  so  many  and  such  rapid  changes  in  environment  that  the  number 
of  people  badly  adjusted  to  their  life  circumstances  increased  tremen- 
dously. Of  itself  the  resultant  misery  was  sufficient  to  call  forth  in- 
creased philanthropic  activity,  but  two  contributing  factors  should  be 
noted.  The  first  was  the  increase  in  wealth  of  a  small  group  with  the 
inevitable  sharp  contrast  to  those  less  well  situated;  the  second  is  the 
growth  of  the  philosophies  and  humanistic  sciences  in  the  realms  of 
economics  and  sociology.  The  result  was,  that  beginning  a  century  ago 
and  developing  along  with  the  growth  of  the  industrial  system  and  of 


199 
urban  population,  there  has  arisen  an  enormous  amount  and  wide  variety 

of  philanthropic  activity Both  in  governmental  activity,  through 

laws  and  administrative  machinery,  and  in  voluntary  activity  supported 
by  financial  contributions,  the  work  has  advanced  to  care  for  the  sick, 
the  dependent,  the  defective;  to  provide  for  recreation,  housing  and 
other  needs;  to  induce  communities  and  states  to  help  in  building  the 
environment  that  would  make  for  better  life;  and  to  educate  people  for 
the  task  of  securing  normal  individual,  family  and  community  life. 

Trying  the  simple  tasks  first,  such  as  accommodating  orphans  in  an 
asylum,  we  have  progressed  to  the  attempt  to  meet  more  scientifically 
the  needs  of  disadvantaged  individuals,  and  in  some  degree  to  the  task 
of  attacking  social  problems  at  their  roots,  with  particular  emphasis  on 
the  possibilities  of  preventing  many  of  the  situations  which  previously 
had  seemed  to  call  for  amelioration  only. 

In  a  parallel  course  there  has  been  increase  in  knowledge  and  develop- 
ment of  the  medical  and  social  sciences,  biology,  bacteriology,  economics, 
psychology,  and  sociology.  Into  them  we  have  dipped  more  and  more 
for  the  scientific  approach  to  the  problems  with  which  social  workers  are 
concerned.  They  have  furnished  us  not  merely  with  the  weapons  with 
which  to  attack  such  problems,  but  they  have  broadened  the  scope  and 
made  visible,  possibilities  of  attack  upon  evils  which  had  heretofore  been 
accepted  as  natural  and  therefore  to  be  borne  with  patience  and  resig- 
nation. 

As  is  always  the  case  where  a  large  number  of  people  are  engaged  in 
a  somewhat  similar  task  this  tremendous  amount  of  work  in  behalf  of 
human  welfare  led  to  exchange  of  ideas  through  discussion  and  tech- 
nical writing,  and  to  experimentation  for  the  development  and  testing  of 
new  methods.  The  effort  to  train  new  workers  and  their  spread  from 
place  to  place  contributed  to  this  development. 

With  the  growth  of  this  common  body  of  knowledge  there  have 
developed  certain  common  processes  or  methods  of  attack  more  or  less 
consciously  employed  by  social  workers.  Whether  these  processes  are 
entitled  as  yet  to  the  dignity  of  the  term  "techniques"  is  a  question  over 
which  one  might  quibble,  but  some  of  them  at  least  have  implications  of 
a  common  body  of  knowledge  plus  acquired  skill  which  seem  to  justify 
here  the  employment  of  the  term. 

Among  these  techniques,  the  oldest  and  best  defined  is  case  work.  It 
has  its  literature,  there  is  a  definite  plan  of  training  for  it,  and  it  has 
stood  the  test  of  being  applied  to  one  type  of  problem  after  another. 
There  are  always  individuals  and  families  who,  under  the  strain  of  life 
emergencies,  lack  the  resources  or  the  capacity  to  use  their  resources,  to 
solve  their  personal  difficulties.  There  are  many  people  so  constituted 
mentally  or  emotionally  that  they  are  never  capable  of  meeting  more  than 
their  simplest  life  problems.  Every  such  case  constitutes  a  clash  between 
the  personality — the  personal  equipment — of  the  individual  and  the 
pressure  of  his  environment,  and  results  in  a  lack  of  adjustment  and  a 
consequently  unsatisfactory  life.  The  increasing  complexity  of  modern 
life  increases  the  proportion  of  these  maladjustments. 

Families  and  individuals  find  themselves  unadjusted  in  many  ways. 
There  are  the  economic  problems  of  loss  of  the  bread  winner,  loss  of 
employment,  illness,  desertion,  housewifely  incompetence  on  the  part  of 
the  mother  and  other  causes.  There  is  the  tragedy  of  the  orphaned 
child,  of  the  neglected  and  ill-treated  child,  the  girl  with  the  illegitimate 
child,  the  individual  who  has  not  found  the  place  in  industry  where  his 
personality  fits,  the  person  whose  mental  disease  makes  his  personality 
unfitted  for  almost  every  ordinary  situation.  A  large  group  are  those 
whose  personalities  are  so  lacking  in  moral  stamina,  in  constructive  life 
habits,  so  full  of  perverted  and  mistaken  viewpoints  about  standards  of 
society,  as  to  make  them  the  delinquents,  the  law  breakers. 

To  more  and  more  of  such  situations  have  social  workers  learned 
to  apply  the  technique  of  adjustment  through  social  case  work.     This 


200 
involves  the  skill  to  make  a  thorough  investigation,  to  learn  the  reactions 
of  people  to  unsatisfactory  environment,  to  bad  housing,  unhygienic 
living,  diet,  lack  of  normal  recreational  opportunities,  difficult  working 
conditions.  The  investigation  must  reveal  further  what  resources  the 
community  has  to  counteract  these  unsatisfactory  conditions  and  how  to 
use  these  resources:  hospitals,  dispensaries,  diet  kitchens,  infant  wel- 
fare stations,  municipal  lodging  houses,  tuberculosis  clinics,  children's 
courts,  reformative  institutions,  special  educational  equipment  and 
methods,  playgrounds,  community  social  centers  and  settlements. 

With  this  knowledge  in  hand,  social  case  workers  must  have  the  skill 
to  make  and  carry  out  a  plan  for  "treatment"  whereby  people  can  be 
helped  to  appreciate  the  elements  of  their  own  strength  and  make  use  of 
them  and  the  community  resources  in  straightening  out  their  difficulties. 

Human  nature  has  an  infinite  capacity  for  responding  in  a  variety  of 
ways  to  outside  influences  or  stimuli.  The  social  case  worker  learns  the 
facts  of  an  individual's  background,  perceives  in  them  the  kind  of  re- 
sponses which  the  individual  has  made  to  surrounding  influences  and 
molds  these  influences  in  a  way  to  secure  the  desired  response  in  the 
behavior  of  that  individual. 

Perhaps  it  is  the  father  of  a  family,  discouraged  and  shiftless  as  a 
result  of  misfit,  low-wage  jobs,  unemployment,  worthless  companions.  He 
must  be  helped  to  secure  a  job  that  interests  him — and  encouraged  to 
keep  it.  Perhaps  it  is  the  delinquent  boy  or  wayward  girl  whose  active 
restlessness  must  be  turned  into  the  channels  of  a  hobby,  a  club,  or  more 
satisfactory  school  opportunities.  Life  presents  to  every  one  innumerable 
opportunities  for  getting  out  of  adjustment.  Where  one's  own  resources, 
helpful  friends,  or  relatives  fail,  or  are  lacking,  there  the  social  case 
worker  finds  a  task. 

Social  case  work  has  progressed  to  this  point  through  its  development 
along  a  number  of  lines,  always  in  connection  with  some  particular 
problem,  some  special  approach  and  with  few  exceptions  is  practised 
through  organizations.  'Among  the  types  of  social  case  work,  each  with 
its  typical  organization,  are  the  following:  child  welfare,  family  welfare, 
medical  social  service,  probation  and  parole,  protective  work,  psychiatric 
social  work,  and  visiting  teaching.'  " 

Until  recent  years,  the  differences  among  the  various  forms  of  social 
case  work  have  seemed  to  be  more  significant  than  their  common  founda- 
tion, but  at  the  present  time  the  differences  are  more  largely  administra- 
tive than  professional,  that  is,  "the  different  forms  of  social  case  work  are 
handled  by  different  agencies  chiefly  to  permit  more  economical  and 
more  efficient  organization  of  service.  To  a  considerable  extent  social  case 
work  is  now  practised  in  association  with  other  professional  services. 
It  is  a  part  of  the  medical  program  of  a  hospital,  it  is  a  part  of  the 
service  of  a  psychiatric  clinic;  it  is  incorporated  into  the  program  of 
the  school;  it  may  be  an  important  part  of  the  work  of  a  court.  These 
are  specialized  forms  of  social  case  work  as  it  is  administered  but  they 
present  fundamentally  the  same  general  purposes  and  technique." 

"What  is  family  case  work?  The  family  and  its  relationships  are  the 
setting  for  the  drama  of  life.  The  first  five  or  six  years  are  lived  en- 
tirely in  its  midst.  During  the  school  years  children  spend  five-sixths  of 
the  time  under  its  guidance  and  control.  Then  comes  the  period  of 
adolescence  and  the  beginning  of  the  efforts  to  break  away  from  the 
family  in  the  attempt  to  establish  adult  independence.  It  is  an  interlude 
of  from  5  to  10  years — a  transition  period  from  the  family  one  was  born 
into,  to  the  family  of  one's  own  making  and  choice.  The  drama  of  life 
is  indeed  enacted  within  the  family. 

The  world  seems  suddenly  to  have  rediscovered  the  family.  A  whole 
literature  has  sprung  up  about  the  significance  of  pre-school  years,  which 
most  children  spend  in  their  own  homes  with  their  families,  and  the  impor- 
tance of  the  role  of  the  parents  in  the  life  and  development  of  children. 
Recently  a   mental   hygiene   association   published   a  pamphlet   entitled 


201 
"Being  a  Parent  is  the  Biggest  Job  on  Earth."  Parents  on  every  social 
and  economic  level  are  beginning  to  realize  this  and  are  making  earnest 
efforts  to  become  more  skillful  practitioners  of  the  art  of  family  life. 
The  amount  of  interest  in  the  parent  movement  can  be  measured  by  the 
child  study  groups  that  are  being  organized  for  parents,  by  the  bibli- 
ographies that  have  been  prepared  for  them  and  by  the  quantity  of 
pamphlets  and  books  that  have  been  written  to  tell  parents  how  to  feed 
their  children,  how  to  keep  them  well  and  how  to  train  them  in  healthy 
mental  habits.  Even  colleges  are  organizing  courses  in  parenthood  for 
undergraduate  students,  men  as  well  as  women. 

It  has  come  to  be  recognized  that  there  is  an  art  of  family  life.  In 
the  problems  arising  in  the  practice  of  this  art  lies  the  field  of  family 
social  work  and  the  need  for  the  expert  skill  of  the  professional  case 
worker 

For  the  first  five  or  six  years  of  life  most  of  our  social  relationships 
are  largely  within  the  family  group.  Increasingly  after  that  period, 
life  for  all  of  us  is  one  of  expanding  social  relations,  is  one  of  adapting, 
adjusting  and  integrating  with  an  ever  larger,  wider  and  changing  social 
environment.  We  continue  to  live  in  families  and  to  meet  new  problems 
in  our  relations  to  the  family  itself,  but  problems  in  other  relationships 
are  increasingly  pressing  upon  us — our  relations  to  teacher,  to  fellow 
pupils,  to  associates  in  play,  recreation,  and  social  life  in  its  restricted 
sense,  to  employers  and  fellow  workmen,  to  friends  and  so  on  as  we 
make  new  contacts.  Here,  too,  problems  arise  that  not  all  of  us  can 
meet  successfully  without  help.  Perhaps  if  there  were  fewer  failures  in 
the  personal  relations  within  the  family,  there  would  not  be  so  many 
difficulties  in  meeting  situations  as  they  develop  outside  the  home.  When 
the  father  of  a  family  goes  away  to  a  sanatorium  for  treatment  of  tuber- 
culosis and  his  wife  and  four  children  go  to  live  with  his  parents,  no 
matter  how  rich  or  how  poor  they  are,  how  much  or  how  little  of  formal 
education  they  have  had,  there  are  bound  to  be  strains  in  either  situation. 
The  wife  will  be  worried  about  her  husband's  illness  and  their  separa- 
tion from  each  other;  she  will  have  the  problem  of  being  father  as  well 
as  mother,  and  it  will  be  no  easy  task  to  make  the  day  to  day  adjust- 
ments that  arise  when  any  two  families  attempt  to  combine  in  a  common 
living  arrangement.  But  how  much  greater  will  be  the  strain  and  how 
much  intensified  will  their  problems  be  when  the  parents-in-law  live  in 
a  five  room  house,  none  too  large  for  their  own  needs,  and  when  the 
wife  has  to  become  the  housekeeper  for  both  families  in  such  cramped 
quarters,  while  the  mother-in-law  and  father-in-law  are  working  to  pay 
for  the  house  they  are  buying  and  to  meet  the  additional  financial  burden 
of  their  son's  family.  The  task  of  straightening  the  life  of  a  family  is 
very  different  from  that  of  setting  to  rights  a  disorderly  room  where 
something  has  played  havoc  with  the  furniture — there  it  is  a  matter  of 
putting  this  table  where  it  ought  to  be,  that  chair  where  it  belongs  and 
this  picture  where  it  will  show  to  most  advantage.  Here  it  is  not  at  all 
a  matter  of  putting  in  place  but  helping  people  see  how  they  came  to  be 
in  their  present  predicaments,  how  they  can  change  their  situations  and 
motivating  them  to  desire  something  different.  In  short  it  is  not  a 
matter  of  doing  the  straightening  for  them,  but  of  interesting  them  in 
doing  it  for  themselves.  This  is  the  fundamental  in  the  philosophy  of 
every  case  worker,  whether  she  is  doing  family  case  work,  medical  social 
work  or  work  with  children. 

"Since  its  inception  approximately  20  years  ago  the  primary  aim  of 
medical  social  service  has  been  to  help  doctor  and  patient  carry  through 
a  satisfactory  plan  of  treatment,  to  gather  such  significant  data  as  may 
help  the  physician  to  discover  the  contributory  causes  of  the  patient's 
present  condition,  to  interpret  to  him  the  patient's  resources  in  such 
fashion  as  to  open  up  new  avenues  of  thought  which  may  prompt  the 
modification  of  the  original  plan  or  create  a  new  plan  which  the  patient 
can  undertake.    Helping  the  patient  carry  through  the  plan  of  treatment 


202 
often  means  utilizing  the  resources  of  the  community  in  new  ways,  and 
sometimes  the  creating  of  new  resources. 

The  tendency  in  medicine  to  place  increasing  emphasis  on  such  values 
as  good  hygiene,  adequate  and  proper  diet,  recreation,  a  job  suitable  to 
one's  strength,  a  constructive  attitude  toward  life,  has  created  new  types 
of  medical  recommendation.  The  physician  who  years  ago  might  have 
prescribed  medicine  for  a  patient  will  today  for  a  similar  condition 
advise  convalescent  care  or  a  change  of  job.  The  taking  of  pills  and 
powders  is  simple.  To  carry  out  a  recommendation  that  a  mother  leave 
her  family  for  several  weeks  convalescent  care  or  that  a  factory  worker 
change  to  an  out-of-door  job,  may  require  the  rearrangement  of  a  whole 
scheme  of  life."  Here  begins  the  task  of  closest  co-operation  between 
social  worker,  the  doctor,  and  the  public  health  nurse. 

Although  the  social  worker  and  nurse  are  concerned  primarily  with 
the  individual  patient,  they  treat  him  in  relation  to  his  family  and  con- 
cern themselves  with  the  family  group.  They  should  both  be  alert  to 
recognize  any  need  of  medical  attention  for  members  of  his  family  or 
for  persons  with  whom  they  may  come  in  contact  in  their  work  in  his 
behalf.  Further  than  this,  they  should  persuade  these  other  individuals 
to  seek  the  advice  of  a  physician,  when  there  seems  to  be  a  need  to  do  so, 
and  to  follow  his  recommendations.  For  instance,  when  visiting  a 
mother  to  plan  for  the  correction  of  defective  vision  of  a  school  child, 
the  nurse  and  medical  social  worker  noticed  that  one  of  the  children 
dragged  his  foot,  and  that  his  shoulders  were  twisted;  another  child 
seemed  unusually  pale,  thin  and  listless.  The  mother  was  easily  per- 
suaded to  take  the  two  children  to  her  family  physician  who  referred 
them  to  the  hospital  where  one  was  found  in  need  not  only  of  general 
building  up  but  also  of  special  exercise  and  a  brace  to  remedy,  if  possible, 
a  condition  resulting  from  infantile  paralysis ;  the  second  child  was  found 
to  be  seriously  malnourished,  to  have  infected  tonsils  and  chest  symptoms 
indicating  a  pre-tuberculous  condition  for  which  he  was  later  sent  to  the 
country. 

Case  work  done  in  connection  with  educational  systems,  or  "pedagogical 
casework"  as  it  has  been  called,  presents  one  of  the  most  interesting 
fields  for  the  psychiatric  social  worker. 

Psychiatric  clinics  and  child  guidance  clinics  dealing  with  personality 
and  behavior  problems  in  children  are  known  under  various  names  and 
are  carried  on  under  the  auspices  of  juvenile  courts,  community  and 
children's  agencies,  special  foundations,  state  departments  and  other 
organizations  interested  in  conserving  the  mental  health  of  children. 
Cases  are  referred  to  these  clinics  by  courts,  schools,  social  agencies, 
physicians,  public  health  nurses,  visiting  teachers,  relatives,  and  other 
organizations  and  individuals.  The  children's  problems  include  unde- 
sirable habits  such  as  enuresis,  food  fads;  personality  difficulties 
such  as  moodiness,  temper,  shyness;  and  conduct  disorders,  such 
as  disobedience,  lying,  stealing.  The  study  of  the  child  consists  in 
a  thorough  physical,  psychological  and  psychiatric  examination,  together 
with  a  social  investigation  of  the  environment,  with  special  attention  to 
the  analysis  of  the  personalities  in  the  child's  home  and  play  groups  and 
the  discipline  to  which  he  has  been  subjected.  The  child's  reactions  are 
often  explainable  in  terms  of  his  surroundings,  and  the  psychiatrist's 
recommendations  frequently  call  for  environmental  changes  which  may 
make  it  possible  for  a  particular  child  in  a  particular  stage  of  his  develop- 
ment to  be  brought  more  nearly  in  line  with  this  capacity  for  better 
integration. 

Some  psychiatric  social  workers  are  employed  as  visiting  teachers  in 
the  elementary  schools  and  to  so-called  "problem  children,"  conspicuous 
because  they  are  "too  much  in  the  foreground  or  too  much  in  the  back- 
ground" are  referred  to  the  visiting  teacher  by  the  classroom  teacher  or 
other  school  official  in  order  that  an  intensive  case  study  of  the  whole 
situation  may  be  made. 


203 

The  visiting  teacher  field  is  closely  related  to  psychiatric  social  work 
and  one  in  which  several  psychiatric  social  workers  are  engaged.  Some 
experience  in  teaching  in  addition  to  training  in  psychiatric  social  work 
is  considered  desirable  for  a  worker  connected  directly  with  a  school. 

Massachusetts,  through  a  state  law,  recognizes  the  fact  that  a 
psychiatric  examination  plus  a  psychological  and  social  inquiry  should  be 
available  for  unadjusted  children.  Any  child  who  is  in  a  given  grade  for 
three  years  or  more  is  given  such  examinations  under  the  joint  auspices 
of  the  department  of  education  and  the  department  of  mental  diseases, 
by  means  of  travelling  clinics.  These  clinics  endeavor  to  awaken  in  the 
family  and  the  local  authorities  a  feeling  of  responsibility  for  the  wel- 
fare of  the  defective  child  and  to  encourage  the  study  of  the  retarded 
child  who  is  not  defective. 

Two  school  systems,  those  of  Minneapolis,  Minnesota,  and  Newark, 
New  Jersey,  have  established  child  guidance  clinics  to  care  for  school 
problems.  The  Minneapolis  clinic,  which  was  established  as  a  result  of 
a  child  guidance  clinic  demonstration  under  the  auspices  of  the  National 
Committee  for  Mental  Hygiene  and  the  Commonwealth  Fund,  is  staffed 
by  a  psychiatrist,  psychologist  and  three  psychiatric  social  workers, 
serves  the  public  schools  and  social  agencies  and  maintains  a  close  work- 
ing relationship  with  the  visiting  teachers  and  speech  teachers  in  the 
school  system.  The  Department  of  Child  Guidance  of  the  Newark  Public 
Schools  has  at  present  a  staff  consisting  of  a  psychiatrist,  four  psychol- 
ogists, and  eight  visiting  teachers  who  have  received  either  full  training 
in  psychiatric  social  work  or  have  had  special  courses  and  field  practice 
in  psychiatric  social  work  as  part  of  their  preparation  for  visiting  teach- 
ing. The  department  concentrates  its  efforts,  so  far  as  possible,  on  the 
problem  children  of  the  lower  grades  and  is  especially  interested  in 
preventive  work  with  children  in  the  kindergarten  and  first  grade. 

Work  somewhat  similar  to  that  of  the  visiting  teacher  is  carried  on 
in  the  LaSalle-Penn  Township  High  School  and  Junior  College  in  LaSalle, 
111.,  where  a  psychiatric  social  worker  who  has  had  special  training  in 
psychology  and  experience  in  teaching  is  holding  the  position  of  educa- 
tional counselor.  Her  approach  to  the  high  school  pupils  is  through  a 
personal  interview  with  each  student,  covering  scholarship,  health, 
hygiene,  interests,  plans  and  behavior  after  which  certain  cases  are 
selected  for  social  case  work  and  psychiatric  attention.  Vocational  guid- 
ance is  a  corollary  to  the  work  and  is  represented  in  the  employment 
service,  which  also  attempts  to  develop  industrial  openings  in  the  com- 
munity for  boys  and  girls  leaving  school." 

"The  mental  hygiene  programs  conducted  within  the  last  three  or  four 
years  by  several  large  public  health  organizations  have  demonstrated 
that  the  public  health  worker  may,  under  expert  supervision,  be  developed 
into  a  valuable  asset  in  the  field  of  mental  hygiene.  Given  something  of 
the  psychiatric  point  of  view,  the  nurse  is  enabled  to  approach  the  family 
problems  she  encounters  with  quickened  powers  of  observation  and  more 
intelligent  understanding.  The  very  nature  of  her  work,  which  entails 
visiting  the  homes  and  helping  at  a  time  when  they  need  and  desire 
assistance,  affords  her  a  splendid  opportunity  for  an  intimate  and 
friendly  contact  with  the  life  of  the  family.  The  public  health  nurse  has 
a  particularly  good  opportunity  for  finding  young  children  who  are 
incipient  behavior  problems  at  a  time  when  they  respond  most  easily  to 
guidance.  It  is  being  increasingly  recognized  by  those  interested  in  the 
development  of  the  public  health  organization  that  the  public  health 
worker  is  not  rendering  the  best  type  of  health  service  unless  he  or 
she  comprehends,  not  only  the  physical  ailments  of  the  patients,  but  also 
understands  something  of  their  mental  and  emotional  problems." 

Time  does  not  permit  to  give  you  more  than  a  bird's  eye  view  of  some 
of  the  phases  of  the  vast  field  of  social  work  and  the  part  they  have  to 
play  in  the  school. 


204 

Family  case  work,  medical  social  work,  psychiatric  social  work,  visit- 
ing teaching,  each  of  these  occupies  only  a  part  of  the  field  of  social  work, 
.just  as  school  nursing  occupies  only  a  part  of  the"  field  of  public  health 
nursing.  No  specialty  can  be  learned  apart  from  the  general  subject  to 
which  it  belongs.  Workers  in  both  professions  require  a  background  of 
general  culture,  a  special  education,  combining  theory  and  practice, 
designed  to  help  them  acquire  the  knowledge,  the  technique  and  a  phil- 
osophy or  theory  of  the  subject. 

The  success  of  the  nurse's  work  in  school  is  dependent  in  no  small 
measure  upon  her  activities  carried  on  outside  of  school.  The  role  of 
the  public  health  nurse  as  well  as  the  case  worker  is  largely  that  of 
interpreter.  They  see  their  task  in  terms  of  helping  people  to  under- 
stand themselves,  of  arousing  in  them  an  appreciation  of  the  handicaps, 
struggles  and  achievements  of  others  and  of  giving  them  insight  into  the 
way  they  are  affecting  each  other.  They  are  dealing  with  attitudes, 
with  breaking  down  those  that  are  destructive  to  themselves  and  to 
others,  and  with  building  up  socially  useful  ones  in  their  places. 

But  how  can  any  one  worker  accomplish  this  alone?  How  can  you  as 
a  school  official,  as  school  physician,  as  public  health  nurse  doing  school 
work,  or  any  other  one  person  or  one  organization  solve  your  problems 
alone — the  way  they  should  be  solved?  To  be  sure  each  has  a  definite 
part  to  play,  but  it  is  only  by  combining  scattered  efforts  that  we  get 
power — just  as  by  combining  all  streams  into  a  mighty  river  we  get 
power. 

Individually  we  humans  are  an  impotent  lot,  but  collectively  we  accom- 
plish things  that  make  us  gasp  in  amazement.  It's  a  lot  more  fun  to  ride 
at  the  head  of  the  procession  on  a  dashing  charger,  but  it's  the  army 
behind  the  man  at  the  head  of  the  procession  that  wins  the  wars.  In 
our  fight  for  better  health  conditions,  we  are  upsetting  traditions,  chang- 
ing the  mode  of  living  and  doing  all  sorts  of  things  that  require  intelli- 
gent understanding,  sympathy,  and  support.  In  this  bloodless  revolu- 
tion for  health  that  is  going  on  in  this  country,  the  hearty,  united  co- 
operation of  everybody  is  needed  if  success  is  to  be  won. 

This  sad  yet  inspiring  story  of  the  wheat  country  portrays  the  value 
of  working  together — side  by  side. 

Some  years  ago  a  small  child  wandered  away  and  became  lost  in  the 
immense  wheat  fields  surrounding  her  home.    The  parents  and  neighbors 
searched   frantically,   but  she  was   not   found.      Finally   one  man   said, 
"Instead  of  each  of  us  searching  independently,  let  us  clasp  hands  and 
move  forward  together."     This  was  done  and  the  child  was  soon  found, 
but  not  in  time  to  save  her  life,  and  the  father  in  his  grief  said,  "Would 
to  God  we  had  clasped  hands  sooner  and  moved  forward  together." 
NOTE:     Most  of  the  content  of  this  paper  includes  exerpts  from  the 
American  Association  of  Social  Workers  publications: 
Vocational  Aspects  of  Psychiatric  Social  Work 
Vocational  Aspects  of  Family  Social  Work 
Vocational  Aspects  of  Medical  Social  Work 

THE  SCIENTIFIC  RESEARCH  WORK  OF  THE  U.  S.  PUBLIC 
HEALTH  SERVICE* 

Surgeon  General  H.  S.  Gumming 

In  the  late  eighties  of  the  last  century  some  of  the  medical  officers  sta- 
tioned at  the  old  Marine  Hospital  at  Stapleton,  New  York,  set  up  in  one 
of  the  large  rooms  of  that  spacious  institution  a  laboratory  in  which  they 
could  investigate  for  themselves  some  of  the  interesting  problems  of  the 
then  new  science  of  bacteriology. 

With  touching  naivete  they  confirmed  the  bacterial  etiology  of  Asiatic 
cholera,  and  Laveran's  plasmodial  cause  of  malaria.     With  a  rather  impres- 

*Address  given  at  the  New  England  Health  Institute,  Boston,  Mass.,  April  15,  1930. 


205 

sive  sureness  of  touch  they  tested  out  various  fumigants  and  disinfectants 
which  were  destined  to  play  a  considerable  part  in  coming  years  of  quaran- 
tine practice.  Here  it  was  that  James  J.  Kinyoun  made  the  beginnings  of 
his  life  career  as  a  bacteriologist. 

It  was  but  a  few  years  before  the  Bureau  of  the  Public  Health  Service 
accorded  deserved  recognition  to  this  little  laboratory,  already  known  as 
the  Hygienic  Laboratory,  by  moving  it  into  more  roomy  quarters  in  the 
Butler  Building  in  Washington.  In  1903  a  separate  building,  authorized 
by  Act  of  Congress,  was  erected  for  the  Hygienic  Laboratory  on  the  present 
site.  Additional  buildings  came  in  due  time,  and  now  we  are  drawing  up 
plans  for  still  another  200-foot  addition. 

During  those  same  early  years,  in  the  yellow-fever-ridden  cities  and 
villages  of  the  Gulf  States,  a  medical  officer  of  the  Public  Health  Service 
labored  with  mind  and  body  to  combat  that  dreadful  scourge.  Though  he 
drove  his  rather  frail  body  hard,  he  spared  his  fine  strong  mind  still  less. 
Epidemiology  was  little  known  as  a  word,  still  less  as  a  science.  Henry 
Carter  made  one  of  the  most  brilliant  applications  of  epidemiological  method 
on  record,  one  of  the  finest  essays  in  accurate  observation  and  rigid  deduc- 
tion. As  a  result  he  announced  in  1901  the  inescapable  conviction  that 
yellow  fever  had  an  extrinsic  as  well  as  an  intrinsic  period  of  incubation, 
defined  the  limits  of  each,  and  predicted  the  discovery  of  the  intermediate 
host  which  was  necessary  for  the  completion  of  the  life  cycle  of  the  parasite. 

I  do  not  cite  these  examples  of  research  work  by  officers  of  the  Public 
Health  Service  as  the  earliest  on  record.  I  assume  that  earlier  instances 
could  readily  be  collected.  But  it  does  seem  of  interest  to  observe  that 
before  the  Pasteur  Institute  was  founded,  and  before  epidemiology  was  a 
generally  accepted  tool  in  the  hands  of  public  health  authorities,  the  Public 
Health  Service  had  established  a  Hygienic  Laboratory,  and  was  making 
good  use  of  epidemiological  methods.  There  has  been  no  remission  of  scien- 
tific research  on  the  part  of  the  Public  Health  Service  since  the  occurrences 
which  I  have  mentioned,  and  the  studies  have  always  been  divisible  into  the 
two  general  groups  illustrated  by  these  examples:  laboratory  studies  and 
field  studies.  Of  course,  the  line  of  demarcation  is  not  and  should  not  be  a 
sharply  defined  one.  Officers  or  parties  of  officers  make  sallies  into  the 
field  from  the  Hygienic  Laboratory  for  the  observation  and  collection  of 
material,  and  field  investigators  retreat  with  their  collected  data  and  speci- 
mens to  the  Hygienic  and  other  laboratories  of  the  Public  Health  Service 
for  that  portion  of  their  studies  requiring  laboratory  facilities.  Perhaps  it 
is  because  the  funds  for  these  two  types  of  investigation  are  necessarily  kept 
separate  that  we  continue  to  make  the  distinction. 

The  legal  enactments  which  authorize  the  research  work  of  the  Public 
Health  Service  are  collectively  very  liberal  as  regards  the  scope,  nature  and 
location  of  the  studies  which  may  be  undertaken.  The  funds,  however,  are 
derived  entirely  from  annual  appropriations,  and  while  I  have  no  desire  to 
imply  that  the  powers  that  be  have  been  parsimonious  when  we  consider 
the  multifarious  demands  on  the  Federal  treasury,  I  am  safe  in  saying  that 
the  funds  have  never  been  adequate  for  the  carrying  out  of  all  of  our  plans 
for  useful  research  in  important  health  problems. 

As  to  what  these  researches  have  consisted  of  in  the  past,  I  cannot  hope 
to  give  a  detailed  statement.  We  have  a  list  of  publications  which  serves 
as  an  index  to  our  published  researches,  which  will  gladly  be  sent  on  request 
to  interested  persons. 

In  the  four  divisions  of  the  Hygienic  Laboratory  as  at  present  constituted, 
work  has  been  and  is  being  prosecuted  along  the  lines  of  fundamental  and 
applied  science  in  the  basic  subjects  which  bear  upon  public  health :  physics 
and  chemistry,  bacteriology,  pathology  and  parasitology,  and  physiology 
and  pharmacology.  In  another  laboratory  in  Cincinnati  those  subjects 
which  bear  upon  the  various  problems  of  stream  pollution,  water  purification 
and  sewage  treatment  are  under  study,  while  at  the  leprosy  investigation 
station  at  Honolulu,  the  question  of  the  treatment  and  management  of 
leprosy  is  being  approached  from  the  clinical-laboratory  standpoint.     Small 


206 

field  laboratories  are  often  established  to  serve  the  needs  of  some  special 
field  investigation.  For  example,  we  have  a  trachoma  laboratory  in  Mis- 
souri, a  malaria  laboratory  in  Virginia,  and  are  projecting  temporary  field 
laboratories  for  the  study  of  air  pollution  and  psittacosis. 

Now  in  all  of  these  studies  we  are  bound  by  circumstances  to  recognize 
the  need  for  two  types  of  laboratory  investigation,  both  indispensable  if 
progress  is  to  take  place.  The  one  type  approaches  the  field  of  pure  science, 
if,  indeed,  it  does  not  invade  and  occupy  it,  in  that  its  object  is  the  enlarge- 
ment of  the  scope  of  knowledge  without  clearly  foreseen  immediate  benefits. 
Before  we  can  answer  many  questions  of  insistent  importunity,  we  must 
clear  away  vast  areas  of  ignorance,  and  if  we  are  wise  we  shall  do  it  funda- 
mentally. My  own  impression  is  that  we  shall  never  make  much  permanent 
change  in  the  cancer  situation  until  we  know  vastly  more  about  the  living 
animal  cell  than  we  do  now;  its  chemistry  in  action,  its  electrical  responses, 
its  permeability,  and  other  physical  phenomena.  This  is  a  job  for  the 
concerted  attack,  not  of  surgeons  and  internists,  not  even  of  pathologists 
or  medical  histologists,  but  for  specialists  in  the  various  disciplines  which 
consider  living  cells  from  the  standpoints  of  fundamental  physics,  chemistry 
and  biology. 

On  the  other  hand  we  have  many  pressing  practical  vicissitudes  of  public 
health  which  we  are  called  upon  to  meet  with  immediate  measures  of  relief. 
It  is  demanded  of  us  that  they  be  quick,  effectual  and  cheap,  and  this  often 
constitutes  what  may  be  called  a  large  order.  Sometimes  it  is  our  privilege 
to  comply  measurably  with  the  demand.  At  other  times  we  are  obliged  to 
respond  with  imperfect  or  belated  answers.  At  other  times  we  try  hard  but 
fail  and  die  both  literally  and  figuratively  in  the  attempt.  You  are  prob- 
ably acquainted  with  the  tragic  first  encounter  with  psittacosis,  an  enemy 
which,  on  the  basis  of  accepted  report,  we  underestimated.  Now  with  a 
small  band  of  workers  whom  we  hope  are  "immunes,"  we  propose  to  return 
to  the  attack.  A  small  thing,  this  little  outbreak  of  the  past  winter,  but  if 
there  is  one  thing  which  health  officials  should  have  learned,  it  is  not  to 
despise  the  day  of  small  things.  Suppose,  for  example,  that  one  or  more 
species  of  wild  birds  or  of  domesticated  fowls  or  animals  should  have  this 
infection  engrafted  upon  it!  At  least  we  should  be  forehanded  and  be  able 
to  speak  with  demonstrated  knowledge. 

I  find  that  I  have  insensibly  slipped  over  from  the  consideration  of  labora- 
tory investigations  into  that  of  field  studies.  Under  this  general  heading 
we  are  taking  up  a  considerable  variety  of  subjects.  For  many  years  we 
have  contributed  to  the  subject  of  child  hygiene.  Interesting  studies  are 
in  process  at  present  bearing  on  three  of  the  major  categories  of  what  might 
be  called  public  pathology  in  this  connection:  the  infections,  nutrition,  and 
mental  causes.  In  my  way  of  thinking  I  have  come  to  believe  that  there 
are  but  three  more  categories  to  consider  in  order  to  make  a  fairly  complete 
program,  and  these  are  the  toxic,  the  social  and  economic,  and  finally 
heredity.  I  am  free  to  confess  that  up  to  the  present  time  the  Public 
Health  Service  has  done  but  little  in  a  public  way  to  influence  heredity  as  a 
health  factor.  But  in  all  of  the  other  categories  we  have  at  least  had  some- 
thing to  say. 

In  nutrition  we  are  still  working  at  pellagra  for  three  very  good  reasons. 
One,  that  the  disease  is  still  unconquered  for  economic  reasons  and  consti- 
tutes a  serious  though  geographically  limited  menace.  We  must  find  the 
cheap  foodstuffs  which  will  prevent  pellagra.  The  second  reason  is  that 
we  have  an  ideal  arrangement  for  the  study  of  this  disease,  and  the  third 
is  that  there  is  a  virtue  in  completing  a  job.  Incidentally,  the  side  issues 
are  proving  most  fruitful, — a  fatty  degeneration  of  the  liver  of  dietary 
origin,  and  a  toxic  anemia  from  over-doses  of  a  common  vegetable. 

Speaking  of  nutrition  reminds  me  of  our  milk  program.  I  hardly  know 
just  what  category  to  place  this  in,  but  it  seems  to  be  heading  up  in  sociology, 
economics  and  mass  psychology.  We  have  known  for  some  years  how  to 
produce  clean  milk  and  how  to  make  it  safe.  Our  study  is  to  find  out  why 
the  people  do  not  actually  get  that  kind. 


207 

Industrial  hygiene  is  fast  heading  toward  a  predominance  of  toxic  ques- 
tions. The  chemistry  of  industry  is  supplanting  its  mechanics.  We  are 
becoming  curious  as  to  the  effect  of  smoke  palls  over  our  cities.  Are  they 
chiefly  toxic  or  do  they  operate  by  deprivation  of  needed  radiations? 

As  I  have  intimated,  it  is  utterly  impossible  to  enumerate  or  consider  in 
any  detail  the  many  lines  of  research  in  which  the  Public  Health  Service 
is  now  engaged.  I  must  take  refuge  in  generalities.  Now,  doubtless, 
such  is  the  uncertainty  of  research,  some  of  our  present  activities  will  prove 
not  to  have  been  very  profitable.  We  shall  charge  that  up  to  profit  and 
loss  and  endeavor  to  guess  better  the  next  time. 

And  on  the  other  hand  there  are  doubtless  some  or  many  health  questions 
demanding  solution,  which  we  are  not  at  present  working  upon.  Now  this 
is  one  of  the  many  junctures  at  which  we  look  to  the  instructed  public,  to 
the  medical  profession,  and  above  all,  to  the  public  health  profession  for 
suggestions  and  advice.  I  therefore  take  this  opportunity  to  invite  sug- 
gestions at  any  time  as  to  lines  of  investigation  which  would  appear  to  be 
demanded  and  which  are  suitable  for  the  Public  Health  Service  to  undertake. 
Not  that  there  is  any  dearth  of  suggestions, — far  from  it,  but  the  source 
and  quality  often  leaves  something  to  be  desired.  If  we  yielded  to  the 
demands  to  investigate  the  healing  qualities  of  apparently  every  privately- 
owned  spring  water  in  the  United  States,  we  could  keep  busy,  but  the  profit 
to  humanity  might  not  be  great,  and  we  should  probably  make  as  many 
enemies  as  friends.  The  man  with  the  axe  to  grind  was  apparently  as 
prolific  as  the  Jukes  and  the  Kallikaks,  and  his  progeny  as  pernicious. 

The  purposes  of  these  investigations  are  the  combating  of  disease  and  the 
encouragement  of  positive  health  by  the  increase  of  knowledge  and  the 
assistance  of  health  officials  in  accomplishing  these  ends.  It  is  natural, 
therefore,  that  they  deal  primarily  with  preventive  as  distinguished  from 
curative  medicine,  but  as  is  well  known,  it  is  sometimes  the  case  that  the 
best  means  of  preventing  the  spread  of  disease  is  the  rapid  cure  of  existing 
cases.  Again,  the  prevention  of  mortality  when  we  are  unable  successfully 
to  restrict  morbidity  is  a  public  health  function.  To  this  extent  we  feel 
justified  in  entering  the  field  of  curative  medicine. 

In  conclusion,  I  wish  to  emphasize  the  fact  that  the  Public  Health  Service 
belongs  to  the  people  of  the  United  States.  It  was  established  and  is  main- 
tained in  their  interest  and,  like  all  of  the  Government  services,  should  be 
made  use  of.  While  we  cannot  undertake  to  solve  the  medical  and  health 
problems  of  individual  citizens,  and  have  no  desire  nor  authority  to  en- 
croach upon  the  field  of  the  practicing  physician  or  the  local  health  official, 
it  is  the  desire  of  the  personnel  of  the  Public  Health  Service  to  be  helpful  to 
all,  and  so  to  direct  the  research  and  other  functions  of  the  Service  as  best 
to  secure  that  end. 

ADDRESS  BY  PRESIDENT  HOOVER 

Opening  Session  of 

the  White  House  Conference  on  Child  Health  and  Protection, 

November  19,  1930. 

Something  more  than  a  year  ago  I  called  together  a  small  group  of  repre- 
sentative men  and  women  to  take  the  initial  steps  in  organization  of  this 
Conference  on  Child  Health  and  Protection.  Under  the  able  chairmanship 
of  Secretary  Wilbur,  and  the  executive  direction  of  Doctor  Barnard,  organ- 
ization was  perfected  and  enlarged  until  by  the  fall  of  last  year  something 
over  1,200  of  our  fellow-citizens  were  enlisted  from  every  field  of  those  who 
have  given  a  lifetime  of  devotion  to  public  measures  for  care  of  childhood. 
These  skillful  and  devoted  friends  of  children  have  given  unsparingly  and 
unselfishly  of  their  time  and  thought  in  research  and  collection  of  the  knowl- 
edge and  experience  in  the  problems  involved.  Their  task  has  been  magni- 
ficently performed,  and  today  they  will  place  before  you  such  a  wealth  of 
material  as  was  never  before  brought  together. 

I  am  satisfied  that  the  three  days  of  your  conference  here  will  result  in 


208 
producing  to  our  country  from  this  material  a  series  of  conclusions  and 
judgments  of  unprecedented  service  in  behalf  of  childhood,  the  benefits  of 
which  will  be  felt  for  a  full  generation. 

I  wish  to  express  my  profound  appreciation  to  all  those  who  have  so 
generously  contributed  the  time  and  thought  and  labor  to  this  preparation, 
and  to  you  for  giving  your  time  to  its  consideration.  The  reward  that  ac- 
crues to  you  is  the  consciousness  of  something  done  unselfishly  to  lighten 
the  burdens  of  children,  to  set  their  feet  upon  surer  paths  to  health  and  well 
being  and  happiness.  For  many  years  I  have  hoped  for  such  a  national 
consideration  as  this.  You  comprise  the  delegates  appointed  by  our  Federal 
departments  and  by  the  governors  of  our  States,  the  mayors  of  our  cities, 
and  the  representatives  of  our  great  national  associations,  our  medical  and 
public  health  professions.  In  your  hands  rest  the  knowledge  and  authority 
outside  of  the  home  itself. 

In  addressing  you  whom  I  see  before  me  here  in  this  auditorium,  I  am 
mindful  also  of  the  unseen  millions  listening  in  their  homes,  who  likewise 
are  truly  members  of  this  conference,  for  these  problems  are  theirs — it  is 
their  children  whose  welfare  is  involved,  its  helpful  services  are  for  them 
and  their  co-operation  is  essential  in  carrying  out  a  united  and  nation-wide 
effort  in  behalf  of  the  children. 

We  approach  all  problems  of  childhood  with  affection.  Theirs  is  the 
province  of  joy  and  good  humor.  They  are  the  most  wholesome  part  of  the 
race,  the  sweetest,  for  they  are  fresher  from  the  hands  of  God.  Whimsical, 
ingenious,  mischievous,  we  live  a  life  of  apprehension  as  to  what  their 
opinion  may  be  of  us;  a  life  of  defense  against  their  terrifying  energy;  we 
put  them  to  bed  with  a  sense  of  relief  and  a  lingering  of  devotion.  We 
envy  them  the  freshness  of  adventure  and  discovery  of  life;  we  mourn  over 
the  disappointments  they  will  meet. 

The  fundamental  purpose  of  this  conference  is  to  set  forth  an  under- 
standing of  those  safeguards  which  will  assure  to  them  health  in  mind  and 
body.  There  are  safeguards  and  services  to  childhood  which  can  be  pro- 
vided by  the  community,  the  State,  or  the  Nation — all  of  which  are  beyond 
the  reach  of  the  individual  parent.  We  approach  these  problems  in  no 
spirit  of  diminishing  the  responsibilities  and  values  or  invading  the  sancti- 
ties of  those  primary  safeguards  to  child  life — their  homes  and  their  mothers. 
After  we  have  determined  every  scientific  fact,  after  we  have  erected  every 
public  safeguard,  after  we  have  constructed  every  edifice  for  education  or 
training  or  hospitalization  or  play,  yet  all  these  things  are  but  a  tithe  of 
the  physical,  moral,  and  spiritual  gifts  which  motherhood  gives  and  home 
confers.  None  of  these  things  carry  that  affection,  that  devotion  of  soul, 
which  is  the  great  endowment  from  mothers.  Our  purpose  here  today  is 
to  consider  and  give  our  mite  of  help  to  strengthen  her  hand  that  her  boy 
and  girl  may  have  a  fair  chance. 

Our  country  has  a  vast  majority  of  competent  mothers.  I  am  not  so 
sure  of  the  majority  of  competent  fathers.  But  what  we  are  concerned 
with  here  are  things  that  are  beyond  her  power.  That  is  what  Susie  and 
John  take  on  when  out  from  under  her  watchful  eye.  She  cannot  count 
the  bacteria  in  the  milk;  she  cannot  detect  the  typhoid  which  comes  through 
the  faucet,  or  the  mumps  that  pass  round  the  playground.  She  cannot 
individually  control  the  instruction  of  our  schools  or  the  setting  up  of  com- 
munity-wide remedy  for  the  deficient  and  handicapped  child.  But  she  can 
insist  upon  officials  who  hold  up  standards  of  protection  and  service  to  her 
children — and  one  of  your  jobs  is  to  define  these  standards  and  tell  her  what 
they  are.  She  can  be  trusted  to  put  public  officials  to  the  acid  test  of  the 
infant  mortality  and  service  to  children  in  the  town — when  you  set  some 
standard  for  her  to  go  by. 

These  questions  of  child  health  and  protection  are  a  complicated  problem 
requiring  much  learning  and  much  action.  And  we  need  have  great  concern 
over  this  matter.  Let  no  one  believe  that  these  are  questions  which  should 
not  stir  a  nation;  that  they  are  below  the  dignity  of  statesmen  or  govern- 
ments.    If  we  could  have  but  one  generation  of  properly  born,  trained, 


209 

educated,  and  healthy  children,  a  thousand  other  problems  of  government 
would  vanish.  We  would  assure  ourselves  of  healthier  minds  in  more 
vigorous  bodies,  to  direct  the  energies  of  our  nation  to  yet  greater  heights 
of  achievement.  Moreover,  one  good  community  nurse  will  save  a  dozen 
future  policemen. 

Our  problem  falls  into  three  groups :  First,  the  protection  and  stimulation 
of  the  normal  child;  second,  aid  to  the  physically  defective  and  handicapped 
child;   third,  the  problems  of  the  delinquent  child. 

Statistics  can  well  be  used  to  give  emphasis  to  our  problem.  One  of  your 
committees  reports  that  out  of  45,000,000  children — 

35,000,000  are  reasonably  normal. 

6,000,000  are  improperly  nourished. 

1,000,000  have  defective  speech. 

1,000,000  have  weak  or  damaged  hearts. 

675,000  present  behavior  problems. 

450,000  are  mentally  retarded. 

382,000  are  tubercular. 

342,000  have  impaired  hearing. 

18,000  are  totaUy  deaf. 

300,000  are  crippled. 

50,000  are  partially  blind. 

14,000  are  wholly  blind. 

200,000  are  delinquent. 

500,000  are  dependent. 

And  so  on,  to  a  total  of  at  least  ten  millions  of  deficients,  more  than  80 
per  cent  of  whom  are  not  receiving  the  necessary  attention,  though  our 
knowledge  and  experience  show  that  these  deficiencies  can  be  prevented 
and  remedied  to  a  high  degree.  The  reports  you  have  before  you  are  not 
only  replete  with  information  upon  each  of  these  groups,  they  are  also  vivid 
with  recommendation  for  remedy.  And  if  we  do  not  perform  our  duty  to 
these  children,  we  leave  them  dependent,  or  we  provide  from  them  the 
major  recruiting  ground  for  the  army  of  ne'er-do-wells  and  criminals. 

But  that  we  be  not  discouraged  let  us  bear  in  mind  that  there  are  35,000,000 
reasonably  normal,  cheerful  human  electrons  radiating  joy  and  mischiefs 
and  hope  and  faith.  Their  faces  are  turned  toward  the  light — theirs  is  the 
life  of  great  adventure.  These  are  the  vivid,  romping,  every-day  children, 
our  own  and  our  neighbor's,  with  all  their  strongly  marked  differences — and 
the  more  differences  the  better.  The  more  they  charge  us  with  their  sepa- 
rate problems  the  more  we  know  they  are  vitally  and  humanly  alive. 

From  what  we  know  of  foreign  countries,  I  am  convinced  that  we  have 
a  right  to  assume  that  we  have  a  larger  proportion  of  happy,  normal  children 
than  any  other  country  in  the  world.  And  also,  on  the  bright  side,  your 
reports  show  that  we  have  1,500,000  specially  gifted  children.  There  lies 
the  future  leadership  of  the  nation  if  we  devote  ourselves  to  their  guidance. 

In  the  field  of  deficient  and  handicapped  children,  advancing  knowledge 
and  care  can  transfer  them  more  and  more  to  the  happy  lot  of  normal 
children.  And  these  children,  less  fortunate  as  they  are,  have  a  passion 
for  their  full  rights  which  appeals  to  the  heart  of  every  man  and  woman. 
We  must  get  to  the  cause  of  their  handicaps  from  the  beginnings  of  their 
lives.  We  must  extend  the  functions  of  our  schools  and  institutions  to  help 
them  as  they  grow.  We  must  enlarge  the  services  of  medical  inspection 
and  clinics,  expand  the  ministrations  of  the  family  doctor  in  their  behalf, 
and  very  greatly  increase  the  hospital  facilities  for  them.  We  must  not 
leave  one  of  them  uncared  for. 

There  are  also  the  complex  problems  of  the  delinquent  child.  We  need 
to  turn  the  methods  of  inquiry  from  the  punishment  of  delinquency  to  the 
causes  of  delinquency.  It  is  not  the  delinquent  child  that  is  at  the  bar  of 
judgment,  but  society  itself. 

Again,  there  are  the  problems  of  the  orphaned  children.  Fortunately 
we  are  making  progress  in  this  field  in  some  of  the  States  through  the  pres- 
ervation for  them  of  the  home  by  support  of  their  mothers  or  by  placing 
them  in  homes  and  thus  reducing  the  institutional  services. 


210 

There  are  vast  problems  of  education  in  relation  to  physical  and  mental 
health.  With  so  many  of  the  early  responsibilities  of  the  home  drained 
away  by  the  rapid  changes  in  our  modern  life,  perhaps  one  of  the  most 
important  problems  we  shall  need  to  meet  in  the  next  few  years  is  how  to 
return  to  our  children,  through  our  schools  and  extra  scholastic  channels, 
that  training  for  parenthood  which  once  was  the  natural  teaching  of  the 
home.  With  the  advance  of  science  and  advancement  of  knowledge  we 
have  learned  a  thousand  things  that  the  individual,  both  parent  and  child, 
must  know  in  his  own  self-protection.  And  at  once  the  relation  of  our  edu- 
cational system  to  the  problem  envisages  itself,  and  it  goes  further.  The 
ill-nourished  child  is  in  our  country  not  the  product  of  poverty ;  it  is  largely 
the  product  of  ill-instructed  children  and  ignorant  parents.  Our  children 
all  differ  in  character,  in  capacity,  in  inclination.  If  we  would  give  them 
their  full  chance  they  must  have  that  service  in  education  which  develops 
their  special  qualities.     They  must  have  vocational  guidance. 

Again,  there  are  the  problems  of  child  labor.  Industry  must  not  rob 
our  children  of  their  rightful  heritage.  Any  labor  which  stunts  growth, 
either  physical  or  mental,  that  limits  education,  that  deprives  children  of 
the  right  of  comradeship,  of  joy  and  play,  is  sapping  the  next  generation. 

In  the  last  half  a  century  we  have  herded  50,000,000  more  human  beings 
into  towns  and  cities  where  the  whole  setting  is  new  to  the  race.  We  have 
created  highly  congested  areas  with  a  thousand  changes,  resulting  in  the 
swift  transition  from  a  rural  and  agrarian  people  to  an  urban,  industrial 
nation.  Perhaps  the  widest  range  of  difficulties  with  which  we  are  dealing 
in  the  betterment  of  children  grows  out  of  this  crowding  into  cities.  Prob- 
lems of  sanitation  and  public  health  loom  in  every  direction.  Delinquency 
increases  with  congestion.  Overcrowding  produces  disease  and  contagion. 
The  child's  natural  play  place  is  taken  from  him.  His  mind  is  stunted  by 
the  lack  of  imaginative  surroundings  and  lack  of  contact  with  the  fields, 
streams,  trees,  and  birds.  Home  life  becomes  more  difficult.  Cheerless 
homes  produce  morbid  minds.  Our  growth  of  town  life  unendingly  imposes 
such  problems  as  milk  and  food  supplies,  for  we  have  shifted  these  children 
from  a  diet  of  ten  thousand  years'  standing. 

Nor  is  our  problem  one  solely  of  the  city  child.  We  have  grave  responsi- 
bilities to  the  rural  child.  Adequate  expert  service  should  be  as  available 
to  him  from  maternity  to  maturity.  Since  science  discovered  the  cause  of 
communicable  disease,  protection  from  these  diseases  for  the  child  of  the 
farm  is  as  much  an  obligation  to  them  as  to  the  child  of  the  city.  The  child 
of  the  country  is  handicapped  by  lack  of  some  cultural  influences  extended 
by  the  city.  We  must  find  ways  and  means  of  extending  these  influences 
to  the  children  of  rural  districts.  On  the  other  hand,  some  of  the  natural 
advantages  of  the  country  child  must  somehow  be  given  back  to  the  city 
child — more  space  in  which  to  play,  contact  with  nature  and  natural  pro- 
cesses. Of  these  the  thoughtless  city  cheats  its  children.  Architectural 
wizardry  and  artistic  skill  are  transforming  our  cities  into  wonderlands  of 
beauty,  but  we  must  also  preserve  in  them  for  our  children  the  yet  more 
beautiful  art  of  living. 

Even  aside  from  congestion,  the  drastic  changes  in  the  modern  home 
greatly  affect  the  child.  Contacts  of  parents  and  children  are  much  re- 
duced. Once  the  sole  training  school  of  the  child,  the  home  now  shares 
with  the  public  school,  the  great  children's  clubs  and  organizations,  and  a 
hundred  other  agencies  the  responsibility  for  him,  both  in  health  and  disci- 
pline, from  birth  to  maturity.  Upon  these  outside  influences  does  his 
development  now  very  largely  depend. 

The  problems  of  the  child  are  not  always  the  problems  of  the  child  alone. 
In  the  vision  of  the  whole  of  our  social  fabric,  we  have  loosened  new  ambi- 
tions, new  energies;  we  have  produced  a  complexity  of  life  for  which  there 
is  no  precedent.  With  machines  ever  enlarging  man's  power  and  capacity, 
with  electricity  extending  over  the  world  its  magic,  with  the  air  giving  us 
a  wholly  new  realm,  our  children  must  be  prepared  to  meet  entirely  new 
contacts  and  new  forces.     They  must  be  physically  strong  and  mentally 


211 

placed  to  stand  up  under  the  increasing  pressure  of  life.  Their  problem  is 
not  alone  one  of  physical  health,  but  of  mental,  emotional,  spiritual  health. 

These  are  a  part  of  the  problems  that  I  charge  you  to  answer.  This  task 
that  you  have  come  here  to  perform  has  never  been  done  before.  These 
problems  are  not  easily  answered,  they  reach  the  very  root  of  our  national 
life.  We  need  to  meet  them  squarely  and  to  accuse  ourselves  as  frankly 
as  possible,  to  see  all  the  implications  that  trail  in  our  wake,  and  to  place 
the  blame  where  it  lies  and  set  resolutely  to  attack  it.  From  your  explora- 
tions into  the  mental  and  moral  endowment  and  opportunities  of  children 
will  develop  new  methods  to  inspire  their  creative  work  and  play,  to  substi- 
tute love  and  self-discipline  for  the  rigors  of  rule,  to  guide  their  recreations 
into  wholesome  channels,  to  steer  them  past  the  reefs  of  temptation,  to  de- 
velop their  characters,  and  to  bring  them  to  adult  age  in  tune  with  life, 
strong  in  moral  fibre,  and  prepared  to  play  more  happily  their  part  in  the 
productive  tasks  of  human  society. 

There  has  not  been  before  the  summation  of  knowledge  and  experience 
such  as  lies  before  this  conference.  There  has  been  no  period  when  it  could 
be  undertaken  with  so  much  experience  and  background.  The  Nation 
looks  to  you  to  derive  from  it  positive,  definite,  guiding  judgments.  But 
greater  than  the  facts  and  the  judgments,  more  fundamental  than  all,  we 
need  the  vision  and  inspired  understanding  to  interpret  these  facts  and 
put  them  into  practice.  I  know  that  this  group  has  the  vision  and  the 
understanding,  and  you  are  the  picked  representative  of  the  people  who  are 
thus  endowed.  It  will  rest  with  you  to  light  the  fires  of  that  inspiration  in 
the  general  public  conscience,  and  from  conscience  lead  it  into  action.  The 
many  activities  which  you  are  assembled  here  to  represent  touch  a  thousand 
points  in  the  lives  of  children.  The  interest  which  they  obtain  in  the  minds 
and  hearts  of  our  country  is  a  turning  to  the  original  impulses  which  inspired 
the  foundation  of  our  Nation,  the  impulse  to  secure  freedom  and  betterment 
of  each  coming  generation.  The  passion  of  the  American  fathers  and 
mothers  is  to  lift  children  to  higher  opportunities  than  they  have  themselves 
enjoyed.  It  burns  like  a  flame  in  us  as  a  people.  Kindled  in  our  country 
by  its  first  pioneers,  who  came  here  to  better  the  opportunities  for  their 
children  rather  than  themselves,  passed  on  from  one  generation  to  the  next, 
it  has  never  dimmed  nor  died.  Indeed  human  progress  marches  only  when 
children  excel  their  parents.  In  democracy  our  progress  is  the  sum  of 
progress  of  the  individuals — that  they  each  individually  achieve  to  the  full 
capacity  of  their  abilities  and  character.  Their  varied  personalities  and 
abilities  must  be  brought  fully  to  bloom;  they  must  not  be  mentally  regi- 
mented to  a  single  mold  or  the  qualities  of  many  will  be  stifled;  the  door  of 
opportunity  must  be  opened  to  each  of  them. 

May  you  who  are  meeting  here  find  in  your  deliberations  new  fuel  with 
which  to  fight  this  flame  of  progress  so  that  this  occasion  may  be  marked 
with  a  fresh  lustre  that  will  set  us  anew  on  the  road  through  the  crowding 
complexities  of  modern  life. 

WHITE  HOUSE  CONFERENCE  ON  CHILD  HEALTH  AND  PRO- 
TECTION 

A  nineteen-point  summary  in  general  terms  of  the  rights  of  the  American 
child  was  presented  and  adopted  at  the  final  meeting  of  the  White  House 
Conference  on  Child  Health  and  Protection  as  the  conclusions  of  a  year's 
intensive  expert  study. 

The  conclusions  adopted  by  the  conference  were: 

Every  American  child  has  the  right  to  the  following  services  in  its  devel- 
opment and  protection.  The  conference  is  mindful  of  the  special  emphasis 
needed  upon  these  services  in  child  health  and  protection  in  Porto  Rico,  the 
Philippines  and  our  other  insular  possessions. 

1.  Every  child  is  entitled  to  be  understood,  and  all  dealings  with  him 
should  be  based  on  the  fullest  understanding  of  the  child. 

2.  Every  prospective  mother  should  have  suitable  information,  medical 
supervision  during  the  prenatal  period,  competent  care  at  confinement. 


212 
Every  mother  should  have  postnatal  medical  supervision  for  herself  and 
child. 

3.  Every  child  should  receive  periodical  health  examinations  before  and 
during  the  school  period,  including1  adolescence,  by  the  family  physician 
or  the  school  or  other  public  physicians  and  such  examination  by  specialists 
and  such  hospital  care  as  its  special  needs  may  require. 

4.  Every  child  should  have  regular  dental  examination  and  care. 

5.  Every  child  should  have  instruction  in  the  schools  in  health  and  in 
safety  from  accidents,  and  every  teacher  should  be  trained  in  health  pro- 
grams. 

6.  Every  child  should  be  protected  from  communicable  diseases  to  which 
it  might  be  exposed  at  home,  in  school  or  at  play,  and  protected  from 
impure  milk  and  food. 

7.  Every  child  should  have  proper  sleeping  rooms,  diet,  hours  of  sleep 
and  play,  and  parents  should  receive  expert  information  as  to  the  needs 
of  children  of  various  ages  as  to  these  questions. 

8.  Every  child  should  attend  a  school  which  has  proper  seating,  lighting, 
ventilation  and  sanitation.  For  younger  children,  kindergartens  and 
nursery  schools  should  be  provided  to  supplement  home  care. 

9.  The  school  should  be  so  organized  as  to  discover  and  develop  the 
special  abilities  of  each  child,  and  should  assist  in  vocational  guidance,  for 
children,  like  men,  succeed  by  the  use  of  their  strongest  qualities  and  special 
interests. 

10.  Every  child  should  have  some  form  of  religious,  moral  and  character 
training. 

11.  Every  child  has  a  right  to  play  with  adequate  facilities  therefor. 

12.  With  the  expanding  domain  of  the  community's  responsibilities  for 
children,  there  should  be  proper  provision  for  and  supervision  of  recreation 
and  entertainment. 

13.  Every  child  should  be  protected  against  labor  that  stunts  growth, 
either  physical  or  mental,  that  limits  education,  that  deprives  children  of 
the  rights  of  comradeship,  of  joy  and  play. 

14.  Every  child  who  is  blind,  deaf,  crippled  or  otherwise  physically  handi- 
capped should  be  given  expert  study  and  corrective  treatment  where  there 
is  the  possibility  of  relief,  and  appropriate  development  or  training.  Chil- 
dren with  subnormal  or  abnormal  mental  conditions  should  receive  adequate 
study,  protection,  training  and  care. 

Where  the  child  does  not  have  these  services,  due  to  inadequate  income 
of  the  family,  then  such  services  must  be  provided  to  him  by  the  community. 
Obviously,  the  primary  necessity  in  protection  and  development  of  children 
where  poverty  is  an  element  in  the  problem  is  an  adequate  standard  of  living 
and  security  for  the  family  within  such  groups. 

15.  Every  waif  and  orphan  in  need  must  be  supported. 

16.  Every  child  is  entitled  to  the  feeling  that  he  has  a  home.  The  exten- 
sion of  the  services  in  the  community  should  supplement  and  not  supplant 
parents. 

17.  Children  who  habitually  fail  to  meet  normal  standards  of  human 
behavior  should  be  provided  special  care  under  the  guidance  of  the  school, 
the  community  health  or  welfare  centre  or  other  agency  for  continued 
supervision,  or,  if  necessary,  control. 

18.  The  rural  child  should  have  as  satisfactory  schooling,  health,  pro- 
tection and  welfare  facilities. 

19.  In  order  that  these  minimum  protections  of  the  health  and  welfare 
of  children  may  be  everywhere  available,  there  should  be  a  district,  county 
or  community  organization  for  health  education  and  welfare,  with  full-time 
officials  co-ordinating  with  a  State-wide  program  which  will  be  respon- 
sible to  a  nation-wide  service  of  general  information,  statistics  and  scientific 
research.     This  should  include: 

a.  Trained  full-time  public  health  officials  with  public  health  nurses, 
sanitary  inspection  and  laboratory  workers. 

b.  Available  hospital  beds. 


213 

c.  Full-time  public  welfare  services  for  the  relief  and  aid  of  children  in 
special  need  from  poverty  or  misfortune,  for  the  protection  of  children  from 
abuse,  neglect,  exploitation  or  moral  hazard. 

d.  The  development  of  voluntary  organization  of  children  for  purposes 
of  instruction,  health  and  recreation  through  private  effort  and  benefaction. 
When  possible,  existing  agencies  should  be  co-ordinated. 

It  is  the  purpose  of  this  conference  to  establish  the  standards  by  which 
the  efficiency  of  such  services  may  be  tested  in  the  community  and  to  develop 
the  creation  of  such  services.  These  standards  are  defined  in  many  particu- 
lars in  the  reports  of  the  committees  of  the  conference. 

The  conference  recommends  that  the  continuing  committee  to  be  ap- 
pointed by  the  President  from  the  conference  shall  study  points  upon  which 
agreement  has  not  been  reached,  shall  develop  further  standards,  shall 
encourage  the  establishment  of  services  for  children,  and  report  to  the 
members  of  the  conference  through  the  President. 

"HEALTH  FORUM" 

On  October  4th  the  following  newspapers  in  the  State  started  to  publish 
a  series  of  questions  and  answers  under  the  caption  "A  Health  Forum," 
conducted  by  the  Massachusetts  Department  of  Public  Health: 
Holyoke  Transcript  Barnstable  Patriot 

Lynn  Item  Fall  River  LTndependent 

Fitchburg  Sentinel  New  Bedford  Times 

Clinton  Item  New  Bedford  Diario  De  Noticias 

Marlborough  Enterprise  New  Bedford  Le  Messager 

Milford  Daily  News  Maiden  News 

Pittsfield  Eagle  Beverly  Times 

Worcester  Sunday  Gazette  Chelsea  Evening  Record 

Worcester  L' Opinion  Publique  Woburn  Times 

Questions  sent  in  by  readers  will  be  answered  within  two  weeks  by  the 
Director  of  the  appropriate  division. 

Questions  should  be  limited  to  subjects  related  to  health  or  the  prevention 
of  disease.     Individual  treatment  cannot  be  prescribed. 

Persons  wishing  an  individual  reply  are  asked  to  send  a  self-addressed 
stamped  envelope  to  Health  Forum,  State  Department  of  Public  Health, 
State  House,  Boston,  Mass. 

THE  PORTO  RICAN  DIET 

That  Porto  Rico  is  in  serious  economic  straits  is  being  impressed  on  all 
of  us.  Assistance  in  their  own  country  is  not  the  only  need.  Many,  under 
the  pressure,  have  emigrated  to  this  country,  where  their  conditions  are 
not  improved  materially.  In  the  United  States,  as  in  their  own  country, 
bettered  nutrition  is  one  of  the  greatest  needs.  Because  large  numbers  have 
settled  around  New  York  City  and  because  very  little  information  had  been 
gathered  about  the  dietaries  of  the  Porto  Ricans,  a  group  of  New  York 
nutritionists  have  published  a  study  of  the  Porto  Rican  diet.  This  is  "for 
the  use  of  social  workers  who  are  interested  in  helping  the  Porto  Ricans 
with  then*  nutrition  and  health  problems." 

A  consideration  of  the  native  Porto  Rican  diet  with  its  deficiencies  is  the 
basis  for  suggestions  as  to  the  method  of  assisting  these  people  to  make  their 
diets  adequate.  As  is  true  of  all  dietary  instruction,  not  only  are  the  types 
of  foods  to  be  added  recommended,  but  also  the  buying,  preparation  and 
serving  of  these  foods.  Recipes  for  the  addition  of  milk,  eggs,  vegetables 
and  meat  substitutes  are  suggested.  A  helpful  outline  of  the  program  by 
which  instruction  in  nutrition  was  effectively  offered  these  mothers  is  also 
submitted. 

Copies  of  this  report  entitled  "The  Porto  Rican  Diet"  are  available  from 
the  Metropolitan  Life  Insurance  Company,  2  Madison  Avenue,  New  York 
City.  This  study  has  added  to  our  knowledge  of  racial  diets  and  should  be 
of  value  to  all  workers  in  this  field. 


,  . '     -        -     -  214 

NECROLOGY 

Dr.  John  A.  Ceconi 

In  this  number  of  "The  Commonhealth"  we  are  privileged  to  publish  a 
paper  presented  at  the  New  England  Health  Institute  last  April  by  Dr. 
John  A.  Ceconi.  Since  then,  on  September  21,  his  death  occurred  at  the 
untimely"  age  of  forty-nine.  It  is,  therefore,  fitting  that  the  Department 
should  take  this  opportunity  of  expressing  its  deep  appreciation  of  his 
services  and  its  profound  sense  of  loss  at  his  passing. 

Educated  in  Boston,  he  gained  his  practical  experience  and  made  his 
professional  mark  with  the  Health  and  School  Departments  of  Boston, 
except  that  during  the  War  he  had  a  heavy  communicable  disease  service 
at  Camp  Dix.  He  was  a  product  of  Boston  and  to  Boston  he  gave  all  that 
he  had. 

Although  Dr.  Ceconi's  official  life  was  as  varied  as  is  that  of  all  alert  health 
administrators,  there  were  certain  of  his  activities  that  we  of  the  State 
Department  of  Public  Health  knew  in  particular  detail:  his  early,  energetic 
and  continued  prosecution  of  diphtheria  immunization;  efforts  toward  con- 
trol of  childhood  tuberculosis  in  the  Boston  schools  with  the  development 
of  practical  administrative  means  of  handling  the  under-privileged  children; 
the  organizing  of  enthusiastic  co-operation  of  the  best  physicians  in  various 
fields  for  surveys  in  the  schools  of  heart  disease  and  other  crippling  defects ; 
skillful  reorganization  so  that  more  reasonable  intervals  of  time  were  avail- 
able for  the  medical  examinations  in  the  schools.  Obstacles  stimulated 
rather  than  atrophied  him.  Probably  few  administrators  ever  had  less  of 
the  art  of  leaving  their  burden  at  the  office  than  had  Dr.  Ceconi.  He  never 
let  go  his  responsibilities  and  carried  them  home  with  him  each  night.  This 
saved  him  from  the  curse  of  indifference  and  irresponsibility,  but  it  made 
him  perhaps  his  own  worst  task  master.  The  inevitable  fatigue  incident 
to  such  high  pressure  driving  of  himself  may  well  in  the  long  run  have  been 
a  factor  in  his  premature  death.  With  so  much  to  be  done  in  his  field  we 
cannot  well  spare  such  as  he. 


Miss  Catherine  A.  Bowen 

We  note  with  regret  the  passing  of  another  of  our  workers,  Miss  Catherine 
A.  Bowen,  who  met  death  by  accident  early  in  November.  She  served  the 
Department  faithfully  as  junior  clerk  since  August,  1919. 

BOOK  NOTES 

American  Red  Cross  Disaster  Relief  Handbook 

The  American  Red  Cross  has  recently  printed  a  new  edition  of  its  Disaster 
Relief  Handbook.  It  is  a  statement  of  Red  Cross  policies  and  procedures 
in  conducting  disaster  relief  work  and  is  intended  primarily  as  a  guide  for 
the  National   Organization  personnel. 

Our  library  has  received  sections  1  and  7  of  this  Manual,  which  deal  with 
general  Red  Cross  policies  and  with  medical  and  public  health  activities. 
Considerable  emphasis  is  placed  on  close  co-operation  with  all  local  agencies 
concerned  with  disaster  relief  problems,  particularly  the  medical  profession 
and  health  department. 

Children  of  the  Covered  Wagon.  Report  of  the  Commonwealth 
Fund,  Child  Health  Demonstration  in  Marion  County,  Oregon,  1925-1929, 
by  Estella  Ford  Warner,  M.D.,  and  Geddes  Smith.  Published  by  the  New 
York  Commonwealth  Fund,  Division  of  Publications,  1930. 

This  small  book  opens  with  the  challenging  statement,  "Of  all  the  forty- 
eight  states,  Oregon  is  the  best  for  babies" — an  excellent  way  to  arouse  our 
interest.  It  goes  on  to  tell  the  story  of  Marion  County,  Oregon,  in  detail 
with  many  illustrations  which  help  to  make  this  report  far  removed  from  a 
dry  statistical  summary. 

In  1925  Marion  County  was  chosen  as  one  of  four  communities  in  the 
United  States  to  co-operate  with  the  Commonwealth  Fund  in  its  demon- 


215 
stration  of  what  can  be  done  through  well-planned  activities  to  increase 
health.  It  has  resulted  in  marked  improvement  along  many  lines  and  also 
in  the  important  decision  made  by  this  community  to  continue  this  health 
work  themselves  by  means  of  the  "Marion  County  Health  Unit,"  which 
now  carries  on  a  well-rounded  program. 

In  1924,  before  the  demonstration  began,  Marion  County  health  work 
cost  14  cents  per  person  for  what  was  called  "fragmentary  health  work." 
In  1930  the  total  cost  of  health  work  was  83  cents  per  person  and  the  gains 
made  were  well  worth  it. 

Sanitation,  epidemic  prevention,  health  protection  and  health  teaching 
all  had  their  share  in  the  program.  To  make  possible  clean  water,  milk  and 
food  was  one  of  the  first  aims,  and  great  improvement  has  taken  place 
along  these  lines.  By  1929,  59%  of  the  school  children  had  been  vaccinated 
and  61%  had  had  toxin  antitoxin.  Popularity  of  these  two  procedures  was 
increased  by  making  both  necessary  requirements  for  the  "honor  roll"  in 
the  schools.  A  large  number  of  preschool  children  and  adults  also  received 
this  protection.  Much  remains  to  be  done  here,  as  elsewhere,  with  these 
diseases  and  also  with  venereal  disease  and  tuberculosis,  but  the  work  is 
progressing  at  an  encouraging  rate. 

Well  child  conferences  were  established  at  the  Marion  County  health 
centers,  with  getting  the  baby  fed  right  as  a  special  aim,  as  this  was  felt  to 
be  a  great  need.  That  interest  grew  steadily  in  child  health  protection  was 
clearly  shown  by  the  steady  increase  in  attendance  at  the  well  child  confer- 
ences— 5.9%  in  1925  to  23.2%  in  1929. 

The  Health  Unit  and  the  County  Medical  Society  agree  upon  the  regula- 
tion that  all  babies  and  preschool  children  should  not  return  to  the  Health 
Center  for  a  second  visit  unless  the  family  doctor  consented.  This  restric- 
tion was  made  in  order  to  get  parents  started  in  going  to  their  family  physi- 
cians regularly.  In  two  towns  the  doctors  found  a  growing  demand  for  such 
service.  The  percentage  tables  showing  the  condition  of  entering  school 
children  before  and  after  this  service  are  most-  enhghtening. 

Prenatal  visits  were  made  by  Unit  nurses  and  mothers  taught  to  take 
care  of  themselves  and  keep  under  their  doctor's  care. 

The  infant  death-rate  shows  considerable  improvement.  For  the  years 
1920-1924  the  rate  was  77  per  one  thousand  live  births;  in  the  years  1925- 
1929  the  rate  was  43.3.  Also,  which  was  most  unusual,  a  good  part  of  this 
drop  in  infant  death  rates  came  in  the  dangerous  first  month. 

Taken  altogether  we  rarely  see  a  report  so  crammed  with  interesting 
items  and  offering  so  much  that  would  be  helpful  to  any  community  seeking 
to  improve  its  citizens'  health.     The  little  book  is  well  worth  careful  reading. 

Cross-Sections  op  Rural  Health  Progress,  by  Harry  S.  Mustard, 
M.D.  Published  by  The  Commonwealth  Fund  Division  of  Publications, 
41  East  57th  Street,  New  York.     $1.00  postpaid. 

Rutherford  County,  Tennessee,  was  chosen  by  the  Commonwealth  Fund 
as  one  of  the  places  to  demonstrate  what  could  be  accomplished  in  public 
health  by  means  of  an  adequate  staff,  a  plan  and  a  budget.  It  is  the  story 
of  the  five-year  program  (1924-28)  and  records  both  successes  and  errors. 

The  per  capita  expenditure  in  1923  before  the  health  unit  was  estab- 
lished was  11  cents.  By  1929  this  had  gradually  increased  to  98  cents  per 
capita  and  this  service  covered  all  branches  of  a  complete  health  program. 
It  included  nursing  care  of  the  sick,  also,  which  is  an  expensive  item  in  itself 
and  cost  62  cents  per  nurse's  visit. 

Excellent  statistical  tables  follow  the  text  and  make  the  report  valuable 
for  reference  and  comparison. 

A  Chapter  in  Child  Health.  Published  by  The  Commonwealth  Fund, 
Division  of  Publications,  41  East  57th  Street,  New  York.     $1.00  postpaid. 

This  is  the  story  of  the  Child  Health  Demonstration  which  was  held  in 
1924-28  in  Clarke  County  and  Athens,  Georgia. 

This  effort  resulted  at  the  end  of  the  demonstration  in  a  local  "budget  for 


216 
health,"  which  was  nearly  twice  the  amount  appropriated  before  the  demon- 
stration. 

There  was  definite  improvement  in  maternal  deaths  among  the  mothers 
who  had  care,  the  death-rate  at  child  birth  being  cut  one-half.  For  the 
babies  who  had  care  the  death-rate  under  one  month  was  cut  one-fourth, 
while  between  one  month  and  one  year  it  was  cut  almost  three-fourths. 

Recording  and  Reforting  for  Child  Guidance  Clinics,  by  Mary 
Augusta  Clark.  Published  by  The  Commonwealth  Fund,  Division  of  Pub- 
lications, 41  East  57th  Street,  New  York.     $2.00  postpaid. 

The  author  has  been  consultant  statistician  for  child  guidance  clinics 
since  1925  and  has  also  developed  methods  of  applying  statistics  in  child 
welfare  work  which  include  study  and  treatment  of  delinquents. 

This  plan  for  keeping  records  and  preparing  reports  has  been  in  use  in 
clinics  for  some  years  and  has  proved  practical. 

The  text  includes  reproductions  of  the  forms  used  and  charts  describing 
methods  of  using  these  forms. 

Medical  Care  for  15,000  Workers  and  Their  Families. 

We  have  received  from  The  Committee  on  the  Costs  of  Medical  Care  a 
copy  of  Abstract  of  Publication  No.  5  entitled  "Medical  Care  for  15,000 
Workers  and  Their  Families,"  a  survey  of  the  Endicott  Johnson  Workers 
Medical  Service,  1928. 

This  is  an  interesting  presentation  of  this  type  of  medical  service. 


217 

Editorial  Comment 

Preparation  f 07'  the  Summer  Round-Up.    A    successful    Summer    Round-Up 

means  early  preparation  and  ener- 
getic follow-up,  for  both  of  which  we  depend  tremendously  upon  our  local 
nursing  service.  Three  steps  are  involved— finding  the  entering  school 
children,  finding  their  defects,  and  getting  their  defects  corrected. 

Registration  of  all  children  who  will  enter  school  the  following  September 
should  take  place  early  in  April  by  means  of  a  request  to  the  parents  from 
the  Superintendent  of  Schools.  Good  publicity  to  interest  the  community 
as  a  whole  is  a  genuine  necessity — people  want  to  know  what  this  Summer 
Round-Up  is  all  about. 

Our  ideal  is  yearly  examination  of  every  child  by  the  family  physician  and 
dentist,  with  prompt  correction  of  all  remediable  defects.  However,  oppor- 
tunity for  examination  may  be  offered  through  the  local  Well  Child  Confer- 
ence or  through  a  special  Summer  Round-Up  conference,  as  an  educational 
measure  and  to  help  insure  examination  of  all  entering  school  children. 
Each  child  found  to  have  defects  at  such  a  conference  is  referred  directly 
to  the  family  physician  and  dentist  for  corrections. 

No  one  has  a  better  chance  to  teach  the  value  of  the  Summer  Round-Up 
than  the  nurse  who  is  constantly  visiting  homes.  She,  in  fact,  prepares  for 
the  Summer  Round-Up  the  year  round  and  upon  her  efforts  depends  its 
success  to  a  great  degree. 

The  financial  side  has  its  rightful  part  in  this  appeal.  Medical  and  dental 
expenses  grow  with  the  years  for  the  child  whose  nutrition  is  poor  or  who 
carries  any  neglected  defects.  Also,  backwardness  and  absenteeism  in 
school  are  far  more  likely  to  occur  in  children  thus  burdened — and  repeating 
grades  does  cost  money. 

The  final  measure  of  success  of  the  Summer  Round-Up  idea  is  the  number 
of  children  who  enter  school  without  defects.  It  will  be  a  proud  day  for 
any  town  when  it  can  truthfully  say  that  its  children  always  start  school 
with  all  remediable  defects  corrected — and  the  sooner  that  day  comes  the 
better! 

Getting  Ready  for  May  Day — Child  Health  Day.      December  storms  do  not 

predispose  to  thoughts  of 
May  unless  perhaps  as  we  huddle  over  the  fire  or  the  steam  radiator  we 
think  longingly  of  the  gentle  showers  of  Spring.  But  May  is  truly  on  the 
way  and  with  it  Child  health  Day. 

Here  in  Massachusetts,  Child  Health  Day  has  become  a  day  of  rejoicing 
over  those  children  who  have  attained  the  highest  point  in  physical  per- 
fection of  which  they  are  capable. 

This  perfection  is  not  attained  in  a  bound — at  the  last  moment.  Often 
it  is  only  after  long  weeks  of  patient  striving  that  muscles  grow  firm  and 
eyes  bright,  that  bad  tonsils  and  teeth  and  poor  posture  are  attended  to. 

Now  is  not  too  soon  to  visit  the  parents,  to  work  up  enthusiasm  in  the 
children,  to  urge  corrections,  to  talk  about  diets,  rest,  and  all  the  other 
things  necessary  to  well  and  growing  children. 

Let  us  look  forward  to  May  this  December  lest  we  neglect  to  get  the  chil- 
dren ready  in  time  and  so  fail  them. 


218 

News  Note 

Maternal  Deaths  in  Massachusetts  in  1929* 

Accidents  of  pregnancy    34 

Abortion   8 

Ectopic  gestation , 15 

Others  under  this  title    11 

Puerperal  hemorrhage    66 

Other  accidents  of  labor 73 

Caesarean  section    30 

Other  surgical  operations  and  instrumental  delivery    ....  4 

Others  under  this  title    39 

Puerperal  septicemia 147 

Puerperal  phlegmasia  alba  dolens,  embolus,  sudden  death ...  44 

Puerperal  albuminuria  and  convulsions 87 

Following  childbirth  (not  otherwise  denned) 2 

Total  ~^53 

Maternal  death  rate    6.1  (453  deaths) 

Infant  death  rate 62.0  (4,592  deaths) 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  July,  August,  and  September,  1930,  samples  were 
collected  in  96  cities  and  towns. 

There  were  1,565  samples  of  milk  examined,  of  which  617  were  below  stand- 
ard; from  33  samples  the  cream  had  been  in  part  removed,  31  samples 
contained  added  water,  and  1  sample  was  skimmed  milk  above  the  legal 
standard.  There  were  22  samples  of  Grade  A  milk  examined,  19  samples 
of  which  were  above  the  legal  standard  of  4.00%  fat,  and  3  samples  were 
below  the  legal  standard. 

There  were  155  samples  of  food  examined,  of  which  36  were  adulterated. 
These  consisted  of  22  samples  of  eggs,  17  samples  of  which  were  sold  as 
fresh  eggs,  but  were  not  fresh,  1  sample  of  cold  storage  eggs  was  not  so 
marked,  and  4  samples  were  decomposed;  1  sample  of  sugar  contained  dirt; 
1  sample  of  vinegar  was  low  in  acid;  1  sample  of  cream  was  below  the  legal 
standard  in  fat;  4  samples  of  hamburg  steak,  3  of  which  contained  a  com- 
pound of  sulphur  dioxide  not  properly  labeled,  and  1  sample  was  decom- 
posed; 1  cardboard  wrapper  which  contained  dye,  used  to  wrap  fish;  and 
6  empty  tonic  bottles  which  showed  a  high  bacterial  count. 

There  were  18  samples  of  drugs  examined,  of  which  3  were  adulterated. 
These  consisted  of  1  sample  of  caustic  poison  which  did  not  bear  a  poison 
label;  1  sample  of  camphorated  oil,  and  1  sample  of  spirits  of  nitrous  ether 
which  were  deficient  in  the  active  ingredient. 

The  police  departments  submitted  1,880  samples  of  liquor  for  examina- 
tion, 1,859  of  which  were  above  0.5%  in  alcohol.  The  police  departments 
also  submitted  27  samples  of  narcotics,  etc.,  for  examination,  11  of  which 
were  morphine  or  morphine  derivatives,  1  silk  dress  which  contained  sul- 
phuric acid,  1  sample  of  soap  which  contained  sodium  sulphite,  1  sample 
of  white  powder  which,  on  examination,  was  corrosive  sublimate,  a  sample 
of  stomach  contents  taken  from  a  live  man,  suspected  of  driving  an  auto- 
mobile while  under  the  influence  of  liquor,  contained  3.44%  alcohol,  a  white 
crystalline  powder  which  contained  cocaine,  a  blue  solution  which  contained 
bordeaux  mixture  and  arsenic,  another  solution  contained  valerianic  acid 
and  ammonium  valerian te,  a  black  paste  which  contained  sulphuric  acid 
and  paraffin,  1  sample  of  chloroform  examined  for  poison  gave  negative 
results,  and  3  samples  of  tablets  and  4  other  samples  were  all  examined  for 
alkaloids  with  negative  results. 

There  were  1,074  bacteriological  examinations  made  of  milk. 

There  were  52  bacteriological  examinations  made  of  soft  shell  clams, 
24  samples  in  the  shell,  20  of  which  were  unpolluted,  and  4  were  polluted, 

*From  Annual  Report  on  the  Vital  Statistics  of  Massachusetts  for  the  year  ending  December  31,  1929. 


219 

and  28  samples  shucked,  24  of  which  were  unpolluted,  and  4  were  polluted. 
There  were  4  bacteriological  examinations  made  of  hard  shell  clams,  in  the 
shell,  3  of  which  were  unpolluted,  and  1  was  polluted.  There  were  5  bac- 
teriological examinations  made  of  fried  clams,  all  of  which  were  unpolluted. 

There  were  122  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  108  cities  and  towns  visited  for  the  inspection  of  pasteurizing 
plants,  and  329  plants  were  inspected. 

There  were  38  convictions  for  violations  of  the  law,  $895.00  in  fines  being 
imposed. 

John  Andre  of  Springfield;  William  Borkowsky  and  Walter  Kapinos  of 
West  Springfield;  Timothy  Murphy,  2  cases,  of  Milford;  Antonio  Rodrigue 
of  Wilbraham;  Damon  Kalkow  of  Newburyport;  Leo  Comeau  of  Essex; 
H.  P.  Hood  &  Sons,  Incorporated,  of  Lawrence;  John  Mederios  of  Somerset; 
Jesse  Motta  of  Silver  Lake;  and  Charles  Sperounis  of  Dracut,  were  all 
convicted  for  violations  of  the  milk  laws. 

Reneo  Stanghellini  of  Plymouth,  2  cases;  First  National  Stores,  Incor- 
porated of  Newton;  and  Gilbert  Robertson  of  Ipswich,  were  all  convicted 
for  violations  of  the  food  laws. 

Manhattan  Food  Stores  Company  of  Somerville  was  convicted  for  mis- 
branding. 

Richard  Denkmejian  of  Somerville  was  convicted  for  violation  of  the  false 
advertising  law. 

Stefanos  Emanouil  of  Chelmsford;  Amede  Guimond  of  Lowell;  Harriet 
M.  Manning  of  Milton;  Felix  Noel,  2  cases,  of  Granby;  John  W.  Pratt, 
2  cases,  of  Peabody;  Freda  H.  Vollert,  2  counts,  and  Frank  J.  Bissell,  2 
cases,  both  of  Holyoke;  Joseph  P.  Alves  of  Fall  River;  Clover  Leaf  Dairy  i 
Incorporated,  Matthew  A.  Currier,  and  Joseph  A.  Rogers,  all  of  Haverhill; 
Henry  Dolinski  of  Saugus;  and  Robert  Sawyer  of  Bradford,  were  all  con- 
victed for  violations  of  the  pasteurization  law. 

Abraham  L.  Creeger  of  Springfield;  Henry  Prince  of  Wenham,  and  Oscar 
Shenkman  of  New  Marlboro,  were  all  convicted  for  violations  of  the  slaugh- 
tering law.     Henry  Prince  of  Wenham  appealed  his  case. 

Max  Cohen  of  Methuen  was  convicted  for  obstruction  of  an  inspector. 
He  appealed  his  case. 

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  packages 
from  manufacturers,  wholesalers,  or  producers: 

Milk  which  contained  added  water  was  produced  as  follows:  4  samples 
each,  by  John  Mederos  of  Somerset,  and  Leonard  W.  Sylvester  of  West 
Acton;  3  samples,  by  Christo  Kostantas  of  Pelham,  New  Hampshire;  and 
2  samples  each,  by  Manuel  Borges  of  Central  Village,  and  Charles  Sperounis 
of  Dracut. 

Three  samples  of  milk  which  had  the  cream  removed  was  produced  by 
Carmine  Di  Pietro  of  West  Acton. 

One  sample  of  cream  which  was  not  labeled  in  accordance  with  the  law 
was  obtained  from  American  Thrift  Stores  of  Worcester. 

One  sample  of  eggs  which  was  sold  as  fresh  eggs  but  were  not  fresh  was 
obtained  from  Spitzer  &  Richton  of  North  Adams. 

One  sample  of  vinegar  which  was  low  in  acid  was  obtained  from  Leon  H. 
Thompson  of  Wales. 

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

1  sample  each,  from  The  Great  Atlantic  &  Pacific  Tea  Company  of  Newton 
and  Somerville,  and  Ideal  Market  of  Cambridge. 

One  sample  of  hamburg  steak  which  was  decomposed  was  obtained  from 
National  Butchers  Company  of  Waltham. 

One  sample  of  ammonia  which  did  not  bear  a  poison  label  was  obtained 
from  Arthur  Fluet  of  Lawrence. 

There  were  seven  confiscations,  consisting  of  15  pounds  of  decomposed 
chickens;  100  pounds  of  sour  fowl;  190  pounds  of  decomposed  roasters; 
200  pounds  of  tainted  beef;  50  pounds  of  hogs'  lips;  2  pounds  of  decom- 
posed bologna;  and  15  pounds  of  decomposed  liverwurst. 


220 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  June,  1930:  1,601,580  dozens 
of  case  eggs;  857,029  pounds  of  broken  out  eggs;  6,292,761  pounds  of  butter; 
1,544,384  pounds  of  poultry;  5,299,0743^  pounds  of  fresh  meat  and  fresh 
meat  products;  and  10,836,807  pounds  of  fresh  food  fish. 

There  was  on  hand  July  1,  1930:  10,059,240  dozens  of  case  eggs;  2,587,651 
pounds  of  broken  out  eggs;  9,534,334  pounds  of  butter;  4,683,105  pounds 
of  poultry;  11, 605, 587 34  pounds  of  fresh  meat  and  fresh  meat  products; 
and  22,651,294  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  July,  1930:  1,117,020  dozens  of 
case  eggs;  461,461  pounds  of  broken  out  eggs;  5,324,566  pounds  of  butter; 
1,143,1433^  pounds  of  poultry;  5,105,4553^  pounds  of  fresh  meat  and  fresh 
meat  products;  and  6,626,895  pounds  of  fresh  food  fish. 

There  was  on  hand  August  1,  1930:  10,360,770  dozens  of  case  eggs;  2,458,- 
651  pounds  of  broken  out  eggs;  12,845,099  pounds  of  butter;  3,123,874 
pounds  of  poultry;  11,252,913  pounds  of  fresh  meat  and  fresh  meat  products; 
and  26,689,970  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  the  month  of  August,  1930:  428,670  dozens  of 
case  eggs;  404,270  pounds  of  broken  out  eggs;  2,772,142  pounds  of  butter; 
872,585  pounds  of  poultry;  3, 373, 888 x/2  pounds  of  fresh  meat  and  fresh 
meat  products;  and  4,937,848  pounds  of  fresh  food  fish. 

There  was  on  hand  September  1,  1930:  9,162,990  dozens  of  case  eggs; 
2,266,915  pounds  of  broken  out  eggs;  12,549,357  pounds  of  butter;  3,160,888 
pounds  of  poultry;  8,918,015  pounds  of  fresh  meat  and  fresh  meat  products; 
and  28,196,199  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  Child  Hygiene 
Division  of  Tuberculosis 
Division  of  Adult  Hygiene 

State  District 

The  Southeastern  District 

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


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer. 

Arthur  D.  Weston,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 

Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

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

Frederick  S.  Leeder,  M.D.,  Pitts- 
field. 


INDEX 

PAGE 

Abstracts  from  the  Treatment  of  Chronic  Running  Ears  or  Chronic  Suppurative 

Otitis  Media,  by  George  Morrison  Coates,  M.D.   .  .  .  .74 

Active  Immunization  the  Only  Effective  Method — Diphtheria  Control,  by  Clarence 

L.  Scamman,  M.D.    . 123 

Address  Given  by  Mrs.  Charles  Sumner  Bird  at  a  Meeting  of  the  Committee  on 

Governor  Allen's  Public  Welfare  Program     ......  52 

Address  of  President  Hoover  at  the  Opening  Session  of  the  White  House  Confer- 
ence on  Child  Health  and  Protection    .......  207 

Adult  Hygiene,  Path-Finding  in,  by  Mary  R.  Lakeman,  M.D.     .  .  .  .50 

Allen,  Governor  Frank  G.,  Letter  to  Local  Health  Officials           ....  119 

American  Red  Cross        ...........  146 

Anderson,  Gaylord  W.,  M.D. ,  The  Diphtheria  Situation  in  Massachusetts               .  121 
Audiometers,  The  4-A  and  Other,  by  Mrs.  James  F.  Norris                    .                    .82 
Audiometers,  Group  Service  and  Use  of  the  4-A  in  Schools  of  Plymouth  County, 

Mass.,  by  Anna  J.  Foley,  R.N.    ........  85 

Average  Day  of  an  Industrial  Nurse  in  a  Modern,  Busy  Factorv,  by  Louise  G. 

Fiske,  R.N 196 

Ayer,  Mary  E.,  In  Memory  of           .........  153 

Benjamin,  Frances  H.,  Parental  Education  in  a  Public  Health  Program        .          .  169 

Berry,  Gordon,  M.D.,  National  Work  for  the  Deaf  and  Hard  of  Hearing       .  88 

Beverly  School  for  the  Deaf  as  an  Educational  Institution,  by  Helen  Wales   .          .  104 

Bigelow,  George  H.,  M.D.,  The  Eighth  New  England  Health  Institute         .         .  54 

Bigelow,  George  H.,  M.D.,  Foreword  to  the  Diphtheria  issue       ....  121 

Bigelow,  George  H.,  M.D.,  The  Specialist  versus  the  Generalist            .         .          .  170 

Bill  of  Rights,  The  Child's 3 

Billmeyer,  Mary  P.,  A.B.,  R.  N.,  How  to  Make  a  Prenatal  Visit  ...  7 
Billmeyer,  Mary  P.,  A.B.,  R.  N.,  Social  Work  and  the  School  .  .  .197 
Billmeyer,  Mary  P.,  A.B.,  R.  N.,  and  Angeline  Hamblen,  A.  B.,  A  Few  High  Spots 

in  Vital  Statistics 184 

Bird,  Mrs.  Charles  Sumner,  Address  at  Meeting  of  the  Committee  on  Governor 

Allen's  Public  Welfare  Program  .          .                    .....  52 

Roard  Members,  The  Relationship  of,  to  Public  Health  Nurses,  by  Gertrude  W. 

Peabody,  R.N. 157 

Book  Notes: 

American  Red  Cross  Disaster  Relief  Handbook  ......  214 

Chapter  in  Child  Health 215 

Children  of  the  Covered  Wagon  .         .  .         .         .         .         .         .214 

Children  Well  and  Happy 62 

Cross  Sections  of  Rural  Health  Progress      .......  215 

Diagnosis  of  Health .          ..........  Ill 

From  Boston  to  Boston     ..........  62 

Medical  Care  for  15,000  Workers  and  Their  Families 216 

Public  Health  Nurse— March,  1930,  Number 62 

Recording  and  Reporting  for  Child  Guidance  Clinic     .....  216 

Bowen,  Catherine  A.,  Obituary         .........  214 

Brehaut,  Elsie,  R.N.,  Staff  Education        .          .  #        .          .          .          .          .  162 

Carriers,  The  Laboratory  Diagnosis  of  Diphtheria  and  Release  of,  by  Francis  H. 

Slack,  M.D 127 

Ceconi,  Dr.  John  A.,  Obituary           .........  214 

Ceconi,  John  A.,  M.D.,  The  Problem  of  the  Undernourished  School  Child — How 

It  May  Be  Solved       .  .193 

Certain  Communicable  Diseases;  Their  Relation  to  the  Prospective  Mother,  the 

Infant  and  the  Pre-School  Child,  by  Clarence  L.  Scamman,  M.D.  22 

Chapter  in  Child  Health 215 

Child  Health  Day  and  Summer  Round-Up,  1930 56 

Child  Hygiene,  by  M.  Luise  Diez,  M.D 4 

Child  Hygiene,  The  Value  of,  in  a  Public  Health  Program,  by  Charles  F.  Wilinsky, 

M.D. 30 

Child's  Bill  of  Rights 3 

Clinics,  Dental,  by  Frank  A.  Delabarre,  D.D.S 107 

Clinics,  Diagnostic,  for  the  Deafened,  by  Edmund  Prince  Fowler,  M.D.        .  .79 

Coates,  George  Morrison,  M.D.,  Abstracts  from  the  Treatment  of  Chronic  Run- 
ning Ears  or  Chronic  Suppurative  Otitis  Media     .         .  .         .  .74 

221 


222 


PAGE 

159 
99 

28 


Coffey,  Ada  Boone,  R.N.,  Education  and  the  Public  Health  Nurse 

Coffin,  Susan  M.,  M.D.,  Hearing  Defects  in  the  Pre-School  Child 

Coffin,  Susan  M.,  M.D.,  Standards  of  Pre-School  Hygiene 

Committee,  Community  Health,  Organization  of,  by  Helen  M.  Hackett,  R.N.,  and 

Albertine  P.  McKellar       .  .  .......     46 

Communicable  Disease  Nurse  in  Diphtheria  Control,  Sarah  P.  Schneider,  R.N.  .  133 
Communicable  Diseases,  Certain;  Their  Relation  to  the  Prospective  Mother,  the 

Infant  and  the  Pre-School  Child,  by  Clarence  L.  Scamman,  M.D.     .  22 

Communities,  Group  Education  in  Small,  by  Katherine  C.  Taft  .  .   163 

Community  Health  Committee,  Organization  of,  by  Helen  M.  Hackett,  R.N., 

and  Albertine  P.  McKellar  ........     46 

Community,  The  Public  Health  Nurse  in  the,  by  Dorothy  Deming,  R.N.     .  .    154 

Community  Immunization  against  Diphtheria,   The  Results  of,  by  Ralph  E. 

Wheeler,  M.D 143 

Control  of  Diphtheria  in  the  Schools,  by  Francis  George  Curtis,  M.D.  .  .   134 

Costs  of  Medical  Care,  The  Scope  and  Aim  of  the  Committee  on  109 

Cross  Sections  of  Rural  Health  Progress    ........  215 

Cumming,  Surgeon  General  H.  S.,  The  Scientific  Research  Work  of  the  U.  S.  Public 

Health  Service 204 

Curtis,  Francis  George,  M.D.,  Control  of  Diphtheria  in  the  Schools      .  .  .    134 

Deaf  and  Hard  of  Hearing,  Education  of,  by  Arthur  B.  Lord       .  .  .  .78 

Deaf  and  Hard  of  Hearing,  National  Work  for,  by  Gordon  Berry,  M.D.  .     88 

Deaf,  The  Beverly  School  for  the,  as  an  Educational  Institution,  by  Helen  Wales     104 
Deafened,  Diagnostic  Clinics  for  the,  by  Edmund  Prince  Fowler,  M.D.         .  79 

Deaths,  Maternal,  in  Massachusetts,  1928  .......     59 

Deaths,  Maternal,  in  Massachusetts,  1929  .......   218 

Delabarre,  Frank  A.,  D.D.S.,  Dental  Clinics 107 

Deming,  Dorothy,  The  Public  Health  Nurse  in  the  Community  ....  154 
Denny,  Francis  P.,  M.D.,  The  Relationship  of  the  Nurse  to  the  Health  Officer  Group  175 
DeNormandie,  Robert  L.,  M.D.,  Standards  in  Obstetrics    .  .  .  .  .10 

Dental  Clinics,  by  Frank  A.  Delabarre,  D.D.S. 107 

Dental  Hygiene,  by  E.  Melville  Quinby,  M.D. 24 

Diagnostic  Clinics  for  the  Deafened,  by  Edmund  Prince  Fowler,  M.D.  .  .79 

Diez,  M.Luise,  M.D.,  Child  Hygiene 4 

Diphtheria  Control — Active  Immunization  the  Only  Effective  Method,  by  Clarence 

L.  Scamman,  M.D * 123 

Diphtheria,  Control  of,  in  the  Schools,  by  Francis  George  Curtis,  M.D.         .  .    134 

Diphtheria  Immunization  Campaign,  Organization  and  Methods  .  .    138 

Diphtheria,  Laboratory  Diagnosis  of,  and  Release  of  Carriers,  by  Francis  H.  Slack, 

M.D 127 

Diphtheria — Methods  of  Prevention,  by  Benjamin  White,  Ph.D.  .    124 

Diphtheria  Control,  The  Communicable  Disease  Nurse  in,  bv  Sarah  P.  Schneider, 

R.N :..-...    133 

Diphtheria,  The  Results  of  Community  Immunization  Against,  by  Ralph  E. 

Wheeler,  M.D 143 

The  Diphtheria  Situation  in  Massachusetts,  by  Gaylord  W.  Anderson,  M.D. .  .    121 

Diphtheria,  Treatment  of,   by  E.  H.  Place,  M.D. 129 

Donovan,  Anna  K.,  R.N.,  A  Pre-School  Child  Visit 37 

Ear  Aches,  by  Margaret  Noyes  Kleinert,  M.D.  .  .  .  .71 

Ear,  Hygiene  and  Physiology  of  the  Normal,  by  Philip  E.  Meltzer,  M.D.     _.  69 

Ears,  Treatment  of  Chronic  Running,  or  Chronic  Suppurative  Otitis  Media,  by 

George  M.  Coates,  M.D 74 

Editorial  Comment: 

Child  Health  Day  and  the  Summer  Round-Up,  1930    .  .  .  .  .56 

Getting  Ready  for  May  Day— Child  Health  Day 217 

Mental  Hygiene  and  the  Eye,  Ear,  Nose  and  Throat  Specialist  .  .    104 

Preparation  for  the  Summer  Round-Up       .......   217 

Well  Child  Conferences  in  1929  ....  ...     56 

Education  and  the  Public  Health  Nurse,  by  Ada  Boone  Coffey,  R.N.  .  .  .    159 

Education,  Group,  in  Small  Communities,  by  Katherine  C.  Taft  .  .  .    163 

Education  of  the  Hard  of  Hearing  and  Deaf,  by  Arthur  B.  Lord  .  .78 

Education,  Parental,  in  a  Public  Health  Program,  by  Frances  H.  Benjamin  .    169 

Education,  Post-Graduate,  by  Helen  M.  Hackett,  R.N.       .  .  ..  .   165 

Education,  Staff,  by  Elsie  Brehaut,  R.N. 162 

Eighth  New  England  Health  Institute,  by  George  H.  Bigelow,  M.D.    .  .54 

Emerson,  Kendall,  M.D. ,  Where  Are  We  Going  in  Tuberculosis  Control?       .  .    188 

Few  High  Spots  in  Vital  Statistics,  A,  by  Mary  P.  Billmeyer,  R.N.,  and  Angeline 

D.  Hamblen,  A.B 184 


223 


PAGE 


Fiske,  Louise  G.,  R.N.,  The  Average  Day  of  an  Industrial  Nurse  in  a  Modern,  Busy 
Factory  .  .  ...  .  .         .  .         . 

Foley,  Anna  J.,  R.N.,  Group  Service  and  Use  of  the  4-A  Audiometer  in  Schools  of 
Plymouth  County,  Mass.    ....... 

Food  and  Drugs,  Report  of  Division  of: 

October,  November,  December,  1929.  ..... 

January,  February,  March,  1930         ...... 

April,  May,  June,  1930 

July,  August,  September,  1930  ....... 

Foreword  to  the  Diphtheria  issue,  by  George  H.  Bigelow,  M.D.  . 

Foster,  Sybil,  The  Importance  of  Habit  Training  for  the  Infant  and  Pre-School 
Child  

Fowler,  Edmund  Prince,  M.D.,  Diagnostic  Clinics  for  the  Deafened 

Getting  Ready  for  May  Day — Child  Health  Day        .... 

Goodrich,  Annie  W.,  R.N.,  How  the  Nurse  Can  Contribute  the  Service  the  Public 
Expects  ....... 

Greenough,  Robert  B.,  M.D.,  To  the  Fellows  of  the  Massachusetts  Medical  Society  120 

Group  Education  in  Small  Communities,  by  Katherine  C.  Taft   .... 

Group  Service  and  Use  of  the  4-A  Audiometer  in  Schools  of  Plymouth  County, 
Mass.,  by  Anna  J.  Foley,  R.N.    ...... 

Habit  Training,  The  Importance  of,  for  the  Infant  and  Pre-School  Child,  by  Sybil 
Foster       ........... 

Hackett,  Helen  M.,  R.N.,  Organization  of  a  Community  Health  Committee 

Hackett,  Helen  M.,  R.N.,  Post-Graduate  Education  .... 

Hamblen,  Angeline  D.,  A.B.,  and  Mary  P.  Billmeyer,  A.B.,  R.N.,  A  Few  High 
Spots  in  Vital  Statistics       ....... 

Hard  of  Hearing  and  Deaf,  Education  of,  b3r  Arthur  B.  Lord 

Hearing  Aids,  The  Use  of,  by  Mrs.  James  F.  Norris   .... 

Hearing  Defects  in  the  Pre-School  Child,  by  Susan  M.  Coffin,  M.D.     . 

Hearing  Defects,  The  Teacher's  and  Nurse's  Part  in  Detecting,  bv  Fredrika  Moore, 
M.D. 

Hearing  of  School  Children  as  Measured  by  the  Audiometer  and  as  Related  to 
School  Work      .......... 

"Health  Forum"     ........... 

Health  Institute,  The  Eighth  New  England,  by  George  H.  Bigelow,  M.D.    . 

Health  Officer  Group,  Relationship  of  the  Nurse  to,  by  Francis  P.  Denny,  M.D. 

Home  Visit  by  Infant  Hygiene  Nurse,  by  M.  Gertrude  Martin,  R.N.   . 

Hoover,  President,  Address  of,  at  the  Opening  Session  of  the  White  House  Confer- 
ence on  Child  Health  and  Protection    ...... 

How  the  Nurse  Can  Contribute  the  Service  the  Public  Expects,  by  Annie  W.  Good- 
rich, R.N.  

How  to  Attend  the  New  England  Health  Institute,  by  Mildred  E.  Kennedy 

How  to  Make  a  Prenatal  Visit,  by  Mary  P.  Billmeyer,  R.N. 

Hygiene,  Adult,  Path-Finding  in,  by  Mary  R.  Lakeman,  M.D.    . 

Hygiene  and  Physiology  of  the  Normal  Ear,  by  Philip  E.  Meltzer,  M.D. 

Hygiene,  Child,  The  Value  of,  in  the  Public  Health  Program,  by  Charles  F.  Wil- 
insky,  M.D 

Hygiene,  Dental,  by  E.  Melville  Quinby,  M.D 

Hygiene  Nurse,  Home  Visit  by  Infant,  by  M.  Gertrude  Martin,  R.N. 

Hygiene,  Standards  of  Pre-school,  by  Susan  M.  Coffin,  M.D. 

Immunization,  A  Diphtheria,  Campaign — Organization  and  Methods  . 

Immunization  against  Diphtheria,  The  Results  of  Community,  by  Ralph  E. 
Wheeler,  M.D 

Importance  of  Habit  Training  for  the  Infant  and  Pre-school  Child,  by  Sybil  Foster      38 

In  Memory  of  Mary  E.  Ayer  .........    153 

Industrial  Nurse,  Average  Day  in  a  Modern  Busy  Factory,  by  Louise  G.  Fiske,  R.N.  196 

Infant  and  Pre-school  Child,  The  Importance  of  Habit  Training  for,  by  Sybil 

Foster 38 

Infant,  Certain  Communicable  Diseases;    Their  Relation  to  the,  by  Clarence  L. 
Scamman,  M.D.         ...  .... 

Infant  Hygiene  Nurse,  Home  Visit  by,  by  M.  Gertrude  Martin,  R.N. 

Interstitial  Keratitis,  by  Joseph  J.  Skirball,  M.D.       .... 

Judging  Nutrition,  by  Eli  C.  Romberg,  M.D.     ..... 

Kennedy,  Mildred,  Please  Walk  In  . 

Kennedy,  Mildred  E.,  How  to  Attend  the  New  England  Health  Institute 

Keratitis,  Interstitial,  by  Joseph  J.  Skirball,  M.D.      .... 

Kleinert,  Margaret  Noyes,  M.D.,  Ear  Aches      ..... 


Lakeman,  Mary  R.,  M.D.,  Path-Finding  in  Adult  Hygiene 

Letter  of  the  Governor  to  Local  Health  Officials         .... 

Linking  up  the  Pre-school  Child  and  the  School  Child,  by  Fredrika  Moore,  M 
Lip  Reading  in  Massachusetts,  by  Ena  G.  MacNutt  .... 

Lord,  Arthur  B.,  The  Education  of  the  Hard  of  Hearing  and  Deaf 
MacNutt,  Ena  G.,  Lip  Reading  in  Massachusetts       .... 

Martin,  M.  Gertrude,  R.N.,  Home  Visit  by  Infant  Hygiene  Nurse 
Maternal  and  Infancy  Nursing  Service,  by  Nora  M.  McQuade,  R.N.    . 
Maternal  Deaths  in  Massachusetts,  1928  ...... 

Maternal  Deaths  in  Massachusetts,  1929  .  .  .  .  .  . 

Maternal  Nursing,  by  E.  P.  Ruggles,  M.D 

Maternity  as  a  Public  Health  Problem,  by  Matthias  Nicoll,  Jr.,  M.D. 
May  Day— Child  Health  Day,  Getting  Ready  For     . 
McKay,  Florence  L.,  M.D.,  The  Value  of  Child  Hygiene  Publicity 
McKellar,  Albertine  P.,  Organization  of  a  Community  Health  Committee 
McQuade,  Nora  M.,  R.N.,  Maternal  and  Infancy  Nursing  Service 
Medical  Care  for  15,000  Workers  and  Their  Families .... 

Medical  Care,  The  Scope  and  Aim  of  the  Committee  on  the  Costs  of   . 
Meltzer,  Philip  E.,  M.D.,  Hygiene  and  Physiology  of  the  Normal  Ear. 
Mental  Diseases,  Massachusetts  Department  of,  Quarterly  Bulletin 
Mental  Hygiene  and  the  Eye,  Ear,  Nose  and  Throat  Specialist    . 
Mental  Hygiene,  First  International  Congress  on        ...  . 

Moore,  Fredrika,  M.D.,  Linking  up  the  Pre-school  Child  and  the  School  Child      .     49 
Moore,  Fredrika,  M.D.,  Teacher's  and  Nurse's  Part  in  Detecting  Hearing  Defects  .     82 
National  Work  for  the  Deaf  and  the  Hard  of  Hearing,  by  Gordon  Berry,  M.D.     .     88 
Nelson,  Sophie  C,  R.N.,  Relationships     .         .  ......   155 

New  England  Health  Institute  (Eighth)  by  George  H.  Bigelow,  M.D.  .  .     54 

News  Notes: 

Beverly  School  for  the  Deaf  as  an  Educational  Institution,  by  Helen  Wales     .   104 

"Dental  Clinics,"  by  Frank  A.  Delabarre,  D.D.S. 107 

First  International  Congress  on  Mental  Hygiene  .  .  .60 

Hearing  of  School  Children  as  Measured  by  the  Audiometer  and  as  Related  to 

School  Work .   Ill 

How  to  Attend  the  New  England  Health  Institute,  by  Mildred  E.  Kennedy     .     57 
Massachusetts  Department  of  Mental  Diseases  Quarterly  Bulletin  .  .     61 

Maternal  Deaths  in  Massachusetts,  1928    .......     59 

Maternal  Deaths  in  Massachusetts,  1929    ...  ...  218 

Scope  and  Aim  of  the  Committee  on  the  Costs  of  Medical  Care  .  .   109 

Summer  Courses  in  Public  Health  and  Biology    .  .  .  .  .  .59 

Summer  School  of  School  Nursing  and  Dental  Hygiene  .  .58 

Survey  by  National  Tuberculosis  Association  and  the  Committee  on  the  Costs 

of  Medical  Care Ill 

Nicoll,  Matthias,  Jr.,  M.D.,  Maternity  as  a  Public  Health  Problem  .  .12 

Norris,  Mrs.  James  F.,  The  4- A  and  Other  Audiometers      .  .  .  .  .82 

Norris,  Mrs.  James  F.,  The  Use  of  Hearing  Aids         .  ....     92 

Nurse,  How  She  Can  Contribute  the  Service  the  Public  Expects,  by  Annie  W. 

Goodrich,  R.N 171 

Nurse,  Industrial,  Average  Day  in  a  Modern  Busy  Factory,  by  Louise  G.  Fiske, 

R.N. 196 

Nurse,  Infant  Hygiene,  Home  Visit  by,  by  M.  Gertrude  Martin,  R.N.    .  .  .33 

Nurse,  Public  Health,  Education  and  the,  by  Ada  Boone  Coffey,  R.N. .  .  .   159 

Nurse,  Public  Health,  in  the  Community,  by  Dorothy  Deming,  R.N.  .  .   154 

Nurse,  Relationship  of  the,  to  the  Health  Officer  Group,  by  Francis  P.  Denny,  M.D.  175 
Nurse,  The  Communicable  Disease,  in  Diphtheria  Control,  by  Sarah  P.  Schneider, 

R.N 133 

Nurse  the  Doctor  Wants 180 

Nurse's  Part  in  Detecting  Hearing  Defects,  by  Fredrika  Moore,  M.D.  .     82 

Nurses,  Public  Health,  The  Relationship  of  Board  Members  to,  by  Gertrude  W. 

Peabody,  R.N.  .  .  157 

Nursing,  Maternal,  by  E.  P.  Ruggles,  M.D 17 

Nursing  Service,  Maternal  and  Infancy,  by  Nora  M.  McQuade,  R.N.  .  .    181 

Nutrition,  Judging,  by  Eli  C.  Romberg,  M.D.   .  .  .  .  .  .41 

Obstetrics,  Standards  in,  by  Robert  L.  DeNormandie,  M.D.  .  .  .10 

Organization  and  Methods,  A  Diphtheria  Immunization  Campaign  .   138 

Organization  of  a  Communitv  Health  Committee,  by  Helen  M.  Hackett,  R.N.,  and 

Albertine  P.  McKellar 46 


225 

PAGE 

Otitis  Media,  Chronic  Suppurative,  by  George  M.  Coates,  M.D.  .  .  .74 

Parental  Education  in  a  Public  Health  Program,  by  Frances  H.  Benjamin    .  .    169 

Path-Finding  in  Adult  Hygiene,  by  Mary  R.  Lakeman,  M.D.      .  50 

Peabody,  Gertrude  W.,  R.N.,  The  Relationship  of  Board   Members  to   Public 

*  Health  Nurses 157 

Physician's  Report  on  Nursing  Supply      ......  .    178 

Place,  E.  H.,  M.D.,  Treatment  of  Diphtheria 129 

Please  Walk  In,  by  Mildred  Kennedy        ........   101 

Porto  Rican  Diet    .  .  213 

Post-Graduate  Education,  by  Helen  M.  Hackett,  R.N 165 

Prenatal  Visit,  How  to  Make  A,  by  Mary  P.  Billmeyer,  R.N 7 

Preparation  for  the  Summer  Round-Up,  by  Susan  M.  Coffin,  M.D.      .  .  .   217 

Pre-School  Child,  Certain  Communicable  Diseases;    Their  Relation  to  the,  by 

Clarence  L.  Scamman,  M.D.        ........     22 

Pre-School  Child,  Hearing  Defects  in  the,  by  Susan  M.  Coffin,  M.D.    .  .99 

Pre-school  Child,  Linking  Up  with  the  School  Child,  by  Fredrika  Moore,  M.D.       .     49 
Pre-school  Child,  The  Importance  of  Habit  Training  for  the,  by  Sybil  Foster .  38 

Pre-school  Child  Visit,  by  Anna  K.  Donovan,  R.N.    .  .  .  .37 

Pre-school  Hygiene,  Standards  of,  by  Susan  M.  Coffin,  M.D.  .  .28 

Prevention  of  Diphtheria— Methods  of  Prevention,  by  Benjamin  White,  Ph.D.  .  124 
Problem  of  the  Undernourished  School  Child — How  It  May  Be  Solved,  by  John 

A.  Ceconi,  M.D.         . 193 

Prospective  Mother,  Certain  Communicable  Diseases;  Their  Relation  to  the,  by 

Clarence  L.  Scamman,  M.D.       ........     22 

Public  Health  Nurse,  Education  and  the,  by  Ada  Boone  Coffey,  R.N.  .         .   159 

Public  Health  Nurse  in  the  Community,  by  Dorothy  Deming,  R.N.     .  .  .   154 

Public  Health  Problem,  Maternity  as  a,  by  Matthias  Nicoll,  Jr.,  M.D.  .         .     12 

Public  Health  Program,  Parental  Education  in  a,  by  Frances  H.  Benjamin  .  .    169 

Public  Health  Program,  The  Value  of  Child  Hygiene  in  the,  by  Charles  F.  Wil- 

insky,  M.D 30 

Public  Welfare  Program,  Address  Given  by  Mrs.  Charles  Sumner  Bird  at  a  Meeting 

of  the  Committee  on  Governor  Allen's  .  .  .  .52 

Publicity,  The  Value  of  Child  Hygiene,  by  Florence  L.  McKay,  M.D. .  .  .     48 

Quinby,  E.  Melville,  M.D.,  Dental  Hygiene  24 

Recording  and  Reporting  for  Child  Guidance  Clinics  .....  216 

Relationship  of  Board  Members  to  Public  Health  Nurses,  by  Gertrude  W.  Peabody, 

R.N 157 

Relationship  of  the  Nurse  to  the  Health  Officer  Group,  by  Francis  P.  Denny,  M.D.  175 
Relationships,  by  Sophie  C.  Nelson,  R.N.  .......   155 

Research  Work  of  the  U.  S.  Public  Health  Service,  by  Surgeon  General  H.  S.  Cum- 

ming  .  .  .  .  .  .  .  .  .   204 

Results  of  Community  Immunization  Against  Diphtheria,  by  Ralph  E.  Wheeler, 

M.D.        .    * 143 

Romberg,  Eli  C,  M.D.,  Judging  Nutrition .41 

Ruggles,  E.  P.,  M.D.,  Maternal  Nursing  .  ...  .  .     17 

Scamman,  Clarence  L.,  M.D.,  Certain  Communicable  Diseases;  Their  Relation  to 

the  Prospective  Mother,  the  Infant  and  the  Pre-school  Child  .  .     22 

Scamman,  Clarence  L.,  M.D.,  Diphtheria  Control— Active  Immunization  the  Only 

Effective  Method 123 

Schneider,  Sarah  P.,  R.N.,  The  Communicable  Disease  Nurse  in  Diphtheria  Con- 
trol   133 

Scientific  Research  Work  of  the  U.  S.  Public  Health  Service,  by  Surgeon  General 

H.  S.  Cumming 204 

School,  Social  Work  and  the,  by  Mary  P.  Billmeyer,  A.B.,  R.N.  .  .  .197 

School  Child,  Linking  up  with  the  Pre-school  Child,  by  Fredrika  Moore,  M.D.  .  49 
School  Child,  The  Problem  of  the  Undernourished,  by  John  A.  Ceconi,  M.D.  .  193 
Schools,  Control  of  Diphtheria  in  the,  by  Francis  G.  Curtis,  M.D.        .  .  .    134 

Schools,  Group  Service  and  Use  of  the  4-A  Audiometer  in  Plymouth  County, 

Mass.,  by  Anna  J.  Foley,  R.N 84 

Scope  and  Aim  of  the  Committee  on  the  Costs  of  Medical  Care   ....   109 

Skirball,  Joseph  J.,  M.D.,  Interstitial  Keratitis         ......         45 

Slack,  Francis  H.,  M.D.,  The  Laboratory  Diagnosis  of  Diphtheria  and  Release  of 

Carriers    ....  .......   127 

Social  Work  and  the  School,  by  Mary  P.  Billmeyer,  A.B.,  R.N 197 

Specialist  versus  the  Generalist,  by  George  H.  Bigelow,  M.D.      .         ...       .   170 

Staff  Education,  by  Elsie  Brehaut,  R.N 162 

Standards  in  Obstetrics,  by  Robert  L.  DeNormandie,  M.D.  .  .  .  .10 
Standards  of  Pre-school  Hygiene,  by  Susan  M.  Coffin,  M.D 28 


226 

Summer  Round-Up,  Child  Health  Day  and  the,  1930  .... 

Summer  Round-Up,  Preparation  for  the,  by  Susan  M.  Coffin,  M.D.     . 

Summer  School  of  School  Nursing  and  Dental  Hygiene       .... 

Survey  by  National  Tuberculosis  Association  and  Committee  on  the  Costs  of 
Medical  Care     .......... 

Taft,  Katherine  C,  Group  Education  in  Small  Communities 

Teacher's  and  Nurse's  Part  in  Detecting  Hearing  Defects,  by  Fredrika  Moore, 
M.D 

To  the  Fellows  of  the  Massachusetts  Medical  Society  .... 

Treatment  of  Chronic  Running  Ears  or  Chronic  Suppurative  Otitis  Media,  Ab- 
stracts from,  by  George  M.  Coates,  M.D.     ..... 

Treatment  of  Diphtheria,  by  E.  H.  Place,  M.  D.        . 

Tuberculosis  Control,  Where  Are  We  Going  In?  by  Kendall  Emerson,  M.D. 

Undernourished  School  Child,  The  Problem  of  the,  by  John  A.  Ceconi,  M.D. 

U.  S.  Public  Health  Service,  The  Scientific  Research  Work  of  the,  by  Surgeon- 
General  H.  S.  Cumming      ........ 

Use  of  Hearing  Aids,  by  Mrs.  James  F.  Norris  ...... 

Value  of  Child  Hygiene  in  the  Public  Health  Program,  by  Charles  F.  Wilinsky, 
M.D 

Value  of  Child  Hygiene  Publicity,  by  Florence  L.  McKay,  M.D.  . 

Visit,  A  Pre-school  Child,  by  Anna  K.  Donovan,  R.N.         .... 

Visit,  Home,  by  Infant  Hygiene  Nurse,  by  M.  Gertrude  Martin,  R.N. 

Vital  Statistics,  A  Few  High  Spots  in,  by  Mary  P.  Billmeyer,  A.B.,  R.N.,  and 
Angeline  D.  Hamblen,  A.B. 

Wales,  Helen,  The  Beverly  School  for  the  Deaf  as  an  Educational  Institution . 

WeU  CMd  Conferences  in  1929 

Wheeler,  Ralph  E.,  M.D.,  The  Results  of  Community  Immunization  Against 
Diphtheria         .......... 

Where  are  We  Going  in  Tuberculosis  Control?  by  Kendall  Emerson,  M.D.    . 

White,  Benjamin,  Ph.D.,  The  Prevention  of  Diphtheria — Methods  of  Prevention 

White  House  Conference  on  Child  Care  and  Protection       .... 

White  House  Conference  on  Child  Care  and  Protection,  Address  of  President 
Hoover  at  the  Opening  Session    ....... 

Wilinsky,  Charles  F.,  M.D.,  The  Value  of  Child  Hygiene  in  the  Public  Health 
Program  ........... 


PAGE 

56 
217 

58 

111 
163 

82 
120 

74 
129 
188 
193 

204 
92 

30 
48 
37 
33 

184 

104 

56 

143 
188 
124 
211 

207 

30 


Publication  of  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
5M-1-'31.     Order  845. 


/  ' 


THE 
COMMONHEALTH 


Volume  18 
No.  1 


JAN. -FEB. -MAR. 
1931 


The  Business  Woman 


MASSACHUSETTS 
DEPARTMENT   OF  PUBLIC  HEALTH 


% 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston   Postoffice. 


M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

What  is  a  Business  Woman?  by  M.  Luise  Diez,  M.D.  ...       3 

The  Housekeepers  of  Industry,  by  Harold  W.  Stevens,  M.D.        .  .       3 

Physically  Fit  Every  Day  in  the  Month,  by  Florence  A.  Somers,  B.S.  .       6 
Mental  Fitness,  by  Sarah  Morse  Beardsley         .....       8 

Recreation,  by  Alma  Porter      ........     10 

Use  of  Leisure,  by  Helen  I.  D.  McGillicuddy,  M.D.    .  .  .  .13 

Recreational  Resources  in  Massachusetts,  by  Eva  Whiting  White         .     15 
Breakfast  and  Luncheon,  by  Esther  V.  Baldwin,  B.S.  .  .  .17 

A  Workshop  of  Life,  by  Frances  Stern       .  .  .  .  .  .20 

Good  Posture  as  a  Business  Asset,  by  Marion  Shepard,  M.D.       .  .     29 

The  Care  of  the  Tissues  Supporting  the  Teeth,  by  William  Rice,  D.D.S., 

D.M.D.     . 30 

Some  Facts  One  Should  Know  about  the  Skin,  by  Loretta  Joy  Cum- 
mins, M.D 33 

Sleep  for  Health  and  Charm,  by  Jean  V.  Latimer,  M.A.                .          .35 
Achieving  a  Successful  Wardrobe,  by  Elsie  K.  Chamberlain          .          .     37 
Successful  Living,  by  Mary  R.  Lakeman,  M.D.,  and  Esther  V.  Bald- 
win, B.S. 39 

Editorial  Comment: 

1931  Child  Health  Day      .  ,  ,..         ...     53 

Summer  Round-Up  .  .  .  .,,,,..  .  .  .  .53 

"Tidings"         .  :  .  . 53 

This  Issue       .  . .  .  .  .  .     53 

News  Notes: 

Infant  Mortality  in  Massachusetts      .  .  .  .  .  .55 

Budgets  for  Low  Incomes  .......     56 

Organizing  for  Better  Health  Service  .  .  .  .  .56 

Industrial  Nursing    .........     57 

The  Doctors  Talk  on  Nursing    .......     57 

Announcement  of  the  First  Award  Under  the  Thomas  W.  Salmon 

Memorial  .........     59 

New  England  Council — Committee  on  Public  Health  .          .          .60 
Report  of  Division  of  Food  and  Drugs,  October,  November,  and  De- 
cember, 1930 61 


WHAT  IS  A  BUSINESS  WOMAN? 

M.  Luise  Diez,  M.D. 
Director,  Division  of  Child  Hygiene 

The  definition  may  vary  much — but  shall  we  say — a  woman  or  girl 
who  seeks  livelihood  through  various  vocations,  trades  or  professions — 
either  in  the  home  or  without. 

It  is  very  interesting  to  know  how  few  of  the  trades  and  professions 
there  are  that  do  not  have  some  women  among  the  workers.  There  is 
discrimination  in  the  way  of  salaries  perhaps — through  necessity  and 
desire  women  are  competing  with  men,  meeting  the  same  responsibilities, 
supporting  one  or  more  people  and  eventually  they  will  be  on  an  equality 
in  all  ways  in  the  business  world.  They  should  be  prepared  and  equipped 
physically  and  mentally  to  accomplish  this  end. 

We  have  been  hearing  for  several  years  much  about  the  "youth  move- 
ment" throughout  the  world.  Some  say  it  is  a  revolt  of  the  young  people 
as  a  result  of  the  war — the  war  planned  by  the  older  group  and  to  which 
the  younger  were  sacrificed.  Aside  from  that  theory  we  will  all  agree 
that  there  is  a  universal  "youth  movement"  on  foot. 

A  tendency  to  cheat  the  years  in  many  ways — clothing,  habits,  recrea- 
tion, attitude  toward  life  and  each  other  have  all  combined  to  retard  age. 
This  is  the  general  trend  and  we  as  individuals  occasionally  should  take 
an  inventory  to  see  whether  we  are  growing  old  or  are  we  retaining  the 
characteristics  of  an  earlier  age.  In  appearance  are  we  as  fastidious  in 
our  toilet  as  we  were  in  the  late  teens  or  early  twenties  ?  We  can  be  with- 
out so  very  much  effort.  Are  we  giving  as  much  thought  to  clothing  as 
we  should — remembering  the  wholesome  effect  in  shedding  years  a  new 
hat,  a  pleasing  gown  or  pretty  gloves  may  have.  What  an  asset  they  are. 
Good  health,  too,  takes  off  the  years.  Headaches,  fatigue,  an  irritated 
throat,  a  bad  posture,  foot  troubles,  constant  pain  or  aches — all  give  the 
appearance  of  encroaching  years  and  they  handicap  in  the  struggle  to 
maintain  one's  place  in  the  field  of  industry. 

Have  we  the  proper  attitude  toward  our  job — do  we  control  the  job  or 
the  job  control  us — are  we  interested — are  we  giving  all  that  we  have  to 
give — are  we  alert  and  ever  adding  to  our  knowledge?  They  say  one  can- 
not teach  an  old  dog  new  tricks.  It  isn't  so!-  Sufficient  interest,  a  keen 
desire  to  progress,  a  zest  for  living  combine  to  enable  anyone  at  any  age 
to  acquire  further  knowledge  and  compete  with  others  of  the  same  age 
and  even  younger  successfully. 

THE  HOUSEKEEPERS  OF  INDUSTRY 

Harold  W.  Stevens,  M.D. 
Harvard  School  of  Public  Health 

Healthy  bodies  and  healthy  ideas  are  important  items  of  the  household 
economy  of  business.  Women  are  our  natural  housekeepers;  but  some- 
how few  women  have  been  deeply  interested  in  health  as  a  matter  of  busi- 
ness. Perhaps  that  is  not  the  fault  of  women.  Perhaps  it  is  the  failure 
of  us  physicians  that  no  very  satisfactory  program  has  yet  been  devised 
for  accounting  the  assets  and  liabilities  of  health.  Perhaps  the  woman 
actually  in  business  is  less  concerned  about  the  assets  and  liabilities  of 
health  because  she  expects  business  to  be  with  her  a  temporary  matter, 
or  an  aside  from  the  more  important  interests  of  life.  Perhaps  not  every 
woman  with  a  husband  or  son  or  father  or  brother  or  sweetheart  has 
heard  stories  like  that  of  the  wife  of  the  British  Chancellor,  whose  watch- 
ful care  of  her  husband's  handicapped  health  has  had  such  an  important 
part  in  his  clear  thinking  and  courageous  judgment  which  have  influ- 
enced the  finance  of  the  world.  Perhaps  too  few  know  of  our  American 
women  who  are  authorities  in  industrial  and  other  public  health.  What- 
ever the  cause,  few  women  have  learned  that  it  is  possible  to  discover, 
much  more  to  influence,  the  design  of  the  basic  pattern  of  individuality 


4 
according  to  which  experience  in  business  or  elsewhere  brings  out  the 
colors  which   make   life  dull,   or   bright   and   intensely   interesting   and 
profitable. 

I  have  heard  attributed  to  Mr.  Charles  W.  Eliot  these  words :  "Health 
is  the  indispensable  foundation  for  the  satisfactions  of  life;  everything 
of  domestic  joy  and  occupational  success  has  to  be  built  upon  bodily 
wholesomeness  and  vitality."  The  words  have  a  sound  of  completeness. 
They  evidently  come  from  a  breadth  of  vision  and  a  depth  of  understand- 
ing; but  they  do  not  quite  picture  health  as  we  hope  sometime  to  see  it, 
boldly  drawn  in  the  practical  business  characters  of  our  time — a  picture 
perhaps  in  the  same  vividness  which  has  made  us  see  Health  as  Religion 
among  the  ancient  Hebrews;  or  Health  as  Physical  Strength  and  Beauty 
among  the  ancient  Greeks.  We  have  yet  to  learn  through  the  hopes  and 
fears  of  lives  dependent  upon  jobs  the  lessons  which  the  discipline  of 
business  is  adding  to  our  unformed  ideas  of  health  and  human  per- 
formance. 

The  earliest  industrial  laws  were  designed  to  protect  the  health  and 
welfare  of  children  and  women  workers.  These  early  laws  together  with 
Workmen's  Compensation  and  other  recent  legislation  taxing  business 
management  with  the  care  and  prevention  of  injury  and  sickness  caused 
by  occupation  have  been  an  immediate  boon  to  the  worker.  It  is  only 
about  eighteen  years  since  our  first  state  workmen's  compensation  law 
became  effective  in  Massachusetts.  Now  all  our  states  excepting  four 
have  such  laws.  Today  among  the  better  organized  industries  all  over 
our  land  the  worker  is  probably  far  safer  from  accidental  injury  or 
disease  at  his  work  than  while  subject  to  the  hazards  of  community  life 
outside  his  place  of  work.  Single  items  of  community  danger,  for 
example  home  accidents,  may  outweigh  the  total  industrial  hazard. 

Is  this  luxury  costing  the  worker  nothing?  One  day  early  in  my  experi- 
ence with  business  medicine  a  young  girl  came  to  my  office  and  dropped 
down  limply  into  a  chair  with:  "Gee,  Doctor,  I  feel  just  like  an  accident 
going  somewhere  to  happen."  I  thought  her  only  an  irresponsible  child  try- 
ing to  be  smart.  Now  I  know  that  her  complaint  was  a  very  real  trouble 
described  in  quite  up-to-date  English,  which  might  be  adopted  as  a  diag- 
nosis of  a  peculiar  kind  of  poor  health  well  known  in  industry.  Today 
every  intelligent  safety  program  recognizes  a  constitutional  liability  to 
accidental  injury  and  disease  which  seems  to  affect  most  individuals  at 
some  times;  some  individuals  more  than  others.  Good  management  re- 
quires that  any  worker  thus  seriously  handicapped  be  relieved  from 
exposure  to  hazard,  either  by  transfer  or  as  a  last  resort  by  removal  as 
a  "liability."  There  is  no  doubt  that  many  of  these  "liabilities"  though 
removed  from  exposure  in  industry  remain  still  "liabilities"  among  the 
unemployed. 

Reliable  figures  are  not  easy  to  get;  but  even  without  figures  directly 
from  business  we  know  that  not  only  gross  sickness  and  complete  dis- 
ability, but  also  fatigue  and  indisposition  and  ill  temper  and  sulkiness 
and  carelessness  and  other  quirks  of  personality  reduce  the  chances  of 
getting  and  holding  jobs  in  industry.  A  little  simple  calculation  from 
figures  of  the  United  States  Census  Bureau  seems  to  show  that  the 
chances  of  an  individual  looking  for  a  job  in  the  manufacturing  indus- 
tries in  1927  were  about  20%  less  than  in  1920.  Corresponding  with  this 
shrinkage  in  jobs  the  records  show  the  increase  in  mechanical  horsepower 
as  about  33%.  These  ratios  since  1927  can  hardly  be  more  encouraging. 
The  "mass-distribution"  idea  indicates  similar  reductions  of  personnel 
throughout  organized  business.  This  information  brings  home  to  us 
some  idea  of  the  competition  for  jobs  which  are  already  too  few  to  go 
around,  and  of  the  increasing  premium  on  physical  fitness. 

Workmen's  Compensation  is  our  first  broad  social  experiment  in  put- 
ting upon  a  sound  economic  basis  the  management  of  some  part  of  the 
misfortune  of  physical  disability.  Its  operation,  together  with  other  new 
conditions  of  competitive  industry  confronts   us  with   another  kind   of 


5 

"industrial  accident."  The  loss  of  a  job,  or  the  failure  to  find  one  because 
of  physical  unfitness  is  the  worst  casualty  that  has  come  out  of  our  indus- 
trial system.  The  next  task  for  business  management  seems  to  be  find- 
ing some  reasonable  compensation  and  prevention  of  this  kind  of  acci- 
dent. This  is  a  problem  for  the  industrialists  and  economists  of  true 
democracy.  Individual  health,  however,  can  only  in  small  part  be  legis- 
lated or  promoted  by  a  social  program.  Our  daily  papers  are  littered 
with  the  evidence  of  personal  indulgence  undermining  systems  of  laws 
designed  to  safeguard  broad  health  interests  of  society.  Health  as  the 
surest  title  to  a  satisfying  job  and  all  that  goes  with  it  must  consist  in 
an  effectual  individual  hygiene  based  upon  a  sense  of  the  essential  one- 
ness of  health  and  economic  worth.  This  is  just  one  of  the  sobering 
health  lessons  of  business. 

A  few  weeks  ago  I  visited  one  of  our  modern  factories  in  Boston  with 
a  Chinese  physician  who  is  to  have  a  share  in  organizing  a  health  pro- 
gram for  his  country.  He  was  the  most  evidently  thoughtful  physician 
I  have  seen  in  a  like  situation.  About  one  after  another  complex  machine 
he  slowly  walked  carefully  studying  its  ingenious  design  and  operation; 
and  now  and  then  he  paused  to  comment  upon  what  he  saw  and  what  he 
thought  only  by  shaking  his  head  in  Oriental  solemnity.  At  one  of  the 
machines  operated  by  a  single  girl  the  manager  of  the  plant  said  to  my 
Chinese  companion:  "In  Shanghai  there  is  a  factory  where  girls  do  that 
operation  entirely  by  hand;  one  Chinese  girl  can  make  about  two  thou- 
sand of  those  parts  in  a  day."  Then,  turning  to  his  own  machine  oper- 
ator, he  asked:  "How  many  do  you  make  in  a  day?"  "Sixty  thousand," 
was  the  answer.  "There,"  said  the  manager,  "you  see  it  takes  thirty 
Chinese  girls  to  do  what  one  American  girl  can  do."  The  Chinese  physic- 
ian smiled  and  again  shook  his  head  in  silence;  but  I  venture  to  guess 
that  among  his  thoughts  were  some  misgivings.  For  even  mechanical 
America  which  built  the  machine  has  not  yet  finished  its  job.  It  has  not 
yet  invented  the  social  complement  of  the  machine  to  answer  the  thought 
that  if  that  machine  were  in  China  today,  at  least  thirty  Chinese  girls 
would  be  competing  for  the  job  of  operating  it;  and  the  successful  one 
would  be  some  brighteyed,  healthy  Chinese  girl,  the  chosen  from  many 
applicants,  like  her  alert,  competent  American  sister  who  is  now  operat- 
ing the  machine. 

Just  now  we  are  unusually  distrustful,  even  fearful  of  the  machine. 
This  is  not  the  first  time  that  sentiment  has  strayed  from  the  path  of 
judgment  in  blaming  mere  things  for  troubles  that  are  within  ourselves. 
We  must  never  forget  that  the  machine  is  a  thing  designed  by  man  for  a 
special  purpose,  made  by  him  and  operated  by  him  to  effect  that  purpose. 
In  that  respect  the  most  complex  and  powerful  machine  is  not  different 
from  the  knife  which  cuts  our  food  and  the  fork  and  spoon  which  convey 
it  to  our  mouths.  We  may  use  poor  judgment  in  managing  our  indus- 
trial machines;  we  also  use  poor  judgment  with  our  eating  implements; 
it  is  not  at  all  certain  which  errors  have  the  worst  effects  upon  our 
health.  Perhaps  the  worst  danger  from  the  machine  is  in  the  vain  im- 
agination that  a  machine-made  life  can  ever  be  completely  satisfying. 
We  must  learn  much  more  about  the  social  values  of  machinery.  The 
hopeful  attention  of  some  of  our  great  thinkers  is  already  turning  toward 
a  public  hygiene  centered  in  the  care  of  human  life  according  to  the  com- 
mon factor  of  all  genuine  personal  need — an  appropriate  and  satisfying 
job  for  every  individual  of  whatever  grade  of  capacity.  It  is  a  fine  pur- 
pose; under  the  social  order  which  undertakes  to  adapt  our  machine 
system  to  that  end,  there  will  certainly  be  plenty  of  work  for  medicine 
and  engineering  and  finance  of  the  highest  caliber. 

Women  usually  regard  machinery  with  contempt  or  indifference.  It  is 
hard  to  understand  why.  Perhaps  there  is  no  explanation  except  the 
ancient,  undebatable  right  which  men  can  only  dimly  and  partially  view 
as  inconsistency.  For  it  is  probably  true  that  women  are,  and  always 
have  been,  the  chief  urge  to  the  invention  of  mechanical  devices  to  am- 


6 

plify  man's  limited  natural  abilities.  Solomon  at  great  cost  of  materials 
and  transportation  and  the  labor  of  thousands  of  the  most  skilled  mechan- 
ics of  his  time  built  a  splendid  palace  to  gratify  his  favorite  princess. 
Dr.  Abraham  Myerson  has  remarked  in  one  of  his  lectures  that,  if  stand- 
ards of  civilization  were  from  today  left  entirely  to  men,  in  two  or  three 
generations  we  should  all  be  living  in  tents. 

Thus  it  is  that  women's  desires  are  present  and  determine  standards, 
not  only  for  trade  in  hats  and  gowns  and  cosmetics,  but  also  in  buildings 
and  automobiles  and  airplanes  and  locomotives  and  ships;  in  fact  in  al- 
most every  demand  for  things  which  machines  are  designed  to  do  or 
make.  Thus  it  is  that  hazards  of  working  conditions  and  hours  and 
wages  and  jobs — or  no  jobs — and  other  industrial  factors  of  health  have 
a  very  direct  dependence  upon  women's  opinions  about  the  things  im- 
portant to  life.  Thus  it  is,  also,  in  that  most  hopeful  portion  of  the  field 
of  public  health,  that  women  by  virtue  of  the  unique  nature  of  their  in- 
dividuality have  the  first  and  most  precious  opportunities — in  rearing  a 
new  generation  of  healthy  bodies  and  wholesome  ideas  of  the  business  of 
living. 

PHYSICALLY  FIT  EVERY  DAY  IN  THE  MONTH 
Florence  A.  Somers,  B.S.  in  Ed.,  M.A. 
Associate  Director  of  Sargent  School  of  Physical  Education 
Boston  University  School  of  Education 
This   is  a  problem   in   which   every  woman   is   vitally   interested.    A 
woman's  outlook  on  life  would  be  entirely  altered  if  she  knew  for  certain 
that  she  were  not  to  be  handicapped  for  a  period  of  her  life,  and  be  temp- 
orarily incapacitated  while  a  function  which  is  said  to  be  perfectly  nor- 
mal is  taking  place. 

Menstruation  is  a  natural  function  and  not  a  malady,  and  the  natural 
or  right  thing  is  for  a  girl  to  feel  quite  well  during  the  period,  and  to  be 
free  from  pain  and  unpleasant  sensations.  Occasionally,  we  hear  it  said 
that  if  the  function  of  menstruation  is  perfectly  normal,  a  woman  should 
be  no  more  aware  of  it  than  of  the  digestive  processes,  of  her  heart-beat, 
or  respiration.  Even  while  we  believe  this  statement  to  be  fairly  sound, 
it  is  not  at  all  unreasonable  that  any  function  which  occurs  only  at  four- 
week  periods  and  which  manifests  physical  symptoms,  is  naturally  more 
to  be  noticed  and  irregularities  dwelt  upon  than  those  occurring  three 
times  a  day,  as  in  digestion,  or  constantly,  as  in  the  heart-beat  or 
breathing. 

However,  we  are  coming  more  and  more  to  believe  today  that  inasmuch 
as  menstruation  is  a  normal  function  of  woman,  it  should  cause  neither 
discomfort  nor  pain.  If  pain  is  present,  it  is  due  to  any  one  of  a  few 
causes,  and  may  be  symptomatic  of  a  pathological  condition.  Dr.  Flor- 
ence Meredith  concludes  from  her  study  of  college  girls  that  many  cases 
of  pain  are  due  to  poor  posture  and  constipation.  Dr.  Norman  Miller 
relates  pain  to  posture  and  muscle  tone,  believing  that  poor  muscle  tone 
is  a  vital  factor  in  congestion.  Congestion  is  a  general  cause  given  by 
many  for  pain  and  discomfort.  Others  think  that  nervousness  or  some 
derangement  of  the  central  nervous  system  is  an  important  factor.  But 
the  persons  who  propound  these  different  theories  agree  that  cases  of 
severe  and  long-continued  pain  during  menstruation  point  so  definitely 
toward  a  structural  abnormality  of  the  pelvic  organs  or  an  underlying 
disease  that  an  examination  should  be  made  to  determine  the  nature  and 
extent  of  the  trouble  and  the  individual  procedure  advisable. 

It  seems  reasonable  to  conclude  from  several  investigations  already 
carried  on  in  this  very  important  field  that,  provided  no  abnormality  or 
disease  is  present,  a  person  will  be  benefited  by  continuing  her  daily  pro- 
gram, her  routine  of  work  and  play,  every  day  of  the  month.  "Time  out" 
for  menstruation  indicates  abnormality.  One  must  play  the  game  of  life 
every  day  in  the  year,  oneself  the  umpire  who  makes  the  important 
decisions  concerning  one's  own  habits  and  one's  responsibilities. 


7 

It  is  probably  true  that  if  a  girl  is  taught  to  continue  her  regular 
activities  from  the  time  of  the  very  first  menstruation  on,  she  will  never 
encounter  the  type  of  dysmenorrhea  due  to  over-congestion.  (The  term 
"dysmenorrhea"  may  be  used  to  mean  any  suffering  definitely  connected 
with  menstruation).  She  will  also  be  forming  such  attitudes  toward  the 
function  in  relation  to  life  that  she  will  be  happier,  more  normal  and  free 
from  neurotic  fancies.  A  movement  should  be  undertaken  to  educate 
parents  of  young  girls  to  the  point  of  view  that  moderate  exercise  during 
the  period  is  beneficial  and  that  the  practice  of  complete  rest  for  a  day 
or  two  at  the  beginning  of  the  period  is  actually  laying  the  foundation 
for  future  suffering.  Dr.  Sarah  Gray  of  England  warns  us  all  against 
the  "dangers  of  the  periodical  rest,"  and  suggests  that  exercise  may  be 
the  future  form  of  treatment  of  dysmenorrhea. 

Dr.  Clelia  Mosher  of  Stanford  University  believes  that  painful  men- 
struation may  be  due  to  the  lack  of  general  muscular  development  and  to 
inactivity  during  the  menstrual  period.  She  has  used  extensively  a  simple 
abdominal  exercise  for  the  purpose  of  relieving  the  over-congestion  of 
blood  in  the  uterus  and.  thus  decreasing  pain.  Dr.  Alice  E.  Sanderson 
Clow  of  England,  who  has  made  exhaustive  studies  with  school  girls  on 
both  the  normal  and  abnormal  aspects  of  menstruation,  gives  us  in  her 
reprinted  addresses  valuable  assistance  in  remolding  our  ideas  on  this 
subject.  She  suggests  that  treatment  for  dysmenorrhea  has  a  two-fold 
object:  "(1)  to  stimulate  the  circulation  of  the  blood  in  order  to  relieve 
the  hyperaemic  uterus.  The  quickest  means  of  doing  this  is  a  hot  bath; 
the  more  lasting  measure  is  vigorous  exercise;  (2)  to  direct  the  patient's 
attention  from  herself  by  providing  interesting  occupation.  Hence, 
games  or  active  work  are  preferable  to  set  exercises." 

The  idea  of  bathing  and  exercising  or  playing  games  as  a  cure  for 
dysmenorrhea  is  so  new  to  many  of  us  that  we  will  want  to  know  more 
about  it.  For  instance,  what  kind  of  a  bath  is  beneficial ;  what  type  of  ex- 
ercises or  what  games  should  we  play?  Warm  baths  for  cleanliness  should 
be  continued  as  usual  throughout  the  period.  It  may  be  questioned, 
however,  whether  cold  shower  or  tub  baths  should  be  taken,  in  considera- 
tion of  the  disturbance  to  the  circulation  which  they  may  cause.  For 
this  reason,  it  is  probable  that  swimming  in  the  cold  ocean  or  lakes 
should  not  be  indulged  in.  One  should  never  go  in  a  swimming  pool 
during  menstruation  for  sanitary  reasons. 

While  exercises  and  games  should  be  carefully  selected  for  adults  who 
are  only  beginning  to  take  over  this  method  of  conduct  for  the  menstrual 
period,  young  girls  should  continue  their  playing  and  dancing  without 
much  thought  of  restrictions  and  limitations.  Many  physicians  agree 
that  activities  involving  jumping  or  jouncing  of  the  body  may  be  in- 
jurious, since  the  general  lack  of  tone  of  the  tissues  of  the  body  at  this 
time  so  affects  the  ligaments  which  hold  the  uterus  in  position  that  the 
uterus  is  apt  to  be  displaced.  This  organ  is  heavier  than  usual  during 
the  first  day  or  two  of  the  menstrual  period,  and  exerts  a  greater  pull 
than  at  other  times  on  the  ligaments  which  hold  it  in  place.  While  it  is 
true  from  experience  that  some  women  are  never  harmed  by  any  type  of 
exercise  or  activity  carried  on  during  the  menstrual  period,  it  seems  a 
reasonable  safeguard  to  suggest  restriction  of  exercises  and  games  where 
there  is  much  jumping,  as  in  track  and  field  events  or  basketball,  or 
jouncing,  as  in  horse-back  riding.  As  one  writer  suggests,  we  would 
not  advocate  high  jumping  or  fancy  diving  when  the  stomach  is  in  a 
much  less  acute  physiological  state  of  hyperaemia  after  a  heavy  meal, 
so  why  advise  it  during  menstruation? 

It  is  possible  for  the  girl  who  does  not  have  access  to  a  golf  course  or 
other  regular  means  of  active  recreation,  to  take  exercises  at  home  every 
night  which  will  assist  in  maintaining  a  normal  circulation  and  healthy 
condition  of  her  body.  Some  of  these  might  be  "picking  up  objects  from 
the  floor  and  placing  them  on  a  shelf  above  the  head ;  kneeling  and  swing- 
ing the  hands  round  alternately  as  if  polishing  the  floor;  squatting  on 


8 
the  floor  and  bending  to  and  fro,  as  in  rowing;  and  standing  and  doing 
swinging  movements  as  in  driving  a  golf  ball."  (Clow)  The  Mosher 
exercise  is  done  as  follows:  lie  on  the  back  in  a  relaxed  position,  with 
the  knees  slightly  raised,  feet  remaining  on  the  bed;  contract  the  abdom- 
inal muscles,  lowering  the  abdominal  wall,  then  relax  the  muscles,  raising 
the  abdominal  wall,  and  alternate  slowly  about  six  times.  These  exer- 
cises may  be  performed  every  night. 

While  it  has  been  previously  believed  that  nervous  symptoms,  such  as 
increased  irritability,  depression,  emotionalism  and  others,  were  a  neces- 
sary accompaniment  of  menstruation,  some  recent  writers  on  the  subject 
see  no  reason  for  this.  It  is  interesting  that  in  several  schools  where 
a  record  of  the  cases  of  pain  have  been  kept,  the  incidence  of  pain  has 
decreased  over  a  period  of  time,  while  at  the  same  time,  the  whole  life 
of  the  girl  seems  to  favor  increased  nervousness.  The  life  of  today  is  a 
tense  one  speeded  up  to  the  limit  of  endurance,  with  many  calls  upon 
one's  nervous  energy.  If,  at  the  same  time,  a  girl  can  actually  reduce 
the  suffering  and  discomfort  of  menstruation  through  normal  living,  we 
are  almost  obliged  to  disregard  the  factor  of  nervousness. 

Physically  fit  every  day  in  the  month !  What  a  slogan  this  would  be  for 
many  women!  It  is  not  to  be  won,  however,  by  writing  it  on  a  card  and 
hanging  it  on  the  wall  where  one  can  see  it  every  day.  Rather  must  it  be 
worked  for, — earned,  just  as  everything  which  is  really  appreciated  in 
life  is  earned.  Regular  hours  for  activity  and  play,  bathing,  sufficient 
rest,  normal  attitudes  of  mind;  these  are  some  of  the  habits  which  must 
be  cultivated  if  one  would  choose  to  rise  above  the  discomfort  and  pos- 
sible pain  of  menstruation.  The  employer  will  no  longer  look  for  poor 
work  from  you  several  days  of  every  month;  the  family  will  not  make 
excuses  for  your  irritability  at  regular  periods;  the  insurance  companies 
will  begin  to  believe  that  women  may  have  health  insurance  under  the 
same  conditions  and  rates  as  men.  But  better  than  any  changes  which 
this  universal  improvement  will  bring  in  the  regard  of  others,  will  be  the 
effect  of  it  on  ourselves,  the  glorious  feeling  of  normality,  of  health,  and 
therefore,  of  happiness. 

MENTAL  FITNESS 

Sarah  Morse  Beardsley 

Mothership  Secretary 

Massachusetts  Society  for  Mental  Hygiene 

Although  today  the  popular  appeal  as  to  "why"  people  behave  or  think 
as  they  do  has  been  shown  by  the  increasing  number  of  lectures,  books 
and  leaflets  appearing  on  the  topics  of  mental  health  and  closely  allied 
subjects,  there  is  still  a  wide  lack  of  understanding,  particularly  on  the 
part  of  the  laity  as  to  the  importance  of  the  role  of  the  emotions  in 
developing  healthful,  happy  lives. 

It  is  not  strange,  however,  that  little  progress  has  been  made  in  the 
prevention  and  treatment  of  mental  disease  and  disorder  when  we  stop  to 
think  that  up  to  the  present  time  practically  all  our  attention  has  been 
focused  on  the  duration  of  life  rather  than  on  the  quality  of  life.  The 
death  rate  has  been  considered  a  criterion  of  progress  or  failure  and 
little  or  no  attempt  has  been  made  to  meet  the  psychological  hazards  of 
everyday  life.  Only  when  the  effort  comparable  to  that  exhibited  in  the 
field  of  physical  hygiene — as  for  example,  the  control  of  communicable 
diseases — has  been  put  forth,  can  the  long  wished  for  results  for  sound 
mental  health  be  forthcoming. 

Let  us  review  for  a  moment  some  of  the  causes  leading  up  to  the 
present  day  emotional  instability.  First,  with  the  rise  of  the  industrial 
era  there  has  come  unusual  stresses  and  strain.  There  was  the  flocking 
to  the  centers  of  industry,  the  herding  together  in  crowded  dwellings, 
the  long  hours  under  insanitary  working  conditions,  the  breaking  up  of 
the  family,  and  the  creation  of  commercial  recreation  enterprises.  Sec- 
ondly, the  great  influx  of  immigrants  at  the  dawn  of  the  twentieth  cen- 


9 
tury    offering   its   new   problem   of   assimilation    and    Americanization. 
Thirdly,   the   World   War  with   its   shell-shocked   victims   and   veterans 
handicapped  from  various  injuries.     And  now  the  great  unemployment 
situation. 

What  can  we  do  in  these  days  of  social  and  economic  unrest  to  keep 
mentally  fit?    Is  there  no  golden  rule? 

Childhood  is  the  time  to  uproot  symptoms  which  may  later  hinder  the 
individual  in  adult  life  from  acquiring  social  adequacy,  efficiency  and 
happiness.  But  what  about  adults?  There  must' be  rules  that  they,  too, 
may  follow.  Most  of  us,  perhaps,  would  consider  them  too  simple  to 
place  in  the  category  of  mental  hygiene. 

Mental  Hygiene,  or  the  science  of  preserving  the  healthy  mind,  is  really 
understanding,  understanding  not  only  your  abilities  but  also  your 
limitations.  Mental  hygiene  teaches  you  how  to  make  the  most  of  your 
mental  skill.  It  teaches  you  how  to  avoid  fatigue,  how  to  use  your  energy, 
how  to  develop  your  abilities,  and  even  more  than  that,  how  to  get  on 
with  your  fellow-beings. 

A  most  important  phase  of  mental  fitness  is  fitness  for  the  job,  since 
most  people  must  work  and  all  should.  It  helps  make  for  a  serious  pur- 
pose in  life. 

Two  conditions  are  necessary  for  good  work;  physical  and  mental 
health, — a  sound  mind  in  a  sound  body, — and  a  favorable  environment. 
To  obtain  a  workable  relation  between  needs  and  their  satisfaction  is  the 
desirable  aim. 

Work  so  that  all  thoughts  irrelevant  to  it  are  excluded  while  engaged  in 
any  pursuit.  Work  for  the  joy  of  achievement.  Work  so  that  you  may 
feel  you  are  a  contributing  force  in  your  community.  Work  hard  and 
play  hard. 

Play,  of  course,  is  just  as  important  as  work.  One  needs  the  oppor- 
tunity for  relaxation,  for  companionship.  Much  of  our  best  work  is 
done  alone,  but  we  play  best  together.  The  zest  for  life  comes  by  having 
an  avocation  with  no  strain.  Hobbies  serve  an  excellent  purpose.  Col- 
lecting for  instance,  is  an  offset  to  business,  and  should  it  come  to  be  a 
business  it  still  retains  the  sentiment  of  attachment.  The  intrinsic  value 
of  collected  articles  and  the  thrill  of  possession  of  a  rare  and  unusual  trea- 
sure is  very  real.  The  educational  value,  too,  is  striking.  It  enlarges 
our  interests  and  develops  appreciation.  After  all,  collecting  is  some- 
thing we  do  for  the  love  of  it  and  it  keeps  the  emotions,  like  the  muscles, 
in  good  working  order. 

Rest,  in  order  to  avoid  fatigue,  is  one  of  the  present-day  problems. 
Little  telltale  signs  of  danger  such  as  working  at  top-speed  and  not  want- 
ing to  stop,  making  errors  in  your  work,  a  cross  and  irritable  attitude, 
should  be  closely  watched.  At  any  rate,  it  is  quite  necessary  and  desir- 
able to  have  reserve  energy  through  rest;  to  have  week-ends  for  rest, 
quiet,  and  play;  to  have  snatches  during  the  day  away  from  work  free 
from  responsibilities,  and  vacations  whenever  possible. 

In  connection  with  rest,  sleep  should  be  considered,  for  it  not  only  rests 
the  nervous  system  but  gives  it  a  chance  to  repair  itself.  Have  a  reserve 
of  sleep  to  avoid  excessive  fatigue  rather  than  to  recover  from  it.  If 
you  cannot  sleep,  rest  in  bed  is  an  excellent  substitute.  Have  sleep  habits 
fitting  in  with  your  regime  of  work  habits,  and  elastic  enough  so  that  a 
break  of  habits  will  not  upset  you.  The  final  test,  of  course,  is  whether 
the  day's  work  is  done  with  zest  and  energy  to  spare. 

Among  good  health  habits,  do  not  forget  the  need  for  exercise  in  the 
open  air.  An  increasing  interest  in  golf,  for  instance,  is  offering  oppor- 
tunity not  only  for  exercise  out-of-doors  but  also  for  relaxation  and  play. 
So  also  it  is  with  the  many  other  types  of  popular  athletics.  Although 
the  ex-Kaiser  Wilhelm  of  Germany,  who  chops  wood  daily  out  in  the  open 
air,  may  be  considered  eccentric,  nevertheless  he  is  no  doubt  finding  this 
simple  habit  of  considerable  help  toward  keeping  mentally  and  physically 
fit. 


10 

One  of  the  most  elusive  needs  of  present-day  living,  particularly  for 
urban  dwellers,  is  privacy.  We  live  in  noisy  crowds  in  apartment  houses 
where  not  only  voices  penetrate  the  walls,  but  radios  and  innumerable 
mechanical  musical  instruments  disturb  our  solitude.  For  work,  for 
concentration  and  development,  one  must  have  a  place  of  retreat.  For 
play,  for  recreation,  one  seeks  company.  Every  normal  person  needs 
frequent  periods  of  solitude  in  which  to  reflect  and  think.  Seclusion 
prepares  you  to  join  your  friends  and  companions.  Of  course,  one  must 
seek  the  middle  ground  and  find  the  proper  balance  of  the  two  needs, 
the  need  for  privacy  and  the  need  for  companionship. 

Temperament  is  a  convenient  name  for  the  balance  of  the  qualities  of 
the  head  and  the  heart,  of  the  thinking  and  feeling  "You"  that  goes  into 
your  work  and  no  less  into  your  play.  It  is  the  emotional  support  of 
your  work,  whether  mind-work  or  muscle-work.  In  fact,  it  is  your  men- 
tal climate.  Temperament  or  mood  is  real,  but  one  cannot  yield  to  it 
unduly.  Undue  susceptibility  to  trifling  discomforts  makes  for  mental 
unfitness.  No  one  inflicted  with  a  pronounced  temperament  can  escape 
its  tyranny. 

The  question  of  incentives^ — ambition,  desire  for  the  esteem  and  love 
of  those  whose  opinions  we  value,  reward  for  achievement — plays  an 
important  part  toward  mental  health.  This  involves  vigor,  steadiness 
of  purpose,  and  direction.  Energy  founded  on  a  well-organized  set  of 
habits,  the  power  to  come  back  to  the  same  job  ready  to  try  again  despite 
interruptions  and  disappointments,  the  definiteness  and  Tightness  of  aim, 
these  incentives  with  the  proper  responses  make  for  social  progress. 

One  could  continue  discussion  of  the  innumerable  factors  making  for 
mental  fitness  ad  infinitum  but  the  more  outstanding  requirements  have 
been  presented.  After  all,  each  individual  is  aware  of  the  simple  rules 
of  health,  and  with  an  ordinary  endowment  of  good  common  sense,  and 
an  increasing  knowledge  of  psychological  mechanisms,  made  possible 
through  reading  and  study,  one  can  gain  considerable  satisfaction  as  to 
why  we  behave  as  we  do.  Insight  into  our  emotional  life  gives  surpris- 
ing relief,  and  although  the  adult,  with  many  habits  firmly  fixed,  cannot 
make  radical  personality  changes,  nevertheless,  with  the  better  under- 
standing of  human  nature,  he  can  be  brought  to  a  more  careful  considera- 
tion for  others  as  well  as  the  ability  to  create  happiness  within  himself. 

RECREATION 

Alma  Porter 
Assistant  State  Supervisor  of  Physical  Education 

After  all,  leisure  time  is  a  part  of  life —  a  part  which  should  be  ex- 
pected to  enrich  and  color  what  otherwise  is  often  a  mere  existence. 
That  for  years  the  leisure  of  children  and  adults  has  been  recognized  as 
a  problem,  as  a  time  of  potential  mischief,  is,  of  course,  true;  that  there 
should  be  a  concerted  effort  toward  education  for  its  better  use,  or  as  a 
matter  of  fact,  recognition  of  the  need  of  such  education,  is  so  new  an 
idea  as  to  be  quite  staggering. 

There  seems  to  be  no  question  in  the  minds  ol  those  who  have  studied 
children,  or  who  work  with  children,  that  their  play  life  is  an  essential 
part  of  their  very  being.  From  the  time  when  the  baby  kicks  and 
squirms  with  his  every  inch,  or  reaches  a  wavering,  uncertain  hand 
toward  the  bright  thing  held  by  his  mother,  all  through  childhood  and 
into  adult  life  there  is  this  urge  toward  play.  There  is  this  urge  toward 
interesting,  soul  satisfying  activity,  which  in  the  growing  child  is  un- 
quenchable, but  which  has  been  considered  all  through  the  ages^as  super- 
fluous, certainly,  and  even  a  little  suspicious  in  adults. 

However,  there  is  some  recognition  that  play  is  not  a  particularly  un- 
pleasant, mischievous  thing  which  a  child  concocts  to  annoy  his  parents 
and  his  teachers,  but  a  vital  something  which  serves  as  a  background, 
a  natural  opportunity  for  that  physical  growth  which  must  come  through 


11 

activity,  and  for  social  growth  which  must  come  through  "give  and  take" 
with  his  kind.  Joseph  Lee  once  said,  in  effect,  that  children  do  not  play 
because  they  are  children,  but  they  have  childhood  that  they  may  play. 

The  play  of  the  very  young  child  is  a  fascinating  study,  about  which 
all  too  little  is  known.  It  is  fairly  safe  to  say,  however,  that  opportunity 
and  facility  for  those  play  activities  which  seem  to  be  natural  for  small 
children  are  so  seldom  made  available  for  them,  either  by  parent  or  com- 
munity, that  anyone  interested  in  the  play  of  children  may  well  focus 
some  of  his  attention  there. 

These  little  people  are  surprisingly  strong  as  well  as  surprisingly  active, 
and  most  of  them,  if  they  are  well,  take  the  utmost  pleasure  in  a  few 
activities  which  seem  to  have  a  definite  relationship  to  their  growth, 
physical  and  social.  They  like  to  creep  and  roll;  they  like  to  walk;  they 
like  to  climb;  they  display  the  deepest  interest  in  all  sorts  of  little  things 
which  they  can  handle  and  investigate ;  they  like  and  need  companionship ; 
they  have  an  insatiable  curiosity  which  they  need  opportunity  to  use,  and 
they  have  a  power  of  persistence  which  is  not  short  of  marvelous.  This 
delightful  curiosity  as  to  what  they  can  do  with  themselves,  as  to  what 
they  can  do  with  all  the  queer  things  this  world  offers  to  an  adventurous 
spirit,  this  persistence  until  they  get  satisfaction — complete  baby  satis- 
faction—  in  activity,  help  to  make  up  a  very  nice  world,  a  very  pleasant 
place  in  which  to  be. 

And  yet  these  strange  adults,  who  might  very  well  provide  opportun- 
ities for  this  pleasant,  satisfying  world,  are  so  busy  entertaining  this  same 
baby  that  it  is  no  wonder  that  it  becomes  a  puzzling  place  to  him.  A  fat, 
brown  baby,  who  was  sitting  on  the  beach,  illustrates  this  point.  With 
infinite  pains  he  was  filling  his  little  pail  with  sand,  using  a  big  spoon 
clumsily,  but  persistently,  completely  absorbed  and  happy.  His  over- 
solicitous  mother,  who  had  thoughtfully  provided  the  sun  suit,  the  pail, 
the  spoon,  the  beach,  and  even  the  baby,  leaned  over  him,  emptied  his 
pail,  filled  it  brimming  full  and  set  it  down  before  him.  The  effect  was 
immediate,  disastrous,  and  noisy.  Unfortunately,  the  fat,  brown  baby 
did  not  want  a  full  pail.  He  had  nothing  to  do  with  it  after  it  was  full, 
but  he  had  wanted  to  fill  it.  That  was  his  own  idea,  and  it  would  have 
afforded  him  glowing  satisfaction  to  accomplish  it. 

It  would  seem  that  children  through  life  are  rather  well  entertained, 
and  largely  in  artificial  ways;  to  fail  to  recognize  the  difference  between 
play  and  entertainment  is  to  fail  to  provide  opportunity  for  natural  activ- 
ity, which  means  growth  and  happiness.  Unfortunately,  the  results  last 
through  life. 

The  White  House  Conference  sums  it  up:  "Since  play  forms  the  chief, 
and  indeed  the  only  activity  of  the  the  preschool  years,  it  follows  that 
the  neglect  of  the  recreation  and  physical  education  of  the  preschool  child 
constitutes  a  serious  flaw  in  any  system  of  child  care  and  protection.  A 
child's  occupations  are  his  whole  existence;  he  is  always  at  work  during 
his  waking  hours.  'His  play  is  the  formative  element  of  the  early  period, 
producing  independence,  self-direction,  joy  of  accomplishment — three 
basic  principles  of  early  life.  For  this  education  he  needs:  a  suitable 
and  safe  place  for  his  activities;  adequate  play  material;  good  com- 
panionship; sufficient  supervision  to  prevent  harm,  or  accident,  yet  not 
enough  to  take  away  the  opportunity  he  needs  for  self -direction  and  spon- 
taneity.' (Baldwin).  Absence  of  motive,  stimulus,  or  opportunity  for 
normal  play  activity,  results  in  retarded  and  unsatisfactory  physical 
and  mental  development." 

Now  the  relation  of  the  play  life  of  children  to  the  leisure  time  of 
adults  is  evident.  To  be  trite  and  platitudinous,  "As  the  twig  is  bent,  so 
is  the  tree,"  or  to  suggest  the  old  Methodist  warning  for  the  upbringing 
of  its  religious  students:  "He  who  playeth  when  he  is  young  will  play 
when  he  is  old,"  is  to  encourage  us  to  believe  that  since  we  cannot  elim- 
inate either  the  play  urge  or  its  expression,  that  we  had  better  build  on 
it  wisely  and  take  joy  in  it.     The  play  life  of  the  adult  is  just  as  im- 


12 

portant  as  the  play  life  of  children — a  little  different  in  emphasis,  a  little 
different  in  conception,  but  a  part  of  life  which  is  real  living — often  in 
this  rather  badly  adjusted  economic  life  of  ours  the  only  real  life. 

Unquestionably  the  attitude  toward  recreation  and  leisure  time  is 
changing.  The  old  idea  that  joy  in  life,  play  and  happiness  were  incur- 
ably wicked — inventions  of  Satan — is  going.  This  feeling,  which  had  its 
inception  in  the  old  religious  teachings,  is  strong  even  in  the  present 
day, —  we  call  it  conscience,  but  it  is  really  a  distrust  of  joy  in  life 
which  has  been  handed  to  us.  But  faith  in  those  things  which  mean 
richer  and  deeper  appreciations  of  life  is  coming — is  already  here. 

To  go  back  a  little,  there  are  reasons  why  this  problem  of  leisure  time 
has  crept  so  persistently  into  modern  life.  In  the  "good  old  days"  of 
this  country,  the  actual  labor  involved  in  supporting  a  family,  feeding  it, 
clothing  it,  and  keeping  it  warm,  was  a  twenty-four  hour  business.  Not 
only  the  father  and  the  mother  were  so  burdened,  but  the  children  like- 
wise had  chores — long,  hard  jobs  of  work — which  contributed  to  the 
need  and  comfort  of  the  family.  Today,  not  only  are  the  families  kept 
warm,  and  fed  and  clothed  by  infinitely  easier  methods,  but  the  industrial 
situation  of  the  machine  age  has  limited  the  number  of  hours  a  man 
may  work;  even,  unfortunately,  has  made  it  impossible  for  many  of  them 
to  work  at  all.  All  this  means  that  both  adults  and  children  have  lei- 
sure hours  thrust  upon  them  with  proportionately  greater  possibilities 
for  trouble.  Without  adequate  understanding  and  education  for  its  use, 
there  are  not  only  greater  possibilities  for  trouble  but  it  becomes  almost 
impossible  to  stay  out  of  it. 

So,  to  speak  broadly,  all  people  have  leisure  time — large  quantities  of 
it.  They  all  do  something  with  it,  good,  bad  or  indifferent.  Where  did 
they  learn  to  do  those  things?  The  fact,  and  it  is  a  fact,  that  they  do 
learn  the  things  they  engage  in  is  encouraging,  for  four  places  are 
largely  responsible,  and  to  a  certain  extent,  open  to  educational  sugges- 
tion— the  home,  the  school,  the  church,  and  the  street. 

There  was  a  time  when  the  home  was  the  center,  the  social  center  of 
life;  the  church,  the  moral  force;  the  school,  a  place  of  dull  preparation 
which  didn't  prepare,  except  in  terms  of  the  so-called  tools  of  learning; 
the  street,  as  a  place  of  undesirable  social  contact,  of  less  importance  in 
considering  the  child's  life  than  at  the  present  time.  As  we  conceive  it 
now,  it  was  an  attempt  to  cut  his  life  into  four  neat  parcels,  from  which 
he  might  be  expected  to  draw  adequate  and  protective  information  to 
meet  the  needs  of  his  experience,  some  times  difficult  experience. 

Today  the  effort  to  draw  the  first  three  together  and  to  reform  the 
fourth  is  evident, — experimental,  to  be  sure,  but  nevertheless  evident. 
The  school  has  attempted  to  do  its  part  by  building  up  in  the  last  ten 
years  seven  big  objectives  which  they  have  called  the  cardinal  prin- 
ciples—  interesting  in  the  light  of  the  time-honored  Three  R's — health, 
worthy  home  membership,  efficient  use  of  the  tools  of  learning,  ethical 
character,  vocational  education,  worthy  use  of  leisure  time,  and  good 
citizenship.  An  amazing  list,  when  one  gives  thought  to  it,  that  the 
school  presumably  a  place  to  inspire  children  to  work,  and  only  work, 
should,  among  the  seven,  set  down,  as  one  great  objective  of  its  existence, 
a  plan  to  help  them,  as  children  and  adults,  to  use  leisure  time  as  a  part 
of  life,  as  recreation,  is  beyond  the  comprehension  of  many  of  those  who 
feel  that  the  new  school  is  built  on  fads  and  fancies. 

As  a  matter  of  fact  there  are  not  so  many  great  categories  of  things 
that  people  engage  in  during  their  leisure  time — entertainments  and 
parties,  theatre  and  movies,  outdoor  and  indoor  sports  and  games,  the 
arts  and  crafts,  reading  and  mischief.  And  they  have  learned  to  do  these 
things  in  terms  of  their  dispositions  and  tendencies,  their  financial  oppor- 
tunities, and  their  education. 

There  is  the  person  known  to  everyone,  who,  except  when  he  is  forced 
into  action,  does  nothing.  Sometimes  he  "sets  and  thinks,"  but  generally 
he  just  "sets."     Who  can  tell  why?     There  is  the  other  extreme — that 


13 

person  who  never  under  any  circumstance  can  enjoy  himself  by  himself, 
who  has  no  resource  within  himself,  whose  whole  life  is  a  round  of  excite- 
ment created  by  other  people,  largely  in  artificial  ways.  Edna  St.  Vin- 
cent Millay  speaks  of  this  person,  perhaps  even  with  justification: 

"My  candle  burns  at  both  ends, 
It  will  not  last  the  night; 
But,  ah,  my  foes,  and  oh,  my  friends — 
It  gives  a  lovely  light!" 

Somewhere  between  those  two  lie  you  and  me. 

The  financial  issue  is  largely  one  of  degree  and  standard.  The  rich 
and  the  poor  do  very  much  the  same  kind  of  things,  and  if  the  first  lays 
its  emphasis  on  luxury,  the  latter  certainly  does  on  getting  the  most  out 
of  an  opportunity.  They  both  go  to  the  movies,  they  laugh  and  cry  at 
the  same  pictures,  indeed,  in  the  same  places.  They  drive  cars  on  the 
same  roads;  they  bathe  in  the  same  ocean;  they  laugh  at  the  same  jokes, 
and  love  and  quarrel  in  much  the  same  old  human  way. 

And  education — what  is  it  doing  to  help?  One  thing,  largely — 
attempting  to  give  opportunity  for  participation  in,  and  appreciation  of 
wholesome  activities  which  meet  the  peculiar  needs  and  tendencies  of 
individuals,  that  are  within  reasonable  financial  bounds,  and  which  may 
be  provided  for  all  kinds  of  people  everywhere.  It  is  impossible  to  give 
a  survey  of  all  that  is  being  done  to  make  happiness  in  leisure  time  pos- 
sible, but  study  the  programs  of  the  schools  with  their  efforts  toward 
fine  appreciation  of  the  arts,  the  crafts,  the  development  of  physical 
education  programs  in  school  and  after  school,  and  the  literature.  Watch 
what  the  museums  and  art  galleries,  the  libraries,  the  big  recreation 
associations,  the  playgrounds,  the  home  magazines,  the  industries,  the 
church,  the  newspapers,  and,  occasionally,  even  the  movies  are  doing  to 
support  the  argument  that  leisure  time  may  be  an  asset  but  that  too 
often  we  have  permitted  it  to  be  a  liability.  And  then  watch  the  juvenile 
courts,  the  delinquency  records,  and  the  pathetic  missteps  of  youngsters. 
Emphasis  on  education  and  facility  for  leisure  time  is  unquestionably  the 
keynote  of  the  future. 

People  will  do  something — those  "somethings"  are  learned.  So  let  the 
home,  the  school,  the  church,  and  yes,  even  the  street,  teach. 

In  an  article  published  in  "Recreation,"  a  publication  of  the  National 
Recreation  Association,  called  "Recreation  and  Living  in  the  Modern 
World,"  and  written  by  Abba  Hillel  Silver,  D.D.,  the  situation  is  inter- 
preted this  way:  "Do  you  know  what  we  need  for  real  living?  We  need 
beauty  and  knowledge  and  ideals.  We  need  books  and  pictures  and  music. 
We  need  song  and  dance  and  games.  We  need  travel  and  adventure  and 
romance.  We  need  friends  and  companionship  and  the  exchange  of  minds 
— mind  touching  mind,  and  soul  enkindling  soul.  We  need  contact  with 
all  that  has  been  said  and  achieved  through  the  cycles  of  time  by  the 
aristocrats  of  the  human  mind  and  hand  and  soul." 

THE  USE  OF  LEISURE 

Helen  I.  D.  McGillicuddy,  M.D. 

Educational  Secretary 
Massachusetts  Society  for  Social  Hygiene 

One  of  the  most  interesting  questions  under  discussion  at  the  present 
time  is  the  "Use  of  Leisure."  On  one  hand  we  have  those  people  who 
declare  they  have  no  leisure ;  on  the  other  hand,  those  who  have  too  much. 
Every  normal  person  hopes  for  leisure,  hopes  for  some  spare  time  in 
which  he  may  express  himself,  recreate  himself. 

While  there  has  always  been  a  leisure  class,  not  all  persons  have  had 
leisure.  In  ancient  Greece  every  free  boy  had  an  opportunity  to  develop 
in  his  school  work  a  taste  for  athletics,  music,  drama,  oratory.  Leisure 
was  for  free  male  citizens  only.     So,  too,  in  ancient  Rome. 


14 

During  the  Middle  Ages,  recreation  was  more  widespread.  Knights 
gave  tourneys,  there  was  fencing  and  hunting.  Festivals  were  celebrated 
by  outdoor  sports,  fairs  and  pageants.  The  village  people  gathered  in 
the  Common,  and  danced  on  the  green.  This,  in  a  word,  was  community 
recreation. 

With  the  coming  of  the  Puritans  to  this  country,  life  became  very 
serious.  Their  struggles  with  the  forces  of  nature,  the  rocks,  trees,  cli- 
mate and  Indians  gave  them  little  time  for  play.  As  a  result,  work  be- 
came the  business  of  life.  No  longer  was  there  any  community  recrea- 
tion, no  longer  any  spare  time.     So  has  come  commercialized  recreation. 

What  do  we  do  when  we  have  spare  time?  We  do  the  thing  we  like  to 
do,  we  are  more  revealed  in  play  than  in  any  other  way. 

Dr.  M.  J.  Exner  of  the  American  Social  Hygiene  Association  has 
said — "Probably  nothing  influences  the  individual  more  profoundly  than 
the  way  he  spends  his  leisure.  Direct  the  play  hours  of  the  young  whole- 
somely and  you  will  need  to  have  little  concern  about  their  character." 

Studies  have  shown  that  we  form  our  habits  for  leisure  during  our 
school  years,  so  that  leisure  is  largely  an  adolescent  problem.  Yet  no 
society  has  solved  the  problem  of  outlets  for  the  impulses  of  youth.  Dr. 
Luther  Gulick,  the  father  of  the  Playground  and  Recreation  Association 
of  America,  just  before  his  death  said: — "There  is  not  yet  a  single  com-' 
munity  in  America  adequately  prepared  to  handle  the  recreational  life 
of  its  people." 

We  all  have  seven  play  instincts:  creation,  rhythm,  fighting,  hunting, 
nurture,  curiosity,  and  team  play.  The  Ancients  had  Gods  dedicated  to 
these  instincts:  Mars,  of  War;  Diana,  of  Hunting.  As  children  we  grow 
through  play;  as  adults  we  sometimes  make  our  work  play.  Living  as 
we  do  in  a  machine  age,  our  ideas  of  play  have  changed.  We  work  at 
high  tension  all  day,  we  want  jazz,  speed  and  excitement  at  night. 
Therein  lies  the  danger. 

Jane  Addams  in  "Spirit  of  Youth  and  the  City  Streets"  has  said: — 
"Only  in  the  modern  city  have  men  concluded  that  it  is  no  longer  neces- 
sary for  the  municipality  to  provide  for  the  insatiable  desire  for  play. 
Never  before  in  civilization  have  such  numbers  of  young  girls  been  sud- 
denly released  from  the  protection  of  the  home.  Apparently  the  modern 
city  sees  in  these  girls  only  two  possibilities,  both  of  them  commercial — 
first,  a  chance  to  utilize  by  day  their  labor  power  in  its  factories  and 
shops,  and  then,  another  chance  in  the  evening  to  extract  from  them 
their  petty  wages  by  pandering  to  their  love  of  pleasure." 

Because  Social  Hygiene  is  concerned  with  the  building  up  of  family 
life  and  sound  leisure  activities,  a  study  was  made  by  the  American  Soc- 
ial Hygiene  Association  of  what  the  modern  girl  does  with  her  leisure. 
One  of  the  most  illuminating  questions  was  the  following : — "What  would 
you  do  with  your  spare  time  if  you  had  your  choice?" 

There  were  1,516  girls  who  answered  this  question  and  they  reported 
3,402  items  of  activity  in  which  they  would  like  to  participate. 

These  choices  fall  into  three  general  classifications : 

1.  Educational  and  creative  or  constructive  activities  chosen  by  42%. 

2.  Organized  athletics  and  outdoor  activities  by  30.5%. 

3.  General  sociability,  passive  forms  of  amusement  by  27-5%. 

Do  girls  do  what  they  like  to  do?  In  this  study  74%  were  gratified  to 
some  extent.  The  study  continues: — "It  is  important  for  those  planning 
leisure  time  activities  for  girls  to  know  if  those  from  the  various  for- 
eign groups  are  especially  interested  in  one  type  of  activity." 

Most  of  the  girls  in  this  study  preferred  reading.  As  they  grow  older 
if  they  do  not  have  access  to  good  books  they  may  lose  interest  in  reading 
and  turn  to  magazines  of  no  literary  value. 

In  the  study  one  fourth  were  not  able  to  do  what  they  desired  to  do. 
The  question  is  asked  will  they  later  lose  their  desire  for  constructive 
forms  of  recreation  or  turn  their  interest  to  unsocial  activities? 

Woods  and  Kennedy  in  "Young  Working   Girls"   stated  that  normal 


15 

recreational  provision  should  consist  of  one  half  holiday,  in  the  open,  one 
evening  devoted  to  a  club,  one  evening  for  attendance  on  a  party,  theatre, 
or  motion  picture  show,  and  an  occasional  red  letter  event  in  addition. 

What  then  shall  we  do  with  our  leisure?  The  best  of  refreshment  or 
the  worst  of  mischief  is  likely  to  happen  in  leisure  hours.  How  to  make 
leisure  recreative  is  the  problem.  Perhaps  we  read,  or  dance,  go  to  the 
theatre,  or  the  pictures.  Why  not  do  other  things?  Read  "Recreation 
in  Boston."  There  you  will  find  cruising  afoot,  bird  and  flower  walks, 
historical  walks,  outdoor  sports  and  outdoor  games.  Within  an  hour's 
ride  from  Boston  there  are  more  than  fifty  golf  courses  and  many  tennis 
courts.  Facilities  for  horseback  riding,  boating,  and  for  folk  dancing 
are  present. 

If  our  work  is  creative  we  find  in  it  opportunities  for  self  expression. 
If  it  is  not,  then  through  music,  art,  drama  may  we  find  self  expression. 
This  means  cultivating  a  taste  for  the  best.  A  love  for  the  best  is  twin 
born  in  the  soul.  It  means  developing  a  taste  for  beauty,  the  blue  sky, 
the  sun,  the  twinkling  stars,  the  lovely  moon,  the  tumbling  brooks,  the 
lakes,  the  rivers,  the  mountains,  the  beautiful  flowers,  the  trees,  all  speak 
of  beauty  to  us.  This  beauty  finds  response  in  our  creative  spirit — it 
helps  to  recreate  us — to  enjoy  some  of  our  leisure  time. 

Tell  me  what  you  do  in  your  leisure  time,  and  I  will  tell  you  what  sort 
of  a  person  you  are ! 

Bibliography 

Addams,  Jane,     The  Spirit  of  Youth  in  the  City  Streets. 

Woods  and  Kennedy,    Young  Working  Girls. 

Exner,  M.  J.,  M.D.     What  is  Social  Hygiene? 

Journal  of  Social  Hygiene,    Vol.  XVI,  No.  6 — June  1930. 

Sizer,  James  Peyton,    The  Commercialization  of  Leisure. 

Van  Waters,  Dr.  Miriam,    Concerning  Parents. 

Prospect  Union  Association,    Recreation  in  Boston. 

RECREATIONAL  RESOURCES  IN  MASSACHUSETTS 

Eva  Whiting  White, 

President,  Women's  Educational  and  Industrial  Union 

and 
Head  Resident,  Elizabeth  Peabody  House 

Today  it  is  clearly  seen  that  a  great  hope  for  the  future  rests  with  the 
leisure  life — both  in  regard  to  physical  vigor  and  mental  power.  Because 
of  this  fact,  the  Commonwealth,  as  well  as  city  and  town  governments, 
have,  within  the  last  twenty-five  years,  expended  much  thought  and 
money  in  making  available  for  our  citizens  a  variety  of  opportunities  that 
range  from  the  development  of  programs  for  enjoying  the  great  out-of- 
doors  to  extended  library  privileges. 

New  England  is  one  of  the  recognized  vacation  spots  of  the  country, 
and  Massachusetts  one  of  the  most  farseeing  of  the  New  England  states 
in  developing  her  water  advantages  and  in  opening  up  her  woods  and 
forests  that  Nature  in  summer  and  in  winter  may  give  of  her  peace  and 
strength  to  those  who  seek  her  quiet. 

The  Appalachian  Mountain  Club  and  the  Field  and  Forest  Club,  two  of 
the  best  known  organizations  of  America,  with  headquarters  in  Boston 
but  with  branches  throughout  the  State,  invite  to  membership  those  who 
would  take  advantage  of  a  series  of  weekly  walks,  week-end  trips  to  our 
coast  and  inland  beauty  spots,  as  well  as  vacation  camping  opportunities. 
Both  societies  make  a  specialty  of  Sunday  outings. 

No  state  can  boast  of  a  more  complete  network  of  motor  roads  extend- 
ing from  the  rockbound  coast  of  Gloucester  or  Nahant  to  the  charming, 
sunny  hills  of  the  Berkshires  and  winding,  as  they  do,  through  the  sand 
dunes  in  the  vicinity  of  Newburyport  and  Ipswich  and  the  cranberry 
bogs  and  marshes  of  Cape  Cod.  Moreover,  there  is  scarcely  a  town 
through  which  the  traveler  passes  that  does  not  give  historic  evidence  of 


16 

the  efforts  of  our  forefathers  in  building  the  foundations  of  the  Republic 
Rockport,  Marblehead,  Salem,  Deerfield,  are  not  only  historic  but  are  as 
fascinating  in  their  architectural  charm  and  variety  as  many  an  area  in 
the  Old  World.  Further,  on  every  hand,  there  are  ample  opportunities 
for  picknicking  or  for  spending  the  night  in  the  open  or  in  one  of  the 
many  inns  or  farmhouses  that  take  the  tourist,  and  Massachusetts  treats 
her  guests  fairly.  Road  maps,  which  are  issued  monthly  by  the  State 
Highway  Commission,  give  accurate  information  as  to  road  construction. 
Off  the  main  highroads  are  thousands  of  miles  of  good  dirt  roads  that 
lead  one  away  from  the  beaten  paths  on  expeditions  of  personal  explor- 
ation. 

There  is  no  man,  woman,  or  child  but  that  is  not  the  better  for  going 
to  Winthrop  after  a  northeast  storm  to  watch  the  rollers  of  the  Atlantic 
dash  to  shore  with  a  spray  mountain  high.  The  salt  tang  gets  into  the 
blood — and  invigorates — indeed.  Then  a  walk  along  Revere  Beach  or 
Lynn  Beach  is  warranted  to  iron  out  nerves.  Again,  one  gets  that  some- 
thing that  comes  from  the  feeling  of  the  wilderness  by  tramping  in  the 
woods  in  the  vicinity  of  Jacob's  Ladder  and  all  the  sense  of  the  space  of 
uninhabited  stretches  by  spending  time  on  the  plateau  inland  from  the 
summit  of  the  Mohawk  Trail  on  Hoosac  Mountain,  where  is  to  be  found 
the  Savoy  Forest,  a  state  reservation  of  some  2,000  acres — to  say  nothing 
of  the  awe  inspired  by  a  curious  and  massive  cavelike  rock  formation 
called  Purgatory  which  is  in  the  vicinity  of  Sutton — a  surprising  geo- 
logical gift  in  the  midst  of  the  surrounding  farm  land.  Further,  there 
is  no  more  beautiful  stretch  of  road  than  the  Barre  Woods.  These  are 
only  a  few  of  the  treasures  of  Massachusetts  that  can  be  had  for  the 
asking.  In  their  enjoyment  every  man  is  as  rich  as  every  other.  Summer 
and  winter  they  have  their  peculiar  allurements.  Perhaps  nothing  is  more 
truly  refreshing  than  the  stillness  of  deep  woods  in  winter  on  snowshoes 
nor  more  stimulating  than  skiing,  coasting,  toboganning  and  ice  skat- 
ing— provisions  for  which  are  made  by  our  recreation  authorities 
throughout  the  State.  Sleighing,  too,  holds  its  own  in  the  western  part 
of  the  Commonwealth,  and  many  a  person  finds  particular  pleasure  in 
ice  boating. 

In  summer,  swimming — which,  it  is  claimed,  is  the  most  perfect  of  all 
exercises — should  be  taken  advantage  of  not  only  along  the  coast  but 
where  opportunities  are  developed  for  its  enjoyment  at  inland  lakes  and 
ponds. 

The  Charles  River,  as  it  winds  in  and  out  in  the  vicinity  of  Boston, 
is  noted  for  its  canoeing,  and  the  Charles  River  Basin  for  its  rowing 
regattas,  while  yachting  is  a  famous  resource  for  many  all  along  our 
Atlantic  seaboard. 

Special  emphasis  is  placed  upon  breaking  away  from  city  and  town 
life  and  getting  into  the  open  because  the  American  needs  the  change 
from  noise  and  rush,  but  within  our  residential  areas  a  wealth  of  advan- 
tages are  to  be  found.  The  playground  movement,  which  is  now  national 
in  scope  was  started  in  Boston  in  the  80's.  So  vital  is  the  playtime  of 
children  to  the  future  stamina  of  the  race,  that  every  parent  should  see 
that  playgrounds  are  easily  accessible,  are  well  equipped,  and  are  in 
charge  of  playground  leaders  who  are  skilled  in  guiding  child  life.  For- 
tunately, great  headway  has  been  made  in  these  respects  in  the  past  few 
years  so  that  most  communities  can  now  boast  of  a  playground  system. 
Many  a  system,  though,  is  operated  for  only  a  part  of  the  year.  They 
should  all  be  run  on  a  twelve-month  basis.  Athletic  fields  are  also  essen- 
tial and  parks  such  as  Franklin  Park  in  Boston  and  Middlesex  Fells. 

Futher,  the  adult  should  be  considered  as  well  as  the  child.  No  more 
important  movement  exists  than  the  community  center  movement.  School- 
houses  should  be  used  after  school  hours  for  the  purpose  of  meeting  the 
recreational  needs  of  men  and  women,  as  is  the  case  in  Springfield  and 
Boston.  Organizations  such  as  the  Young  Men's  and  Young  Women's 
Christian  Associations  build  the  fibre  of  our  manhood  and  womanhood — 


17 

developing,  as  they  do,  companionship  and  a  rich  series  of  avocational 
enterprises. 

Important  as  it  is  to  build  up  the  physical  self,  it  is  as  important  to 
deepen  the  resources  of  the  mind,  and  those  personal  powers  which  mean 
happiness.  Many  a  person  cannot  be  freed  from  certain  external  cir- 
cumstances but  every  one  can  be  master  of  those  inner  desires  for  enjoy- 
ment if  they  are  given  vent  in  ways  which  mean  satisfaction  and  joy. 
Therefore,  the  extension  education  movement  has  been  developed  by  the 
State  in  order  to  offer  the  best  of  instruction  throughout  Massachusetts 
during  the  fall,  winter  and  spring  months.  Any  local  community  can 
obtain  the  advantages  of  rich  courses  by  applying  to  the  Massachusetts 
Board  of  Education.  The  Extension  Division  of  the  Massachusetts 
Board  of  Education  has  also  a  series  of  illustrated  lectures  and  interest- 
ing educational  moving  pictures  which  can  be  obtained  by  writing  in  care 
of  that  department,  State  House,  Boston. 

Every  civic  unit  should  have  as  many  singing  groups  and  ensemble 
musical  groups  as  possible,  ranging  from  harmonica  clubs  for  boys  and 
ukulele  clubs  to  bands '  and  orchestras.  Community  Service  of  Boston, 
739  Boylston  Street,  will  assist  with  this  work.  This  organization  will 
also  assist  in  organizing  dramatic  groups  or  societies  by  giving  advice 
as  to  the  selection  of  plays  and  the  staging,  lighting  and  costuming  of 
the  same. 

The  drama  maintains  its  popularity  because  it  brings  joy  to  old  and 
young  by  keeping  alive  the  age  of  imagination.  It  is  one  of  the  oldest 
forms  of  creative  art. 

Handicraft,  too,  occupies  an  important  place  in  a  leisure-time  program. 
The  Women's  Educational  and  Industrial  Union,  264  Boylston  Street, 
Boston,  will  assist  in  this  phase  of  a  program. 

The  Metropolitan  Art  Museum  of  New  York  and  the  Boston  Museum 
of  Fine  Arts  will  send  an  exhibit  of  paintings  or  etchings  if  application 
is  made  to  them. 

Nature  study  material  can  be  obtained  from  the  Natural  History 
Rooms  of  Boston,  from  the  Society  for  Preserving  Wild  Flowers  at  Hor- 
ticultural Hall,  Boston,  and  from  the  Audubon  Society,  care  Natural 
History  Rooms,  Boston. 

Now  as  to  reading :  Massachusetts  is  the  only  state  in  the  Union  which 
has  a  free  public  library  in  every  city  and  town.  Nothing  that  the  Com- 
monwealth has  by  way  of  assets  is  more  creditable.  To  supplement  local 
libraries,  the  State  Library  of  Massachusetts  has  a  complete  file  of  official 
documents;  while  the  American  Antiquarian  Society  of  Worcester  and 
the  Library  of  the  Massachusetts  Historical  Society,  Boston,  have  rich 
treasures  for  the  students  of  history.  Perkins  Institute  for  the  Blind, 
in  Watertown,  and  the  Library  of  Congress,  Washington,  D.  C,  both  send 
books,  in  the  special  type  of  print  which  blind  people  are  taught  to  use, 
to  those  applying  for  them. 

It  is  significant  that  this  article  is  printed  in  a  publication  devoted 
per  se  to  health.  It  is  significant  because  bodily  and  spiritual  health 
means  the  practice  of  hygiene  and  more;  the  living  up  to  health  codes 
and  more.  It  means  tapping  the  sources  of  joy  and  the  personal  forces 
of  the  thought  life. 

BREAKFAST  AND  LUNCHEON  ' 

Esther  V.  Baldwin,  B.S. 

Consultant  in  Nutrition 
State  Department  of  Public  Health 

"It's  time  to  get  up!"   And  what  next?    Dressing  and  then  breakfast! 

Does  breakfast  mean  to  you  a  leisurely  well  planned  meal  or  one  of  hur- 
riedly swallowed  coffee  and  doughnuts  or  might  it  be  dubbed  the  missing 
meal?    And  if  hurried  or  missing,  what  is  the  reason? 

Before  even  considering  what  the  business  girl  eats  and  should  eat  for 


18 

breakfast,  the  conditions  under  which  breakfast  is  most  enjoyable  might 
be  suggested.  The  languid  "no  appetite  for  breakfast"  feeling  is  often 
met,  not  due  to  organic  difficulties  but  simply  to  poor  hygiene!  A  late 
rising  hour  due  to  a  late  retiring  hour  is  poor  hygiene.  Fatigue  is 
detrimental  to  a  healthy  appetite  but  easily  overcome  by  increased  hours 
of  sleep  and  rest.  The  lack  of  appetite  might  be  due  to  too  hearty  refresh- 
ments at  a  party  the  preceding  evening  or  to  a  habit  of  eating  heavily 
before  retiring.  Brushing  the  teeth  and  rinsing  the  mouth  will  very 
often  remove  the  unhappy  taste  resulting  from  this  overeating.  Long 
enough  time  should  be  allowed  between  rising  and  breakfast  for  the 
appetite  to  develop.  Fruit  juices  the  first  thing  in  the  morning  help  to 
whet  the  appetite.  The  girl  who  eats  at  a  restaurant  on  her  way  to  the 
office  has  an  advantage  in  that  the  walk  stimulates  her  appetite.  To 
make  breakfast  the  most  delightful  of  meals,  adequate  rest  and  time  for 
eating  should  be  planned. 

And  now — what  shall  we  eat? 

A  group  of  business  girls  were  questioned  as  to  their  breakfasts. 
These  varied  from  the  coffee  and  bread  of  one  who  planned  no  time  for 
eating  to  the  more  substantial  breakfast  of  orange  juice,  oatmeal  with 
cream,  cocoa  and  two  slices  of  toast  of  the  girl  who  gave  thought  to  her 
meals.    Both  of  these  girls  eat  at  home. 

Breakfast  should  be  planned  with  a  consideration  of  the  needs  of  the 
individual  and  in  relation  to  the  other  meals.  Every  person  requires 
certain  foods  for  maintenance  of  health.  Minerals  for  tooth  and  bone 
development,  blood  building,  and  regulation  of  the  body  processes;  vita- 
mins for  building  up  resistance  against  infections,  maintaining  appetite, 
protection  against  certain  dietary  diseases,  for  the  best  tooth  develop- 
ment; proteins  for  building  and  repairing  body  tissue;  roughage  to  regu- 
late the  bowels;  water  to  aid  in  digestion-,  elimination  and  regulation  of 
body  temperature.  A  certain  amount  of  energy  is  required  depending 
upon  the  activities  of  the  person,  the  more  active  requiring  more  energy. 
Energy  is  measured  by  the  amount  or  quantity  of  food,  the  other  require- 
ments making  up  the  quality  of  the  diet. 

To  insure  a  good  quality  diet  the  inclusion  of  plenty  of  milk,  fruits, 
vegetables  and  eggs  is  the  best  method.  Every  business  girl,  in  con- 
sidering her  whole  day's  diet,  should  plan,  for  her  own  health  and 
efficiency,  to  include  daily  these  foods  in  the  following  amounts:  one  pint 
of  milk  which  may  be  taken  as  a  beverage  or  in  foods;  a  raw  vegetable 
and  one  other  besides  potato,  remembering  that  the  green  vegetables  are 
important;  two  servings  of  fruit,  one  of  which  it  is  best  to  have  raw; 
one  egg,  in  some  form.  In  addition  to  these  protective  foods,  we  add  a 
serving  of  whole  grain  cereal  or  bread;  not  more  than  one  serving  of 
meat  or  fish  or  substitute;  butter  on  bread  and  vegetables;  four  to  six 
glasses  of  water.  These  foods  plus  plenty  of  rest  and  sleep,  fresh  air 
and  sunlight,  exercise  and  good  mental  hygiene,  will  help  the  average 
business  girl  or  any  adult  to  attain  and  maintain  maximum  health  and 
earning  power. 

Now  then,  in  selecting  breakfast,  luncheon  or  dinner,  we  bear  in  mind 
the  necessary  foods,  determined  first  of  all  to  include  these  and  then,  if 
we  have  room,  to  choose  other  foods  less  essential.  Breakfast  for  the 
sedentary  worker  may  be  light,  as  for  instance,  one  consisting  of  fruit, 
whole  wheat  toast  or  muffin,  and  milk,  cocoa  or  coffee,  or  it  may  be  a  bit- 
heavier,  adding  to  this  light  breakfast  a  serving  of  whole  grain  cereal, 
as  oatmeal,  or  an  egg,  poached,  scrambled,  boiled  or  in  an  omelet.  Either 
of  these  breakfasts  might  be  adequate  for  the  business  girl. 

To  the  girl  living  at  home  the  item  of  the  expense  of  breakfast  does  not 
loom  as  large  as  to  the  girl  who,  living  in  a  room,  must  get  her  break- 
fast in  a  restaurant.  First  of  all,  the  latter  attempts  to  find  a  restaur- 
ant where  clean,  wholesome,  appetizing  food  is  served  at  a  moderate  cost. 
Because  breakfasts  are  more  or  less  standardized  this  is  the  easiest  meal 
to  obtain  at  a  fairly  constant  price.     The  first  or  light  breakfast  sug- 


19 

gested  would  cost  on  the  average  thirty  cents,  that  is  ten  or  fifteen  cents 
for  fruit,  ten  cents  for  toast  or  muffins,  five  or  ten  cents  for  coffee,  milk  or 
cocoa.  Fruit  is  very  evidently  the  most  expensive  item  and  one  which 
can  easily  be  reduced  by  planning  to  buy  fruit  to  eat  in  one's  room.  A 
dozen  oranges  may  be  purchased  now  for  twenty  or  twenty-five  cents,  a 
dozen  bananas  for  twenty-five  cents,  apples  (Mcintosh)  three  or  four 
pounds  for  twenty-five  cents,  prunes  (which  may  simply  be  washed  and 
eaten  uncooked)  for  ten  cents  a  pound.  Purchasing  fruit  at  the  fruit  or 
grocery  store  instead  of  at  the  restaurant  reduces  the  cost  of  breakfast 
materially,  fruit,  toast  and  a  hot  drink  costing  under  these  conditions 
about  seventeen  cents.  Prices  will  vary  according  to  the  restaurant  pat- 
ronized. The  second  or  heavier  breakfast  with  one  egg  will  average 
forty  cents  if  fruit  is  ordered;  twenty-seven  cents  if  fruit  is  eaten  at 
home.  Restaurant  prices  for  raw  fruit  are  higher  than  for  cooked,  hence 
another  argument  for  eating  fruit  at  home. 

What  of  our  daily  needs  have  been  furnished  through  breakfast?  The 
raw  or  cooked  fruit,  a  whole  grain  cereal  (bread,  muffin,  or  breakfast 
cereal)  in  some  cases  the  egg,  and  in  some,  part  of  the  milk  on  cereal,  in 
cocoa  or  as  a  beverage.     A  good  start  that  is! 

It's  lunch  time!  Now  the  question  is  whether  to  eat  in  the  office  food 
that  has  been  brought  from  home,  to  supplement  this  with  a  hot  food 
bought  at  the  restaurant  or  to  eat  "out."  The  business  house  or  office 
building  which  provides  for  its  women  employees  a  comfortable,  attractive 
room  in  which  lunches  may  be  eaten  is  to  be  commended.  A  change  of  en- 
vironment at  noon  contributes  to  the  enjoyment  of  lunch.  Get  away  from 
the  office  for  awhile!  With  this  change,  lunch  time  grows  in  importance, 
the  appetite  is  improved.  In  such  a  room,  facilities  for  cooking  simple 
foods  or  heating  foods  brought  from  home  should  be  provided.  One 
business  girl  always  carried  in  a  jar  beef  stew  or  soup  or  some  food 
which  might  be  heated.  A  hot  food  should  generally  be  included  in  each 
meal.  It  stimulates  the  appetite,  improves  digestion  and  makes  the  meal 
more  interesting. 

Lunches  brought  from  home  may  consist  of  sandwiches,  preferably  of 
dark  bread,  and  some  kind  of  fruit.  Cocoa  added  to  this  makes  a  good 
lunch.  Sandwich  fillings  of  raw  vegetables  moistened  with  salad  dress- 
ing are  a  novelty  and  nutritious.  Lettuce  may  be  added  to  practically 
any  sandwich  filling.  Raw  spinach  sandwiches  are  the  "latest."  The 
spinach  may  be  chopped  or  placed  whole  between  the  bread.  Any  salad 
dressing  may  be  used.  In  some  offices  arrangements  may  be  made  to 
have  milk  delivered  regularly  so  that  this  nourishing  food  may  be  added 
to  the  lunch. 

The  restaurant,  tea  room,  or  cafeteria  offering  a  satisfying  meal  at  a 
moderate  cost,  quick  service  and  in  a  reasonably  attractive  setting, 
appeals  to  the  girl  who  is  deciding  where  to  eat.  Among  the  same  group 
of  business  girls  who  were  questioned  about  breakfasts,  it  was  found  that 
the  average  amount  spent  for  lunch  was  thirty-five  cents.  One  or  two 
went  as  high  as  fifty  cents.  The  thirty-five  cent  lunch  generally  included 
a  sandwich,  cup  of  coffee  and  cake  for  dessert.  Sandwiches  are  quickly 
served  and  eaten.  Hence  their  popularity  since  the  time  Lord  Sandwich 
first  conceived  the  idea.  This  group  was  fond  of  salad  sandwich  fillings. 
In  another  group  which  had  not  been  exposed  to  as  much  health  material 
as  the  first,  more  meat  sandwiches  were  selected.  A  more  nutritious  hot 
food  than  the  coffee  may  be  chosen  in  a  hot  soup  or  hot  cocoa.  A  cup  of 
soup  and  a  sandwich  form  the  basis  of  a  good  lunch.  Fruit  brought 
from  home  will  complete  it. 

For  the  girl  who  allows  forty-five  or  fifty  cents  at  noon,  a  vegetable 
plate  is  a  good  investment.  One  tea  room  has  this  in  a  combination  with 
milk  and  a  dessert  for  fifty  cents.  Creamed  or  baked  dishes  form  a  good 
"one  dish"  luncheon.  Restaurants  are  changing  their  menus  to  approach 
the  teaching  of  health  authorities.  Vegetable  plates  are  more  in  evi- 
dence as  are  raw  vegetable  salads.    Whole  wheat  or  rye  bread  is  nearly 


20 

always  available  for  sandwiches.  A  cup  of  soup,  a  salad  and  dessert  may 
be  purchased  for  fifty  cents.  For  less  than  this,  one  may  order  a  sand- 
wich, a  vegetable  and  a  drink  or  dessert.  Milk  makes  a  very  satisfying 
dessert ! 

Through  our  lunch,  then,  we  may  contribute  to  the  daily  body  needs 
milk,  a  fruit,  possibly  one  or  more  vegetables,  whole  grained  bread  or 
sometimes  egg  (in  salad  or  sandwich  filling)  all  depending  upon  our 
choice  for  lunch. 

The  girl  who  has  a  heavy  breakfast  may  be  satisfied  with  a  lighter 
lunch;  that  is,  the  sandwich,  beverage,  dessert  type  and  then  complete 
her  daily  food  requirements  with  a  liberal  dinner  at  night.  The  person 
eating  a  light  breakfast  will  require  the  more  substantial  type  of  lunch- 
eon in  order  to  carry  her  through  the  day  without  a  lowered  efficiency 
during  the  latter  part  of  the  afternoon.  The  sensation  of  gnawing  hun- 
ger which  some  girls  experience  about  10:30  or  11  A.M.  may  be  overcome 
by  a  heavier  breakfast  or  by  taking  at  that  time  a  bottle  of  milk. 

Breakfast  and  luncheon  are  two  important  meals.  The  tendency  too 
often  is  to  hurry  and  thereby  minimize  them,  one  because  morning  sleep 
seems  so  desirable  and  the  other  because  shopping  seems  essential. 
These  two  meals,  however,  materially  affect  our  working  ability  and 
should  therefore  be  planned  to  give  to  the  body  the  maximum  nourish- 
ment obtaining  as  a  result  maximum  efficiency. 

»      A  WORKSHOP  OF  LIFE 

Frances  Stern, 
Chief  of  the  Food  Clinic,  Boston  Dispensary 

The  alarm  clock!  The  cold  plunge — perhaps!  Then  a  glance  in  the 
mirror  as  she  pushes  back  the  dishevelled  locks.  What  does  the  woman 
see  that  disturbs  her?  What  are  the  thoughts  that  run  through  her 
mind? 

"Oh,  I  wish  I  weren't  so  fat!  I'm  sure  I  couldn't  get  into  that  dress 
I  saw  in  the  store,  and  it  was  so  pretty  and  so  cheap !"  Yes,  she  knew  she 
had  to  grow  up.  But  why  did  she  allow  herself  to  become — in  business 
lingo — so  overstocked  with  fat? 

Even  as  she  gazes  into  the  mirror,  querying  so,  the  intelligence  within 
her — her  business  sense — demands:  What  do  you  know  about  yourself? 
You,  who  are  so  familiar  with  the  details  of  a  business  organization,  do 
you  know  as  much  about  the  wonderfully  organized  workshop  which  is 
your  body  ?  Do  you  know  how  it  is  built  up  and  renewed  ?  Do  you  know 
how  to  manage  it  for  happiest  and  most  successful  response  to  the  calls 
and  demands  of  life?  And  do  you  realize  that  the  management  of  a 
workshop  such  as  this  should  be  no  haphazard  matter, — that  there  are 
definite  principles  to  guide  you? 

The  questions  her  intelligence  proposes  are  of  concern  to  us  all.  Let 
us  consider  some  of  the  principles  and  laws  that  govern  body  growth  and 
renewal  and  expenditure  of  energy,  as  modern  science  is  revealing  them. 

Of  what  is  the  body  composed?  Flesh  and  muscle,  partly.  How  is  this 
tissue  created,  and  how  is  it  maintained  in  the  stress  of  daily  wear  and 
tear? 

Look  beneath  the  skin  and  flesh  to  the  very  bone.  There  is  the  skeleton, 
marvelously  planned,  the  framework  of  the  body  structure.  What  has 
assisted  in  its  development  from  a  condition  of  pliability  in  infancy  to 
the  firm  bones  of  our  goodly  height? 

And  the  blood  that  flows  in  a  steady  stream,  day  and  night,  through 
vessels  or  pipes,  infinitely  multiplied,  that  carry  it  to  every  part  of  the 
body, — what  keeps  it  up  to  the  color  standard,  a  bright  red,  that  is  an 
indication  of  good  health? 

Now  think  of  the  rhythmic  regulations  and  co-ordinations  of  the  whole 
body  structure, — the  regular  breathing,  the  steady  pulsations,  the  daily 


21 

bowel  movement,  all  of  its  many  fine  adjustments.     What  helps  to  keep 
the  body  going  and  regulated  so  perfectly  in  its  processes? 

"Mute  and  still,  by  day  and  night,  labor  goes  on 
in  the  workshops  of  life.  Here  an  animal  grows, 
there  a  plant,  and  the  wonder  of  it  all  is  not  less 
in  the  smallest  being  than  in  the  greatest." 

Your  body!  Your  workshop  in  this  scheme  of  life!  It  is  beyond 
mortal  power  to  create!  And  yet  it  is  placed  in  the  care  of  a  human 
intelligence — the  mother's,  the  child's,  yours — to  guide  to  its  best  out- 
come. 

By  what  standards  can  its  development  be  measured,  its  status  defined  ? 
There  are  many  standards.  We  will  discuss  one  in  particular,  that  of 
body  weight.  From  a  study  of  hundreds  of  thousands  of  men  and  women, 
scientists  have  formulated  a  weight-height-age  table*  which  indicates 
approximately  what  an  individual  should  weigh  for  his  height  and  age. 
It  will  show  you  whether  you  were  justified  in  your  petulant  exclamation 
addressed  to  the  image  in  the  mirror.  It  will  tell  you  in  terms  of  pounds, 
how  far  you  have  become  overstocked. 

Suppose  that  on  reference  to  this  table  you  find  that  your  self-estimate 
is  correct,  and  that  you  are  in  fact  overladen.  "What,"  you  will  ask, 
"has  been  happening  during  my  years  of  growth?    What  led  me  astray?" 

Your  physician,  to  whom  you  now  appeal  for  a  general  inspection  of 
your  workshop,  (you  should  have  him  make  one  annually,  at  least,  just  as 
a  business  organization  has  its  accounts  audited  regularly),  will  probably 
find  it  organically  sound.  However,  he  will  say,  there  is  a  tendency  here 
that  had  better  be  kept  in  check.  And  he  will  give  you  a  diet,  or  refer 
you  to  a  dietitian  or  to  a  Food  Clinic  for  specific  advice  concerning  a 
wiser  management  of  the  food  supply.  The  dietitian,  following  his  sug- 
gestions, and  assisted  by  her  expert  knowledge  of  the  values  of  food  and 
its  relationships  to  the  body,  will  direct  you  in  unloading  your  fat,  and 
then  in  maintaining  a  judicious  balance  in  the  supply  of  foodstuffs  re- 
quired for  your  workshop.  She  will  carefully  consider  with  you  the  needs 
of  the  body  for  building,  maintenance,  and  functioning,  and  the  kinds 
and  amounts  of  food  that  will  meet  these  various  requirements.  Perhaps 
she  can  give  you  an  outline,  like  the  following,  entitled  "The  Body  as  a 
Builder  of  its  Own  Substance,"  in  which  these  considerations  are  set 
down  very  plainly,  as  you  will  see  from  a  little  study  of  it. 


*  Given  in  many  books  on  health  and  nutrition  and  can  be  procured  from  the  Mass.   Dept.  of 
Public   Health,   Boston,   Mass. 


22 


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23 

The  dietitian  will  talk  with  you  about  the  protein  foods — meat,  fish, 
eggs,  milk,  cheese,  nuts.  Yes,  you  know  that  these  build  body  tissue, — 
flesh  and  muscle.  Yes,  they  create!  Protein  is  a  part  of  every  living 
cell.  In  his  great  book,  "The  Chemistry  of  Food  and  Nutrition,"  Dr. 
Sherman  says,  "There  is  no  known  life  without  them  (proteins)." 

And  you  know,  too,  that  for  the  formation  of  the  bony  substance  of 
your  body,  food  must  provide  the  necessary  calcium  and  phosphorus,  and 
the  vitamins  that  serve  as  "aides."  A  quart  of  milk  a  day  for  the 
child,  a  pint  for  the  adult,  along  with  fruits  and  vegetables  to  insure 
the  presence  of  the  vitamins,  is  essential  for  adequate  provision  for  good 
bone  and  tooth  development.  To  your  question — ever  present  in  your 
mind — the  dietitian  will  answer,  "No,  none  of  these  foods  accounts  for 
your  overweight.  Milk  is  so  nearly  the  perfect  food,  rich  in  materials 
that  build  and  maintain  the  body  and  help  it  to  function,  that  it  belongs 
in  every  diet." 

As  to  the  foods  that  contain  iron,  the  element  necessary  to  healthy 
blood, — meat,  eggs,  vegetables,  fruits  and  berries, — again  the  dietitian 
will  tell  you  that  the  cause  of  your  overweight  does  not  lie  in  them. 

No!  Surely  you  will  see  that  the  body  must  have  a  constant  and  ade- 
quate supply  of  the  materials  it  uses  for  the  building  and  upkeep  of  its 
own  substance.  Practically  the  only  sources  of  these  materials  are  the 
proteins,  minerals  and  vitamins  ("foodstuffs",  they  are  called)  that  are 
present  in  various  amounts  in  different  foods.  The  dietitians  will  tell 
you  that  a  day's  meals  that  will  include  the  following  foods,  in  the  por- 
tions given,  are  typical  of  what  you  should  eat  daily  to  take  care  of  your 
body's  requirements  of  the  protein,  mineral  and  vitamin  foodstuffs: 

Meat 

Egg 

Cheese 

Milk 

Butter 

Bread   (whole  wheat) 

Macaroni 

Potato 

Orange 

Apple 

Banana 

String  Beans 

Lettuce 

Carrots 

It  is  an  interesting  truth  that  the  foods  here  listed,  or  their  equivalents, 
will  furnish  your  day's  protein  requirement,  in  full,  as  well  as  your 
mineral  requirements. 

But  you  are  getting  impatient!  "If  not  these  foods,"  you  exclaim, 
"what  kind  of  food  is  it  that  caused  me  to  grow  fat?" 

Well,  the  body  has  another  requirement  that  the  food  supply  must  ful- 
fill. It  must  have  food  to  burn  as  fuel,  to  give  it  energy  for  its  activ- 
ities— work  and  play.  Dr.  Mary  Swartz  Rose  states  it  very  clearly  in 
her  "Foundation  of  Nutrition": 

"The  body  is  an  active  working  machine,  spending 
energy  in  the  form  of  work  and  heat,  and  demand- 
ing that  the  expenditure  be  made  good  by  fresh 
supplies  of  fuel  in  the  form  of  food." 

Now  all  foods  will  contribute  something  to  the  fuel  needs  of  the  body, 
but  in  the  interests  of  conserving  protein  foods  (which  you  will  notice 
are  of  the  expensive  kind)  for  their  special  purposes  of  growth  and  main- 
tenance, we  depend  upon  the  sugars  and  starches  (grouped  as  carbohy- 
drates) and  the  fats  as  the  best  sources  of  fuel  for  our  energies — work 
and  play.    Children  call  them  the  "go"  foods.    And  just  as  the  engineer 


3 

to  4  ounces 

1 

1 

ounce    ' 

2 

2 
2 

cups 

teaspoonfuls 

slices 

1 
1 

serving 
medium 

1 

medium 

1 

medium 

x/<2,  medium 

1 

a 

serving 
few  leaves 

1 

serving 

24 
measures  the  heat  or  fuel  value  of  coal  or  oil,  so  we  can  measure  the  heat 
or  fuel  value  of  food,  in  terms  of  the  calorie.  It  has  been  found,  for 
example,  that  an  ounce  of  fat,  i.  e.,  six  level  teaspoons,  or  six  small  pats 
of  butter,  will  yield  about  270  calories;  while  an  ounce  of  sugar  i.  e.,  six 
lumps  of  loaf  sugar,  yields  120  calories.  You  see  fat  has  a  higher  heat 
or  fuel  value  than  sugar,  as  an  ounce  of  fat  will  furnish  two  and  a 
quarter  times  as  much  heat  or  fuel  as  the  same  amount  of  sugar. 

Now  we  come  to  something  that  is  of  utmost  concern  to  the  economy 
of  your  particular  workshop,  if  your  tendency  is  to  be"  overweight.  If 
you  take  in  an  excess  of  fuel  food,  and  thus  provide  more  fuel  than  the 
body  demands  for  its  expenditure  of  energy,  the  excess  is  stored  in  your 
body  as  extra  fat.  A  certain  amount  of  such  storage  is  necessary  for 
protection  of  the  body,  but  it  should  be  kept  within  the  limits  of  the 
body's  average  weight.  Reason  will  tell  you  that  a  daily  excess  in  the 
supply  of  fuel,  even  in  small  amounts,  means  a  daily  increase  in  the  stor- 
age of  fat  in  the  tissues  of  your  body,  and  eventually  your  workshop 
becomes  overstocked! 

How  can  you  prevent  this  condition,  and  yet  fulfill  every  need  of  your 
body?  Well,  let  us  figure  out  together  the  body's  energy  needs;  for  it 
is  here  that  the  oversupply  is  most  likely  to  occur. 

For  every  2.2  pounds  of  body  weight  there  is  needed  daily  about  as 
much  carbohydrate  as  is  contained  in  one  lump  of  loaf  sugar.  If  your 
weight  is,  say,  about  132  pounds,  your  daily  need  of  carbohydrate  will 
be  the  equivalent  of  the  content  of  about  60  lumps  of  sugar,  or  about  2/3 
of  a  pound. 

Sixty  lumps  of  sugar  daily !  Oh, — but  you  are  not  have  all  your  carbo- 
hydrate in  the  form  of  granulated  or  concentrated  sugar!  No,  indeed! 
And  right  here  we  will  say:  Beware  of  candy, — you  who  are  overweight! 

Look  at  the  outline  again, — "The  Body  as  a  Builder  of  Its  Own  Sub- 
stance." The  full  100%  of  the  sugar  and  starch  content  of  the  carbo- 
hydrate foods — breads,  cereals,  sugars,  fruits,  vegetables  and  milk — is 
changed  in  the  body  to  the  kind  of  sugar  that  can  enter  into  the  blood 
stream.  Here  we  come  to  an  important  consideration  for  you  who  are 
overweight.  About  50%  of  your  protein  supply  and  10%  of  your  fat 
supply  are  also  converted,  in  the  body,  into  sugar.  This  means  that  since 
you  must  not  cut  down  on  protein,  you  must  be  the  more  cautious  with 
carbohydrate. 

Yet  you  can  eat  your  favorite  foods,  if  you  will  watch  what  they  do 
to  your  weight.  Take  an  inventory  every  week!  Watch  your  weight, 
and  if  it  indicates  overstocking,  limit  the  portions  of  carbohydrate. 

Compare  the  following  two  columns  representing  (1)  the  supply  of 
carbohydrate  typical  of  what  is  allowable  in  the  daily  diet  of  a  person 
when  she  is  of  average  weight,  say,  for  example,  about  132  pounds;  and 
(2)  the  adaptations  of  that  supply  that  would  be  necessary  if  she  were 
overweight. 


Milk 

Bread  (whole  wheat) 

Cereal 

Macaroni 

Potato 

Sugar 

Jelly 

Cake 

Fruit — Orange 
Apple 
Banana 


Vegetables- 


-Tomato 
String  Beans 
Lettuce 
Carrots 


Typical  of  a  day's  carbi 

jhydrate 

Typical  of  a  day's  carbohydrate 

supply  for  one  who  is  of 

average 

allowance  for  one  whose  average 

weight  for  height  and 

age, 

say 

weight  is  132  pounds,  but  who 

132  pounds 

is  overweight. 

2  cups 

2  cups 

5  slices 

2  slices 

1  serving    1 

f  Either  one 

1  serving     J 

I         or 

{  the  other 

1  large 

1  medium 

3  teaspoons 

None 

1  teaspoon 

None 

1  piece 

None 

1  medium 

1  medium 

1  medium 

1  medium 

One-half 

One-half 

1 

1  serving 

1 

1  serving 

A  few  leaves 

A  few  leaves 

1  serving 

1  serving 

25 

That  is,  if  you  are  maintaining  your  average  weight,  say  132  pounds, 
your  supply  of  carbohydrate  for  a  day — sugars  and  starches  equivalent 
to  60  lumps  or  2/3  of  a  pound  of  sugar — could  be  furnished  as  shown 
in  Column  No.  1.  But  if  you  are  overtopping  your  average  weight — if 
you  are  obese — your  daily  allowance  of  carbohydrate  should  be  cut  down 
one-h^lf,  as  shown,  typically,  in  Column  No.  2. 

Yet  within  her  restrictions  the  diet  of  the  obese  can  be  widely  varied. 
Following  is  a  list  of  portions  of  food  that  are  each  approximately  equiv- 
alent in  their  carbohydrate  content  to  two  lumps  of  sugar,  from  which 
you  who  are  obese  can  choose  by  exchanging  or  "swapping"  one  for  an- 
other, as  you  please. 

3  tablespoons  oatmeal  (cooked) 
TMj  tablespoons  farina  (cooked) 
V2  shredded  wheat  biscuit 

2  Uneeda  crackers 

4  saltines 

%  small  potato 

7  tablespoons  macaroni   (cooked) 

2/3  slice  of  graham  bread 

2  large  prunes 

2  tablespoons  seeded  raisins 

1  serving  of  any  10%  vegetables  (such  as  the  root  vegetable) 

21/2  servings  of  any  5%  vegetable  (such  as  leafy  vegetables) 

When  all  this  has  been  said,  do  you  appreciate  the  fact  that  in  these 
itemized  statements  of  the  carbohydrate  supply  in  a  diet  for  the  obese 
person,  nowhere  has  the  carbohydrate  been  provided  in  a  concentrated 
sugar,  but  always  in  the  form  of  a  starchy  food,  or  in  milk,  a  fruit  or  a 
vegetable  ? 

Fat,  too,  is  essential  to  the  body  for  the  production  of  heat  and  energy. 
But  again  an  excess  of  it  is  deposited  as  adipose  tissue,  and  you  become 
a  "fatty!"  A  person  who  weighs  about  132  pounds  needs  3%  ounces  of 
fat  daily,  or  the  equivalent  of  20  level  teaspoons  of  butter  (or  20  of  the 
small  pats  served  in  restaurants).  Remember  that  butter,  bacon,  cream, 
mayonnaise,  oil  and  the  fat  of  meat  are  concentrated  fats.  As  we  did  in 
the  case  of  carbohydrate,  let  us  illustrate  with  our  common  foods  the 
fat  intake  typical  for  the  person  of  average  weight,  and  the  adaptation 
that  should  be  made  for  the  obese: 


A  day's  fat 

for  the  person 

of  average  weight 

A  day's  fat 

for  the 

obese 

3  oz.  meat,  medium  fat 
1  egg 

1  oz.  cheese 

4  tbsps.  cream 
6  tsps.   butter 

1  tbsp.  mayonnaise 

2  glasses  milk 

3  oz.  meat,  medium  fat 

1  egg 

x/2  oz.  cheese 
none 

2  tsps.  butter 

1  tbsp.     supr'emaise,     a 
mineral  oil  dressing 

2  glasses  milk 

26 

Again  there  is  opportunity  for  "swapping."  Following  is  a  list  of 
foods  whose  fat  content  is  the  same,  being  equivalent  in  every  case  to  the 
amount  of  fat  in  one  teaspoon  of  butter: 

1  thick  slice,  or  2  thin  slices  of  bacon 

2  tablespoons  grated  cheese  or  a  piece  1"  x  1"  x  %" 

1  egg 

2  oz.  cooked  meat 
%  cup  whole  milk 

3  green  olives,  large 

2  teaspoons  peanut  butter 

3  whole  walnuts 

2  tablespoons  cream 

y<i  tablespoon  French  dressing 

There  are  several  kinds  of  fat.  It  is  the  animal  fats — milk,  butter, 
cream,  and  eggs,  and  some  meat  fats — that  contain  the  vitamins. 

And  as  with  the  carbohydrates,  so  with  the  fats — be  careful!  Watch 
your  weight! 

Here  let  us  repeat  a  caution,  and  so  re-emphasize  it.  Whether  you  are 
overweight  or  not,  you  must  not  cut  down  on  protein!  Neither  should 
you  overindulge  in  it.  For  every  15  pounds  of  body  weight  you  need 
about  %  of  an  ounce  of  protein, — 2  to  3  ounces  daily  if  your  average 
weight  is  132  pounds.  What  foods  will  provide  this  quota?  Each  of  the 
following  will  contribute  ^4  of  an  ounce  toward  your  total  requirement: 

1  ounce  of  meat 

1  ounce  of  fish  '  . 

1  large  egg 

1  ounce  of  cheese 

1  glass  of  milk 

So  a  day's  meals  typical  of  one  that  will  cover  in  full  the  body's  protein 
requirements  will  include  the  following: 

3  ounces  meat  (or  fish  or  chicken) 
1  egg 

1  ounce  cheese 

2  cups  milk 

2  slices  bread   (whole  wheat) 
1  serving  macaroni 
1  medium  potato 

Vegetables,  especially  the  green  ("above  the  ground")  vegetables. 

The  minerals — calcium  and  phosphorus  for  bones  and  teeth,  and  iron 
for  red  blood — and  the  vitamins — that  are  being  proved  to  be  of  marvel- 
ous importance  in  their  capacity  of  "staff  aides" — will  be  assured  to  you 
in  adequate  amounts  if  you  are  faithful  to  milk,  eggs,  fruits  and  vege- 
tables and  the  whole  grain  in  bread  and  cereal. 

Now  let  us  unite  these  various  computations  and  estimates  of  the  par- 
ticular need  for  protein,  carbohydrate,  fat,  minerals,  and  vitamins,  into 
one  composite  group,  in  the  form  of  the  following  day's  menu  that  is 
typical  of  one  recommended  for  obesity: 


27 

MEALS  FOR  ONE  DAY 
Based  on  the  Typical  Diet  for  Obesity 


FOOD 

HOUSEHOLD   MEASURE 

Breakfast: 

Orange 

1  medium 

Egg 

1 

Bread — whole  wheat 

1  slice 

Butter 

3^  teaspoon 

Coffee 

1  cup 

Milk— for  coffee 

4  tablespoons 

Macaroni — cooked    1 

%  cup — cooked 

Milk                            [  Baked  Macaroni 

Yi  cup 

Cheese                        J 

2  tablespoons,  grated 

Tomato                                 ) 
Lettuce — Iceberg                [  Salad 

1  medium 

3  leaves 

Mayonnaise — Mineral  Oil  j 

1  tablespoon 

Butter 

Y2  teaspoon 

Apple 

1  small 

Milk 

y<i  cup 

Dinner : 

Broth 

%  cup 

Meat 

4  ounces 

Potato 

1  medium 

5%  Vegetable,  String  Beans  (young) 

1  sauce  dish  or  2  heaping  tablespoons 

10%  Vegetable— Carrots 

1  sauce  dish  or  2  heaping  tablespoons 

Bread — whole  wheat 

1  slice 

Butter 

1  teaspoon 

Gelatin  I  Fruit  Gelatin 
Fruit      1 

yi  tablespoon 

J-1  small  banana 

Milk 

%  cup 

On  this  diet  you  should  lose  from  one  to  two  pounds  a  week.  When 
you  have  reached  your  average  weight,  transfer  to  what  is  called  the 
"maintenance"  diet  to  keep  yourself  there.  There  are  many  pamphlets 
and  books  and  people  to  help  you  to  do  this.  You  will  find  them  in  such 
places  as  the  State  Department  of  Health  or  the  Food  Clinic  of  The  Bos- 
ton Dispensary.  You,  yourself,  must  do  some  figuring  as  the  business 
woman  must  keep  accurate  records  and  accounts.  Certain  things  con- 
cerning your  workshop  are  now  known  factors  to  you;  namely,  the  types 
of  goods  with  which  you  should  stock  up, — protein,  carbohydrate,  fat, 
mineral  and  vitamin ;  the  approximate  amounts  of  these  that  will  maintain 
a  proper  balance,  always  with  strict  attention  paid  to  a  limitation  in 
amount  that  the  nature  or  condition  of  the  workshop  demands;  the  par- 
ticular usefulness  of  each  type;  i.e.;  protein  in  milk,  meat,  etc.,  and  cal- 
cium in  milk,  cheese,  etc.,*  and  their  various  sources  of  supply,  as  for 
carbohydrate,  the  breads,  cereals,  sugars,  fruits,  vegetables  and  milk.* 
You  must  manage  these  supplies  so  that  they  will  give  you  satisfactory 
"returns."  And  in  what  shape  will  these  returns  come?  In  better  health 
and  in  greater  usefulness  and  happiness  in  your  career.  In  your  work- 
shop is  carried  on  the  business  that  is  of  utmost  consequence  to  you, — 
the  business  of  living  healthfully. 

For  the  benefit  of  the  person  whose  workshop  is  naturally  of  larger 
dimensions  than  that  of  yours  whose  average  weight  is  about  132  pounds, 
we  have  arranged  the  following  chart  to  show  the  carbohydrate,  protein, 
fat,  mineral  and  caloric  content  of  a  day's  diet  typical  for  a  person  whose 
average  weight  is  about  150  pounds,  and  the  variations  from  it  necessary 
for  the  condition  of  overweight.  Notice  that  the  protein,  calcium  and 
iron  content  is  practically  the  same  for  both  the  normal  and  obesity  diets, 
while  the  carbohydrate  and  fat  content  is  considerably  less  in  the  obesity 
diet. 


*  See  the  outline ;  The  Body  as  a  Builder  of  its  own  Substance. 


28 


29 

And  this  is  our  final  advice  to  the  overweight,  given  somewhat  in  the 
style  of  Polonius,  that  tiresome,  good  old  man:  Cut  out  all  sugar  bowl 
sugar,  and  candy;  cut  down  on  bread;  take  dessert,  other  than  fruit, 
only  twice  a  week,  better  even  but  once  a  week;  indulge  not  in  snacks 
of  food  between  meals;  but  eat  three  good  meals  of  the  foods  that  are 
allowed  you! 

Underneath  all  this,  we  assure,  is  Science,  as  well  as  the  Art  of  Living. 

"The  workshops  of  life  require  fuel  to  maintain  them,  and  a  neces- 
sary function  of  nutrition  is  to  furnish  fuel  to  the  organism,  that 
the  motions  of  life  may  continue. 

Furthermore,  the  workshops  of  life  are  in  a  constant  state  of  par- 
tial breaking  down,  and  materials  must  be  furnished  to  repair  the 
worn  out  parts.  In  the  fuel  factor  and  the  repair  factor  lie  the 
essence  of  the  Science  of  Nutrition."  (Graham  Lusk.) 

GOOD  POSTURE  AS  A  BUSINESS  ASSET 

-   Marion  Shepard,  M.D. 
Medical  Adviser  to  Women,  University  of  Pittsburgh 

The  business  woman  of  today  is  eager  to  learn  of  ways  that  will  in- 
crease her  efficiency  and,  at  the  same  time,  will  leave  her  less  tired  at 
the  end  of  a  busy  day.  Studies  that  have  been  made  in  industry  show 
that  these  two  problems  are  practically  identical;  that  the  way  to  in- 
crease production,  which  is  but  another  way  of  saying  increase  the 
efficiency  of  the  worker,  is  to  lessen  fatigue.  So  we  might  well  put  the 
question:  How  can  the  business  woman  decrease  the  fatigue  that  accom- 
panies her  work? 

Among  the  causes  of  fatigue  among  office  workers  are  poor  ventila- 
tion, poor  lighting,  noise  and  confusion,  and,  to  some  extent,  monotony 
of  work.  These  factors  are  only  partly  under  control  of  the  girl  herself, 
but  she  can  control  her  own  habits  of  living,  her  own  body  mechanics, 
She  can  learn  to  give  her  body  at  least  the  amount  of  care  that  an  in- 
telligent man  gives  his  automobile;  or  to  be  exact,  can  see  to  it  that  she 
has  three  unhurried  meals  a  day,  eight  hours  of  sleep,  and  exercise  in 
the  open  air — these  are  the  minimum  requirements;  she  can  cultivate 
mental  poise,  and  she  can  learn  to  carry  herself  so  that  the  upright  pos- 
ture is  maintained  with  the  minimum  of  strain.  She  can  learn  to  stand 
tall  and  to  sit  tall  so  that  her  organs  will  have  room  to  function  and  the 
blood  can  circulate  freely.  Just  for  your  own  interest  try  blowing  all 
the  air  out  of  your  lungs,  and  then  note  how  this  posture  of  complete 
expiration  is  almost  exactly  the  one  you  assume  when  you  are  tired. 
How  can  the  lungs  be  properly  ventilated  if  you  habitually  assume  this 
pose?  Dr.  Wade  Wright  of  the  Metropolitan  Life  Insurance  Company 
tells  us:  "Tuberculosis  of  the  lungs  is  the  chief  cause  of  death  among 
clerks,  followed  in  order  of  importance  by  heart  disease,  influenza,  pneu- 
monia, and  Bright's  disease."  This  seems  a  pretty  strong  hint  that  office 
workers  need  to  be  particularly  careful  that  they  do  not  sit  at  their  work 
in  such  a  way  as  to  interfere  with  the  proper  functioning  of  the  organs 
of  the  chest.  Dr.  Goldthwait  says  that  the  body  should  be  kept  straight 
from  the  hips  to  the  neck,  should  not  be  allowed  to  bend  at  the  waist 
line,  and  that  any  posture  which  allows  this  bending  lowers  the  vitality 
of  the  individual,  leads  to  strain  of  the  back,  and  naturally  lessens  the 
efficiency  of  the  worker. 

A  flattened  chest  inevitably  results  in  a  relaxed  and  prominent  ab- 
domen. Try  sitting  in  a  slumped  position  and  note  the  effect  on  the 
abdominal  wall.  It  is  a  matter  of  interest  to  note  that  the  deep  trans- 
verse groove  across  the  abdomen  that  accompanies  this  posture  marks 
pretty  closely  the  location  of  the  stomach;  perhaps  this  fact  would  sug- 
gest to  the  office  worker  who  complains  of  indigestion  that  she  give  her 
much  abused  stomach  room  in  which  to  function. 


30 

A  correctly  designed  chair,  one  that  is  adjustable  to  the  proportions 
of  the  individual,  can  do  much  to  make  it  easier  to  sit  properly  while  at 
work.  Choose  one  that  is  the  right  height  for  your  work,  that  will  allow 
your  feet  to  rest  easily  on  the  floor  without  undue  pressure  on  the  under 
part  of  the  thigh,  that  will  support  the  lower  part  of  your  back  while 
you  are  working  yet  will  not  interfere  with  the  movements  of  your 
arms.  Most  chairs  are  designed  to  support  the  back  while  the  occupant 
is  resting,  but  there  are  chairs  on  the  market  that  meet  the  above  re- 
quirements. 

The  standing  posture  of  most  people  is  more  nearly  correct  than  that 
which  they  assume  when  they  sit  at  their  work,  yet  if  you  glance  critic- 
ally at  the  women  you  meet,  you  will  see  that  few  carry  themselves  well. 
The  fashions  of  the  last  few  years  have  hidden  the  outlines  of  flat  chests 
and  the  hollow  backs  that  have  been  so  prevalent,  but  with  the  return  of 
the  normal  waist  line  and  the  fitted  hip,  girls  are  scrutinizing  their 
profiles  in  the  mirror  with  new  interest.  The  cause  of  the  hollow  back 
is  in  most  cases  the  high  heeled  shoe  that  tilts  the  body  forward  and 
produces  the  compensating  backward  sway  of  the  upper  portion  of  the 
body  in  order  to  maintain  equilibrium.  High  heels  are  also  responsible 
for  the  painful  feet  which  so  many  women  accept  as  a  matter  of  course. 
The  whole  weight  of  the  body  is  thrust  forward  on  to  the  anterior  arch 
of  the  foot  which  in  time  gives  way  under  the  strain,  resulting  in  ob- 
struction of  circulation  and  in  nerve  pressure  evidenced  by  painful  and 
burning  feet.  Of  course  your  shoes  are  sensible — one's  own  always  are — 
but  can  you  enjoy" a  brisk  two-mile  walk  without  weariness?  Can  you 
stand  in  line  for  tickets  to  some  popular  show  without  painfully  shift- 
ing from  one  foot  to  another?  In  the  world  of  sport  the  low  heeled  shoe 
is  the  fashionable  shoe ;  any  other  would  make  the  wearer  appear  ridicu- 
lous. High  heels  are  equally  out  of  place  in  a  business  office  and  are 
rarely  worn  there  by  the  woman  who  is  a  leader  in  her  business  or 
professional  field. 

Have  you  ever  considered  how  much  the  opinion  of  a  prospective  em- 
ployer in  regard  to  the  health  and  capabilities  of  an  applicant  is  based 
upon  her  appearance?  If  she  carries  herself  in  a  slovenly  manner,  if  she 
is  always  looking  for  a  chance  to  sit  down  or  to  lean  against  something, 
she  rarely  gets  a  chance  to  show  what  she  can  do.  The  tired  girl  with 
nerves  and  headaches  is  not  unknown  to  the  average  employer,  and  he 
avoids  all  possibility  of  adding  one  to  his  staff.  A  man  who  has  im- 
portant work  to  be  done  selects  a  woman  who  carries  herself  erect,  one 
who  by  her  poise  and  her  elertness  gives  evidence  of  health  and  vitality, 
and  of  ability  to  do  a  given  task  calmly  and  efficiently.  Then  too,  standing 
erect  gives  the  girl  herself  new  confidence.  "Assume  a  virtue  if  you 
have  it  not"  is  still  good  advice.  Assume  the  posture  of  efficiency  and 
note  that  you  really  do  think  more  clearly  and  that  hesitancy  and  un- 
certainty tend  to  disappear. 

THE  CARE  OF  THE  TISSUES  SUPPORTING  THE  TEETH 

William  Rice,  D.D.S.,  D.M.D. 

Dean,  Tufts  College  Dental  School 

So  much  has  been  said  and  written  about  the  teeth  and  their  care 
that  it  would  seem  that  the  subject  must  be  exhausted,  and  nothing  new 
could  be  said;  yet,  until  positive  facts  can  be  given  relative  to  the  cause 
of  dental  decay,  speculation  will  be  rife  regarding  the  prevention  of  this 
affliction.  Some  one  has  termed  this  malady  "The  People's  Disease,"  but 
this  term  is  inapplicable,  for  whether  or  not  it  is  really  a  disease  or  a 
chemical  dissolution  of  a  soluble  material;  whether  it  is  due  to  environ- 
ment or  is  a  degenerative  process  originating  from  within  the  tooth; 
whether  persistent  cleaning  will  prevent  its  occurrence;  or  whether  it  is 
a  nutritional  problem,  depending  on  adequate  food  supply  to  the  body  as 


31 

whole,  are  still  debatable  questions.  Prinz  says:  "Dental  caries  is  not 
a  disease  in  the  strict  sense  of  the  word  in  which  the  latter  term  is 
usually  applied." 

In  this  brief  discussion  I  shall  discreetly  avoid  an  expression  of  opinion 
on  this  subject,  leaving  the  matter  for  the  further  consideration  of  re- 
search workers,  and  offering  as  a  suggestion  only  that  the  public  "play 
safe"  by  eating  protective  foods,  and  scrubbing  the  teeth  thoroughly 
after  each  dietary  indulgence. 

It  is  an  axiom  that  no  structure  as  a  whole  is  stronger  than  its  weakest 
part.  Applying  this  to  our  present  subject  it  can  be  said  that  the  teeth 
can  retain  their  function  no  longer  than  the  structures  supporting  them 
retain  their  integrity.  I  am,  therefore,  turning  to  a  less  threadbare,  but 
no  less  important  question — the  care  of  the  supporting  tissues — a  sub- 
ject perhaps  even  more  closely  related  to  the  preservation  of  good  health 
than  is  the  care  of  the  teeth.  Let  us  briefly  consider  the  relation  of  the 
teeth  to  these  tissues.  The  roots  of  the  teeth  are  set  in  the  portion  of 
the  bone  of  the  jaw  known  as  the  alveolar  process,  a  structure  contain- 
ing cavities  for  their  reception.  Bone  surrounds  the  roots  of  the  teeth, 
and  the  crest  of  the  bone  rises  well  up  into  the  space  between  the  teeth. 
The  roots  of  the  teeth  are  covered  with  a  membrane  which  serves  to 
attach  them  to  the  bone  of  the  jaw.  From  this  membrane,  numberless 
fibres  are  thrown  out,  which  penetrate  the  outer  bony  covering  of  the 
root;  they  also  attach  themselves  to  the  membrane  covering  the  bone. 
The  gums  clothe  the  bony  structure  surrounding  the  roots  of  the  teeth, 
and  form  a  continuous  tissue  covering  the  hard  palate,  composed  of  com- 
pact, inelastic  fibres.  These  fibres  interlace  with  the  membrane  covering 
the  bone  (the  periosteum).  The  blood  supply  of  the  gum  is  rich,  and 
the  nerve  supply  good,  but  strangely  enough  these  tissues  are  singularly 
insensitive  to  the  pressure  of  rough  foods  which  are  forced  over  their 
surfaces  in  the  process  of  mastication. 

From  this  brief  description  of  the  tissues  which  surround  the  teeth,  it 
may  be  seen  that  Nature  has  done  much  to  provide  a  secure  foundation 
for  the  teeth,  and  by  means  of  the  fibrous  attachment  to  the  bone,  suffic- 
ient mobility  to  compensate  for  the  shock  received  in  the  performance 
of  their  function,  thus  safeguarding  against  disruption.  Paradoxical  as 
it  may  seem  the  severe  exercise  of  function  is  an  important  factor  in 
the  maintenance  of  the  health  of  these  tissues,  for  it  is  through  their 
reaction  to  the  stimulation  thus  received  that  the  activity  of  the  circu- 
lation is  increased,  and  the  necessary  nutritional  material  conveyed  to 
them.  Unfortunately,  however,  in  spite  of  the  seemingly  ample  protec- 
tive agencies  provided  by  Nature,  inherent  tendencies  resulting  in  faulty 
development  of  the  jaws,  mechanical  injuries,  and  nutritional  inadequa- 
cies as  well,  frequently  cause  a  lowered  resistance  in  these  tissues,  and 
render  them  so  susceptible  to  disease  processes  that  the  persistently 
asserted  expression  "four  out  of  five  have  it,"  has  become  common  par- 
lance, and  is  understood  by  the  people  at  large.  "It,"  commonly  known 
as  Pyorrhea,  but  duly  christened  by  men  of  science  with  the  euphonic 
term  "Periodontoclasia"  is  not  of  so  frequent  occurrence  as  the  slogan 
would  imply,  but  is  certainly  present  in  one  of  its  stages  in  the  mouths 
of  the  majority  of  adults.  This  malady  has  a  wide  range  of  indications, 
varying  in  intensity  according  to  the  stage  of  progress  in  its  develop- 
ment. In  the  first  stage  its  presence  will  seldom  be  realized  by  the  person 
afflicted,  and  even  the  dentist  may  fail  to  detect  its  early  symptoms 
unless  he  has  schooled  himself  in  the  practice  of  close  observation  when 
making  his  routine  examination  of  the  teeth  and  mouth. 

In  view  of  the  fact  that  the  soft  tissues  surrounding  the  teeth  are  end 
organs,  they  do  not  have  a  collateral  circulation  as  an  aid  to  recovery 
after  congestion  has  taken  place.  It  therefore  follows  that  early  detec- 
tion of  conditions  favoring  the  development  of  this  disease  is  of  the 
highest  importance,  for  when  extensive  destruction  of  tissue  has  taken 
place,  the  disease  is  not  amenable  to  treatment.     In  this  connection  it 


32 

should  be  stated  that  the  fact  of  its  presence  in  the  mouth  may  be  indi- 
cative of  nutritional  disturbances  or  degenerative  processes  taking  place 
in  organs  or  tissues  in  other  parts  of  the  body,  as  it  is  an  accepted  fact 
that  fully  developed  periodontoclasia  frequently  accompanies  diseases  of 
the  heart,  kidneys  and  pancreas. 

At  the  point  of  juncture  between  the  root  and  the  crown  of  the  tooth, 
the  protective  covering  is  gum  tissue,  which  for  a  short  distance  is  not 
attached  to  the  tooth  itself.  This  tissue  is  called  the  free  margin  of  the 
gum.  It  beautifully  festoons  this  portion  of  the  tooth,  but  because  it  is 
not  attached,  a  space  exists  between  it  and  surface  of  the  tooth.  This 
space  affords  a  favorable  place  for  the  lodgment  of  food  materials;  also 
for  the  deposit  of  limy  substances  precipitated  from  the  saliva,  which 
become  attached  to  the  tooth  surface.  These  foreign  substances  are  a 
source  of  irritation  to  the  soft  tissue,  and  frequently  inflammation  is 
initiated,  the  products  of  which  serve  still  further  to  irritate  the  soft 
tissues.  In  some  instances  hard  accretions  are  formed  which  impinge 
upon  the  gum,  and  the  recession  of  this  tissue  takes  place.  This  process 
continues  progressively,  causing  atrophy  of  the  alveolar  bone,  and  finally 
disruption  of  the  teeth  from  insufficient  support.  In  other  instances  the 
accumulation  of  material  under  the  free  margin  of  the  gum  becomes 
invaded  by  pus-producing  micro-organisms,  and  infection  takes  place 
with  the  formation  of  pus  pockets,  which  gradually  extend  vertically 
along  the  root  of  the  tooth,  destroying  bone  and  membrane. 

The  anatomical  relations  of  the  teeth  of  the  opposing  jaws  in  their 
highest  perfection  is  very  wonderful,  for  Nature  has  provided  a  machine 
of  great  power  for  the  performance  of  the  function  of  mastication,  and 
at  the  same  time  so  to  distribute  effectively  the  accompanying  strain  as 
to  protect  the  tissues  from  injury.  The  shape  of  the  teeth  and  their 
arrangement  in  the  jaws  is  also  such  as  to  afford  protection  to  these 
tissues.  Unfortunately,  however,  so-called  "normal  occlusion"  is  not 
common  in  youth,  and  is  seldom  present  in  adult  life. 

Neither  time  nor  space  will  permit  an  attempt  to  explain  the  reasons 
for  the  frequent  presence  of  imperfect  occlusions.  Suffice  it  to  say  that 
imperfect  development  is  one  factor,  and  the  disharmony  resulting  from 
the  extraction  of  teeth,  another.  It  frequently  happens  that  a  single 
tooth  or  group  of  teeth  are  subjected  to  undue  strain,  resulting  in 
increased  mobility  of  these  teeth  and  consequent  inflammation  of  the  soft 
tissues  and  the  eventual  breaking  away  of  the  attachment  between  the 
tooth  and  the  bone  of  the  socket.  A  form  of  treatment  for  this  condi- 
tion consists  in  attempting  to  readjust  and  restore  harmonious  relation- 
ship by  grinding  the  teeth  at  the  point  of  greatest  stress.  It  is 
apparent,  however,  that  this  treatment  should  be  performed  with  the 
greatest  discretion  and  skill,  or  the  result  will  be  injurious  rather 
than  beneficial. 

In  the  opinion  of  the  writer  the  factor  of  greatest  importance  in  the 
prevention  of  this  disease,  which  is  responsible  for  the  loss  of  countless 
numbers  of  sound  teeth,  is  a  problem  in  nutrition.  Howe,  Mellanby  and 
others  have  incited  conditions  in  animals  closely  simulating  the  syn- 
drome so  frequently  present  in  human  beings  by  depriving  them  of 
natural  foods  in  the  raw  state.  It  is  true,  however,  that  the  health  of 
the  tissues  may  be  maintained  in  spite  of  structural  disharmony,  if  the 
body  functions  can  be  kept  up  to  a  degree  which  insures  sufficient  supply 
of  the  essential  nutritional  elements  to  maintain  circulatory  activity  in 
these  tissues.  Whole  grains,  milk,  fruits,  and  a  moderate  amount  of 
meat  and  sugar  are  the  essentials  of  diet,  but  as  Howe  has  stated:  "There 
are  at  least  two  things  to  be  considered  in  bodily  metabolism;  first,  an 
ample  supply  of  the  materials  out  of  which  the  various  tissues  are  to  be 
built;  and  second,  the  ability  of  the  organism  to  properly  utilize  these 
materials." 

It  is  obvious  that  only  when  these  food  materials  are  properly  utilized, 
can  tissue  tone  be  maintained,  The  question  arises— what  can  the  indi- 


33 

vidual  do  to  aid  in  preventing  the  onset  of  disease  of  the  tissues  sup- 
porting the  teeth? 

The  following  generalities  may  be  helpful,  and  the  direction  for  stimu- 
lation, a  concrete  suggestion : 

1.  Proper  food. 

2.  Sufficient  exercise. 

3.  Avoidance  of  extreme  fatigue. 

4.  Adequate  rest. 

5.  Sufficient  fresh  air  and  sunlight. 

6.  Frequent  bathing. 

7.  Active  elimination. 

8.  Frequent  examinations  of  the  teeth  and  gums. 

9.  Early  removal  of  deposits. 

10.  Stimulation  of  the  gums  in  the  daily  toilet  of  the  teeth  and  mouth. 
Directions  for  Mechanical  Stimulation  of  the  Gum  Tissue: 

1.  Moisten  the  brush  with  water;  place  the  end  of  the  bristles  of 
the  brush  against  the  gums  just  above  the  margin  of  the  teeth, 
pressing  gently  and  agitating  the  brush  for  a  few  seconds  with- 
out permitting  the  bristles  to  slide  over  their  surfaces. 

2.  Change  the  position  of  the  brush,  and  repeat  the  procedure  de- 
scribed until  the  entire  tissue  surrounding  the  teeth  has  been 
stimulated. 

SOME  FACTS  ONE  SHOULD  KNOW  ABOUT  THE  SKIN 

Loretta  Joy  Cummins,  M.D. 
Boston,  Mass. 

Unless  one  has  been  afflicted  with  some  skin  disease,  or  been  associated 
with  someone  who  has  been  suffering  from  such  a  condition,  her  chief 
interest  in  skin  is  in  learning  what  she  can  do  to  increase  its  beauty. 
It  is  very  commendable  that  everyone  today  is  interested  in  improving 
her  appearance  as  much  as  possible;  we  want  to  encourage  that,  but 
there  is  a  great  deal  for  women  to  learn  about  the  true  facts  of  how  to 
properly  care  for  the  skin  and  hair. 

This  is  a  simple  statement  of  scientific  facts.  In  the  first  place,  one 
must  remember  that  the  skin  is  not  merely  the  covering  of  the  body.  It 
is  an  organ  of  the  body  and  as  such  must  be  given  the  consideration  one 
would  give  to  any  other  organ.  It  is  a  secreting  organ.  In  the  skin  over 
the  surface  of  the  body,  there  are  millions  of  tiny  glands  of  two  types: 
oil  glands  and  sweat  glands.  These  are  pouring  out  their  secretions  onto 
the  surface  of  the  body  during  the  whole  twenty-four  hours.  These 
secretions  are  taken  care  of  through  evaporation  and  absorption  by  the 
clothing.  I  will  not  go  into  the  details  of  the  structures  and  functions 
of  the  skin,  but  I  do  want  to  correct  the  idea  so  many  have  that  the  skin 
is  merely  a  covering  of  simple  cells.  The  skin  is  vitally  connected  with 
the  whole  system  and  is  not  a  thing  apart.  One's  general  health  is 
reflected  in  the  skin  in  many  ways:  many  cases  of  diabetes  are  first  dis- 
covered by  the  dermatologist;  focal  infections  of  various  kinds  and  gland 
disturbances  are  unearthed  in  our  search  for  the  causes  of  some  skin 
eruptions.  The  care  we  take  of  our  whole  body  is  of  great  importance  to 
the  skin.  If  one  would  have  a  beautiful  clear  complexion  one  must 
observe  all  the  laws  of  general  hygiene;  proper  amount  of  bathing,  exer- 
cise, diet,  sleep,  etc.  The  importance  of  bathing  would  be  thoroughly 
understood  if  everyone  knew  the  amount  of  secretion  poured  out  onto 
the  skin  every  twenty-four  hours.  The  average  normal  person  should 
take  a  daily  bath  in  order  to  keep  the  pores  free  and  clear.  It  is  an  amaz- 
ing fact  that  so  many  persons  would  think  they  were  very  unclean  if 
they  didn't  wash  their  body  every  day,  but  they  are  satisfied  to  go  days 
or  weeks  without  washing  their  face.  Now  the  skin  of  the  face  is 
exactly  the  same  as  that  of  the  body  but  is  more  exposed  to  dust  and 
dirt  so  why  not  wash  it  with  soap  and  water  too?   I  am  speaking  now  of 


34 
the  average  normal  skin;  I  allow  there  are  many  sensitive,  delicate  skins, 
but  generally  when  a  normal  person  cannot  use  soap  and  water  on  her 
face,  it  is  because  she  is  using  too  strong  or  too  drying  a  soap,  or  many 
times  because  she  has  an  idea  that  creams  are  better.  Creams  have 
their  place,  but  they  do  not  take  the  place  of  soap  and  water.  Now  just 
a  word  about  nourishing  the  skin:  The  average  woman  is  very  gullible 
and  will  believe  anything  told  her  by  a  clever  person  selling  cosmetics. 
The  skin  cannot  be  fed  locally.  There  is  no  such  thing  as  a  skin  food. 
The  skin  can  be  creamed  and  softened  but  it  has  no  power  of  assimilat- 
ing or  digesting  a  local  application;  the  only  nourishment  it  gets  is  from 
the  blood.  The  skin  is  filled  with  a  fine  network  of  blood  vessels  which 
brings  it  all  its  nourishment.  Remember  the  only  means  of  feeding  the 
skin  is  through  the  stomach. 

The  causes  of  skin  diseases  are  both  external  and  internal.  Many 
persons  still  hold  the  old  idea  that  every  skin  eruption  is  due  to  some- 
thing in  the  blood.  There  are  many  conditions  which  are  purely  localized. 
I  want  to  speak  briefly  of  a  group  of  conditions  which  have  quite  recently 
been  found  to  be  of  local  origin,  due  to  the  fungus  infection:  First  there 
is  a  condition  which  for  years  was  considered  an  eczema;  it  is  seen  both 
in  infants  and  adults.  It  occurs  most  commonly  behind  the  ears,  in  the 
bend  of  the  elbow,  under  the  arms  and  in  the  groins.  In  many  of  these 
cases  we  find  the  organism  by  examining  scrapings  under  the  microscope. 
It  is  mildly  contagious  and  a  very  small  area  on  the  hand  of  the  mother  or 
any  person  caring  for  a  child  may  produce  an  eczema-like  eruption  on  the 
child.  The  following  case  from  our  clinic  at  the  Massachusetts  General 
Hospital  illustrates  this  point.  A  child  eight  months  old  had  eczema  off 
and  on  since  it  was  one  month  old.  The  eruption  was  on  the  face,  arms 
and  legs.  The  skin  tests  were  negative  and  changes  in  diet  had  no  effect. 
It  cleared  up  under  local  treatment  but  would  reappear.  There  were  short 
intervals  of  freedom  from  the  eruption.  One  day  when  the  nurse  was 
making  a  house  visit,  the  mother  showed  her  a  spot  on  her  hand  and 
stated  she  had  had  an  itching  eruption  on  her  hand  off  and  on  for  years. 
This  was  reported,  and  on  the  next  visit  to  the  hospital  the  mother's 
hands  were  treated  and  cleared  up.  Since  then  the  baby's  eczema  has 
remained  cured.   The  child  was  undoubtedly  infected  from  the  mother. 

Another  fungus  condition  is  commonly  seen  on  the  hands  and  feet. 
It  occurs  as  small  water  blisters  which  first  appear  deep  in  the  skin  on 
the  side  of  the  fingers,  on  the  webs  of  the  fingers  and  palms  of  the  hands. 
On  the  feet  they  appear  between  the  toes,  producing  a  thickened  whit- 
ish appearance  of  the  skin,  or  peeling  and  fissures,  or  deep  seated  vesicles. 
Occasionally  the  skin  on  the  palms  and  soles  becomes  thickened  and  cal- 
loused areas  form.  The  name  of  this  condition  is  epidermophytosis.  It 
is  a  form  of  ring  worm  but  has  none  of  the  appearances  of  the  ordinary 
ring  worm.  The  condition  is  very  common  to  quite  a  large  per  cent  of 
people  who  have  it  in  a  very  mild  form.  At  times  the  fungus  goes  into  a 
spore  or  rest  state  causing  the  condition  to  temporarily  clear  up  and 
later  it  develops  and  the  eruption  appears  again.  These  outbreaks 
and  remissions  are  quite  characteristic.  There  is  a  great  effort  being 
made  to  prevent  the  spread  of  this  very  troublesome  condition  which  is 
very  commonly  picked  up  in  shower  baths,  swimming  pools,  bath  houses 
and  any  place  where  people  walk  around  barefooted.  Many  new  cases 
appear  every  year  at  the  close  of  the  camp  season.  Another  condition 
which  is  in  this  same  group  is  plantar  warts.  A  plantar  wart  is  a  small 
thickened  callous-like  area  developing  on  the  soles  of  the  feet.  They  are 
often  very  painful.  There  have,  been  real  epidemics  of  plantar  warts 
in  some  of  our  colleges.  Some  of  the  smaller  lesions  clear  up  with  the 
application  of  proper  ointments  but  generally  they  require  treatment 
with  either  x-ray  or  radium. 

I  am  very  glad  to  have  this  opportunity  to  give  a  word  of  warning 
about  exposing  the  skin  unnecessarily  to  the  irritating  rays  of  the  sun. 
Nature  had  provided  us  with  a  body  covering  which  is  marvelously  con- 


35 

structed.  It  will  stand  a  great  deal  of  abuse  in  most  cases,  but  after  a 
certain  length  of  time  it  will  show  the  effects  of  these  abuses.  Sunlight 
is  very  beneficial  in  certain  cases  and  in  certain  amounts,  but  repeated 
exposures  to  the  irritating  rays  of  the  sun  produce  degenerative  changes 
which  may  lead  up  to  the  early  development  of  serious  skin  diseases. 

People  leading  outdoor  lives  like  farmers,  policemen,  chauffeurs,  etc., 
often  show  age  changes  quite  early.  After  the  age  of  thirty-five,  every 
man  and  woman  must  be  on  the  lookout  for  these  signs.  They  start  as 
roughened  light  brownish  spots  on  any  part  of  the  face  and  hands.  These 
may  remain  quite  small  for  months  or  years  with  only  a  slight  amount 
of  roughness.  They  may  come  off  at  times  and  later  reappear.  These 
spots  are  called  keratosis  and  in  themselves  are  simple  age  changes  but 
they  are  the  potential  sites  of  skin  cancers  and  should  be  properly 
treated  before  they  show  any  signs  of  degeneration. 

Everyone  naturally  dislikes  to  hear  anything  about  cancer  but  why 
shun  hearing  facts  which,  if  understood,  will  bring  health  and  happiness 
to  us  all.  It  is  an  appalling  fact  that  between  three  and  four  thousand 
persons  die  every  year  in  the  United  States  of  cancer  of  the  skin  and 
we,  as  skin  specialists,  know  there  should  not  be  one  death.  There  is  no 
condition  in  dermatology  more  satisfactory  to  treat  than  the  beginning 
skin  cancer,  because  with  the  proper  application  of  radium  the  results 
are  marvelous.  One  must  look  out  not  only  for  these  gradual  new  de- 
velopments, but  also  for  any  degenerative  change  taking  place  in  a  mole 
or  wart.  Any  skin  lesion  should  be  removed,  no  matter  how  simple  it  is 
if  it  is  subjected  to  repeated  irritation. 

SLEEP  FOR  HEALTH  AND  CHARM 

Jean  V.  Latimer,  M.  A. 

Educational  Secretary    . 
Massachusetts  Tuberculosis  League 

This  is  an  age  of  self-realization.  Never  before  have  girls  had  such 
opportunities  for  being  themselves.  The  young  business  woman  today  is 
a  "go-getter,"  and  that  she  is  being  successful  has  been  demonstrated 
all  around  us.  Moreover,  the  young  business  woman  today  is  the  best 
groomed  and  the  best  looking  woman  found  anywhere,  and  often  puts 
her  more  leisurely  sisters  to  a  disadvantage.  Our  girls  with  their  vanity 
cases  and  hand  mirrors  seem  to  think  that  saving  the  surface  is  very 
essential.  But,  the  process  that  treats  beauty  as  being  only  skin  deep 
is  superficial  and  not  lasting.  Beauty  is  blood  deep,  lung  deep,  heart  deep, 
food  deep,  air  deep  and  sleep  deep.  The  most  captivating  beauty  and 
the  most  lasting  is  that  which  is  not  put  on,  but  which  comes  out.  The 
Chinese  dread  "losing  face" — so  do  we.  The  most  lasting  beauty  is  that 
which  is  based  on  everyday  healthful  living,  and  of  all  the  habits  for 
health,  possibly  the  most  important  and  the  ones  busy  girls  of  today  are 
likely  to  forget  are  sleep  and  rest.  Here  are  a  few  of  the  whys  and  hows : 

Activity  of  any  kind  must  be  followed  by  recovery  through  rest.  The 
human  organism  must  adjust  itself  through  rest  and  sleep.  This  is  par- 
ticularly true  during  youth  when  the  bones,  muscles  and  tendons  are 
growing  together  for  firm  union.  Industrial  authorities  tell  us  that 
young  persons  are  permanently  and  more  seriously  damaged  by  the 
poisons  and  toxins  of  fatigue  than  are  those  of  maturity.  Fatigue  not 
only  lessens  effective  life,  but  it  impairs  a  girl's  working  power  even 
during  the  hours  she  is  able  to  devote  to  work;  it  impairs  the  quality  of 
her  performance  and  reduces  the  ability  to  keep  her  attention  on  the  task 
at  hand.  Some  of  our  biggest  blunders  and  saddest  mistakes  are  made 
when  we  are  fatigued  through  lack  of  sleep.  All  girls  in  business,  I  am 
sure,  have  experienced  such  regretful  days ! 

Not  only  success  but  popularity  depends  somewhat  on  that  surplus 
vigor  called  "pep."  Popularity  is  often  effective  by  having  at  our  com- 
mand the  greatest  possible  supply  of  energy,  and  it  is  during  sleep  that 


36 

the  body  is  repaired  and  the  surplus  energy  is  stored  up  for  this  future 
use.  It  is  probable  that  when  human  life  was  lived  under  primitive  con- 
ditions, that  is,  when  man's  activities  consisted  of  getting  food  and  shel- 
ter for  himself  by  his  own  efforts,  the  sensation  of  weariness  could  be 
relied  on  to  regulate  the  amount  of  rest  needed,  and  there  was  no  need 
for  considering  fatigue  as  a  social  problem.  But,  with  the  advance  of 
civilization,  many  things  develop  that  tend  to  upset  this  natural  balance 
between  work  or  play,  and  rest.  It  seems  to  be  a  fact  noio  that  human 
beings  are  constantly  stimulated  to  continue  work  or  play  beyond  the 
point  where  they  feel  fatigued — this  natural  signal  to  them  to  stop  be- 
comes weakened  and  is  no  longer  a  reliable  guide.  In  fact,  Dr.  Johnson 
of  the  Mellon  Institute,  Pittsburgh,  has  shown  that  fatigue  may  act  as  a 
stimulant  similar  possibly  to  that  of  the  effect  of  alcohol  on  the  organ- 
ism— in  that  it  may  drive  a  person  on.  Dr.  Johnson  states  that  there  are 
many  points  of  resemblance  between  excessive  fatigue  and  drunkenness, 
and  states  that  every  effect  of  alcohol,  which  has  any  social  significance, 
can  be  produced  by  some  degree  of  fatigue.  Therefore,  a  sense  of  fatigue 
is  no  longer  a  safe  guide.  Over-fatigue  may  whip  a  person  along  by 
stimulating  the  higher  nerve  centers.  Have  you -ever  been  so  tired  you 
just  did  not  want  to  stop  and  rest,  though  you  had  the  opportunity?  But, 
this  "keeping  on  the  go"  business,  after  one  is  already  tired,  is  danger- 
ous, for  it  is  often  in  a  fatigued  body  that  the  common  cold  finds  a  good 
place  to  lodge  and  grow.  Also,  often  in  a  fatigued  body  those  giants — 
pneumonia  and  influenza — follow.  Again,  studies  of  young  women  who 
have  broken  down  with  tuberculosis  would  lead  us  to  believe  that  the 
tubercle  bacillus  finds  a  friendly  growing  place  in  the  over-tired  body 
which  has  put  off  until  some  future  time  rest  and  sleep.'  The  human  body 
needs  rest  and  sleep  at  shorter  intervals  than  that  which  has  been  sup- 
posed, and  deferred  rest  and  sleep  is  not  the  same  as  that  taken  regu- 
larly at  shorter  intervals.  Therefore,  we  cannot  put  this  off  and  say  that 
we  are  going  to  take  the  necessary  rest  and  sleep  at  some  future  time. 
The  longer  it  is  put  off,  the  more  difficult  and  longer  does  it  take  the 
human  body  to  repair  itself  and  get  back  to  normal.  But,  the  tragic 
danger  is  that  we  step  too  far,  and  burn  the  candle  so  that  both  ends 
come  too  closely  together,  and  then  some  serious  impairments  to  the 
human  body  occur. 

What  are  some  of  the  conditions  which  promote  the  best  sleep?  First 
of  all,  have  a  regular  time  for  going  to  bed — and  allow  few  exceptions 
to  this.  Possibly  this  is  what  is  meant  by  beauty  sleep,  extra  sleep,  sleep 
before  twelve  o'clock.  Although  we  have  no  scientific  proof  that  sleep 
before  midnight  is  any  better  for  the  human  organism  than  sleep  at 
any  other  time,  it  is  reasonable  to  suppose  that  if  we  get  in  these  early 
hours,  the  length  of  the  sleep  period  will  be  longer.  Therefore,  there  is 
good  reason  for  indulging  in  what  we  call  beauty  sleep,  even  though  we 
do  not  feel  the  need  of  it. 

Second:  Dr.  Laird  of  Colgate  University  in  his  research  has  shown 
that  we  sleep  more  profoundly  at  certain  times  than  at  others  and 
that  certain  kinds  of  sleep  seem  to  refresh  us  more  than  others.  Here 
is  an  attempt  to  actually  measure  the  amount  of  relaxation  in  sleep.  One 
fact  these  experiments  seem  to  show  is  that  noises,  even  when  we  do 
not  actually  awaken,  increase  our  muscular  tension  and  so  interfere 
with  complete  repose. 

Third:  Good  sleep  does  not  mean  that  we  "sleep  like  a  log."  Scientific 
investigation  shows  that  in  normal  sleep,  the  human  body  turns  over  fre- 
quently. The  Mellon  Institute  research  shows  that  everyone  has  a  regu- 
lar rate  of  stirring,  and  for  this  reason,  each  individual  should  sleep 
alone,  if  possible.  The  mattress  should  be  one  which  gives  somewhat 
with  the  body.  The  covering  should  be  light  and  warm.  Very  often 
restfulness  is  interfered  with  during  the  winter  months  by  the  addition 
of  too  heavy  covering.  The  sleeping  room  should  have  the  windows  open 
and  the  heat  turned  off. 


37 

Last:  Going  to  bed  when  we  are  not  too  tired  and  when  we  have  not 
been  over-stimulated  by  our  occupation  just  before  going  to  bed,  usually 
results  in  our  falling  asleep  quickly  and  sleeping  more  restfully  than  we 
should  otherwise.  It  is  a  good  idea  not  to  think  of  what  has  happened 
during  the  day.   Not  too  exciting  reading  will  often  cause  us  to  relax. 

The  amount  of  definite  knowledge  we  have  about  sleep  is  very  limited, 
since  the  very  nature  of  sleep  does  not  lend  itself  to  accurate  scientific 
experiment.  However,  as  a  practical  procedure,  we  seem  justified  to 
take  into  consideration  the  known  facts  about  fatigue  and  the  opinions 
physicians  have  formed  as  a  result  of  their  experience  in  regard  to  sleep 
and  draw  the  following  conclusions: — 

For  every  activity  of  our  bodies,  there, is  a  required  period  of  rest,  any 
cutting  down  of  which  results  in  a  lessened  ability  to  repeat  or  con- 
tinue the  activity. 

During  rest  the  breaking  down  processes  of  the  cells,  of  which  our 
bodies  are  composed,  are  slowed  down  without  a  corresponding  decrease  in 
the  building  up  processes.  The  most  complete  rest  is  obtained  during 
sleep. 

Before  full  maturity  is  reached  a  greater  amount  of  sleep  is  needed 
than  is  required  later  in  life,  because  the  activity  of  the  cells  of  the  body 
has  to  provide  for  growth  as  well  as  repair. 

Over-fatigue,  constant  stimulation  by  pleasurable  excitement,  irregular 
hours,  may  operate  to  weaken  the  signals  which  nature  sends  to  tell  us 
that  it  is  time  to  sleep,  and  result  in  our  getting  less  than  the  amount 
of  sleep  we  need. 

It  pays  to  consider  what  experience  has  taught  are  the  usual  sleep  re- 
quirements for  persons  of  our  age,  and  plan  to  get  that  amount  of  sleep 
if  we  want  to  assure  ourselves  of  the  fullest  amount  of  vigor  and  reserve 
force  for  all  the  demands  of  life. 

ACHIEVING  A  SUCCESSFUL  WARDROBE 

Elsie  K.  Chamberlain 

Director,  Chamberlain  School  of  Everyday  Art 
Boston,  Mass. 

While  the  number  of  well  dressed  women  has  increased  materially  in 
the  last  few  years,  there  is  still  too  great  a  proportion  who  are  dressed 
in  an  uninteresting  and  commonplace,  though  entirely  respectable 
fashion.  Most  of  us  would  prefer  to  be  well  dressed  if  it  didn't  take  too 
much  time  or  trouble.  Of  course,  there  are  those  who  rather  glory  in 
being  superior  to  beauty  or  fashion  in  their  clothes,  and  with  those  bold 
souls,  serene  in  their  self-satisfaction,  we  are  not  concerned. 

We  do  want  to  be  comfortable  in  our  clothes  even  though  it  does  not 
always  appear  so.  For  example,  when  we  see  our  young  girls  on  a  wintry 
day  with  the  thermometer  at  ten  above  wearing  a  thin  silk  dress  with  only 
the  thinnest  of  silk  underwear  underneath,  we  give  thinks  for  the  adver- 
tisements which  appear  from  time  to  time  in  our  newspapers  of  very 
lovely  sheer  "woollies"  which  are  very  smart,  and  we  can  but  hope  that 
the  girls  will  see  fit  to  adopt  some  of  these  comfortable  garments. 

A  phase  of  comfort  too  little  thought  of  is  the  mental  comfort,  or  we 
may  call  it  self-satisfaction,  which  comes  from  a  consciousness  of  being 
suitably  and  as  far  in  us  as  it  lies,  beautifully  dressed.  It  is  difficult 
to  appear  at  ease  with  a  hole  in  your  stocking  or  in  your  cotton  morning 
dress  when  someone  calls  on  you  at  five  minutes  past  three  in  the  after- 
noon. It  is  also  difficult  to  appear  at  your  best  when  you  are  wearing  a 
skirt  which  stops  just  below  your  knee  and  everyone  else  is  wearing  an 
ankle  length  skirt.  That  is,  fashion  for  most  of  us  might  be  considered  a 
definite  factor  in  obtaining  mental  comfort  in  order  that  we  may  be  at 
our  best  when  with  our  friends. 

We  all  know  that  our  appearance  has  much  to  do  with  our  success  in 
life.    Many  a  girl  has  obtained  her  first  job  because  of  her  looks,  and 


38 

many  another  has  lost  a  good  position  because  of  her  appearance.  And 
it  is  by  no  means  the  choice  of  clothes  which  is  the  only  consideration. 
How  she  puts  them  on,  whether  they  have  been  carefully  fitted  to  the 
figure,  the  placing  of  the  belt,  the  tightness  of  the  sleeve,  etc.,  all  these 
things  are  matters  which  affect  tremendously  her  general  appearance. 
I  am  reminded  of  a  student  of  mine  who  was  a  delightful  woman  but 
who  gave  the  impression  of  always  being  rather  poorly  dressed.  In 
analyzing  her  costume,  I  found  that  it  was  a  matter  of  fit  and  small 
details  rather  than  actual  mistakes  in  the  purchasing  of  the  clothes  she 
was  wearing.  I  spoke  to  her  about  this  and  she  laughed  and  said  that 
one  of  her  friends  had  told  her  that  her  clothes  looked  as  though  she  said : 
"I  am  going  down  town,  clothes,  come  on  if  you  want  to  go  with  me," 
and  the  clothes  never  quite  caught  up. 

One  of  the  favorite  questions  which  is  always  engaging  the  attention 
of  writers  is  "For  whom  does  a  woman  dress,  for  other  women  or  for 
men?"  From  my  own  observations,  I  am  inclined  to  believe  that  she 
dresses  to  please  no  one  but  herself!  She  looks  in  the  mirror  and  says, 
"Oh!  this  hat  doesn't  look  like  me,"  and  refuses  to  believe  that  anyone 
who  looks  at  the  hat  from  the  back  or  the  side  is  better  qualified  to  judge 
the  hat  than  she  herself.  The  most  valuable  asset  in  the  problem  of 
being  well-dressed  is  the  possession  of  a  friend  with  taste,  patience 
and  a  willingness  to  go  with  you  and  express  her  truthful  opinion.  We 
must,  however,  emphasize  the  necessity  for  the  possession  of  taste.  Any 
mere  friend,  no  matter  how  dear  she  may  be  to  you,  is  not  sufficient. 

It  is  necessary  to  study  one's  own  type  to  know  what  lines  do  to 
the  human  figure  to  realize  that  while  a  surplice  front  may  have  a  tend- 
ency to  slenderize,  if  that  surplice  comes  too  far  to  one  side,  it  defeats 
its  own  end,  because  it  carries  the  eye  to  the  edge  of  the  figure  with  a 
sign  post  that  says,  "I  stop  over  here,  it  is  a  long  trip." 

Color,  too,  should  be  carefully  considered  and  experimented  with.  One 
of  the  hardest  things  to  tell  young  women  is  that  a  large  amount  of 
bright  red  or  any  other  vivid  color  is  not  going  to  make  their  skins  look 
any  more  delicate  or  beautiful,  but  will  detract  from  them. 

And  do  not  let  us  minimize  the  importance  of  fashion.  There  are  many 
women  who  are  always  a  season  behind  the  fashion  and  they  always  look 
a  bit  dowdy  for  that  reason.  Keeping  up  with  the  fashion  in  your  mind 
is  a  definite  economic  benefit  in  that  it  keeps  you  from  buying  clothes 
that  are  on  their  way  out  instead  of  on  their  way  in.  It  is  said  that 
every  important  fashion  has  a  three  year's  lifetime  at  least,  and  it  is 
reasonable  to  believe  that  if  you  bought  a  coat  last  year  when  fitted 
coats  were  just  coming  in,  you  are  in  the  height  of  fashion  this  year 
and  you  will  not  be  out  of  fashion  next  year.  Of  course,  this  is  not 
always  possible,  but  a  study  of  the  prevailing  mode  will  help  enormously. 

How  to  achieve  this  well-dressed  feeling  without  the  expenditure  of 
too  large  an  amount  of  money  is  the  problem  which  confronts  us  all. 
There  is  only  one  answer  and  that  is:  PLAN.  Sit  down  with  a  piece  of 
paper  and  a  pencil  and  list  your  activities.  Where  do  you  spend  most  of 
your  time?  Are  you  a  housekeeper  or  are  you  a  business  woman?  If 
you  are  a  housekeeper,  there  will  be  many  hours  of  the  day  when  cottons 
and  wash  silk  dresses  are  suitable.  If  you  are  a  business  woman,  one 
house  dress  will  be  all  you  have  time  to  wear.  Sunday  morning  before 
church  will  be  the  only  chance  you  have  to  put  it  on.  What  sort  of  social 
functions  do  you  attend?  Do  you  play  bridge  with  the  same  people  once 
in  two  weeks?  If  so,  you  need  a  change  of  dress  or  at  least  accessories 
to  keep  your  self-respect.  Do  you  entertain  at  home  or  do  you  live  in 
such  a  way  that  your  amusements  must  be  theatres,  movies,  and  restaur- 
ants? In  each  case  a  different  type  of  dress-up  clothes  is  needed.  If  you 
are  young  and  going  to  gay  parties,  evening  dresses  are  required.  If 
you  have  got  over  the  party  age,  you  can  probably  get  along  without 
an  evening  dress  and  simply  have  a  dinner  dress  with  a  coat.  Is  a  suit 
economical  for  you  or  is  it  an  extravagance?    This  is  easily  determined 


39 

by  considering  the  problem  of  whether  you  can  wear  the  skirt  with  sep- 
arate blouses  and  look  well,  or  whether  deficiencies  of  figure  make  it 
necessary  to  keep  the  coat  on.  If  you  belong  to  the  latter  group,  don't 
buy  a  suit  unless  you  have  plenty  of  money  and  can  afford  many  changes. 

If  your  money  is  at  all  limited,  you  will  find  it  of  great  help  to 
have  a  definite  color  plan  for  this  reason:  Our  clothes  are  no  longer 
distinctly  seasoned.  We  wear  a  flat  crepe  dress  all  the  year  round.  A 
lightweight  wool  in  the  same  way.  Therefore,  these  dresses  must  be  of 
such  a  color  that  they  may  be  worn  underneath  both  the  spring  coat  and 
the  winter  coat.  Choose,  then,  a  basic  color  for  your  major  purchases, 
and  get  your  variety  in  accessories  or  less  expensive  dresses  and  blouses. 

A  concrete  example  may  help  to  make  this  point  clear.  While  black 
is  the  easiest  color  to  use,  many  people  prefer  blue,  so  we  shall  start  with 
a  blue  winter  coat  trimmed  with  a  beaver  collar  and  cuffs.  We  say 
beaver  instead  of  gray,  as  it  allows  so  much  more  variety  in  a  wardrobe. 
Our  young  woman  has  for  her  winter  outfit  a  blue  cloth  dress,  a  blue 
hat,  brown  bag,  and  tan  brown  shoes.  She  also  has  a  second  bag 
and  shoes  of  black  kid.  She  wears  with  these,  black  gloves  and  with 
the  other,  cream  colored  gloves.  For  a  second  dress  she  has  a  light 
brown  flat  crepe  with  lace  at  neck  and  sleeves,  and  for  a  second  change 
a  print  dress  having  tan,  blue  and  perhaps,  a  touch  of  red.  With  this 
she  may  still  wear  her  blue  hat  and  brown  shoes.  The  print  dress,  the 
tan  flat  crepe  and  the  blue  dress  have  all  to  be  considered  in  planning 
her  spring  wardrobe  which  means  another  blue  coat  or  a  light  brown 
coat.  She  may  have  her  choice.  The  blues  may  be  different  in  shade, 
thus  adding  variety  to  her  wardrobe.  If,  however,  she  chooses  a  brown 
coat  for  spring,  she  is  able  to  put  into  her  definitely  summer  wardrobe 
other  colors  such  as  soft  green  or  lavender,  these  being  dresses  that  she 
will  not  wear  with  the  winter  coat,  but  may  wear  with  the  spring  coat. 

The  foregoing  is  simply  a  suggestion  as  to  how  to  start  planning 
your  wardrobe. 

SUCCESSFUL    LIVING 
Mary  R.  Lakeman,  M.D. 

Division  of  Adult  Hygiene 

and 
Esther  V.  Baldwin,  B.S. 

Division  of  Child  Hygiene 
State  Department  of  Public  Health 
What  Is  Health? 

We  may  say  that  "Health  is  a  positive  state  of  well-being  in  which 
there  is  freedom  from  any  disagreeable  awareness  of  body  functioning 
and  a  readiness  of  the  body  to  act  in  all  its  functions  and  at  all  times 
freely  and  comfortably  when  reasonable  demands  are  made  in  it."  1 

The  Value  of  Health: 

Is  there  any  one  thing  which  figures  more  largely  in  the  sum  total  of 
human  well-being  than  abounding  health?  Possibly,  to  the  spiritually 
minded — but  even  he  will  admit  that  health  plays  a  very  large  part  in 
a  truly  successful  life.  We  notice  that  no  one  is  willing  deliberately  to 
part  with  such  health  as  he  may  possess,  though  the  same  individual 
may  throw  it  away  by  thoughtless  living. 

Let  us  talk  it  over  and  see  if  we  are  making  the  most  of  our  physical 
equipment.  Are  we  intelligently  striving  to  add  to  our  strength  and 
vigor  year  by  year?  Do  we  know  the  sum  of  our  physical  bank  account, 
or  are  we  playing  the  part  of  the  spendthrift — eternally  drawing  on  our 
account  and  never  depositing? 

"When  we  were  very  young"  we  were  constantly  forming  habits,  some 


1 ROSENAU,   M.   J. — Preventive  Medicine  and  Hygiene,   New   York :   P.   Appleton   and   Com- 
pany.     Fifth    edition,    1928. 


40 
good,  some  not  so  good,  from  which  we  now  find  it  difficult  to  escape. 
We  made  mistakes,  of  course,  made  some  bad  investments  on  which  we 
are  still  paying  interest.  Fortunate  are  we  if,  with  the  hero  of  the  old 
rhyme,  we  are  paying  in  the  coin  of  the  realm  and  not  in  suffering  and 
pain.    It  was  he  who 

".  .  .  spent  his  health  to  get  his  wealth, 
Until  with  might  and  main 
He  turned  around  and  spent  his  wealth 
To  get  his  health  again." 

Now  that  we  are  a  little  older  we  begin  to  ask — "Is  it  possible  to 
remake  habits  which  have  fastened  themselves  upon  us  through  the 
years?"  "A  thousand  times,  yes" — is  the  answer.  It  has  been  done 
over  and  over  again.  It  may  take  strength,  it  undoubtedly  will  require 
definite  effort,  but  let  us  see  what  can  be  done  with  a  small  expenditure 
of  time  and  thought,  to  form  sound  habits  of  living,  taking  advantage  of 
modern  ideas,  some  of  which  have  greatly  changed  our  older  ways  of 
thinking. 

We  can  acquire  the  habit  of  directing  the  daily  activities  of  our  in- 
dividual body  and  mind  as  a  job  which  is  distinctly  and  definitely  our 
own.  So  let  us  apply  to  it  the  same  degree  of  intelligence  that  we  put 
into  the  task  we  are  paid  for.   It  is  a  job  which  ensures  a  good  income. 

The  Periodic  Medical  Examination: 

First,  let  us  have  a  thorough  medical  examination,  that  we  may  know 
our  assets  and  liabilities.  We  need  to  know  where  we  may  conserve  or 
increase  our  principal,  what  limitations  we  must  set  upon  our  expendi- 
tures, and  what  investments  will  be  likely  to  yield  the  best  return  in 
terms  of  strength  and  vigor.  Then  we  may  balance  up  at  regular  inter- 
vals and  learn  whether  we  are  gaining  or  losing  the  health  that  is  in 
truth  our  wealth. 

Where  can  one  have  a  medical  examination?  Naturally,  we  turn  to 
our  own  doctor  if  we  have  one  who  is  interested  in  conserving  health 
and  helping  his  patients  to  make  the  best  investment  of  their  physical 
assets.  If  it  so  happens  that  our  own  doctor  is  engrossed  in  other  fields 
of  medical  practice,  he  can,  as  he  undoubtedly  will,  refer  us  to  another 
physician  who  takes  an  especial  interest  in  the  conservation  of  health. 
For  those  who  have  no  physician,  there  are  various  clinics  and  hospitals 
where  examination  can  be  had,  and  advice  in  habits  of  hygiene  obtained. 

You  can't  afford  it — did  someone  say?  You  can't  afford  not  to  do  it. 
By  actual  figures  it  has  been  shown  that  the  health  examination  is  a 
profitable  investment.  It  pays  dividends  in  increased  efficiency;  it  saves 
cost  in  medical  care;  it  saves  loss  of  time  from  work;  while  in  terms  of 
life  saving,  one  of  the  large  insurance  companies  shows  a  financial  gain 
of  approximately  two  dollars  for  every  dollar  invested  in  periodic  exam- 
inations, offered  at  the  company's  expense  to  policy  holders.  Why  did 
this  company  offer  free  examinations?    Think  it  over. 

Go  to  your  doctor  before  he  has  to  come  to  you! 
Positive  Health: 

We  will  suppose  then  that  your  doctor  finds  you  among  the  favored 
few  who  have  so  far  withstood  the  physical  dangers  and  temptations 
that  beset  the  wayfarer  on  the  path  of  civilization.  He  has  given  you 
a  clean  bill  of  health  and  an  outline  of  the  habits  of  living  which  will 
bring  you  the  best  returns  in  prolonged  vigor.  May  we  go  with  you  for 
a  way  as  you  start  on  your  career  in  health  building? 

The  doctor  says  you  must  plan  to  build  a  reserve  of  strength  beyond 
the  daily  expenditure,  for  now  and  then  an  emergency  will  arise  in  which 
you  will  need  all  the  physical  resources  you  can  muster,  for  it  no  more 
pays  to  run  in  debt  physically  than  financially.  Then,  too,  it  is  from 
this  reserve  that  you  will  draw  the  abounding  energy  that  puts  the  joy 


41 

into  living  and  gives  you  the  zest  for  a  bit  of  real  play,  that  keen  delight 
in  active  sport  which  marks  you  as  young  regardless  of  the  telltale 
calendar.    Thus  may  we  cheat  old  age  for  many  years! 

The  Body  Cells: 

This  body  of  ours,  the  doctor  goes  on,  is  a  vast  community  of  cells  so 
organized  that  they  act  as  a  whole.  The  life  of  the  entire  community 
depends  upon  the  vitality  of  each  cell,  yet  no  cell  can  exist  apart  from 
the  community.  The  pessimist  puts  it  this  way:  "An  organism  is  a 
whole  so  wonderfully  put  together  that  any  part  can  make  trouble  for 
all  the  rest." 

Though  we  as  individuals  live  in  the  air,  the  cells  of  which  our  bodies 
are  made  can  live  only  in  the  fluids  of  the  body.  Exposed  to  air  they 
dry  up  and  cease  to  live.  This  is  indeed  what  happens  to  the  cells  on  the 
surface  of  the  body  where  they  are  in  contact  with  the  air. 

So  living  cells  must  have  water.  They  are  very  fastidious  about  their 
surroundings.  They  insist,  not  only  that  they  shall  have  a  fluid  medium 
to  live  in,  but  that  there  shall  be  in  that  fluid  certain  substances  among 
them  the  salts  of  sodium,  potassium,  calcium,  and  others — and  that  these 
salts  shall  be  present  in  a  certain  proportion  one  to  another. 

The  temperature,  too,  must  be  just  right — that  is,  at  or  very  close  to — 
98.6  °F.  This  temperature  is  maintained  in  spite  of  outside  changes  by 
a  complicated  method  not  yet  perfectly  understood.  Fever  is  one  sign 
that  this  heat-regulating  system  is  out  of  order. 

There  are  many  similar  self-regulating  devices  within  this  complex 
body  machine,  all  of  them  requiring  just  the  right  sort  of  surroundings 
in  order  that  each  cell  may  fulfill  its  part  in  the  work  of  the  community 
of  cells.  Thus  we  see  the  importance  of  giving  each  one  of  these  insistent 
little  cells  just  the  conditions  it  demands  in  order  that  it  may  carry  out 
its  special  work  which  no  other  can  do. 

Food: 

The  adult,  whether  planning  a  meal  at  home  or  selecting  his  food  at 
a  restaurant,  is  guided  greatly  by  his  tastes.  To  develop  tastes  for  the 
foods  which  will  make  for  happiness  through  better  health  is  indeed  an 
achievement.  Better  health  means  increased  earning  power  as  has  been 
shown  by  several  firms.  A  well  known  firm  reports  a  large  reduction  in 
absenteeism  among  groups  of  workers  given  extra  food,  in  this  case  cod 
liver  oil  and  milk.  Among  those  who  did  not  have  these  foods,  1900 
hours  were  lost  from  work;  among  those  who  had  them  for  one  year, 
1230  hours,  and  among  those  taking  the  foods  for  two  years,  730  hours. 
Even  better  results  may  be  hoped  for  as  the  work  continues. 

Malnutrition  is  felt  to  be  a  predisposing  cause  to  many  chronic 
diseases  of  adult  life.  To  help  prevent  these  diseases  one  method  is  the 
realization  of  the  proper  foods  forming  a  diet  which  will  prevent  mal- 
nutrition, and  the  consumption  of  these  foods.  According  to  Sherman 
the  preservation  of  the  characteristics  of  youth  depends  upon  a  high  pro- 
portion of  protective  foods  (milk,  fruits,  vegetables  and  eggs).  An  inter- 
esting experiment  with  rats,  one  corresponding  in  age  to  a  sixty  year 
old  person  and  the  other  to  an  eighty  year  old  person,  resulted  in  equal 
degrees  of  senility,  the  result  of  different  diets.  The  "eighty-year  old" 
had  the  optimal  diet  (as  suggested  on  page  8)  ;  the  "sixty-year  old"  a 
deficient  diet.  Proper  food  when  taken  into  the  body  does  more  than 
satisfy  hunger.  It  provides  the  necessary  materials  for  the  functioning 
of  the  body;  that  is,  the  building  and  repair  that  constantly  goes  on;  for 
the  regulation  of  internal  processes  as  digestion,  circulation,  respiration, 
etc.,  and  for  energy  needed  for  every  activity. 

Building  and  Repair: 

In  the  adult,  though  little  building  is  going  on,  repair  work  continues. 
For  this  purpose  the  proper  diet  provides  proteins,  minerals  and  water. 


42 

There  is  much  discussion  as  to  the  amount  of  protein  that  should  be  eaten. 

The  main  point  is  that  there  are  definite  types  of  protein,  the  best 
for  the  body  being  found  in  milk,  meat,  fish,  eggs,  cheese.  Protein  may 
also  be  furnished  through  dried  peas  and  beans,  and  nuts  and  because  of 
the  quantities  eaten,  through  cereals.  There  are  proponents  for  a  high 
intake  of  protein  as  well  as  for  a  low  intake.  Practically,  when  a  great 
deal  of  meat,  for  instance,  is  included  in  the  diet,  the  result  is  a  smaller 
proportion  of  fruits,  vegetables  and  milk,  which  are  very  important  for 
the  health  of  the  individual.  Another  point  is  that  meat  is  expensive. 
When  a  large  per  cent  of  the  food  budget  is  spent  on  this  food,  naturally 
less  will  be  available  for  other  foods  which  are  more  necessary. 

The  proportion  of  proteins  as  a  whole  may  well  be  kept  low  with  ad- 
vancing years  because  of  the  strain  brought  upon  the  kidneys  in  caring 
for  the  end-products  of  foods  of  high  protein  value. 

Minerals : 

For  building  blood,  teeth  and  bones,  these  are  essential.  It  has  recently 
been  shown  that  the  tooth  is  a  living  substance  in  which  there  is  circula- 
tion. We  cannot  longer  say  with  truth  that  only  during  childhood  does 
diet  influence  teeth  but  very  hopefully  can  state  that  even  the  adult  diet, 
properly  selected,  can  aid  in  improving  the  condition  of  the  teeth.  Dental 
decay  may  be  arrested  and  prevented  and  the  health  of  the  gums  im- 
proved by  proper  diet. 

Minerals  are  best  provided  through  the  use  of  large  amounts  of  fruits, 
vegetables  and  milk  in  the  diet.  Calcium  for  tooth  and  bone  building  is 
found  in  the  largest  amount  in  whole  milk,  buttermilk,  skim  milk,  cheese. 
The  safest  milk  is  either  tuberculin  tested  or  pasteurized.  Other  sources 
of  calcium  are  leafy  vegetables  as  spinach  or  lettuce;  oranges,  carrots, 
figs,  dried  beans.  Phosphorus,  also  a  constituent  of  bones  and  teeth, 
occurs  in  milk,  cheese,  eggs,  lean  meat,  fish,  potatoes,  whole  grain  cereals. 

Iron  in  the  body  is  found  principally  in  the  blood,  where  it  serves  as 
a  carrier  of  oxygen.  The  oxygen  causes  the  foodstuffs  to  be  burned  and 
helps  to  release  energy.  Many  foods  contain  but  little  iron,  therefore 
special  effort  is  required  to  meet  the  needs  of  the  body  for  this  substance. 
Liver  is  the  best  source  of  iron,  spinach  very  good:  egg  yolk,  lean  beef, 
molasses,  potato,  dried  fruits  as  dates,  figs,  prunes,  apricots,  and  dried 
vegetables  as  beans  and  peas,  all  contribute  iron.  Whole  grain  cereals 
contain  more  iron  than  do  the  refined. 

Regulation: 

Certain  substances  are  required  by  the  body  for  regulation  of  its  activ- 
ities— the  co-ordination  of  the  various  organs,  the  utilization  of  building 
material  and  energy.  Minerals,  vitamins,  water  and  roughage  all  act 
in  the  capacity  of  regulators. 

In  addition  to  the  minerals  listed  above,  iodine  is  necessary  for  the 
normal  functioning  of  the  body.  Salt  water  fish  is  the  best  source  of 
this  mineral.  Clams,  oysters  and  lobsters,  salmon,  cod,  all  contribute 
iodine.  Vegetables  grown  near  the  salt  water  are  rich  in  iodine  also. 
Copper,  because  it  functions  in  the  utilization  of  iron  by  the  body  should 
be  provided.  Liver  is  a  good  source  of  copper  as  are  egg  yolk,  whole  grain 
cereals,  dried  peas  and  beans,  vegetables. 

Water : 

Nearly  seventy  per  cent  of  the  body  weight  normally  consists  of  water. 
Again  recalling  the  demand,  made  by  the  cells  which  make  up  the  body, 
for  fluid  in  which  to  live,  it  is  easy  to  realize  that  we  must  take  in  daily 
at  least  enough  to  replace  the  daily  loss.  A  healthy  human  being  de- 
prived of  water  for  only  a  few  days  becomes  delirious  and  is  not  likely 
to  live  more  than  twelve  days. 

According  to  Vedder,  the  amount  of  water  lost  daily  from  the  human 
body  is  four  or  five  quarts.   This  is  given  off  by  the  lungs,  skin  and  intes- 


43 

tines  as  well  as  by  the  kidneys.  It  is  somewhat  surprising  to  learn  that 
the  lungs  carry  off  more  water  than  any  one  of  the  other  organs. 

As  a  good  deal  of  water  is  taken  in  the  form  of  foods,  especially  the 
juicy  fruits  and  green  vegetables,  we  may  feel  that  we  have  done  our 
duty  as  citizens  of  our  community  of  cells  if  we  provide  them  with  about 
a  quart  and  a  half  of  fluid  (5-6  glasses)  daily  in  the  form  of  drink. 

A  false  impression  that  it  is  injurious  to  drink  water  with  meals  seized 
the  imagination  of  people  some  years  ago.  There  is  no  ground  for  this 
theory.  Through  fear  of  drinking  with  meals  many  persons  are  probably 
depriving  their  bodies  of  greatly  needed  fluid. 

Roughage: 

A  discussion  of  food  and  its  relation  to  the  body  is  incomplete  unless 
the  importance  of  elimination  of  the  waste  products  by  regular  bowel 
action  is  brought  in.  The  muscles  of  the  intestines  cannot  act  as  they 
should  unless  a  rather  generous  amount  of  indigestible  residue,  so-called 
roughage,  is  provided  as  bulk  on  which  the  muscles  may  act.  Unless 
there  is  some  organic  or  mechanical  trouble,  regulation  of  bowel  move- 
ment may  be  established  by  good  habits  of  living,  that  is,  proper  diet, 
exercise  and  regulation.  For  a  further  discussion  of  this  subject  see 
page  46. 

Vitamins : 

The  vitamins  are  always  fascinating.  Though  we  do  not  know  what 
they  are,  we  have  learned  of  their  effects  on  the  body  through  experi- 
ments with  animals  and  through  observations  on  human  beings.  Their 
numbers  are  rapidly  increasing,  each  one  being  a  specific  for  a  certain 
condition  and  yet  all  of  them  together  being  necessary  for  perfect  nutri- 
tion. These  are  necessary  to  increase  resistance  of  the  body  to  infection, 
for  growth  and  health,  for  the  prevention  of  various  specific  diseases, 
for  successful  reproduction  and  lactation,  for  the  health  of  the  teeth 
and  gums  and  for  proper  digestion.  An  adult  diet  including  one  pint  of 
whole  milk,  plenty  of  fruits  and  vegetables  as  well  as  eggs,  butter  and 
whole  grain  cereals  will  probably  furnish  all  the  necessary  vitamins. 

Because  some  of  the  vitamins,  especially  C,  are  destroyed  by  heat,  it 
is  a  good  plan  to  include  a  raw  fruit  or  a  raw  vegetable  or  both  in  the 
daily  diet.  Canned  tomatoes  are  an  exception  to  the  rule  and  contain 
much  Vitamin  C. 

In  general,  when  cooking  vegetables,  the  smallest  amount  of  water 
should  be  used  and  the  cooking  process  made  as  short  as  possible. 

Energy : 

In  discussing  diet,  one  must  consider  it  from  two  angles,  the  quality 
and  the  quantity  essential  for  bodily  activities.  The  amount  of  food  re- 
quired varies  with  the  activity  of  the  individual,  the  size  and  age  of  that 
person.  In  youth,  a  hearty  appetite  has  been  cultivated  to  meet  the  enor- 
mous demands  for  energy.  With  increasing  years,  the  hearty  appetite 
is  maintained  but  the  body  needs  for  energy  have  been  reduced  both 
because  of  the  lessened  amount  of  exercise  usually  taken  and  because  of 
the  slowing  down  of  internal  processes.  The  person  over  thirty-five  then 
finds  himself  gaining  weight  beyond  the  limit  set  by  his  body  build. 
When  more  food  than  is  necessary  is  eaten,  the  surplus  is  retained  by 
the  body  as  extra  weight;  when  too  little  food  is  consumed  the  result 
is  a  loss  in  weight  or  if  such  a  practice  has  always  been  maintained,  a 
condition  of  underweight  exists. 

Energy  is  furnished  by  proteins,  fats  and  carbohydrates,  proteins  and 
carbohydrates  ( starch  and  sugar)  giving  the  same  number  of  calories, 
whereas  fats  give  two  and  a  quarter  times  as  many.  Because  of  the 
expense  of  protein  foods,  we  do  not  depend  upon  them  for  energy. 
Carbohydrates  are  less  expensive  and  more  completely  digested,  not  plac- 
ing as  great  a  task  on  the  kidneys  as  do  the  proteins. 


44 

Sources  of  carbohydrate  are  cereals,  bread,  crackers,  flour,  potato, 
sugar,  molasses,  honey,  jam  and  jellies.  In  a  budget  which  is  barely 
minimum,  a  large  per  cent  of  food  is  from  the  carbohydrate  group,  espec- 
ially cereals  because  of  the  relative  cheapness  of  these  foods.  In  such 
cases,  especially  because  fewer  fruits  and  vegetables  are  afforded,  it  is 
advantageous  to  use  whole  grain  cereals  so  that  the  minerals  and  vita- 
mins and  bulk  may  be  provided.  Natural  sweets  as  molasses,  honey,  and 
maple  syrup  are  to  be  preferred. 

Fat  is  found  in  butter,  cream,  bacon,  olive  oil,  peanut  butter,  oleo, 
cod  liver  oil. 

What  to  Eat: 

Food,  then,  not  only  satisfies  hunger  but  when  selected  properly  usually 
furnishes  the  necessary  substances  to  keep  the  body  functioning.  Pro- 
teins, minerals,  vitamins,  carbohydrates,  fat,  water  and  roughage  con- 
stitute the  diet  which  the  body  demands  for  its  needs.  Checking  the  daily 
diet  for  these  constituents  is  comparatively  simple.  The  following  foods 
will  furnish  the  essential  foods  or  the  optimal  diet.  A  distinction  should 
be  made  between  those  foods  which  contribute  to  the  health  of  the  body 
and  those  which  contribute  simply  to  the  enjoyment  of  the  food  itself. 
After  the  needs  of  the  body  are  met,  non-essential  foods  may  be  intro- 
duced if  desired. 

The  safe  adult  diet  is  built  around  the  following  as  a  nucleus:  One 
pint  of  milk  daily  as  a  beverage  or  in  food;  besides  potato,  two  servings 
of  vegetables,  one  of  these  raw;  two  servings  of  fruit,  one  raw;  one  egg 
or  a  serving  of  some  other  protein  food ;  a  serving  of  meat  or  substitute ; 
a  serving  of  whole  grain  cereal  or  bread;  butter.  Additional  servings  of 
any  of  these  foods  may  be  used  to  furnish  the  required  number  of 
calories. 

Great  variety  is  offered  as  to  selection  of  specific  foods,  as  for  instance, 
vegetables.  Individual  differences  as  to  taste  and  ability  to  digest  may 
occur.  To  some  individuals,  certain  foods  are  more  desirable  than  others, 
both  equal  in  nutritive  value.  No  hard,  set  rule  about  eating  specific 
foods  can  be  made  as  diet  must  be  adapted  to  the  individual.  For  clean, 
pasteurized  milk  there  is  no  substitute.  Fruits  and  vegetables  are  more 
or  less  interchangeable  as  are  various  whole  grained  cereals  among  them- 
selves.  Eggs  are  in  a  unique  class  because  of  high  nutritive  value. 

There  is  a  tendency  among  the  American  people  to  consume  too  much 
meat,  too  much  starch  and  sugar  and  too  little  of  the  fruits  and  green 
vegetables  that  supply  the  minerals,  vitamins  and  bulk  or  roughage. 
Plenty  of  milk,  fruits  and  vegetables  will  add  a  large  factor  of  safety  to 
the  American  diet,  helping  in  the  building  and  regulating  of  the  body 
as  well  as  providing  energy. 

Sherman  has  stated  with  trite  common  sense  "The  diet  can  be  kept 
well  balanced  both  financially  and  nutritionally  by  observing  two  rules — 
(1)  At  least  as  much  should  be  spent  for  milk,  cream  and  cheese  as  for 
meats,  poultry  and  fish,  and  (2)  At  least  as  much  should  be  spent  for 
fruits  and  vegetables  as  for  meats,  poultry  and  fish." 

Where  available  money  for  food  is  low,  the  optimal  diet  will  prove  too 
expensive.  Milk  is  not  an  expensive  food  when  one  considers  the  nutri- 
tive value  and,  because  it  acts  as  a  protector,  should  be  included  in  the 
inexpensive  dietary.  A  cup  and  a  half  of  milk  for  the  adult  daily;  a 
serving  of  potato  and  another  vegetable,  using  raw  vegetables  three  or 
four  times  weekly;  a  serving  of  fruit,  using  raw  three  or  four  times 
weekly,  are  the  chief  changes  from  the  optimal  diet.  The  tendency  when 
the  food  money  is  low  is  toward  a  deficiency  in  minerals  and  vitamins. 
The  foods  listed  with  the  use  of  whole  grain  cereals  will  help  offset  this 
deficiency. 

Many  adults  are  forced  because  of  circumstances  to  eat  most  of  their 
meals  in  restaurants.  Even  so  it  is  possible  to  attain  the  optimal  diet. 
The  trend  in  planning  "specials"  is  to  include  more  vegetables — witness 
the  salad  and  the  vegetable  plate !    Fruit  desserts  are  to  be  recommended. 


45 
Whole  wheat,  graham  or  rye  bread  are  generally  available  for  the  asking. 
Tomato  juice  is  served  in  most  restaurants.     Bottled,  pasteurized  milk 
is  on  the  menu. 

Remembering  the  outline  of  the  optimal  diet  will  aid  materially  in 
selecting  one's  food  at  the  restaurant.  Fried  foods  should  be  avoided 
because  of  difficulty  in  digesting.  Leisurely  eating  of  wholesome  foods 
at  regular  hours  may  be  acquired  at  home  or  away  from  home. 

Average  Weight: 

Every  individual,  especially  as  he  grows  older,  should  learn  to  main- 
tain the  weight  that  is  normal  for  his  height  and  age.  A  physical  exam- 
ination is  the  best  means  of  determining  the  average  weight  of  the  indi- 
vidual because  of  hereditary  differences,  racial  and  otherwise.  The 
weight  of  the  normal  person  can  be  controlled  by  making  the  dietary 
intake  of  food  correspond  to  the  body  needs  for  energy.  A  certain 
amount  of  food  is  necessary  to  keep  the  body  working  at  complete  rest. 
Beyond  this  minimum,  the  amount  needed  by  the  individual  depends 
upon  the  amount  and  •  kind  of  activity  he  is  carrying  on.  A  sedentary 
worker,  one  whose  occupation  keeps  him  sitting  or  standing  most  of  the 
time,  requires  but  little  more  food  than  would  be  needed  if  he  were 
actually  at  rest.  This  person  needs  food  which  is  easily  digested,  which 
contains  all  the  essential  elements  and,  in  addition,  a  large  amount  of 
roughage  and  water  to  counteract  the  tendency  to  constipation  which 
nearly  always  accompanies  an  inactive  life. 

Overweight : 

Some  of  us,  perhaps  a  good  many,  in  the  course  of  our  health  examina- 
tion will  be  reminded  that  we  are  too  heavy  for  safety,  not  to  mention 
good  looks  and  other  minor  considerations.  Extreme  overweight  after 
thirty-five  or  forty  may  tend  to  certain  chronic  diseases  as  diabetes.  In 
estimating  what  should  be  our  ideal  weight,  we  must  not  forget  to  give 
due  consideration  to  our  inherited  tendencies  and  to  lifelong  habits. 
Neither  must  be  forget  these  in  the  attempt  we  make  to  reach  our  goal 
of  normal  weight.  In  undertaking  to  reduce  weight  to  any  considerable 
degree,  one  should  be  under  frequent  guidance  from  a  physician. 
One  should  also  content  himself  with  small  reductions  carried  over 
a  comparatively  long  period.  A  loss  of  two  pounds  a  week  over  a  long 
time  should  be  considered  sufficient,  unless  one  is  under  the  immediate 
supervision  of  a  physician. 

Often  it  is  better  after  several  weeks  of  reducing  to  take  a  resting 
spell,  not  attempting  further  reduction  in  weight  until  the  body  has  had 
a  chance  to  adjust  itself  to  new  conditions.  It  is  wise,  too,  not  to  attempt 
marked  reduction  during  the  winter  season.  Exercise,  intelligently 
adapted  to  the  individual  need,  is  of  assistance  in  reducing  excessive 
weight,  but  little  effect  is  likely  to  be  felt  by  increasing  the  amount  of 
exercise  unless  the  food  intake  is  decreased.  Heavy  persons  are  unable 
to  take  sufficient  exercise  to  bring  about  weight  reduction  without  at  the 
same  time  limiting  the  diet.  The  point  to  be  remembered  in  weight  re- 
duction is  that  the  needs  of  the  body  for  building,  repair  and  regulating 
continue.  Freak  diets  are  treacherous.  Often  they  do  not  furnish  the 
body  enough  upon  which  to  sustain  itself. 

Foods  rich  in  fat  or  to  which  fat  has  been  added  should  be  reduced 
to  a  minimum.  Sugars,  which  add  calories  only,  should  be  minimized.  For 
made  desserts  should  be  substituted  fruit.  Green  vegetables,  raw  or 
cooked  plain,  may  be  used.  These  and  fresh  fruits  will  furnish  the 
necessary  and  pleasing  bulk.  Eating  less  of  everything,  especially  the 
foods  containing  much  fat  and  those  giving  carbohydrate  alone,  with  a 
proportionate  increase  in  fresh  fruits  and  green  vegetables  will  help 
reduce  the  pounds.  Milk  is  still  necessary — skim  milk  or  buttermilk 
being  of  value.  If  the  weight  still  continues  to  increase,  too  much  food 
is  being  consumed  for  the  body's  actual  needs. 


46 
Underweight: 

On  the  other  hand,  our  health  examination  may  inform  us  that  we  are 
tod  thin.  The  extremely  underweight  adult  may  find  himself  low  in  re- 
sistance and  vitality,  with  malnutrition  a  hindrance  to  maximum  effic- 
iency. Barring  organic  disturbances,  underweight  signifies  too  low  an 
intake  of  food  for  the  activities  carried  on.  Rest  is  one  important  means 
of  increasing  weight,  both  daytime  rest  and  increased  hours  of  sleep.  A 
ten-minute  rest  before  or  after  meals  is  very  helpful.  Increasing  the 
amount  of  food  eaten  should  be  done  with  consideration  for  digestion. 
Fats  as  butter,  cream,  olive  oil  may  be  added  with  discretion.  Cod  liver 
oil  very  often  is  recommended.  An  extra  meal  at  a  regular  time  may  be 
helpful.   The  optimal  diet  is  the  basis  upon  which  a  gaining  diet  is  built. 

Food  for  the  adult,  then,  represents  simple,  wholesome,  nourishing 
foods  selected  to  meet  the  needs  of  his  body,  well  prepared  and  well 
served.  The  safest  guide  to  food  selection  is  the  optimal  diet  with  a 
consideration  of  the  capacity  of  the  individual  to  digest  certain  foods 
and  his  ability  to  obtain  these  foods.  Food  is  important  to  the  health 
and  happiness  and  efficiency  of  the  adult  as  well  as  that  of  the  growing 
child. 


Elimination: 

We  must  not  leave  our  discussion  of  food  without  speaking  of  the  im- 
portance of  .elimination  of  the  waste  products  by  regular  bowel  action. 
The  muscles  of  the  intestines  cannot  act  as  they  should  unless  a  rather 
generous  amount  of  indigestible  residue,  the  so-called  roughage,  is  pro- 
vided as  bulk  on  which  the  muscles  may  act.  So  essential  is  some  sort  of 
roughage  for  this  purpose  that  when  laboratory  animals  are  for  any  rea- 
son kept  on  purified  foods,  it  is  customary  to  give  them  blotting  paper. 

Unless  there  is  some  organic  or  mechanical  trouble  regularity  of  bowel 
movement  may  be  established  by  good  habits  of  living,  such  as  these: 

1.  Go  to  the  toilet  at  the  same  hour  each  day. 

2.  Eat  the  right  foods  regularly. 

Start  the  day  with  a  good  breakfast. 

Eat  some  food  supplying  bulk  at  each  meal. 

Eat  some  fruits  daily.   One  should  be  raw. 

Fresh:  Apples,  with  skin  (provide  bulk) 
Grapefruit  Pears 

Melons  Peaches 

Oranges  Rhubarb 

Dried:  Figs  Raisins 

Prunes  Dates 

These  may  be  taken  at  bedtime  if  desired. 

Eat  daily  two  large  servings  of  vegetables  besides  potato.    One 
of  these  should  be  raw.   Green  leafy  vegetables  are  best. 

Asparagus  Endive  Parsnips 

Beets  Greens  String  beans 

Cabbage  Dandelion  Tomatoes 

Carrots  Spinach  Turnips 

Cauliflower  Lettuce  Baked  potato 

Celery  Broccoli  with  skin 

Eat  whole  grain  breads  daily: 

Bran  bread  Brown  bread         Rye  bread 

Bran  muffins         Oatmeal  bread       Whole  wheat  bread 


47 
Eat  a  large  serving  of  whole  grain  cereal  daily: 

Barley  Oatmeal  Shredded  wheat 

Cracked  wheat      Ralston  Wheatena 

Use  plenty  of  butter,  cream  and  oil  salad  dressing,  unless  over- 
weight. 

Bacon  Cream 

Butter  Olive  oil 

Molasses  and  honey  are  good  sweets.  Use  them  on  whole  wheat 
bread  for  dessert.  The  juice  of  one  medium  orange  half  an 
hour  before  breakfast  is  helpful. 

3.  Exercise  the  abdominal  muscles  daily. 

4.  Drink  six  glasses  of  water  daily. 

5.  Avoid  over-fatigue. 

6.  Take  no  cathartics  unless  ordered  by  physician. 

A  series  of  simple  exercises  as  a  further  aid  toward  normal  elimin- 
ation are  presented  in  a  folder  distributed  by  the  Massachusetts  Depart- 
ment of  Public  Health  under  the  title  "Aids  to  Bowel  Movement." 


Sunlight : 

Science  is  just  beginning  to  discover  the  effects  of  direct  sunlight  on 
the  human  body.  We  all  know  that  plants  depend  for  their  very  exist- 
ence upon  the  action  of  light.  It  is  only  within  the  past  few  years,  how- 
ever, that  we  have  learned  much  about  the  action  of  light  on  animal  life. 
Light  consists  of  radiations  transmitted  in  waves  of  differing  lengths. 
Those  used  in  radio  transmission  may  be  hundreds  of  feet  in  length, 
while  those  given  out  as  heat  and  visible  light  rays  at  the  violet  end  of 
the  spectrum  are  an  infinitesimal  fraction  of  an  inch  in  length.  Beyond 
the  violet  of  the  spectrum  are  the  ultra-violet  rays.  Though  we  are  un- 
able to  perceive  these  with  any  of  our  sense  organs  they  act  on  a  photo- 
graphic plate  which  is  more  sensitive  than  are  our  eyes  to  these  rays. 
Beyond  the  ultra-violet  are  yet  shorter  rays,  the  Roentgen  or  X-rays, 
and  shortest  of  all  the  rays  yet  discovered  are  those  given  off  by  radium. 

The  shorter  of  the  ultra-violet  rays,  those  just  beyond  the  violet  of 
the  spectrum,  are  absorbed  by  the  human  skin  and  there  give  evidence  of 
their  effect  in  sunburn  or  tan.  The  deepened  color  is  but  one  sign  of  the 
chemical  changes  brought  about  in  the  cells.  More  oxygen  is  absorbed, 
more  waste  is  thrown  off,  more  food  is  used,  and  there  is  an  increase  in 
energy  of  body  and  mind. 

The  longer  of  the  ultra-violet  rays  apparently  reach  as  far  as  the 
blood  itself  where  they  exert  an  influence  upon  the  use  made  by  the  blood 
of  its  calcium  and  phosphorus.  It  is  because  of  this  action  that  sunlight 
has  been  found  of  value  in  the  prevention  as  well  as  the  cure  of  rickets. 

Ordinary  window  glass  interferes  with  the  passage  of  the  shorter 
ultra-violet  rays,  hence  we  cannot  expect  to  obtain  the  full  benefit  of  sun 
baths  if  they  are  taken  through  a  windowpane.  Special  glass  is  now 
made  which  allows  some  of  the  ultra-violet  rays  to  pass  through. 

We  are  perhaps  at  present  going  to  extreme  lengths  in  adopting  the 
fad  for  sun-tanning.  It  is  well  to  bear  in  mind  that  it  is  not  the  heat 
rays  but  the  light  rays,  and  only  some  of  those,  which  have  health-giving 
properties.  In  this  climate  the  sun's  rays  are  rich  in  ultra-violet  during 
the  summer  months,  hence  the  time  of  exposure  does  not  need  to  be  long 
in  order  to  obtain  the  desired  effect. 

Air: 

To  be  truly  up-to  date  one  no  longer  speaks  of  the  air  we  breathe.  We 
refer  rather  to  the  air  which  bathes  our  bodies.    Provided  our  clothing 


48 
is  light  and  loose,  as  it  should  be,  we  are  taking  such  air  baths  all  the 
time  we  are  out  of  doors. 

Indoors  it  is  somewhat  different.  According  to  Winslow1  five  changes 
take  place  in  the  air  of  a  room  which  has  been  occupied  for  a  consider- 
able length  of  time: 

1.  Reduction  in  oxygen 

2.  Increase  in  carbon  dioxide 

3.  Production  of  certain  organic  products  from  perspiration,  respira- 
tion or  from  an  open  flame. 

4.  Increase  in  moisture 

5.  Increase  in  temperature 

While  oxygen  is  the  very  essence  of  life,  it  has  only  recently  been 
clearly  shown  that  we  are  able  to  obtain  a  sufficient  supply  of  oxygen  for 
all  practical  purposes,  even  from  atmosphere  which  is  badly  vitiated. 

It  is  high  temperature,  lack  of  motion  in  the  air,  and  excessive  humid- 
ity which  produce  the  ill  effects  of  poor  ventilation,  and  it  is  upon  the 
heat-regulating  mechanism  that  the  burden  falls  most  heavily.  The  body 
is  an  air-cooled  engine  and  operates  satisfactorily  only  within  a  com- 
paratively small  range  of  temperature  and  humidity. 

Less  muscular  work  can  be  done  in  a  high  temperature  as  has  been 
shown  by  practical  experiments.  At  a  temperature  of  86 °F.,  29%  less 
muscular  work  was  done  than  when  the  temperature  was  at  68  °F.  At  a 
temperature  of  75  °F,  15%  less  work  was  done.  Mental  work  did  not 
show  a  similar  slackening  either  in  quality  or  quantity. 

It  is  quite  clear  that  we  are  physically  at  our  best  when  we  are  sur- 
rounded by  air  in  gentle  motion  at  a  temperature  of  66-68  °F. 

There  is  among  us  a  deep-rooted  prejudice  against  air  in  motion.  By 
gradually  becoming  accustomed  to  air  in  motion,  however,  the  tendency 
to  take  cold  will  inevitably  be  diminished.  A  clear  distinction  should  be 
made  between  gentle  motion  in  air  currents  at  an  even  temperature  and 
a  rush  of  air  coming  through  a  limited  space  at  a  temperature  distinctly 
lower  than  that  of  the  room.  To  expose  oneself  to  a  draft  of  that  nature, 
unless  fully  accustomed  to  it,  is  to  invite  disaster  in  the  form  of  a  cold 
or  worse.  Sudden  chilling  brings  about  changes  in  the  mucous  mem- 
branes of  the  nose  and  throat  which  render  it  unduly  sensitive  to  the 
action  of  bacteria. 

Not  much  is  known  of  the  effects  of  varying  degrees  of  moisture  in 
the  air  at  different  temperatures,  but  it  has  been  shown  that  at  a 
temperature  of  68  °F.  the  humidity  should  be  at  or  near  50%  of  the 
saturation  point  as  shown  by  a  wet  bulb  thermometer,  for  comfort  and 
general  well-being. 

We  are  all  conscious  of  the  added  effort  needed  to  accomplish  anything 
when  "General  Humidity"  takes  command,  as  he  often  does  in  hot  sum- 
mer weather.  The  excess  of  moisture  in  the  air,  sometimes  as  great  as 
80  or  90%,  prevents  evaporation  from  the  surface  of  the  body  with 
consequent  slowing  down  of  bodily  functions.  We  welcome  a  breeze,  even 
of  hot  air,  for  the  relief  it  brings  by  allowing  freer  evaporation. 

***** 
Rest  and  Sleep: 

"It  is  a  wise  man  who  knows  when  he  is  tired."  It  is  a  wiser  one  yet 
who  knows  how  to  rest. 

Our  sensations  are  not  always  to  be  trusted.  When  we  feel  especially 
lively  and  energetic  it  may  be  that  we  are  greatly  in  need  of  sleep,  and 
when  we  feel  most  tired  it  may  be  that  we  need  exercise  or  change  of 
occupation  more  than  sleep. 

As  the  cells  do  their  work  they  give  rise  to  substances  known  as 
"fatigue  poisons." 

Sleep  is  Nature's  own  remedy  for  the  wastes  from  muscle  and  brain 

1  Charles   E.   A.   Winslow — Unpublished   lecture — Harvard    Medical    School,    February    13,    1929 


49 

activity  which  the  physiologists  tell  us  give  the  sensation  of  fatigue. 
Most  of  us  who  have  reached  adult  years  need  about  eight  hours  of 
sound  sleep  in  every  twenty-four.  Often  we  can  lose  a  part  of  this  for  a 
few  nights  without  harm,  but  few  can  get  on  with  less  than  seven  hours 
of  sleep,  over  a  long  period,  without  serious  consequences. 

While  fresh  air  undoubtedly  is  an  aid  to  sound  sleep,  the  newer 
knowledge  shows  us  that  to  open  all  the  windows  in  cold  winter  weather 
and  then  to  spend  the  night  trying  to  keep  warm,  is  mere  folly.  It  is 
quite  as  important  to  keep  the  body  warm  as  it  is  to  have  fresh  air. 

During  sleep  the  heart  beats  more  slowly,  the  blood  pressure  is  slightly 
lowered,  the  circulation  in  the  brain  is  diminished;  in  fact,  all  the  vital 
functions  are  slowed  down,  yet  breathing,  the  circulation  and  digestion 
go  on,  though  with  lessened  force. 

If  we  were  living  the  active  life  of  a  healthy  animal,  it  is  probable  that 
we  should  drop  off  to  sleep  as  a  little  child  does,  when  we  had  accumu- 
lated a  sufficient  amount  of  fatigue  poisons,  and  we  should  awaken  the 
next  morning  refreshed  and  ready  for  another  day's  strenuous  living. 
Some  of  us  by  good  fortune  are  able  to  do  this,  but  others  find  it  difficult 
to  relax  from  the  tension  of  the  day's  activity  and  sleep  refuses  to  come 
until  the  brain  can  forget  the  business  of  the  day. 

The  daily  life  of  most  of  us  is  not  ordered  for  the  sole  advantage  of 
our  individual  health  and  we  must  either  adjust  our  physical  resources 
to  our  task,  or  modify  the  task  in  accordance  with  our  physical  limitations. 

It  calls  for  keen  intelligence  and  a  carefully  thought  out  plan,  so  to 
adjust  our  work  and  rest  as  to  bring  out  the  best  that  is  in  us. 

Sleepiness  during  the  day,  if  one  is  getting  sufficient  sleep  at  night,  is 
not  normal  and  warrants  a  visit  to  the  doctor. 

Recreation: 

Sound  judgment  is  needed  to  guide  one  to  the  proper  form  of  rest  or 
recreation.  For  one  it  may  be  the  movies,  where  the  attention  is  strongly 
attracted  by  action  quite  apart  from  the  daily  cares.  Another  may  keep 
a  light  to  all  hours,  reading  a  detective  story  as  a  sleep  producer.  One 
who  would  consider  such  forms  of  diversion  a  punishment  finds  wonder- 
ful solace  in  some  simple  task  such  as  clearing  out  a  bureau  drawer. 
The  active  worker  finds  rest  and  mental  stimulus  in  a  game  that  calls 
for  thought,  while  the  person  who  has  been  meeting  people  all  day  asks 
no  greater  bliss  than  to  be  left  alone  with  a  book. 

It  may  be  said,  however,  that  to  the  sedentary  worker,  in  general, 
there  is  no  refreshment  to  body  and  mind  alike,  which  compares  with  an 
hour  of  brisk  muscular  effort  in  some  game  which  is  thoroughly  enjoyed 
and  in  which  there  is  enough  of  excitement  to  absorb  every  ounce  of 
energy. 

The  wise  young  person  of  today  is  acquiring  enough  of  skill  in  a  few 
active  sports  to  derive  wholesome  enjoyment  from  them  all  through  life. 

Vacations: 

We  must  not  forget  the  longer  vacation  time  nor  let  it  be  crowded  out, 
and  let  us  put  into  it  a  good  bit  of  real  play  and  laughter.  It  is  only 
those  few  rare  spirits  who  have  succeeded  in  making  a  perfect  adjust- 
ment between  job  and  self  who  appear  to  be  able  to  go  on  year  after 
year  without  a  season  of  entire  change  of  occupation.  For  most  of  us 
the  rule  holds  true  that  "A  man  can  do  fifty-two  weeks'  work  in  fifty 
weeks,  but  cannot  do  fifty  weeks'  work  in  fifty-two." 

The  benefit  to  be  derived  from  a  vacation  depends  largely  upon  the 
wisdom  used  in  choosing  the  vacation  occupations  and  in  combining  with 
them  the  amount  of  complete  rest  needed. 


Mental  Attitude: 

After  all  is  not  a  need  for  rest  largely  brought  about  by  our  state  of 


50 

mind  as  we  go  about  our  daily  duties  and  pleasures?  Worrying  is  like 
thinking  around  a  circle.  If  we  could  only  acquire  a  habit  of  thinking 
a  thing  through  in  a  straight  line,  starting  with  such  information  as  we 
have,  then  decide  what  is  to  be  done  with  it — and  either  do  it  or  lay  it 
aside,  we  would  save  ourselves  a  great  deal  of  wear  and  tear  as  a  result 
of  which  we  find  ourselves  obliged  to  lay  by  for  repairs  every  now  and 
again  when  we  might  be  using  this  time  for  real  enjoyment — storing  up 
energy  and  zest  for  the  future. 

"Rest  is  not  quitting  this  busy  career ; 
Rest  is  the  fitting  of  self  to  one's  sphere." 

Dr.  Richard  C.  Cabot  suggests  that  nerve  energy  is  somewhat  like  the 
stream  of  water  which  comes  from  a  faucet  at  a  turn  of  your  hand.  A 
dripping  faucet  leads  to  much  waste  of  water.  We  should  all  do  well 
to  learn  to  turn  our  faucet  of  nervous  energy  way  on  when  there  is  need 
and  to  shut  it  off  tight  when  we  are  not  using  it.  To  be  continually 
mulling  over  troubles  and  difficulties  is  as  wasteful  of  nerve  energy  as 
a  dripping  faucet  is  of  water. 


Exercise : 

If  we  would  have  health  and  strength  we  must  work  for  it.  Work  with 
the  big  muscles  of  the  trunk  develops  fundamental  nerve  centers  which 
help  us  to  endure  the  strains  of  modern  life.  Enough  of  work  for  these 
big  muscles  we  must  have.  Enough,  but  not  too  much.  How  is  one  to 
judge?  A  medical  man  of  wide  experience  replies.  "If  you  get  up  the 
morning  after  active  .work  still  tired,  it  was  too  much.  If  you  fall  right 
to  sleep  and  wake  feeling  refreshed  and  rested  it  was  right,  however 
tired  you  may  have  been  when  you  went  to  bed  at  night." 

Exercise  as  well  as  rest,  must  of  necessity  be  adapted  to  the  daily 
routine  of  each  individual.  To  the  person  who  sits  or  stands  most  of  the 
time  a  brisk  walk,  a  game  of  ball,  a  swim  or  a  half -hour  in  a  gymnasium 
with  active  use  of  the  larger  muscles,  is  well-nigh  a  necessity,  if  he  is 
to  enjoy  physical  vigor.  The  young  people  of  today,  as  they  grow  older, 
will  be  better  equipped  than  were  those  of  the  last  generation  with  an 
acquaintance  with  sports  and  games  adapted  to  people  not  so  young. 
Prolonged  vigorous  exercise  and  competitive  games  may  well  be  left  to 
the  young  folks  or  indulged  in  only  after  a  careful  physical  examination, 
and  a  period  of  training. 

We  are  too  apt  to  take  our  exercise  spasmodically,  with  long  intervals 
interrupted  by  an  all-day  hike  or  a  distance  swim.  We  are  likely  to  be 
quite  out  of  condition,  and  such  a  spurt  may  do  harm  and  be  positively 
weakening  in  its  effect. 

Every  one  of  us  is  daily  missing  first-class  opportunities  for  exercise 
by  failing  to  do  our  everyday  tasks  in  such  fashion  as  to  give  our 
muscles,  especially  the  big  ones,  a  chance  to  work  effectively. 

The  simple  act  of  rising  from  a  low  seat  may  become  either  an  added 
strain  upon  already  overworked  and  tense  muscles,  or  if  we  will,  it  may 
be  a  bit  of  wholesome  and  rather  pleasant  exercise  of  the  big  thigh  and 
trunk  muscles.  By  drawing  the  feet  well  under  the  body  and  leaning 
forward ,  slightly  the  trunk  almost  lifts  itself. 

Constant  reaching  to  high  shelves,  a  practice  bitterly  complained  of 
by  many  women,  may  afford  an  excellent  stretching  exercise. 

Picking  up  a  heavy  laundry  basket  may  be  a  back-breaking  perform- 
ance or  an  interesting  little  stunt,  as  we  choose. 

Walking  in  correct  form  and  with  good  bodily  mechanism  is  an  excel- 
lent exercise  sadly  neglected  by  most  of  us.  Walking  up  stairs  in  correct 
form  vies  with  any  one  of  the  daily  dozen  in  cultivating  poise.  Correct 
form  means  merely  lifting  the  weight  perpendicularly  with  body  and 
head  poised  in  a  straight  line  above  the  balls  of  the  feet.   Try  it. 

The  man  or  woman  of  forty  or  more  who  keeps  up  the  habit  of  putting 


51 

on  shoes  while  sitting  on  the  floor  and  rising  to  a  standing  position  with- 
out touching  the  hands  to  the  floor,  has  earned  the  self-respect  that 
makes  him  carry  his  chin  a  shade  higher  as  he  watches  his  more  bulky 
companions  puff  as  they  pull  their  ponderous  weight  out  of  an  armchair. 
Our  daily  life  is  bristling  with  such  opportunities  to  gain  muscle  and 
nerve  control  which  will  make  of  the  daily  routine  an  interesting  ad- 
venture in  human  mechanics. 


Bathing: 

The  skin  is  not  a  mere  garment.  It  is  an  active  organ  with  various 
functions.  One  of  the  most  important  is  the  throwing  off  of  waste 
materials  in  the  perspiration — not  alone  the  perspiration  which  is  quite 
obvious  when  we  become  heated,  but  also  in  the  perspiration  of  which  we 
are  unaware  though  it  goes  on  continuously.  The  amount  of  water  thus 
given  off  is  just  under  five  quarts  lost  daily  from  the  body. 

We  bathe,  of  course,  for  purposes  of  cleanliness,  at  least  twice  a  week 
with  an  abundance  of  good  soap  and  warm  water.  Besides  this,  however, 
a  dip  or  a  shower  in  cool  or  (if  one  reacts  promptly)  in  cold  water  every 
morning,  followed  by  a  brisk  rub  does  set  one  up  in  fine  shape,  keeps 
the  skin  clear  of  waste  products  and  appears  to  act  as  a  preventive  of 
colds. 

It  seems  strange,  doesn't  it,  that  we  should  think  of  reminding  grown 
folks  that  it  is  a  good  idea  to  wash  the  hands  before  eating,  yet  a  num- 
ber of  diseases  are  undoubtedly  carried  from  band  to  mouth.  We  washed 
our  hands  before  eating  when  we  were  children  because  we  had  to,  but 
now  that  we  may  do  as  we  like  we  surely  have  fallen  from  grace.  As 
evidence,  look  about  you  in  any  public  eating  place — the  most  fashionable 
tea  room  is  not  exempt — and  note  the  scorn  with  which  a  patron  lays 
aside  the  spoon  which  has  dropped  to  the  floor,  while  we  all  break  bread 
with  fingers  whose  recent  history  will  not  bear  repeating. 


Teeth: 

While  the  actual  structure  of  the  teeth  is  laid  down  in  the  months 
before  birth  and  is  completed  long  before  the  years  of  adult  life,  the 
teeth  will  last  longer  and  serve  us  better  if  they  are  given  the  care  and 
the  food  they  require.  We  have  all  seen  the  rapid  softening  of  the  teeth 
after  a  long  illness.  Whenever  the  lime  salts  are  lacking  as  occurs  dur- 
ing many  forms  of  illness  the  teeth  suffer  in  consequence. 

The  materials  needed  to  keep  the  teeth  in  condition  are  all  found  in 
milk,  green  vegetables,  fresh  fruit,  dark  bread,  and  coarse  cereals,  with 
special  emphasis  on  milk  and  the  juicy  fruits. 

If  we  stop  to  consider  how  intimately  everything  we  eat  comes  into 
contact  with  the  teeth  and  the  lining  of  the  mouth,  we  shall  want  to 
keep  that  cavity  as  clean  as  the  food  and  utensils  we  put  into  it.  A  small 
toothbrush,  fairly  stiff,  with  bristles  so  separated  that  sun  and  air  can 
get  at  them,  should  be  used  with  a  firm  stroke  up  and  down  and  in  and  out 
and  round  about,  at  least  every  night  and  morning.  We  should  like  to 
use  it  again  after  the  noon  meal,  but  this  is  not  always  practicable  in 
everyday  life.   An  apple  or  other  juicy  fruit  makes  a  fair  substitute. 

The  growing  custom  of  visiting  a  dentist  once  or  twice  a  year  without 
waiting  for  trouble  to  arise,  will  undoubtedly  be  reflected  in  improved 
health  as  well  as  better  teeth  in  mature  years  among  those  who  practice  it. 

The  Span  of  Health: 

We  are  glibly  told  by  those  who  know,  that  human  life  has  been  length- 
ened during  the  past  quarter  century  by  some  nine  years,  and  we  are 
expected  to  rejoice  with  our  informants  over  this  triumph  of  modern 
science.    But  who  rejoices  in  the  prospect  of  long  life  unless  he  can  be 


52 

assured  of  a  reasonable  degree  of  health  with  which  to  face  these  added 
years  ?  We  have  it  largely  within  our  power  to  hold  on  to  the  health 
that  is  ours,  often  to  increase  our  physical  assets,  if  we  will  but  make 
intelligent  use  of  our  physical  and  mental  resources. 

Time  must  pass  before  we  can  know  how  much  can  be  accomplished 
in  prolonging  lives  now  being  lost  all  too  early  from  the  so-called  degen- 
erative diseases  of  middle  life.  We  have  reason  to  believe  that  in  certain 
instances  lives  have  been  prolonged  for  years  by  intelligent  supervision 
even  after  they  have  been  seriously  threatened  by  one  or  another  of 
these  conditions. 

We  have  ground  for  the  faith  that  is  in  us  that  if  each  one  will  take 
pains  to  learn  his  physical  and  mental  resources  and  adapt  his  daily 
routine  to  his  own  individual  health  needs  a  good  many  of  these  disease 
conditions  will  be  discovered  at  the  very  beginning  and  may  then  be  kept 
at  bay  for  many  years. 

To  Sum  Up: 

We  now  know  our  strong  points  and  our  weak  ones  and  we  have  become 
sufficiently  familiar  with  the  working  of  our  body  engine  to  recognize 
the  knocks  that  suggest  a  departure  from  its  normal  smooth  running. 
Do  we  not  owe  it  to  those  who  have  to  live  with  us  or  work  with  us — if 
not  to  ourselves — to  make  use  of  this  knowledge  with  as  much  judgment 
as  we  show  in  handling  an  automobile  or  any  other  complicated  engine? 

A  part  of  its  care  will  consist  in  an  overhauling  at  intervals — probably 
about  once  a  year — at  the  hands  of  the  expert,-  your  physician.  We  are 
then  in  a  position  to  apply  such  knowledge  as  we  have  at  hand  with  such 
intelligence  as  we  can  command  to  the  problem  of  keeping  the  engine  in 
good  running  order.  It  is  a  good  idea  to  "make  of  the  doctor's  office  a 
service  station,  not  a  repair  shop." 

The  time  has  come  when  the  physician  is  called  in  not  only  when  there 
is  sickness,  but  to  prevent  it.  A  large  amount  of  sickness  can  be  pre- 
vented, and  the  modern  physician  is  aware  of  his  opportunity  to  be  of 
service  in  the  prevention  of  disease. 


'Give  light  and  the  people  will  find  their  own  way." 


53 


Editorial  Comment 


1931   Child  Health  Day.     Material  for  the  celebration  of  Child  Health 

Day  has  been  prepared  again  this  year  by 
the  Departments  of  Public  Health  and  Education.  In  response  to  several 
requests  another  pageant  is  offered.  It  is  called  the  "Health  of  America" 
and  in  three  acts  shows  America's  melting  pot,  a  modern  Child  Health 
Day  and  the  hopes  for  the  future.  As  expressed  in  the  Child's  Bill  of 
Rights — Yesterday,  Today  and  Tomorrow  are  represented  by  the  three 
acts.  "A  Toy  Shop"  has  been  prepared  for  the  little  people  (1st,  2nd 
and  3rd  grades)  who  show  in  pantomime  several  of  the  health  habits. 
Suggestions  for  a  Health  Day  in  the  high  school  were  compiled  by  a 
committee  of  high  school  teachers  and  administrators  working  with  the 
two  State  Departments.  The  high  schools  throughout  the  State  have 
never  before  taken  a  very  active  part  in  the  Health  Day-  celebration. 
The  1931  Health  Day  may  well  include  some  contribution  from  the  high 
school.  The  same  health  reward  tags  will  be  distributed — the  Physically 
Fit  tag,  the  Improvement  tag  and  the  Teeth  Tag — earned  according  to 
the  stipulations  printed  on  each  tag.  A  Child  Health  Day  poster  is  also 
available. 

Demonstrations  of  the  use  of  this  material  will  be  given  in  Beverly  at 
the  Rial  Side  School  on  March  13th,  at  the  Ware  Town  Hall  on  March  20 
and  at  Plymouth  Memorial  Hall  on  April  10th.  Each  demonstration 
begins  at  2:15  P.M.  Send  your  order  for  Child  Health  Day  material  to 
Room  546,  State  House,  Boston,  Mass. 

Summer  Round-Up.  Summer  Round-Up  naturally  follows  close  on  Child 
Health  Day — they  are  the  child  hygiene  twins! 
This  year  we  can,  with  good  conscience,  come  down  hard  on  community 
responsibility  and  co-operation  in  any  such  project,  backed  as  we  are  by 
the  watchword  issuing  from  the  White  House  Conference — "Community 
responsibility  and  co-operation  for  child  health  and  protection." 

There  are  no  radical  changes  in  plans  for  the  1931  Summer  Round-Up. 
The  suggestions  offered  urge  the  importance  of  early  registration  before 
May  1st  of  all  entering  school  children  by  means  of  a  request  to  parents 
from  the  school  superintendent  in  each  town  in  Massachusetts.  Equal  in 
importance  is  the  necessity  of  competent  nursing  follow-up  to  interest 
and  help  parents  in  getting  physical  examination  and  correction  of  re- 
mediable defects  of  the  prospective  "first  graders"  before  September  1st. 

Why  have  thousands  of  children  enter  our  first  grades  in  September, 
only  to  toddle  home  with  requests  for  vaccination,  dentistry,  adenoid 
removal  and  what-not,  when  we  have  at  hand  so  simple  and  so  useful  a 
procedure  as  the  Summer  Round-Up? 

An  order  blank  of  all  material  available  for  use  at  the  Summer  Round- 
Up  may  be  had  on  request  from  the  Massachusetts  Department  of  Pub- 
lic Health,  545  State  House,  Boston,  Mass. 

"Tidings."  "Tidings"  has  been  revived.  To  those  who  did  not  know  it 
in  the  past  we  wish  to  introduce  it.  "Tidings"  is  a  bulletin 
containing  informal  articles,  news  items,  from  other  states  and  coun- 
tries as  well  as  from  Massachusetts,  book  reviews,  etc.  It  will  go  to  all 
public  health  workers  five  times  during  the  winter,  alternating  with  the 
more  formal  Commonhealth. 

As  the  Department  wishes  to  make  this  little  bulletin  of  real  interest 
it  will  welcome  comments,  suggestions  and  news  items. 


54 
THIS  ISSUE 
Contains  articles  by  the  following  authors: 

Stevens,  Harold  W. — Officer,  British  Army  Medical  Corps  and  United 
States  Army  Medical  Corps,  1916  to  1919;  Assistant,  Medical  Depart- 
ment, Ludlow  Manufacturing  Associates,  1920;  Medical  Director,  Jor- 
dan Marsh  Company,  1920  to  1930.  At  present,  Instructor  in  the 
Harvard  School  of  Public  Health. 

Somers,  Florence  A. — Graduate  of  the  Sargent  School  of  Physical  Edu- 
cation, Boston  University  and  New  York  University.  Experience  in 
public  schools  of  Baltimore,  Md.,  Cleveland,  Ohio,  and  East  Orange, 
N.  J.,  Oberlin  College,  State  Normal  School  at  Salem,  in  all  of  which 
there  was  ample  opportunity  to  study  the  adolescent  girl  in  relation 
to  her  reactions  to  activity.  Four  years  as  Assistant  State  Supervisor 
of  Physical  Education  in  Massachusetts.  At  present,  Associate  Di- 
rector of  Sargent  School  of  Physical  Education,  Cambridge,  Mass. 

Beardsley,  Mrs.  Sarah  Morse — Membership  Secretary  of  the  Massa- 
chusetts Society  for  Mental  Hygiene  March  1,  1930  to  January  31, 
1931  when  the  Membership  Campaign  of  the  Society  ended.  From 
her  many  contacts  with  the  members  of  her  various  committees 
throughout  the  State  she  has  known  some  of  the  questions  in  regard  to 
mental  fitness  which  are  uppermost  in  the  minds  of  many  adults.  In 
her  article  she  answers  some  of  them. 

Porter,  Alma — Graduate  of  Sargent  School  for  Physical  Education; 
nine  years  in  the  public  schools  of  Massachusetts  as  teacher  and  super- 
visor of  physical  education;  three  years  in  the  State  Normal  School 
at  North  Adams  as  Director  of  Physical  Education;  two  years  as 
Assistant  State  Supervisor  of  Physical  Education  in  Massachusetts. 

McGillicuddy,  Helen  I.  D.,  M.D. — Graduate  from  the  Women's  Medical 
College  of  Pennsylvania  and  also  a  special  student  at  the  Harvard  Col- 
lege of  Public  Health  (1918-1920).  Served  as  Medical  Director  for 
women  and  children  at  two  of  the  Boston  city  gymnasia.  Later,  living 
in  Panama,  was  a  member  of  the  Public  Health  Education  Committee 
with  Colonel  Gorgas.  During  and  after  the  war  she  was  connected 
with  the  Federal  Social  Hygiene  Board.  She  was  lent  to  the  New 
Hampshire  Department  of  Health,  Division  of  Venereal  Diseases  for 
nearly  two  years,  then  served  on  the  Mexican  border  in  Texas  and 
Arizona.  She  is  now  special  lecturer  for  the  Massachusetts  Depart- 
ment of  Public  Health,  Educational  Secretary  for  the  Massachusetts 
Society  for  Social  Hygiene,  and  State  Chairman  of  Social  Hygiene  in 
the  Massachusetts  Parent-Teacher  Association. 

White,  Eva  Whiting — Head  resident  of  the  Elizabeth  Peabody  House, 
West  End,  Boston,  20  years;  president  of  the  Women's  Educational 
and  Industrial  Union  1929-  ;  Vocational  Department,  Massachusetts 
Board  of  Education  1910-13;  director  Extended  Use  of  the  Public 
Schools,  City  of  Boston,  1914-18;  general  secretary  Community  Service 
of  Boston  1922-29;  director  of  the  Simmons  College  School  of  Social 
Work  1922-29;  member  of  the  Board  of  Public  Welfare,  City  of  Bos- 
ton, 1925-  ;  member  of  the  Division  of  Americanization  and  Immi- 
gration, Massachusetts  Board  of  Education,  1926-  ;  non-resident 
lecturer  at  Bryn  Mawr  College,  Bryn  Mawr,  Pennsylvania. 

Baldwin,  Mrs.  Esther  Erickson,  B.S. — Consultant  in  Nutrition  for 
the  State  Department  of  Public  Health,  obtained  her  B.  S.  at  Simmons 
College  and  has  done  some  graduate  work  at  the  University  of  Chicago. 
Before  coming  to  the  Department  of  Public  Health,  she  was  nutrition- 
ist with  the  Nutrition  Bureau  of  Providence,  Rhode  Island;  with  the 
American  Red  Cross,  working  in  Texas  and  Missouri. 

Stern,  Frances — Was  a  special  student  at  the  Massachusetts  Institute 
of  Technology  and  prior  to  that  acted  as  Secretary  to  Ellen  H.  Rich- 
ards. During  the  war  she  was  a  Member  of  the  Home  Economics 
Division  of  the  Federal  Food  Conservation  Committee  at  Washington, 
D.  C.    Miss  Stern  has  written  many  articles  and  is  joint  author  of 


55 
"Food  for  the  Worker."  The  Food  Clinic  at  the  Boston  Dispensary- 
was  established  under  Miss  Stern's  guidance  in  1918.  She  gave  war 
service  under  the  American  Red  Cross  in  Paris  in  1918.  She  was  a 
special  student  in  the  London  School  of  Economics,  1921-22;  and  has 
been  chief  of  Food  Clinic  at  Boston  Dispensary  since  1922. 

Shepard,  Marion,  M.D. — Medical  Adviser  to  Women  at  the  University 
of  Pittsburgh,  1918  to  1931.  Dr.  Shepard  is  a  graduate  and  gold 
medalist  of  the  Savage  School  of  Physical  Education;  she  received  her 
medical  degree  cum  laude  from  Boston  University  School  of  Medicine 
in  1912  and  later  was  for  four  years  Assistant  Physician  and  In- 
structor in  Corrective  Gymnastics  at  Smith  College. 

Rice,  William,  D.D.S.,  D.M.D.— D.D.S.,  Boston  Dental  College,  1888; 
D.M.D.  Tufts  College  Dental  School,  1905;  Hon.  Sc.  D.,  Tufts  College, 
1929;  began  practice  at  Boston,  1888;  Instructor  in  Clinical  Dentistry, 
Tufts  College  Dental  School,  1900-11,  Assistant  Professor  1911-13,  Pro- 
fessor of  Operative  Dentistry  since  1913,  Dean,  Tufts  College  Dental 
School  since  1916. 

Cummins,  Loretta  Joy,  M.D. — Graduate  Tufts  College  Medical  School; 
President,  New  England  Dermatological  Society  1922-23 ;  First  Woman 
appointed  on  the  staff  of  the  Massachusetts  General  Hospital;  Appoint- 
ments now  held  are:  Dermatologist,  Massachusetts  General  Hospital; 
Consulting  Dermatologist,  Massachusetts  Eye  and  Ear  Infirmary;  Con- 
sulting Dermatologist,  The  New  England  Hospital  for  Women  and 
Children;  Assistant  Dermatologist,  Children's  Hospital,  Boston. 

Latimer,  Jean  V. — Educated  at  Brown  and  Columbia  Universities  and 
had  some  special  training  in  public  health  at  Massachusetts  Institute 
of  Technology.  In  addition  in  1925,  was  a  Rockefeller  Fellow  at  the 
Institute  of  Child  Welfare  Research,  Columbia.  Had  many  year's  ex- 
perience in  teaching  and  in  contact  Avith  young  women,  and  for  a  while 
was  head  of  the  Industrial  Research  Division  of  the  National  Board 
of  the  Young  Women's  Christian  Association. 

Chamberlain,  Elsie  K. — Director  of  the  Chamberlain  School  of  Every- 
day Art;  teacher  of  art  at  the  Garland  School  of  Homemaking;  doing 
Advisory  Styling  for  manufacturers  and  retail  stores  and  also  has  a 
daily  column  in  the  Boston  Herald  entitled  "Your  Home." 

Lakeman,  Mary  R.  M.D. — Was  in  general  practice  until  1918  when  she 
became  associated  with  the  Massachusetts  Department  of  Public 
Health.  After  service  successively  in  Venereal  Disease  and  Child 
Hygiene  she  was  transferred,  in  1926,  to  the  new  Cancer  Section 
which  has  now  been  merged  with  the  Division  of  Adult  Hygiene. 
Doctor  Lakeman  is  in  charge  of  the  educational  work. 

News  Notes 

Infant  Mortality  in  Massachusetts 

Infant  mortality  rates  in  Massachusetts  have  dropped  from  102  in 
1915  to  62  in  1929.  The  big  decrease  has  been  in  g astro  intestinal  and 
respiratory  diseases  which  involve  mostly  infants  over  one  month  old. 
The  drop  in  gastro  intestinal  causes  during  this  period  was  from  25.2  to 
4.9  and  in  respiratory  diseases  from  17.3  to  11.1. 

Congenital  debility  and  premature  birth,  as  causes  of  early  infant 
death  dropped  from  30.6  to  19.7.  Deaths  from  congenital  malformation 
remained  at  a  standstill,  7.1.  Deaths  from  injuries  at  birth  have  increased 
from  3.5  to  4.8,  which  certainly  gives  us  food  for  thought.  (New  York 
State  figures  show  slightly  greater  increase,  3.9  to  5.5). 

Total  deaths  under  one  day  increased  slightly,  14  to  14.5.  Total  deaths 
under  one  month  decreased  from  42.6  to  35.4  and  deaths  over  one  month 
decreased  from  52.8  to  31.4.   These  rates  are  per  1,000  live  births. 

These  three — prematurity,  congenital  malformations  and  birth  injur- 
ies— keep  the  death  rates  under  one  day  stationary  and  those  under  one 
month  are  little  better.  If  we  want  more  live  babies  these  are  the  causes 
for  our  first  consideration. 


56 

Adequate  prenatal  care  is  certainly  some  help  as  a  preventive  of  pre- 
maturity but  doubtless  not  a  cure-all.  Adequate  prenatal  care  and  skill- 
ful medical  and  nursing  service  at  and  after  delivery  would  surely  cut 
down  some  of  the  deaths  from  injuries  at  birth.  This  would  often  mean 
a  lot  of  time,  patience  and  experience  on  the  part  of  the  doctor. 

Congenital  malformations  we  are  still  largely  in  the  dark  about,  hav- 
ing shed  the  comforting  old-time  theories  of  marking,  etc.  and  not  having 
adopted  anything  else  equally  soothing. 

Mothers  have  got  to  be  taught  young  to  expect  and  demand  good  pre- 
natal and  delivery  service  and  to  know  what  it  is.  Doctors  can't  go  out 
and  drag  them  in  for  prenatal  care  but  they  can  give  more  thorough 
care  to  those  who  come,  and  can  do  more  teaching.  Nurses,  social  service 
workers,  health  workers  of  all  sorts  can  do  a  lot  of  teaching. 

Recently  a  woman  was  seen  who  had  five  or  six  prematures,  stillbirths 
and  miscarriages  before  somebody  got  around  to  do  a  Wasserman  and 
found  her  syphilitic — and  she  a  city  dweller  all  her  life. 

Budgets  for  Low  Incomes 

With  many  limited  incomes  this  year,  added  interest  is  being  given 
the  minimum  budget  which  will  insure  the  family  a  diet  furnishing  the 
essentials  for  growth  and  health.  It  should  be  realized  that  these  bud- 
gets are  simply  typical  and  that  for  each  family  with  its  individual  differ- 
ences, the  budget  should  be  carefully  adapted. 

In  each  of  the  budgets  mentioned,  the  allowance  is  for  the  family  of 
five — father,  mother  and  three  children,  boy,  13;  girl,  7;  boy  3. 

The  Community  Health  Association,  Park  Square  Building,  Boston, 
Massachusetts,  has  recently  repriced  its  budget,  the  new  total  being 
$9.65.  This  cost  may  be  lowered  by  using  evaporated  milk  for  cooking. 
If  ten  quarts  of  evaporated  milk  (5  large  cans,  diluted  with  equal  amount 
of  water)  and  eleven  quarts  of  fresh  milk  are  used,  the  cost  is  lowered 
thirty-five  cents.  The  vegetable  allowance  has  been  increased  three 
pounds  over  previous  orders.  This  plan  includes  foods  typical  of  this 
area  and  at  Boston  prices. 

The  Extension  Service,  Washington,  D.  C,  is  distributing  a  budget 
prepared  at  the  direction  of  the  National  Drought  Relief  Committee.  The 
budget  is  country  wide  in  its  application  but  considers  the  needs  of  the 
South  particularly.  Special  attention  is  paid  to  the  inclusion  of  the 
pellagra  preventive  factor  in  the  form  of  yeast  or  wheat  germ  as  well  as 
through  foods  containing  this  vitamin. 

Through  the  press,  the  Bureau  of  Home  Economics  and  the  Woman's 
Division  of  the  President's  Emergency  Committee  for  Unemployment 
together  are  releasing  budget  information  with  menus.  The  family  of 
ten  (three  adults  and  seven  children)  can  obtain  this  food  order  for  an 
average  of  $12.23. 

The  Association  for  Improving  Conditions  of  the  Poor  of  New  York 
City  suggests  a  budget  of  food  for  seven  (two  adults,  five  children — 10, 
7,  5,  3,  and  1  years  of  age)  at  a  cost  of  $11.00,  New  York  prices.  Menus 
are  also  given. 

The  Evaporated  Milk  Association,  Chicago,  Illinois,  offers  suggestions 
for  a  Good  Fellow  Basket,  costing  $8.87.  This  allows  only  evaporated 
milk,  with  no  fresh  milk  for  drinking.  This  may  be  successful  in  some 
families. 

All  of  these  budgets  represent  the  minimum  and  are  basically  about 
the  same  with  more  variety  in  some  than  in  others.  As  stated  before, 
they  are  purely  suggestive  and  must  be  adapted  to  each  individual  family. 

Organizing  for  Better  Health  Service 

The  Health  Officer,  the  School  Superintendent  and  Physician,  the  In- 
dustrial   Health    Director,    the    Board    Member    of   the    Private    Health 


57 

Group,  all  take  an  active  part  in  furthering  the  health  of  the  community 
through  the  services  of  the  public  health  nurse. 

As  active  participators  in  this  phase  of  community  health  work,  they 
will  be  interested  in  allying  themselves  with  the  new  State  Organization 
for  Public  Health  Nursing,  organized  December  3,  1930.  This  organ- 
ization was  created  because  of  the  general  conviction  that  more  effective 
health  service  could  be  rendered  by  closer  teamwork  and  more  concerted 
thought  on  the  part  of  both  the  nurses  and  those  interested  people  who 
were  administering  or  aiding  public  health  nursing.  It  was  formed  by  an 
amalgamation  of  the  Massachusetts  Association  for  Directors  of  Public 
Health  Nursing  Organizations  and  the  Public  Health  Section  of  the 
Massachusetts  State  Nurses'  Association. 

Through  the  medium  of  this  state  organization,  it  will  be  possible  not 
only  to  study  the  job  in  hand  more  intelligently  and  to  co-ordinate  the 
nurse's  service  more  satisfactorily  with  the  general  state  health  pro- 
grams, but  also  to  share  in  the  most  constructive  current  thought  re- 
garding public  health  nursing. 

The  greatest  usefulness  of  this  association  can  come,  of  course,  only 
from  active  membership  from  general  public  health  nurses,  boards  of 
health,  school  superintendents,  school  and  industrial  nurses  and  others 
who  take  some  part  in  the  direction  of  the  work  of  public  health  nurses. 

Individual  membership  is  available  for  anyone  interested  in  the  de- 
velopment of  public  health  nursing.  Professional  membership  is  avail- 
able for  any  nurses  eligible  for  NOPHN  membership.  The  dues  are  50c. 
Corporate  membership  is  available  for  any  organization  or  group  inter- 
ested in  public  health  nursing.  If  employing  less  than  ten  professional 
workers  the  dues  are  $3.00.  If  employing  more  than  ten  professional 
workers,  the  dues  are  $5.00. 

Applications  may  be  sent  to  Miss  Marie  Knowles,  Treasurer,  82  Savin 
Street,  Roxbury,  Massachusetts. 

Industrial  Nursing 

The  Public  Health  Nurse  Magazine,  official  organ  of  the  National 
Organization  for  Public  Health  Nursing,  Inc.  announces  a  special  issue 
on  Industrial  Nursing  which  will  be  the  February  1931  number. 

The  following  are  some  of  the  articles  to  appear  in  this  special  issue: 

Organization   and   administration   of   Industrial    Health   Units,   by 

Glenn  S.  Everts,  M.D. 
Industrial  Nurse's  Responsibility  in  the  Safety  Program,  by  Robert 

P.  Knapp,  M.D. 
The  Industrial  Nurse  and  Heart  Disease,  by  R.  B.  Crain,  M.D. 
The  Industrial  Nurse's  Introduction  to  Her  Job,  by  Mary  E.  Zehring, 

R.N. 
Flying  Nurses,  by  Ellen  E.  Church,  R.N. 
Finger  Wrapping  Plus,  by  Alice  Burton,  R.N. 
What  the  Industrial  Nurse  Should  Know  About  Sight  Conservation, 

by  Mildred  Smith,  R.N. 
List  of  Industrial  Nurses'   Clubs   in  the  United   States  Reference 

Reading. 

The  Doctors  Talk  on  Nursing 

When  756  physicians  discussed  the  nursing  question  informally,  the 
greatest  numbers  commented  on  the  fact  that  there  is  no  shortage  in 
the  nursing  supply,  that  registered  nurses  are  generally  competent,  and 
that  nursing  charges  are  too  high  from  the  point  of  view  of  the  patient. 

This  open  forum  for  physicians  was  held  by  the  Committee  on  the 
Grading  of  Nursing  Schools,  which  is  studying  the  problem  of  providing 
ample  and  adequate  nursing  service  to  the  public,  at  a  price  within  its 
reach.    When  the  Committee  sent  out  questionnaires  to  the  physicians, 


58 
it  asked  them  to  write  their  frank  opinions  on  nurses  and  nursing  on  the 
backs  of  the  questionnaires,  after  the   formal   questions  had  been  an- 
swered. 

Of  376  who  talked  about  the  shortage  question,  281,  or  three-fourths, 
said,  "There  is  no  shortage  of  nurses."  Of  the  318  who  discussed  the 
capability  of  nurses,  264,  or  eighty-three  per  cent,  said,  "Nurses  are 
generally  competent.'-' 

A  smaller  number,  171,  were  interested  in  commenting  on  the  cost  of 
nursing  service  to  the  patient.  All  but  twelve  believed  the  charges  to  be 
excessive,  from  the  point  of  view  of  the  patient.  On  the  other  hand,  of 
twenty-seven  doctors  who  commented  on  the  earnings  of  nurses,  twenty- 
six  said  they  thought  the  annual  income  of  the  nurse  is  too  low. 

A  composite  picture,  built  up  from  these  informal  comments,  might  be 
described  as  follows: 

"The  registered  nurse  is  generally  competent,  often  positively  heroic. 
She  follows  orders,  uses  good  judgment,  is  usually  ethical,  is  skilled  in 
handling  people  and  has  a  pleasing  personality.  But  she  sometimes  steps 
on  medical  toes  by  discussing  symptoms  and  suggesting  treatments;  she 
could  sometimes  be  more  industrious,  and  show  more  interest  in  the 
patient. 

"She  often  lacks  skill  in  special  techniques  and  picks  and  chooses  cases. 

"There  is  no  shortage  of  nurses.  The  nurse's  hours  are  too  long,  and 
her  income  too  low.  On  the  other  hand,  charges  are  excessive,  for  the 
patient." 

The  physicians  who  took  part  in  this  symposium  on  nursing  represented 
many  branches  of  the  profession  and  came  from  ten  representative  states. 

It  is  significant  that,  when  they  could  talk  of  whatever  they  pleased,  so 
many  doctors  should  stress  the  same  aspects  of  the  nursing  situation, 
and  that  there  would  be  the  general  agreement  that  exists  among  the 
states. 

These  informal  remarks  check  with  the  statistical  findings,  gathered 
from  the  questionnaires  of  4,000  physicians.  Thus,  it  was  found  that 
only  two  patients  out  of  each  100  could  not  find  a  nurse  when  they  needed 
one.  This  is  confirmed  by  the  general  opinion  of  physicians  that  there 
is  no  shortage  in  the  nursing  supply.  Nine  out  of  ten,  tabulation  showed, 
answered  in  the  affirmative,  "Would  you  like  to  have  the  same  nurse  on 
a  similar  case?"  Again,  the  large  majority  of  those  who  commented  on 
the  ability  of  the  nurse  felt  she  is  generally  competent. 

The  Grading  Committee  has  been  studying  some  of  the  problems  im- 
plied in  these  comments  from  the  physicians.  Its  findings  show  that 
often,  probably,  the  nurse  is  not  to  blame  because  she  "registers  against" 
certain  types  of  illness;  or  that  she  lacks  skill  in  special  techniques.  The 
reports  of  what  the  student  nurse  does  in  training  reveal  that  important 
basic  services  are  omitted  from  her  program  by  many  nursing  schools, 
so  that,  as  a  graduate  nurse,  she  either  registers  against  such  cases,  or 
shows  herself  unable  to  perform  properly  the  nursing  duties  involved  in 
them. 

Physicians  commented  on  this  relation  between  the  training  of  the 
student  nurse  and  the  fitness  of  the  graduate  nurse  to  deal  with  certain 
types  of  patients. 

An  Oklahoma  physician  wrote:  "In  this  section  of  the  country,  most 
nurses  have  excellent  operating  room  training,  but  poor  bedside  train- 
ing." A  Massachusetts  physician  wrote,  "The  nursing  problem  in  ob- 
stetrics is  very  acute."  From  Illinois  came  the  comment,  "Psychiatric 
postgraduate  training  of  R.  N.'s  is  too  rare  and  there  are  not  enough 
really  well  trained  psychiatric  nurses  for  private  duty." 

New  York  physicians  seem  better  pleased  than  those  of  other  states 
with  the  breeding  and  personality  of  the  nurses  with  whom  they  come 
in  contact.  More  physicians  of  Washington  said  there  was  a  shortage  of 
nurses,  than  said  they  believed  the  supply  adequate. 


59 

Other  matters  talked  about  by  the  physicians  were: 

13 — "Young  nurses  are  better  than  old  ones." 

8 — "Old  nurses  are  better  than  young  ones." 
14 — "Nurses'  hours  are  too  long." 
14 — "The  schools  should  raise  the  entrance  requirements." 

9 — "The  professional  registries  send  better  nurses." 
24— "She  talks  too  much." 
14 — "She  doesn't  talk  too  much." 

Some  of  the  miscellaneous  comments  were : 

"Many  good  nurses  work  too  hard." 

"My  worst  trouble  is  that  I  never  know  a  nurse's  name.  She  is  a  part 
of  the  machine  and  usually  fills  the  bill." 

"I  have  never  had  any  difficulty  in  securing  nurses  in  this  city  or  its 
vicinity.  In  fact,  various  registries  are  continually  reminding  me  that 
they  have  nurses  on  hand." 

"This  particular  nurse  is  intelligent,  observing,  not  afraid  to  take  a 
severe  case  twelve  miles  in  the  country,  well  trained,  pleasant  but  strict 
in  following  the  doctor's  orders  in  regard  to  the  patient,  family,  and 
visits.  I  have  had  many  nurses  like  this,  and  some  dismal  failures.  Finan- 
cial conditions  here  are  such  that  we  have  few  trained  nurses,  but  we 
have  very  little  trouble  getting  one  when  required.  My  experience  with 
practical  nurses  is  not  so  pleasant.  I  wish  every  one  of  my  seriously  ill 
patients  could  have  a  registered  nurse." 

Many  physicians  took  pains  to  stress  the  value  of  the  nurse's  under- 
standing of  the  mental  habits  of  sick  people,  in  writing  of  specific  ex- 
amples of  nursing  care,  and  her  ability  to  be  intelligent  and  tactful  about 
home  situations. 

Announcement  of  the  First  Award  Under  the  Thomas  W.  Salmon 

Memorial 

Dr.  Adolf  Meyer,  Professor  of  Psychiatry  of  Johns  Hopkins  Uni- 
versity, has  been  chosen  to  receive  the  first  award  under  the  recently 
established  Thomas  W.  Salmon  Memorial.  Announcement  to  this  effect 
was  made  Saturday,  January  10,  at  a  meeting  held  at  the  New  York 
Academy  of  Medicine  at  which  an  endowment  fund  of  $100,000  con- 
tributed by  friends  and  associates  of  the  late  Dr.  Salmon  was  officially 
presented  to  the  Academy  and  active  work  under  the  Memorial  was 
begun. 

The  award  was  made  by  a  committee  appointed  by  the  Academy  to 
survey  the  field  and  select  the  outstanding  contributor  to  scientific  ad- 
vance in  mental  medicine,  and  Dr.  Meyer  was  selected  in  recognition  of 
his  distinguished  services  to  psychiatry  and  mental  hygiene  over  a  period 
of  years.  The  award  carries  with  it  an  honorarium  of  $2,500  and  the 
recipient  will  give  the  Thomas  W.  Salmon  lectures  during  1931.  The 
dates  of  the  lectures  and  the  places  at  which  they  are  to  be  delivered 
will  be  announced  later. 

Dr.  Meyer  is  an  outstanding  man  among  the  psychiatrists  of  the 
world  and  has  been  for  many  years  a  leader  in  the  development  of  his 
specialty.  A  teacher  from  his  earliest  days  in  the  United  States,  his  in- 
fluence on  psychiatry  expressed  through  his  pupils  is  well  known  abroad. 
Conservative  and  sound,  but  with  broad  vision,  and  at  all  times  in  con- 
tact with  his  anatomical,  neurological,  physiological  and  psychobiological 
laboratories,  he  has  given  a  powerful  stimulus  to  the  building  up  of  a 
dynamic  and  progressive  conception  of  psychiatry. 

Not  generally  known  is  the  fact  that  Dr.  Meyer  is  the  man  who  sug- 
gested and  first  used  the  term  "mental  hygiene"  and  gave  the  mental 
hygiene  movement  its  name.  By  that  very  naming  of  this  great  move- 
ment, with  which  he  has  been  identified  from  the  very  beginning,  he 
gave  to  it  its  initial  impetus  and  forward-looking,  comprehensive  pro- 


60 

gram.  He  was  one  of  the  original  organizers  of  the  National  Committee 
for  Mental  Hygiene,  the  agency  largely  responsible  for  the  development 
of  the  mental  hygiene  movement  in  this  country  and  the  world  over.  A 
leader  in  the  social  sciences,  Dr.  Meyer  is  at  the  present  time  engaged 
in  the  work  of  integrating  the  several  sciences  upon  which  psychiatry 
and  mental  hygiene  are  based  for  the  further  development  and  progress 
of  this  branch  of  medicine. 

Biographical  Notes 

Dr.  Meyer  is  the  Director  of  the  Henry  Phipps  Psychiatric  Clinic  of 
Johns  Hopkins  Hospital  which  he  planned  and  organized  in  1913,  and 
has  been  a  leader  in  the  development  of  his  specialty  in  this  country  for 
many  years.  He  received  his  early  medical  training  in  Switzerland,  tak- 
ing his  degree  at  the  University  of  Zurich,  and  after  postgraduate  study 
in  various  medical  centers  in  Europe  came  to  the  United  States  in  1892. 
He  served  in  the  state  hospitals  of  Illinois  and  Massachusetts,  and  taught 
psychiatry  and  neurology  at  the  University  of  Chicago  and  at  Clark  Uni- 
versity. Subsequently  he  entered  the  New  York  State  Hospital  service 
and  reorganized  the  State  Psychiatric  Institute,  the  research  center  of 
the  state  hospital  system,  serving  as  Director  of  that  institution  until 
1913.  From  1904  to  1909  he  was  Professor  of  Psychiatry  at  Cornell 
University.  He  is  a  past  President  of  the  American  Psychiatric  Associa- 
tion and  the  American  Neurological  Association.  His  scientific  contribu- 
tions cover  a  wide  range  of  subjects  dealing  with  fundamental  aspects 
of  psychiatry,  neurology,  psychobiology,  mental  hygiene  and  related 
fields. 

New  England  Council 
Committee  on  Public  Health 

In  accordance  with  a  resolution  adopted  by  the  Executive  Committee 
of  the  New  England  Council,  there  is  being  organized  a  Committee  on 
Public  Health,  to  deal  with  matters  in  that  field  in  which  co-operation 
between  the  several  New  England  States  is  particularly  desirable. 


61 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  October,  November,  and  December  1930,  samples 
were  collected  in  185  cities  and  towns. 

There  were  801  samples  of  milk  examined,  of  which  141  were  below 
standard;  from  11  samples  the  cream  had  been  in  part  removed,  and  6 
samples  contained  added  water.  There  were  27  samples  of  Grade  A  milk 
examined,  25  samples  of  which  were  above  the  iegal  standard  of  4.00% 
fat,  and  2  samples  were  below  the  legal  standard. 

There  were  777  samples  of  food  examined,  of  which  161  were  adulter- 
ated. These  consisted  of  4  samples  of  cider,  3  samples  of  which  con- 
tained benzoate  and  were  not  properly  labeled,  and  1  sample  contained 
an  appreciable  quantity  of  arsenic;  3  samples  of  clams  which  contained 
added  water ;  99  samples  of  eggs,  27  samples  of  which  were  sold  as  fresh 
eggs  but  were  not  fresh,  61  samples  of  cold  storage  eggs  not  marked, 
and  11  samples  were  decomposed;  2  samples  of  extract  of  lemon  which 
were  deficient  in  lemon  oil;  2  samples  of  extract  of  vanilla  which  con- 
tained coumarin;  19  samples  of  hamburg  steak,  all  of  which  contained 
a  compound  of  sulphur  dioxide  not  properly  labeled;  20  samples  of  saus- 
age, 11  samples  of  which  contained  a  compound  of  sulphur  dioxide  not 
properly  labeled,  and  9  samples  contained  starch  in  excess  of  2  per  cent; 
2  samples  of  bread  which  contained  soap;  1  sample  of  vinegar  which  was 
low  in  acid;  2  samples  of  dried  fruits  which  contained  sulphur  dioxide 
and  were  not  properly  labeled;  3  samples  sold  as  butter  which  proved  to 
be  oleomargarine;  and  4  samples  of  preserves  which  contained  com- 
mercial glucose. 

There  were  97  samples  of  drugs  examined,  of  which  24  were  adulter- 
ated. These  consisted  of  1  sample  of  caustic  poison  which  did  not  bear 
a  poison  label;  3  samples  of  lime  water,  19  samples  of  spirit  of  nitrous 
ether,  and  1  sample  of  magnesium  citrate,  all  of  which  were  deficient  in 
the  active  ingredient. 

The  police  departments  submitted  1,478  samples  of  liquor  for  examina- 
tion, 1,434  of  which  were  above  0.5%  in  alcohol.  The  police  departments 
also  submitted  16  samples  of  narcotics,  etc.,  for  examination,  9  of  which 
were  morphine  or  morphine  derivatives,  1  cocaine,  2  samples  of  brown- 
ish-white powders  which  contained  fungus  and  lime,  a  sample  of  yellow 
paste  which  contained  soap,  free  alkali  and  a  starchy  substance,  a  color- 
less liquid  which  contained  ethyl  alcohol,  methyl  alcohol  and  chloroform, 
and  2  samples  examined  for  alkaloids  and  poisons  which  gave  negative 
results.  The  Fish  and  Game  Commission  submitted  a  sample  of  alleged 
poisonous  bait  which  was  examined  for  poison  with  negative  results. 

There  were  778  bacteriological  examinations  made  of  milk. 

There  were  57  bacteriological  examinations  made  of  soft  shell  clams, 
19  samples  in  the  shell,  13  of  which  were  unpolluted,  and  6  were  polluted, 
and  38  samples  shucked,  25  of  which  were  unpolluted,  and  13  were  pol- 
luted. There  were  3  bacteriological  examinations  made  of  hard  shell 
clams,  2  samples  in  the  shell,  and  1  sample  shucked,  all  of  which  were 
unpolluted. 

There  were  133  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  84  cities  and  towns  visited  for  the  inspection  of  pasteuriz- 
ing plants,  and  169  plants  were  inspected. 

There  were  69  convictions  for  violations  of  the  law,  $1,285  in  fines 
being  imposed. 

Carmine  Di  Pietro  of  Stow;  Fannie  Finkelstine  and  Samuel  Novick  of 
Millis;  Lemuel  Friend  of  Gloucester;  Thomas  J.  Gavin  of  Sherborn; 
Irving  Dawson  of  Needham  Heights;  Louis  Karras  of  Needham;  Octave 
Leconte  and  Sarah  A.  Pierce  of  Acushnet;  Manuel  Reposa  of  Fairhaven; 
Leonard  W.  Sylvester  of  Acton;  and  Salvatore  Coronella  of  Arlington, 
were  all  convicted  for  violations  of  the  milk  laws.  Lemuel  Friend  of 
Gloucester,  Octave  Leconte  and  Sarah  A.  Pierce  of  Acushnet,  and  Manuel 
Reposa  of  Fairhaven,  all  appealed  their  cases. 


62 

Victor  Wells  of  Winthrop;  First  National  Stores,  Incorporated,  of 
Somerville;  Mitchell  Mendick  of  Worcester;  Joseph  Carbone  of  Fitch- 
burg;  Fitts  Brothers,  Incorporated,  of  Framingham;  William  Cramer  of 
North  Adams;  Edward  J.  Kaufman  and  Richard  W.  Yeoman  of  Lynn; 
and  John  Ferejohn  of  Pittsfield,  were  all  convicted  for  violations  of  the 
food  laws. 

Chamberlain  &  Company,  Incorporated,  2  cases,  of  Boston;  and  Genery 
Stevens  Company  of  Worcester,  were  convicted  for  misbranding.  Gen- 
ery Stevens  Company  of  Worcester  appealed  their  case. 

Morris  Alpert  of  Somerville;  Henry  E.  L'Heureux  and  Bernard  Sushel 
of  Salem;  Charles  R.  Allen  of  Lowell;  Pasquale  Turo,  Julius  Goldman, 
and  James  Van  Dyk  Company,  all  of  Worcester ;  Jack  Levy  of  Lynn ; 
and  Charles  Gullason  of  Watertown,  were  all  convicted  for  violation  of 
the  false  advertising  law.   Pasquale  Turo  of  Worcester  appealed  his  case. 

Peter  Spaneous,  Albert  Bouchard,  Walter  Brzozoski,  Harry  Castleman, 
Samuel  Lander,  and  Joseph  Richard,  all  of  Salem;  Morris  Abrahms  and 
Guisseppi  Sangiovanni  of  Pittsfield;  Morris  Myzenberg,  Pietro  D.  Am- 
brose, Wolf  Garber  and  Samuel  Kramer,  all  of  Lynn;  Milan  Barsarian 
and  Fred  Espinola  of  Lowell;  Antonio  Tassone,  Dominick  Boschetti  and 
Julius  Kronick,  all  of  North  Adams;  Ralph  Genthner  of  Danvers;  Brock- 
elman  Brothers,  Incorporated,  of  Fitchburg;  Dominick  De  Block,  Eli 
Finklestein,  and  William  J.  Kosofsky,  all  of  Everett;  Frank  Gai  of  Pitts- 
field; Louis  Gotroff  of  Holyoke;  and  Ulric  Litarte  and  Stanislao  Tersigni 
of  Leominster,  were  all  convicted  for  violations  of  the  cold  storage  laws. 
Walter  Brzozoski  of  Salem  appealed  his  case. 

William  L.  Davis  &  Company  and  Frank  W.  Lavoine  of  Worcester;  and 
Maurice  Penn  of  Lawrence,  were  all  convicted  for  violations  of  the  drug 
laws. 

James  Boutournes  of  Haverhill;  Hugh  Rodden,  2  cases,  of  Salem;  and 
Stefanos  Emmanouil  of  Chelmsford,  were  all  convicted  for  violations  of 
the  pasteurization  law.   Hugh  Rodden  of  Salem  appealed  his  two  cases. 

William  B.  Davis  of  Dartmouth  was  convicted  for  violation  of  the 
slaughtering  laws. 

Samuel  Young  of  Brockton  was  convicted  for  violation  of  the  mattress 
law. 

Edward  J.  Kaufman  of  Lynn  was  convicted  for  obstruction  of  an  in- 
spector. 

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: 

Cider  which  contained  sodium  benzoate  and  was  not  properly  labeled 
was  obtained  as  follows : 

1  sample  each,  from  United  Fruit  and  Vegetable  Stores,  Incorporated, 
of  Brockton,  and  Driscoll,  Church  and  Hall  of  New  Bedford. 

Clams  which  contained  added  water  were  obtained  as  follows: 

1  sample  each,  from  First  National  Stores,  Incorporated,  of  Somer- 
ville, Fitts  Brothers,  Incorporated,  of  Framingham,  and  F.  H.  Snow  of 
Pine  Point,  Maine. 

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

1  sample  each,  from  Nation  Wide  Store  of  Beverly,  and  H.  P.  Hood  & 
Sons  of  Danvers. 

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

2  samples,  from  The  Great  Atlantic  &  Pacific  Tea  Company  of  Lynn; 
1  sample  each,  from  The  Great  Atlantic  &  Pacific  Tea  Company  of  Dan- 
vers; Fall  River,  Ipswich,  Beverly,  Quincy,  Everett,  Maiden  and  Auburn- 
dale;  Samuel  Helpern,  Mitchell  Mendick,  and  Alex  Goldstine,  all  of  Wor- 
cester; Samuel  Polimer  of  Somerville;  William  Cramer  of  North  Adams; 
Baker's  Market,  Incorporated,  of  Fall  River;  John  Moscal  of  Holyoke; 


68 

Mayflower  Meat  Market,  Incorporated,  of  Lynn;  and  E.  Moro  of  Fram- 
ingham. 

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

1  sample  each,  from  William  Cramer  of  North  Adams;  5,  10  &  25c. 
Store  of  Salem;  E.  Moro  of  Attleboro;  and  F.  L.  Scheu  of  Boston. 

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

2  samples  each,  from  John  Ferejohn  of  Pittsfield,  and  Henry  Staveley 
of  Fitchburg;  1  sample  each,  from  E.  Moro  and  Thurbers  Market,  both 
of  Attleboro;  and  William  H.  Allison  of  Lynn. 

One  sample  of  maple  syrup  adulterated  with  cane  syrup  was  obtained 
from  Efstratios  Koulouris  of  Somerville. 

Four  samples  of  preserves  which  contained  commercial  glucose  were 
obtained  from  Mayflower  Products  Company  of  Boston. 

One  sample  of  vanilla  extract  which  contained  coumarin,  and  one 
sample  of  lemon  extract  which  did  not  contain  sufficient  lemon  oil,  were 
obtained  from  New  England  Sugar  Supply  Company  of  Worcester. 

There  were  four  confiscations,  consisting  of  55  pounds  of  decomposed 
miscellaneous  poultry;  10  pounds  of  decomposed  turkey;  200  pounds  of 
decomposed  sausage  meat  and  veal;  and  14  gallons  of  sour  scallops. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  September,  1930 : — 624,990 
dozens  of  case  eggs;  336,155  pounds  of  broken  out  eggs;  1,776,792  pounds 
of  butter;  741,657  pounds  of  poultry;  3,218,127y2  pounds  of  fresh  meat 
and  fresh  meat  products;  and  3,499,011  pounds  of  fresh  food  fish. 

There  was  on  hand  October  1,  1980: — 7,739,880  dozens  of  case  eggs; 
1,990,056  pounds  of  broken  out  eggs;  11,610,398  pounds  of  butter;  2,877,- 
685^  pounds  of  poultry;  7,975,392y2  pounds  of  fresh  meat  and  fresh 
meat  products ;  and  27,728,859  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  the  month  of  October,  1930: — 247,770 
dozens  of  case  eggs;  274,627  pounds  of  broken  out  eggs;  1,120,084  pounds 
of  butter;  886,018  pounds  of  poultry;  2,080,455  pounds  of  fresh  meat 
and  fresh  meat  products;  and  2,456,298  pounds  of  fresh  food  fish. 

There  was  on  hand  November  1,  1930: — 5,303,295  dozens  of  case  eggs; 
1,658,295  pounds  of  broken  out  eggs;  9,687,850  pounds  of  butter;  2,902,- 
894^2  pounds  of  poultry;  G^OG^SG1/^  pounds  of  fresh  meat  and  fresh 
meat  products;  and  24,500,551  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  November,  1930: — 337,710  dozens  of 
case  eggs;  832,011  pounds  of  broken  out  eggs;  686,274  pounds  of  butter; 
1,469,931  pounds  of  poultry;  3,463,190  pounds  of  fresh  meat  and  fresh 
meat  products;  and  1,748,725  pounds  of  fresh  food  fish. 

There  was  on  hand  December  1,  1930 : — 2,893,380  dozens  of  case  eggs ; 
1,926,710  pounds  of  broken  out  eggs;  7,321,145  pounds  of  butter;  3,501,- 
703y2  pounds  of  poultry;  7,188,962%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  21,604,414  pounds  of  fresh  food  fish. 


64 


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  Child  Hygiene 
Division  of  Tuberculosis 
Division  of  Adult   Hygiene 


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer, 

Arthur  D.  Weston,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  Pittsfield. 


Publication  of  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
6M.    3-'31.    Order  1523. 





ITATt  HOUSE.  BOtW 

COMMONHEALTH 


Volume  18 
No.  2 


APR. -MAY- JUNE 
1931  * 


Sanitation 


MASSACHUSETTS 
DEPARTMENT   OF  PUBLIC  HEALTH 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

What  is  Pure  Water?  by  H.  W.  Clark 67 

Importance  of  the  Public  Water  Supply,  by  A.  D.  Weston               .  69 

Industrial  Waste  Problems,  by  H.  W.  Clark         ....  72 

Laboratory  Supervision  of  Milk,  by  David  L.  Belding,  M.D.  .  76 

Future  Policies  in  Sanitary  Milk  Control,  by  James  D.  Brew  80 

Sanitation  of  Food  Establishments,  by  Hermann  C.  Lythgoe           .  89 

Relation  of  Typhoid  Carriers  to  Food  Supply,  by  Gaylord  W.  An- 
derson,  M.D 93 

Sanitation  of  Wayside  Stands,  by  Walter  E.  Merrill   ...  96 

Camp  Sanitation,  by  Walter  E.  Merrill       .....  99 

Healthful  Lighting,  by  William  Firth  Wells  .  .105 

Smoke  Nuisance,  by  David  A.  Chapman     .....  106 

The  Community  Health  Organization  in  Massachusetts,  by  W.  F. 

Walker,   Dr.  P.  H .108 

The  Health  Officer  in  the  Control  of  Gonorrhea  and  Syphilis,  by 

Nels  A.  Nelson,  M.D.      .......  113 

Editorial  Comment: 

Then  and  Now?          ........  122 

Book  Notes' 

Home  Guidance  for  Young  Children    .          .          ...          .  122 

Prenatal  Care    .........  123 

Year  Book  of  Obstetrics  and  Gynecology     ....  123 

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

March,  1931 124 


WHAT  IS  PURE  WATER?* 

H.  W.  Clark,  Chief  Chemist, 
Director,  Division  of  Water  and  Sewage  Laboratories 

The  talk  this  morning  comes  from  the  Division  of  the  State  Depart- 
ment of  Public  Health  engaged  in  analytical  and  research  work  concern- 
ing everything  that  pertains  to  water,  sewage,  industrial  wastes  and 
many  other  allied  sanitary  subjects.  This  Division  is  equipped  with  chem- 
ical, bacterial  and  microscopical  laboratories  and  also  with  what  perhaps 
should  be  called  an  hydraulic  laboratory  filled  with  filters  and  tanks  of  spe- 
cial construction  and  other  apparatus  for  carrying  on  research  or  experi- 
mental work  on  the  sanitary  problems  of  the  State. 

We  are  often  asked  by  visitors  to  these  laboratories  if  a  certain  water 
supply  in  which  they  are  particularly  interested  is  not  the  purest  in  the 
State.  Generally  the  questioner  has  little  or  no  knowledge  what  pure 
water  really  is.  When  a  sanitary  chemist  or  engineer,  however,  speaks 
of  pure  water  he  means  a  water  entirely  satisfactory  for  household  use, 
not  one  absolutely  free  from  all  mineral  and  organic  substances  but  one 
that  contains  no  harmful  or  disease-producing  bacteria  and  that  is  clear, 
tasteless,  odorless,  low  in  color,  soft  and  free  from  organic  and  mineral 
matter  showing  recent  or  even  remote  pollution.  All  these  properties  or 
qualities  or  conditions  of  water  can  be  determined  by  the  chemist  and 
bacteriologist  with  a  great  degree  of  accuracy.  We  are  fortunate  in 
Massachusetts  in  having  in  almost  every  municipality  satisfactory  public 
water  supplies.  The  policy  of  this  State,  and  it  is  of  course  the  policy  of 
the  whole  country  where  it  can  be  followed,  is  to  obtain  a  supply  for  every 
city  and  town  that  is  not  only  safe  but  also  satisfactory  to  the  consumer 
in  appearance  and  taste,  and  one  that  can  be  used  for  all  domestic  and 
industrial  purposes  without  being  submitted  to  any  purification  other 
than  storage.  Massachusetts  has  been  almost  phenomenally  successful 
in  accomplishing  this,  and  there  are  only  a  few  supplies  that  need  a  more 
drastic  purification  than  storage  gives.  Throughout  a  considerable  por- 
tion of  the  country,  however,  it  is  impossible  to  obtain  unpolluted  water 
in  sufficient  volume  to  supply  many  municipalities  and  recourse  is  had  to 
water  purification  by  various  types  of  municipal  filters  and  to  sterilizing 
agents  such  as  chlorine ;  in  fact,  in  other  parts  of  the  country  many  river 
waters  receiving  large  volumes  of  domestic  sewage  and  industrial  wastes 
are  subsequently  rendered  safe  for  domestic  use  by  various  purification 
methods.  They  are  safe  but  would  not  be  considered  satisfactory  supplies 
in  this  State. 

Waters  for  household  use  in  Massachusetts  are  from  private  wells, 
springs  or  municipal  supplies,  and  at  the  present  time  96  per  cent  of  our 
people  take  water  from,  or  have  access  to,  public  supplies.  These  supplies 
are  grouped  as  ground  and  surface  waters.  The  ground  water  supplies 
are  taken  from  curb  wells  or  groups  of  driven  wells,  25  to  40  feet  deep, 
and  the  surface  supplies  very  largely  from  lakes  and  storage  reservoirs. 
No  direct  taking  from  a  badly  polluted  river  is  made  except  by  one  city 
and  this  supply  is  rendered  safe  by  filtration  and  chlorine  treatment. 

The  chief  characteristic  of  the  ground  water  supplies  is  their  freedom 
from  color  and  their  generally  attractive  and  palatable  taste.  They  must, 
of  course,  be  taken  from  porous  soil,  that  is,  sand  or  gravel,  in  order  that 
a  sufficient  volume  may  be  obtained ;  they  also  must  be  taken  from  regions 
free  or  practically  free  from  pollution..  Certain  of  these  ground  water 
supplies  contain  no  more  mineral  and  organic  matter  than  the  best  spring 
waters  sold  throughout  the  country.  They  are  perhaps  safer  for  use 
because  they  have  not  been  bottled  or  touched  by  human  hands  as  is 
the  case  with  some  of  the  spring  waters.  A  few  of  the  ground  water 
supplies  contain,  however,  considerable  iron  and  manganese  taken  into 


*  Radio  broadcast — Station  WEEI — February  13,   1931. 


68 
solution  from  the  soil  through  which  the  water  passes  and  these  bodies 
oxidize  when  the  water  is  drawn  from  the  ground  and  exposed  to  the  air. 
This  oxidation  changes  the  iron  and  manganese  from  soluble  to  insoluble 
forms  and  makes  these  waters  turbid.  Hence  there  are  a  number  of  munic- 
ipal ground  water  supplies  in  the  State  which  are  filtered,  not  to  remove 
bacteria  and  increase  their  safety,  but  to  remove  iron  and  manganese. 

Domestic  supplies  for  household  use,  where  the  municipal  supply  can- 
not be  obtained,  are  almost  invariably  from  dug  wells  and  springs.  These 
domestic  supplies  are  often  from  wells  so  poorly  located  that  drainage 
from  houses,  out-buildings,  barns,  etc.,  reaches  them.  This  water  may 
have  been  rendered  bacterially  safe  by  filtration  through  the  ground  be- 
fore reaching  the  well,  although,  of  course,  this  is  not  always  the  case, 
and  these  waters  may  often  be  the  cause  of  illness.  The  organic  matter 
of  the  sewage  from  these  out-buildings  can  be  so  changed  and  oxidized 
by  this  filtration  that  the  water  is  clear,  colorless  and  hence  attractive  in 
appearance  and  with  an  agreeable  taste,  this  taste  being  due  partly  to 
the  gases  formed  by  oxidation  of  organic  matter  and  partly  to  the  min- 
eral salts  resulting  from  the  oxidation  of  the  organic  matter  of  the  sew- 
age or  drainage.  Even  if  these  waters  are  safe,  it  is  not  an  agreeable 
thought,  no  matter  how  pleasant  to  the  taste  they  are,  that  the  users  are 
drinking  purified  sewage. 

Municipal  supplies  of  surface  water  vary  in  their  attractiveness  accord- 
ing to  the  geological  formation  of  the  territory  in  which  they  are  col- 
lected. A  stream  flowing  through  swampy  regions  or  a  lake  in  such  a 
region,  collects  its  water  from  a  watershed  containing  peat,  muck,  decay- 
ing organic  matter,  such  as  accumulated  grass,  leaves  and  other  vegeta- 
tion, from  all  of  which  the  water  extracts  coloring  matter  and  taste.  Such 
a  water  may  be  absolutely  safe;  that  is,  free  from  harmful  bacteria  and 
may  be  in  a  sense  pure  in  respect  to  freedom  from  dissolved  mineral 
matter  but  is  not  attractive  for  domestic  use  until  improved  as  to  color 
at  least  by  storage  or  filtration.  When  stored  it  may,  because  of  its  qual- 
ity, be  favorable  to  the  growth  of  microscopic  organisms,  some  of  which 
impart  strong,  disagreeable  tastes  and  odors  to  the  water.  Aeration, 
filtration  or  treatment  with  algicides  can  be  and  are,  resorted  to,  to  over- 
come these  troubles.  The  microscopic  organisms  producing  tastes  and 
odor,  with  the  rather  peculiar  names  of  Anabaena,  Uroglena,  Asterion- 
ella,  Dinobryon,  etc.,  are  harmless  in  themselves  so  far  as  effect  upon 
health  is  concerned  but  exceedingly  harmful  to  the  attractiveness  of  a 
water  supply  for  domestic  use  and  the  cause  of  many  bitter  complaints 
from  time  to  time  from  consumers  of  such  water.  Fortunately,  only  a 
few  supplies  in  Massachusetts  have  these  disagreeable  odor-  and  taste- 
producing  organisms  except  occasionally  or  seasonally,  and  generally  for 
limited  periods.  On  the  other  hand,  surface  water  may  be  collected  from 
a  territory  of  such  geological  formation,  that  is,  a  sandy,  gravelly  region 
full  of  rocks,  boulders,  etc.,  and  with  only  a  thin  covering  of  exhausted 
soil  or  humus  in  which  the  elements  producing  color  have  been  largely 
destroyed.  The  water  from  such  a  catchment  area  may  resemble  in 
attractiveness  certain  ground  water  supplies.  There  are,  moreover,  cer- 
tain ponds  in  the  State  in  the  Cape  region  which  are  really  filled  with 
ground  water;  that  is,  the  rain  falling  on  this  region  enters  the  ground 
and  filters  through  to  brooks  and  the  ponds  instead  of  flowing  over  the 
ground  and  because  of  this  filtration,  assumes  the  character  of  ground 
rather  than  of  surface  water. 

Finally,  an  entirely  satisfactory  water  for  domestic  use  should  be  clear, 
practically  colorless,  tasteless  or  nearly  so ;  free  from  organic  and  mineral 
matter  showing  present  or  past  pollution,  low  in  bacteria  and  absolutely 
free  from  all  disease  germs.  For  many  years,  towns  and  cities  and  the 
consumers  of  water  were  content  with  a  safe  water;  today,  however, 
there  is  a  strong  demand  for  these  other  qualities.  It  must  not  only  be 
safe  but  attractive,  and  much  money  is  being  expended  all  over  the  coun- 


69 

try,  and  undoubtedly  will  be  expended  in  the  future,  to  satisfy  water 
consumers  in  this  latter  respect.  More  and  more  they  complain  of  tastes, 
odors  and  color  that  would  not  have  been  particularly  objectionable  to 
their  predecessors  of  twenty  or  thirty  years  ago. 

IMPORTANCE  OF  THE  PUBLIC  WATER  SUPPLY 

A.  D.  Weston,  Chief  Engineer 
Division  of  Sanitary  Engineering 

The  importance  of  the  public  water  supply  was  recognized  as  long  ago 
as  the  days  of  the  pyramids  when  the  people  of  Cairo  constructed  Joseph's 
well,  which  consisted  of  an  excavation  some  297  feet  deep,  a  remarkable 
engineering  feat  for  that  period.  Later  the  importance  of  the  public 
supply  was  more  pronounced  in  the  construction  by  the  ancient  Romans 
of  some  very  substantial  water  works  systems.  Many  of  the  old  Roman 
aqueducts  are  still  standing  and  one  of  them,  built  about  270  B.  C, 
brought  water  into  Rome  from  a  distance  of  nearly  40  miles. 

In  Massachusetts  the  need  of  public  water  supplies  was  first  recognized 
as  early  as  1652  when  a  small  reservoir  or  cistern  was  established  in  the 
city  of  Boston  near  the  corner  of  Elm  and  Union  streets.  Since*  that  time 
public  water  supplies  have  been  introduced  in  many  parts  of  the  State, 
and  as  early  as  1870  nearly  40%  of  the  population  of  the  State  was  in- 
cluded in  cities  and  towns  having  such  supplies.  As  time  went  on  and 
the  density  of  population  increased,  it  became  increasingly  difficult  to 
maintain  wells  and  other  private  sources  of  water  supply  free  from  pollu- 
tion and  public  water  supplies  were  more  generally  introduced.  Without 
the  public  supply  the  establishment  of  our  present  day  cities  of  large 
population  would  have  been  impossible.  At  the  present  time  236  of  the 
355  cities  and  towns  in  this  State  obtain  water  wholly  or  in  part  from 
public  works,  and  over  97%  of  the  total  population  of  the  State  is  in- 
cluded in  the  cities  and  towns  having  such  works. 

Public  water  supplies  were  originally  introduced  with  a  view  to  supply- 
ing water  for  drinking  purposes,  but  in  later  years  as  property  values 
and  the  need  of  water  for  industrial  and  mechanical  purposes  increased 
the  public  supply  was  designed  for  adequate  fire  protection  and  for  in- 
dustrial and  public  use  as  well  as  for  ordinary  domestic  purposes.  Of 
the  total  amount  of  water  consumed  in  the  average  municipality  about 
36%  is  used  for  domestic  consumption  and  other  household  uses,  about 
52%  for  manufacturing  and  general  mechanical  uses,  and  about  12% 
for  testing,  flushing  and  other  public  purposes,  including  the  extinguish- 
ment of  fires. 

The  public  water  supply  has  played  an  important  part  in  the  protec- 
tion of  the  public  health  and  in  the  economic  development  of  those  com- 
munities in  which  these  supplies  have  been  established.  The  influence 
of  such  supplies  on  the  public  health  can  probably  best  be  illustrated  by 
comparing  the  rate  of  introduction  of  public  water  supplies  with  the  de- 
crease in  death  rates  from  typhoid  fever  in  this  State  since  1885,  the 
year  before  the  oversight  of  public  water  supplies  was  granted  to  this 
Department.  The  number  of  deaths  from  typhoid  fever  in  1885  in  the 
State  was  about  768,  or  40  per  100,000  population.  The  number  of  deaths 
from  this  disease  in  this  State  in  1929  was  42  (a  rate  of  1  per  100,000), 
a  decrease  in  the  death  rate  of  about  97%  since  1885.  The  following  table 
is  arranged  to  show  the  relation  between  the  death  rate  from  typhoid 
fever  and  the  population  throughout  the  State  supplied  wholly  or  in  part 
with  water  from  public  water  supplies. 


70 

Typhoid  Fever         Per  cent  of  Total  Population  of 
Death  rate  in  State    State  included  in  Cities  and  Towns 
Year  (Deaths  per  100,000)     having  public  water  supplies 

1885  40  70.6 

1890  37  86..0 

1895  27  89.5 

1900  23  91.4 

1905  17  93.0 

1910  12  94.2 

1915  7  95.5 

1920  2  96.1 

1925  2  96.2 

1930  1  97.0 

The  late  Hiram  Mills,  to  whom  much  of  the  credit  for  the  success  of 
the  Engineering  Division  of  the  Department  should  be  given,  in  an  ad- 
dress to  the  State  District  Health  Officers  in  the  year  1913  made  the  fol- 
lowing statement  when  he  compared  the  death  rates  in  Lowell  and 
Lawrence  before  and  after  improvements  in  the  water  supplies  had  been 
carried  out: 

"The  decrease  in  deaths  from  all  diseases  in  Lowell  and  Lawrence  in 
the  two  periods,  due  principally  to  the  improvement  of  their  water  sup- 
plies, was  1.7  times  as  great  as  the  decrease  in  deaths  from  typhoid  fever. 

"The  decrease  in  death  rates  from  all  diseases  was  16  per  cent  in 
Lowell  and  20  per  cent  in  Lawrence,  or  10  per  cent  and  14  per  cent  re- 
spectively, greater  than  in  the  State. 

"In  order  to  compare  the  death  rates  in  the  two  five-year  periods  at 
Lowell  and  Lawrence  with  those  at  the  city  of  Haverhill,  situated  about 
as  far  down  the  river  below  Lawrence  as  Lawrence  is  below  Lowell,  and 
where  the  water  supply  was  not  from  the  river  but  from  ponds  around  the 
city,  and  was  not  materially  changed  in  the  two  periods,  in  Haverhill  in 
the  second  period  the  total  deaths  per  1,000  living  gave  2  per  cent  decrease 
greater  than  in  the  State. 

"The  deaths  per  1,000  in  the  second  period  from  the  special  diseases 
were  as  follows: — 

Measles,  6  per  cent  greater  than  in  the  State. 

Scarlet  fever,  53  per  cent  less  than  in  the  State,  which  result  was  evi- 
dently due  to  an  epidemic  in  the  first  year  of  the  first  period,  when  the 

deaths  were  seven  times  as  many  as  in  the  other  years. 
Diphtheria,  etc.,  3  per  cent  less  than  in  the  State. 
Typhoid  fever,  37  per  cent  greater  than  in  the  State. 
Consumption,  3  per  cent  less  than  in  the  State. 
Pneumonia,  21  per  cent  greater  than  in  the  State. 

"Since  the  filter  was  built  in  Lawrence  some  effort  has  been  made  to 
determine  some  of  the  causes  of  the  continuing  typhoid  fever  there,  from 
which  it  appears  that  11  per  cent  of  the  deaths  were  from  disease  con- 
tracted away  from  the  city,  about  33  per  cent  were  of  persons  who  had 
access  to  canal  water  in  the  mills  for  drinking,  leaving  46  per  cent  that 
may  have  been  due  to  milk  or  other  contaminated  food  or  drink." 

To  what  extent  the  reduction  in  deaths  from  all  causes  can  be  attrib- 
uted to  the  introduction  of  public  water  supplies  is  something  which  only 
the  physicians  skilled  in  such  statistical  studies  are  qualified  to  state,  but 
when  one  considers  the  important  bearing  of  the  public  water  supply  on 
the  prevalence  of  typhoid  fever  and  other  water-borne  diseases,  it  can 
readily  be  understood  that  the  reduction  in  the  death  rate  in  the  State 
must  have  been  considerably  influenced  in  various  parts  of  the  State  by 
the  introduction  of  water  from  public  works. 

A  large  amount  of  water  supplied  to  the  individual  homes  is  for  gen- 
eral domestic  and  sanitary  purposes,  only  a  small  part  of  the  water  actu- 


71 

ally  being  used  for  drinking,  and  studies  made  by  the  Department  of 
Public  Health  have  shown  that  the  increased  use  of  water  in  many  com- 
munities can  be  attributed  to  improved  living  conditions.  A  much  larger 
amount  of  water  is  required  in  the  modern  home  of  today  than  in  that  of 
a  generation  ago  as  such  homes  generally  have  several  bathrooms  and 
other  modern  toilet  fixtures,  including  flushometer  valves  in  the  bath- 
rooms which  require  a  large  amount  of  water  under  adequate  pressure 
for  proper  operation.  In  addition  a  large  amount  of  water  is  used  in 
the  modern  hotel  and  apartment  house  for  the  flushing  of  fixtures  and 
many  of  the  rooms  in  such  buildings  have  adjoining  bathrooms  or  other 
toilet  facilities.  While  the  installation  of  plumbing  equipment  requiring 
large  quantities  of  water  may  not  have  an  important  bearing  on  public 
health,  it  does  have  an  important  bearing  on  improved  living  conditions. 

The  importance  of  the  public  water  supply  so  far  as  it  relates  to  the 
economic  development  of  the  community  is  shown  in  the  investment  made 
in  water  works  systems  to  provide  supplies  of  suitable  quality  and  in 
sufficient  quantities  to  meet  the  industrial,  public  and  fire  protection  re- 
quirements. Except  in  the  distributing  systems  of  the  larger  commun- 
ities, much  of  the  cost  of  the  distributing  works  is  for  supply  water  in 
sufficient  quantity  for  industrial  and  fire  protection  requirements. 

The  public  supply  plays  a  particularly  important  part  in  the  economic 
development  of  many  communities.  In  Massachusetts  the  water  of  most 
of  the  public  supplies  is  clear  and  colorless,  soft,  and  of  excellent  quality 
for  most  manufacturing  purposes,  and  for  that  reason  a  large  number 
of  tanneries,  bleacheries,  paper  mills  and  certain  textile  industries  re- 
quiring a  large  amount  of  water  for  their  processes  have  been  established 
within  the  limits  of  the  State,  and  in  many  communities  much  of  the 
water  supplied  is  for  manufacturing  purposes. 

The  importance  of  the  public  water  supply  on  the  economic  develop- 
ment of  the  community  is  probably  most  emphasized  in  the  use  of  such 
a  supply  in  the  protection  of  property  against  fire  and  the  design  of  the 
water  works  plant  is  generally  influenced,  especially  in  the  smaller  com- 
munities, chiefly  by  the  demands  for  water  for  fire  protection.  Studies 
made  regarding  the  relation  of  the  size  of  the  plant  for  fire  protection 
compared  to  the  size  of  the  plant  for  domestic,  industrial  and  other  uses 
have  shown  that  in  some  of  the  smaller  communities  over  80%  of  the 
cost  of  the  plant  might  well  be  charged  to  fire  protection. 

Studies  of  a  number  of  communities  of  different  sizes  have  shown  the 
following  percentages  of  total  plant  cost  chargeable  to  fire  protection: 

Percentage  of  Total 

Population  Plant  Cost  Chargeable 

of  Municipality  to  Fire  Protection 

4,229  84 

14,178  54 

16,164  51 

55,251  .                                            31 

62,354  29 

81,643  25 

In  all  cases  the  introduction  of  an  adequate  public  water  supply  results 
in  a  reduction  of  the  amount  of  insurance  premiums  as  the  insurance 
authorities  consider  that  a  building  is  under  protection  and  entitled  to 
a  protected  rate  when  it  is  within  500  feet  of  a  public  hydrant  and  within 
two  miles  of  an  available  fire  department  station.  In  many  communities 
the  saving  in  insurance  premiums  is  so  great  that  it  might  well  be  con- 
sidered a  substantial  contribution  to  the  financing  of  the  water  works 
plant. 

It  has  been  stated  that  "water  is  the  most  essential  commodity,  other 
than  air,  to  the  continuation  of  life."  This  statement  is  undoubtedly  true 


72 

and  to  it  might  be  added  that  the  public  supply  makes  available  water 
clear,  colorless  and  safe  for  drinking  in  quantities  not  only  sufficient  for 
the  usual  domestic,  public  and  industrial  requirements  but  also  for  ade- 
quate fire  protection.  In  most  communities  such  service  is  supplied  for 
a  trivial  amount.  Considering  the  value  received  from  a  public  water 
supply,  it  is  not  to  be  wondered  that  in  Massachusetts  most  of  the  larger 
communities  are  now  supplied  with  water  from  public  works. 

INDUSTRIAL  WASTE  PROBLEMS 

H.  W.  Clark,  Chief  Chemist, 
Director,  Division  of  Water  and  Seivage  Laboratories 

Industrial  waste  problems  are  really  of  two  kinds,  namely, — those  of 
water  pollution  and  those  of  air  pollution.  Generally,  however,  when  they 
are  mentioned  water  pollution  is  the  one  referred  to.  They  come,  as  do 
all  sanitary  problems  pertaining  to  polluted  water,  with  the  increase  of 
population  in  a  civilized  community  or  state  and  the  subsequent  growth 
of  industrial  enterprise.  For  the  past  one  hundred  years  they  have  been 
serious  enough  in  England  to  cause  the  enactment  of  many  laws  for  their 
prevention  or  abatement  and  while,  of  course,  in  this  country  they  had 
been  referred  to  in  early  reports  of  the  Massachusetts  State  Board  of 
Health,  they  were  perhaps  first  seriously  recognized  and  discussed  in  a 
report  famous  in  the  annals  of  sanitary  science,  namely,  that  of  the 
Massachusetts  Drainage  Board  of  1886.  This  Board  stated  that  while 
its  report  dealt  largely  with  the  question  of  pollution  from  household 
waste  and  the  science  of  its  purification,  still  it  was  "not  to  be  inferred 
that  we  are  inclined  to  admit  any  inherent  distinction  between  household 
sewage  and  the  pollution  of  water  by  other  instrumentalities.  Chief 
among  these  is  the  contamination  caused  by  the  use  of  water  in  manu- 
facturing processes  and  the  incidental  damage  to  the  purity  of  water 
resulting  from  the  establishment  of  great  industrial  activities  upon 
stream  and  rivers."  It  advised,  however,  that  "mindful  of  the  tender- 
ness with  which  Massachusetts  has  always  treated  her  industrial  classes" 
no  mandatory  but  only  advisory  powers  be  given  to  any  Commission  or 
Board  established  to  handle  questions  of  industrial  pollution  and  other 
sanitary  problems  of  a  similar  nature.  Such  a  Board  was,  according  to 
their  recommendation,  to  make  it  a  part  of  their  duties  to  advise  and 
assist  and  cooperate  with  the  industries  polluting  streams  in  experi- 
mental work  in  regard  to  the  treatment  of  their  wastes.  In  this  they 
patterned  after  an  old  English  law  which  states  that  whatever  is  done 
for  the  maintenance  of  the  purity  or  improvement  of  a  stream  must  be 
done  with  full  understanding  of  the  importance  to  state  or  nation  of 
industry. 

Upon  the  reorganization  of  the  State  Board  of  Health  in  1886  and  the 
establishment  of  the  Lawrence  Experiment  Station  in  1887,  studies  were 
begun  upon  methods  for  the  purification  of  domestic  sewage  but  indus- 
trial wastes  were  not  investigated  with  a  view  to  their  treatment  or  puri- 
fication until  1895.  In  the  report  of  the  Station  for  that  year,  the  first 
prepared  by  the  writer  of  this  article,  some  slight  investigations  on  this 
question  were  described  and  in  the  Station  report  for  1896  some  thirty- 
five  pages  were  devoted  to  describing  experiments  on  this  subject  and 
their  results.  In  1909  a  paper  of  considerable  length  was  presented  in 
the  annual  report  of  the  Department*  describing  investigations  upon 
wastes  from  tanneries,  woolen  factories,  paper  mills,  dye  works,  cream- 
eries, binders'  board  works,  yeast  factories,  carpet  works,  batting  works, 
silk  mills,  gas  works,  bleacheries,  shoddy  mills,  glue  works,  paint  mills,  etc. 
As  a  result  of  these  investigations  more  or  less  satisfactory  methods  for 


*  Disposal  and   Purification  of   Factory   Wastes  or  Manufacturing   Sewage   by   H.   W.   Clark, 
pp.    341-403   incl. 


73 

the  disposal  of  many  of  these  wastes  were  developed  and  a  number  of  puri- 
fication plants  were  built  in  the  State  for  treatment  of  some -of  these 
wastes.  Every  year  since  the  publication  of  that  article  more  or  less 
work  has  been  done  by  this  Department  upon  the  treatment  of  industrial 
wastes  of  many  kinds  and  short  descriptions  of  this  work  have  been  given 
in  the  annual  reports  of  the  Experiment  Station.  Besides  these,  various 
special  reports  have  been  issued  dealing  with  the  wastes  from  groups  of 
industries  such  as  those  upon  the  Neponset  River,  the  Merrimack  River 
and  in  what  is  now  known  as  the  South  Essex  Sewerage  District,  the 
wastes  entering  the  Neponset  River  being  largely  from  paper  mills  and 
tanneries,  those  entering  the  Merrimack  being  largely  from  textile  indus- 
tries and  paper  mills  and  those  in  the  South  Essex  Sewerage  District 
being  largely  the  wastes  from  tanneries,  leather  works  and  glue  and 
gelatin  works. 

The  subject  is  a  broad  one  and  many  difficulties  are  encountered  that 
are  absent  from  the  problems  involved  in  the  disposal  of  domestic  sewage 
and  these  difficulties  prevent  any  general  application  of  the  results  ob- 
tained. Some  of  the  chief  difficulties  in  the  treatment  of  industrial  wastes 
can  be  summarized  as  follows:  (1)  The  nature  of  the  waste  liquor  from 
many  manufacturing  processes  whereby  purification  by  bacterial  action 
or  nitrification  is  prevented ;  that  is,  there  is  little  nitrogenous  and  much 
carbonaceous  matter  in  these  wastes  and  this  latter  matter  is  acted  upon 
but  slowly  by  the  forces  of  decomposition,  putrefaction  and  oxidation.  Of 
course,  much  of  the  matter  in  suspension  in  these  wastes  can  be  removed 
by  sedimentation,  chemical  precipitation,  screening  or  straining  through 
certain  types  of  strainers  or  filters  or  treatment  with  mechanical  devices 
like  the  Dorr  thickener  but  the  remaining  liquid  with  its  dissolved  or- 
ganic matter  may  be  exceedingly  difficult  to  treat.  In  other  words,  it  is 
acted  upon  by  bacteria  so  slowly  that  filtration  is  almost  impracticable 
and  yet  if  allowed  to  enter  a  stream  it  becomes  a  nuisance  by  robbing  the 
stream  of  its  dissolved  oxygen  and  giving  a  disagreeable  appearance  to 
the  stream  and  causing  odors;  (2)  the  excessive  amount  of  organic  matter 
per  unit  volume  of  liquid  discharged,  often  many  times  as  great  as  that 
found  in  the  strongest  domestic  sewage;  (3)  the  enormous  volume  of 
water  used  in  many  industries  which  comes  from  such  plants  loaded  with 
this  organic  matter  and  often  with  chemicals  of  many  kinds.  The  volume 
of  water  from  a  single  industrial  plant  is  often  greater  than  the  volume 
of  domestic  sewage  from  a  town  of  15,000  or  20,000  people ;  that  is,  sev- 
eral million  gallons  daily,  and  the  liquid  may  be  so  strongly  alkaline  or 
acid  that  bacterial  life  and  fish  life  in  the  stream  it  enters  are  destroyed. 
For  example,  during  studies  by  this  Department  of  the  wastes  from  a 
pulp  mill  it  was  shown  that  one  gallon  of  the  liquid  from  the  soda  process 
carried  on  at  the  mill  and  entering  the  river  would  absorb  10.78  grams 
or  7,544  cubic  centimeters  of  oxygen  in  twenty-four  hours  and  this  liquid 
would,  of  course,  owing  to  its  caustic  alkalinity,  destroy  bacteria  and 
fish.  Fortunately,  however,  about  90  per  cent  of  this  waste  liquid,  amount- 
ing to  10,000  or  12,000  gallons,  daily,  is  now  evaporated  for  recovery  of 
the  soda  ash;  (4)  the  varying  character  of  the  liquid  coming  from  manu- 
facturing plants  doing  smiliar  work,  a  fact  which  prevents  the  results 
from  one  set  of  experiments  at  a  certain  factory  being  applicable  to 
another  industrial  plant  of  practically  the  same  kind;  (5)  the  liability 
to  changes  from  time  to  time  in  the  processes  carried  on  in  any  indus- 
trial plant,  this  causing  a  change  in  the  character  of  the  wastes;  (6) 
the  fact  that  the  chief  industries  of  an  entire  district  may  change  in  the 
course  of  a  few  years,  this  causing  absolutely  new  problems  of  treatment. 
In  fact,  nearly  every  industrial  plant  presents  a  problem  differing  in  many 
respects  from  that  of  all  others.  Perhaps  the  greatest  problem,  however, 
is  to  persuade  industrialists  to  expend  money  for  any  treatment  what- 
ever. It  is  much  easier  to  persuade  a  municipality  to  spend  money  for 
sanitary  work  from  which  there  is  no  financial  return  than  a  corpora- 


74 
tion, — one  is  the  expenditure  of  public  and  the  other  of  private  funds. 

Besides  work  at  individual  industries,  the  following  paragraphs  illus- 
trate some  of  the  group  work  carried  on  by  this  Department.  For  ex- 
ample, many  years  ago  investigations  were  made  by  the  writer  of  all  the 
waste  liquors  from  the  industrial  plants  on  the  Neponset  River  consist- 
ing largely  of. tanneries  and  paper  mills.  During  this  investigation  fair- 
sized  experimental  filters,  sedimentation  tanks,  etc.,  were  operated  at 
these  plants  during  different  years.  Following  this,  various  devices  were 
installed  in  the  paper  mills  to  clarify  the  waste  and  to  save  valuable 
material,  and  sedimentation  tanks  and  filters  were  constructed  at  the  tan- 
neries. These  treatment  plants  were  afterwards  improved  and  enlarged 
from  time  to  time  by  chemists  and  Sanitary  engineers  employed  by  the 
corporations. 

In  a  sanitary  survey  of  the  Merrimack  River  ordered  by  the  General 
Court  in  1909  and  extending  from  that  year  through  1912,  studies  were 
made  of  all  the  industries  upon  the  river,  especially  those  at  Lawrence, 
which  was  at  that  period  and  still  is  the  great  woolen  center  of  New 
England,  and  especial  attention  was  given  to  the  wool-scouring  carried 
on  in  that  city  as  the  waste  from  this  process  was  the  chief  industrial 
pollution  of  the  river  at  that  point.  Measurements  were  made  of  the 
volume  of  waste  discharged  from  this  process  into  the  river  by  the  various 
mills  and  the  character  of  this  waste  determined.  It  was  found  that  the 
volume  of  such  waste  amounted  to  about  500,000  gallons  daily  and  that 
owing  to  the  potash  soap  used  and  the  potash  and  grease  scoured  from  the 
wool  it  would  at  that  time  undoubtedly  have  been  a  paying  proposition  if 
the  mills  could  have  united  in  piping  this  waste  to  a  central  plant  and  there 
treat  it  for  the  recovery  of  fatty  matters  and  potash.  Studies  made  at  that 
time  showed  that  at  least  $400,000  worth  of  these  bodies  could  be  recov- 
ered yearly.  Incidentally,  the  sanitary  condition  of  the  river  would  have 
been  vastly  improved  by  the  removal  of  these  bodies  as  75  per  cent  of  the 
biological  oxygen  demand  upon  the  river  water  was  by  the  wastes  from 
the  mills  rather  than  domestic  sewage.  A  few  years  later,  owing  to  the 
World  War,  potash  could  not  be  obtained  at  a  reasonable  price  for  wool- 
scouring,  different  soaps  were  used  and  consequently  this  waste  lost  a 
considerable  portion  of  its  value.  Other  changes  of  this  sort  have  come 
under  the  writer's  observation  but  at  various  industrial  plants  in  New 
England  much  valuable  material  once  considered  a  part  of  the  necessary 
waste  from  a  mill  is  being  recovered  at  a  profit  and  it  is  now  a  part  of 
the  duties  of  many  industrial  plant  chemists  to  do  research  work  in 
regard  to  such  recovery. 

During  the  past  ten  years  this  Department  and  the  South  Essex  Sewer- 
age Board  have  investigated  all  the  industrial  plants,  more  than  fifty  in 
number,  in  that  District, — largely  tanneries,  hair,  leather,  glue  and 
gelatin  works.  At  practically  all  of  these  plants  some  attempt  is  made 
to  clarify  their  waste  liquor  by  means  of  screens,  sedimentation  tanks, 
Dorr  thickeners,  etc.,  or  a  combination  of  all  three.  By  these  devices  a 
very  large  amount  of  organic  matter,  lime,  etc.,  in  suspension  is  removed 
from  the  waste.  It  is  of  interest  to  note,  however,  that  in  this  District 
much  caustic  lime  in  solution  has  entered  the  sewers  and  meeting  the 
carbonic  acid  of  the  domestic  sewage  has  been  precipitated  in  these  sew- 
ers and  at  the  pumping  station  as  a  hard,  encrusting  scale.  With  the 
installation  of  a  new  $1,500,000  sea  outlet,  studies  were  begun  to  prevent 
this  deposit  of  lime  and  at  the  present  time  carbonation  plants,  so  called, 
planned  by  this  Division  are  in  use  treating  waste  liquors  at  a  number 
of  these  industrial  plants.  By  this  method  lime  in  solution  is  precipitated 
before  entering  the  sewers. 

There  are  sometimes  extravagant  demands  by  certain  people  and  organ- 
izations for  waste  treatment  and  stream  improvement  but  all  problems 
of  this  sort  must  be  looked  at  not  only  from  the  viewpoint  of  the  sanita- 
rian but  also  from  that  of  the  manufacturer  who  hesitates  to  expend  large 


75 

sums  in  the  erection  and  operation  of  works  to  satisfy  these  extravagant 
and  unreasonable  demands.  We  must  acknowledge  that  where  industrial 
streams  are  not  used  for  public  water  supplies,  and  this  is  almost  wholly- 
true  in  Massachusetts,  about  all  that  is  necessary  in  the  treatment 
of  industrial  wastes  is  purification  adequate  enough  to  prevent  the  stream 
from  becoming  a  nuisance  to  the  communities  through  which  it  flows 
on  account  of  its  appearance,  deposits  on  its  banks  and  odors.  It  should, 
if  humanly  possible,  be  kept  clean  enough  to  be  a  source  of  enjoyment  to 
these  communities.  Massachusetts  has  been  an  industrial  state  for  many 
years  and  it  is  apparently  the  sensible  thing  to  acknowledge  that  certain 
streams  must  be  used  for  industrial  purposes  and  often  find  their  chief 
value  when  so  used.  These  industrial  streams  cannot  now  be  returned  to 
the  condition  of  pristine  purity  of  colonial  times.  Streams  now  clean  or 
nearly  so  should  be  kept  clean,  however,  and  industries  with  polluting 
waste  liquids  prevented  from  becoming  established  upon  them. 

The  Royal  Commission  on  River  Pollution  of  Great  Britain  stated  in 
its  first  report  (1868)  that  "of  the  many  polluting  matters  which  now 
poison  the  rivers  there  is  not  one  that  cannot  be  either  kept  out  of  the 
stream  altogether  or  so  far  purified  before  admission  as  to  deprive  it  of 
its  noxious  character  and  this  not  only  without  interfering  with  manu- 
facturing operations  but  even  in  some  instances  with  a  distinct  profit  to 
the  manufacturer."  That  up  to  a  certain  point  is,  of  course,  a  true  state- 
ment but  it  has  been  learned  in  the  years  since  then,  both  in  England  and 
in  this  country,  that  there  are  certain  industries  producing  a  waste  the 
cost  of  the  treatment  of  which,  in  a  manner  satisfactory  to  those  demand- 
ing absolutely  clean  streams  in  industrial  districts,  would  be  so  great  as  to 
put  the  industry  producing  this  waste  out  of  business.  There  are,  of  course, 
places  or  communities  where  the  industrial  sewage  can  enter  municipal 
sewers  and  be  treated  at  the  municipal  filtration  areas.  In  most  instances, 
however,  preliminary  treatment  at  the  plants  should  be  given  to  remove 
as  much  as  reasonable  of  the  polluting  matter  else  the  filtration  area  may 
be  rendered  useless  or  operated  with  great  difficulty;  that  is,  it  cannot 
purify  the  mixed  domestic  sewage  and  industrial  wastes  efficiently.  With 
the  extension  of  trunk  sewers  along  the  river  valleys  in  eastern  Massa- 
chusetts many  more  industries  will  eventually  send  their  wastes  mixed 
with  municipal  sewage  out  to  sea,  the  cheapest  and  in  most  respects  the 
most  satisfactory  method  of  disposal.  There  is  one  objection  to  this  meth- 
od, however,  if  carried  too  far,  and  that  is  the  sewage  and  wastes  of  com- 
munities more  or  less  remote  from  the  sea  may,  and  in  some  instances 
will  become  a  nuisance  to  communities  on  the  seashore ;  that  is,  the  nuis- 
ance will  be  passed  from  the  guilty  to  the  innocent  community, — a  most 
unfair  procedure. 

There  are  many  statements  by  those  who  have  written  on  this  subject 
in  regard  to  the  small  amount  of  work  that  has  actually  been  done  in  this 
country  concerning  investigations  of  waste  treatment.  As  a  matter  of 
fact,  however,  in  Massachusetts  the  actual  construction  of  plants  on  a 
practical  scale  has  not  kept  step  with  the  knowledge  gained  from  experi- 
mental work.  That  is  quite  natural  because,  as  has  been  stated  already, 
it  is  difficult  to  persuade  manufacturers  or  corporations  to  expend  money 
for  treatment  plants  as  there  is  always  a  chance  that  not  only  will  meth- 
ods for  treatment  be  improved  but  that  if  sufficient  work  is  done  by  the 
industrialists  themselves  through  their  skilled  chemists  and  other  em- 
ployees not  only  will  much  pollution  be  removed  from  our  streams  but 
methods  for  the  recovery  of  valuable  by-products  be  discovered. 

Finally,  practically  all  industrial  waste  problems  are  actually  river  or 
stream  problems  and  the  organization  of  River  Boards  made  up  of  repre- 
sentatives of  the  industries,  of  the  communities  most  affected  by  pollu- 
tion, and  Departments  of  Health,  might  well  be  the  most  effective  way  of 
grappling  with  these  problems;  and,  indeed,  this  is  done  in  Germany, 
England  and  to  some  extent  in  this  country. 


76 
LABORATORY  SUPERVISION  OF  MILK* 

David  L.  Belding,  M.D. 

Department  of  Pathology  and  Bacteriology 
Boston  University  School  of  Medicine 

The  production  of  milk  safe  for  human  consumption  has  followed  two 
main  lines: 

1.  Production  under  hygienic  conditions  to  give  maximum  nutritive 
value  and  comparative  freedom  from  disease-producing  bacteria. 

2.  Pasteurization  to  render  milk  safe  despite  sanitary  defects  in  pro- 
duction and  handling. 

The  former  places  greater  emphasis  on  clean  milk  and  the  latter  on 
safe  milk,  but  both  are  essential  for  a  well-regulated  milk  supply.  Safe 
milk  is  milk  which  has  been  both  properly  produced  and  properly 
pasteurized. 

In  order  to  meet  the  requirements  of  clean  and  safe  milk,  standards 
governing  the  production  and  handling  of  milk  have  been  established. 
It  is  my  purpose  to  discuss  certain  phases  of  the  bacteriological  tests 
which  form  an  essential  part  of  the  standards  for  judging  milk. 

Table  1. — Milk  Standards 

Chiefly  concerned  with 


Cleanliness 

Freedom 

Standards 

and 

from 

Quality 

Disease 

Sanitary 

Dairy  Building 

— 

Production 

— 

Transportation 

— 

Cows 

+ 

Employees 

Pasteurization 

— 

+ 

Laboratory 

Physical 

— 

Chemical 

— 

Bacteriologic 

Non-pathogenic 

+ 

— 

Pathogenic 

+ 

A.    General  Laboratory  Tests 

The  more  common  laboratory  tests  have  been  designed  for  the  purpose 
of  determining  whether  a  sample  of  milk  came  up  to  a  designated  stand- 
ard and  are  not  directly  concerned  with  the  transmission  of  human  dis- 
ease. They  are  designed  for  the  production  of  (1)  good  quality  milk, 
(2)  clean  milk,  and  indirectly  as  a  result  of  the  first  two  (3)  safe  milk. 

Good  Quality  Milk. 
The  quality  of  the  milk  is  largely  determined  by  physical  and  chemical 
tests,  although  bacteriological  tests  also  furnish  information.  Physical 
tests  include  color,  taste,  odor,  specific  gravity,  etc.  Among  the  various 
chemical  tests  the  most  important  are  fat  and  total  solids,  indicating 
skimming  and  a  high  water  content.  In  this  connection  the  work  of 
Tocher1  regarding  the  variations  in  butter  fat  and  water  in  the  milk  of 
individual  cows  is  of  interest.    He  obtained  from  676  unselected  cows 


*  Read     at    the     Annual     Convention     of     the     Massachusetts     Milk     Inspectors'     Association,. 
Worcester,    Mass.,    January    7-8,    1931. 


77 
milk  varying  in  water  content  from  82  to  90  per  cent  and  concluded  that 
it  was  practically  impossible  to  determine  whether  milk  has  been  watered 
or  not  unless  the  original  water-content  of  the  milk  was  known.  He  also 
found  that  the  butter  fat  varied  from  1.63  to  7.38  per  cent  in  these  cows 
although  the  average  was  well  over  4  per  cent  and  that  the  variations 
tended  to  disappear  when  the  milk  was  mixed  in  proportion  to  the  num- 
ber of  cows. 

Clean  Milk. 
Clean  milk  tends  to  insure  a  safe  milk.    The  presence  of  dirt  may  be 
determined  by  eye  or  by  filtering  but  clean  milk  is  ordinarily  determined 
by  bacteriologic  methods,  since  the  number  of  bacteria  in  fresh  milk 
usually  indicates  the  cleanliness  of  production. 

Bacteria  in  Milk. 
Even  when  drawn  aseptically  milk  always  contains  a  certain  number  of 
bacteria  which  are  derived  from  the  teat  canals.  When  aseptic  precau- 
tions are  not  employed,  bacteria  are  in  greater  abundance  and  are  derived 
from:  (1)  skin  of  the.  udder,  (2)  dirt  in  the  milk  vessels  and  utensils, 
(3)  dirt  on  the  milker's  hands  and  clothing,  and  (4)  dust  in  the  atmos- 
phere of  the  milking  shed.  The  number  of  bacteria  in  milk  depends  upon 
the  care  with  which  it  is  collected,  the  temperature  at  which  it  is  kept, 
and  the  time  during  which  it  is  stored.  The  various  bacteria  in  milk  may 
be  classified  as  follows : 

1.  Acid-forming  bacteria,  such  as  the  streptococcus  lacticus 

2.  Gas-forming  bacteria,  such  as  members  of  the  colon  group  and 
anaerobes,  as  C.  Welchii  and  C.  Butyricum. 

3.  Proteolytic  bacteria.    Such  as  B.  subtilis,  B.  mesentericus,  and 
Proteus  vulgaris. 

4.  Inert  bacteria,  which  cause  no  visible  change  in  milk. 

5.  Pathogenic  bacteria,  from  bovine  and  human  sources. 

Bacteriological  Tests. 
Excluding  colorimetric  tests  with  chemical  indicators,  three  methods 
are  employed  in  the  bacteriological  laboratory  for  the  determination  of 
clean  milk:  (1)  total  count;  (2)  milk  sediment;  and  (3)  colon  count. 

1.  Total  Count. — The  number  of  bacteria  per  cubic  centimeter  of  milk 
is  determined  by  direct  count  and  by  plating,  the  latter  being  the  stand- 
ard procedure.  Since  plating  only  gives  the  number  of  viable  bacteria 
and  records  clumped  bacteria  as  single  individuals,  it  differs  from  the 
direct  count,  particularly  with  pasteurized  milk. 

The  plate  count  is  subject  to  several  sources  of  error.  Among  these 
may  be  enumerated  (1)  the  media,  (2)  pin  point  colonies,  (3)  spreaders, 
and  (4)  the  person  making  the  count.  Schacht  and  Robertson2  of  the 
New  York  State  Department  of  Agriculture  and  Markets  recently  carried 
out  tests  to  determine  the  personal  error.  They  found  that  careful 
workers  would  vary  5  per  cent  in  counts  on  the  same  plate  and  some 
individuals  as  high  as  25  per  cent.  One  careless  worker  gave  a  difference 
of  180  per  cent.  They  concluded  that  in  check  counts  between  two  indi- 
viduals a  variation  of  10  per  cent  is  permissible. 

A  high  count  indicates  uncleanliness  or  unsatisfactory  storage.  The 
temperature  and  the  time  of  holding  should  be  known  before  a  diagnosis 
of  unclean  methods  of  production  can  be  made  from  a  high  count.  The 
specimens  for  laboratory  examination  should  be  properly  iced  and  should 
be  brought  to  the  laboratory  as  rapidly  as  possible. 

2.  Milk  Sediment. — Examination  of  the  milk  sediment,  which  has  been 
thrown  down  in  the  centrifuge  according  to  Slack's  method,  gives  the 
cellular  content.  The  presence  of  excessive  leucocytes  and  bacteria  usually 
indicate  udder  infection. 

3.  Colon  Bacillus. — By  use  of  lactose  bile  fermentation  tests  the  pres- 
ence of  the  colon  bacillus  can  be  determined  in  the  same  manner  as  for 


78 
water.  Due  allowance  for  gas-producing  anaerobes  must  be  made.  The 
number  of  colon  organisms  can  be  determined  approximately  by  the 
amount  of  milk  added  to  the  fermentation  tube.  The  presence  of  colon- 
like bacilli  is  suggestive  but  not  absolutely  indicative  of  contamination 
of  the  milk  by  fecal  material. 

B.    Tests  for  Pathogenic  Bacteria 

Milk-borne  Diseases. — Armstrong  and  Parran3  reported  612  outbreaks 
of  disease  between  1908  and  1927  in  the  United  States  traceable  to  milk 
(567)  or  milk  products  (45).  In  211  the  character  of  the  milk  was  given 
as  raw  179,  pasteurized  29  and  certified  3.  These  facts  are  of  particular 
interest  as  they  show  that  pasteurization  without  suitable  supervision 
is  unsafe  and  that  even  when  the  pasteurization  process  is  technically 
satisfactory  the  milk  may  be  subsequently  contaminated.  It  also  shows 
that  certified  milk,  while  essentially  free  from  disease-producing  organ- 
isms, at  times  may  be  the  means  of  transmitting  disease. 

Table  2  gives  the  more  prominent  milk-borne  diseases.  The  diseases 
derived  from  human  sources  have  their  origin  in  persons  suffering  from 
the  disease  or  in  carriers  who  are  engaged  in  the  handling  of  milk.  The 
percentage  of  prevalence  is  derived  from  the  612  outbreaks  reported  by 
Armstrong  and  Parran.  Tuberculosis,  a  chronic  disease,  is  not  included 
among  these  outbreaks. 

Table  2 — Milk-borne  Diseases 


Prevalence 

Disease 

of 
Outbreaks 

Primary 

Source 

Per  cent 

Human 

Bovine 

Enteric  Diseases 

Typhoid  and  Paratyphoid 

79 

+ 

— 

Dysentery 

1 

+ 

— 

Food  poisoning 

1    t 

+ 

+ 

Streptococcus  Infections 

Mastitis  (Bovine) 

— 

+ 

Septic  Sore  Throat 

7 

+ 

Scarlet  Fever 

7 

+ 

— 

Diphtheria 

4 

+ 

— 

Undulant  Fever 

0.1 

+ 

Miscellaneous 

0.9 

Tuberculosis  -j-  -j- 

Foot  and  Mouth  -     —  -\- 

Medical  Inspection 

The  laboratory  is  an  aid  to  veterinary  surgeons  in  the  diagnosis  of  (1) 
tuberculosis  and  (2)  abortus  infection  in  cattle.  The  material  for  the 
tuberculin  test  is  prepared  in  the  laboratory.  Abortus  infection  may  be 
diagnosed  by  the  agglutination  test  or  less  frequently  by  the  complement 
fixation  test.  At  times  histo-pathologic  diagnoses  of  infected  tissues  are 
made. 

The  frequent  medical  inspection  of  milk  handlers  necessary  to  safe- 
guard milk  completely  is  practically  impossible  at  the  present  time. 
Therefore  it  is  important  to  use  all  possible  means  of  laboratory  diagnosis 
to  aid  in  the  elimination  of  dangerous  milk  handlers.  Typhoid  carriers 
are  detected  by  (1)  serum  agglutination  test  and  (2)  isolation  of  typhoid 
bacilli  from  feces  and  urine.  Diphtheria  carriers  are  identified  by  nose 
and  throat  cultures,  with  subsequent  virulence  tests.  Scarlet  fever  and 
septic  sore  throat  carriers  are  suspected  by  finding  hemolytic  streptococci 
in  their  throats.  The  diagnosis  of  pulmonary  tuberculosis  may  be  veri- 
fied by  examination  of  sputum. 


79 

Enteric  Diseases. 
The  common  enteric  diseases  are  (1)  typhoid  fever,  (2)  food  poison- 
ing by  some  member  of  the  paratyphoid  group,  and  (3)  dysentery.  The 
actual  finding  of  typhoid  or  dysentery  bacilli  is  difficult  since  the  milk 
as  a  rule  no  longer  contains  these  organisms  when  finally  examined.  The 
procedure  is  isolation  by  brilliant  green  broth  and  Endos  medium. 

1.  Typhoid. — Carriers  are  the  chief  source  ef  milk  infection  with 
typhoid  bacilli  and  more  rarely  wafer.  Carriers  may  be  detected  by  his- 
tory of  infection,  Widal  and  bacteriologic  tests  of  feces  and  urine.  Out- 
breaks due  to  milk  not  infrequently  occur. 

2.  Food  Poisoning. — Instances  of  food  poisoning  by  members  of  the 
paratyphoid  group  are  less  common.  Diagnosis  is  made  by  finding  the 
organism  in  the  feces  of  the  patients,  in  the  milk  or  in  the  cows. 

3.  Dysentery. — The  dysentery  bacteria  form  two  groups,  the  Shiga  and 
the  Flexner.  The  latter  comprises  several  strains.  Outbreaks  and  even 
epidemics  have  been  reported  from  time  to  time,  in  which  milk  has  been 
the  vehicle  of  transmission.  Fyfe1  reports  an  epidemic  due  to  the  Sonne 
dysentery  bacillus. 

Diseases  due  to  Hemolytic  Streptococci. 
The  finding  of  hemolytic  streptococci  in  milk  indicates  the  possibility 
of  (1)  Streptococcus  infection  of  the  udder  of  bovine  origin,  or  (2)  the 
possibility  of  the  presence  of  the  causative  agent  of  septic  sore  throat  or 
scarlet  fever  of  human  origin.  The  presence  of  hemolytic  streptococci 
can  be  suspected  from  the  appearance  of  the  milk  smear  but  actual  proof 
requires  isolation  on  defibrinated  blood  agar  plates.  The  differentiation 
of  scarlet  fever  and  septic  sore  throat  streptococci  from  bovine  types 
requires  special  laboratory  tests.  Hemolytic  bacteria  other  than  strep- 
tococci may  be  found. 

1.  Bovine  Mastitis. — There  is  no  conclusive  evidence  that  the  strep- 
tococci of  bovine  origin  produce  human  disease.  Smith  and  Brown5 
showed  a  differentiation  between  streptococcus  of  human  and  bovine 
origin.  However  the  Hendon  (England)  outbreak  suggests  the  possibil- 
ity that  a  scarlet  fever  type  of  disease  may  be  produced  by  certain  strains 
of  streptococci  of  bovine  origin.  Milk  from  infected  cows  is  unsuitable 
for  human  consumption  even  if  not  definitely  disease-producing.  The 
methods  of  detection  of  mastitis  are  (1)  the  examination  of  the  cow  and 
(2)  laboratory  examination  of  milk  from  individual  cows  particularly 
the  fore  milk.  Usually  there  is  close  check  between  the  laboratory  tests 
and  the  physical  examination. 

2.  Epidemic  Sore  Throat. — The  causative  organism  is  a  hemolytic 
streptococcus  of  human  origin  with  a  distinct  capsule.  Infection  reaches 
the  milk  via  the  cow  and  not  directly  from  an  infected  human  being.  An 
infected  udder  may  show  no  gross  change  and  the  infected  milk  may  be 
difficult  to  detect.    White8  gives  an  historical  account  of  these  epidemics. 

3.  Scarlet  Fever. — Milk  as  a  vehicle  for  the  dissemination  of  scarlet 
fever  is  infected  by  convalescents  or  by  patients  with  the  disease.  It  is 
a  controversal  topic  whether  this  infection  is  direct  or  via  an  infected 
udder.  Jones  and  Little7  found  a  scarlet  fever  streptococcus  in  a  cow's 
udder  in  a  milk-borne  outbreak  of  scarlet  fever.  They  also  bring  proof, 
based  on  the  inhibitory  action  of  milk,  that  direct  infection  of  milk  by  a 
carrier  does  not  produce  a  milk-borne  outbreak  of  scarlet  fever. 

Diphtheria. 
The  presence  of  diphtheria  as  a  disease  in  cows  has  never  been  estab- 
lished. The  only  lesion  which  has  any  significance  in  the  spread  of 
diphtheria  is  the  occasional  infection  of  superficial  lesions  on  the  teats 
from  the  hands  of  a  milker  who  is  a  carrier.  The  usual  source  of  infection 
is  from  a  carrier  handling  the  milk.  Epidemiologic  evidence  serves  as  the 
sole  basis  of  incrimination  of  milk  since  the  isolation  of  the  diphtheria 


80 

bacillus  from  milk  is  a  rare  event.  It  requires  the  most  stringent  labora- 
tory tests  and  in  most  instances  the  infected  milk  is  no  longer  available 
for  laboratory  examination. 

Tuberculosis. 

Tuberculosis  is  the  most  important  disease  transmitted  by  milk.  The 
bovine  bacillus  causes  an  appreciable  percentage  of  the  tuberculosis  of 
children.  Of  the  pathogenic  organisms  the  tubercle  bacillus  approaches 
in  its  thermal  death  point  most  nearly  the  pasteurizing  temperature. 
Milk  may  also  contain  tubercle  bacilli  of  human  origin.  Recent  studies 
in  bacterial  mutation  have  raised  the  question  of  the  differentiation  be- 
tween the  human  and  bovine  strains. 

The  laboratory  methods  of  diagnosis  usually  employed  are:  (1)  guinea 
pig  inoculation  with  the  suspected  milk,  (2)  cultural  methods  for  isolat- 
ing the  tubercle  bacillus,  (3)  tuberculin  test  in  cows,  and  (4)  autopsy  of 
suspected  cows.  The  elimination  of  tuberculosis  is  now  being  undertaken 
by  accredited  herds  and  accredited  areas.  Immunization  of  children  by 
B.  C.  G.,  a  low  virulent  strain,  is  being  tried  in  France.  Time  alone  will 
tell  the  success  of  these  measures. 

Undulant  Fever. 

There  are  three  varieties  of  Brucella  which  produce  similar  diseases: 
(1)  Brucella  melitensis,  which  is  the  cause  of  Malta  fever  is  transmitted 
through  goat's  milk,  (2)  Brucella  abortus  (bovine)  causes  infectious 
abortion  in  cattle  and  possibly  infects  man,  (3)  Brucella  abortus 
(porcine)  is  definitely  pathogenic  for  man. 

The  isolation  of  these  organisms  is  more  readily  obtained  from  cream. 
The  laboratory  diagnosis  of  the  disease  is  usually  by  agglutination  tests. 
Th  abortus  infection  in  cattle  is  quite  common.  Undulant  fever  in  man  is 
more  widespread  than  formerly  considered.  It  is  more  prevalent  in  the 
country  and  among  milk  handlers. 

Bibliography 

1.  Tocher,  Scottish  J.  Agric.    1926  and  1927. 

2.  Schacht,  F.  L.  and  Robertson,  A.  H.,  J.  Bact.  1931,  21,  22. 

3.  Armstrong  and  Parran,  U.  S.  Pub.  Health  Report  Suppl.  62,  1927. 

4.  Fyfe,   (Brit.)  J.  Hyg.,  1927,  26:  271-278. 

5.  Smith,  T.  and  Brown,  J.  H.,  J.  Med.  Res.,  1914,  31,  501. 

6.  White,  B.,  N.  E.  J.  Med.,  1929,  200 :  797-805. 

7.  Jones,  F.  S.,  and  Little,  R.  B.,  J.  Exp.  Med.,  1928,  47:  945-956;  and 
47:  957-963. 

FUTURE  POLICIES  IN  SANITARY  MILK  CONTROL 

James  D.  Brew 
New  York  State  Department  of  Health 

A  discussion  of  this  subject  naturally  calls  for  predictions.  In  at- 
tempting to  indicate  future  policies  there  is  no  thought  that  all  that 
might  be  prophesied  will  come  true.  To  expect  even  a  high  per  cent 
fulfillment  would,  in  fact,  be  more  or  less  presumptuous  because  milk 
control,  being  primarily  a  public  health  problem,  is  rendered  so  com- 
plex by  economical  aspects  that  are  world-wide  in  scope  and  by  bio- 
liogical  relationships  unlike  that  of  any  other  commodity,  that  any 
attempt  to  prophesy  is  fraught  with  many  uncertainties.  But  even  the 
possibility  of  falling  far  short  of  the  mark  should  in  no  way  be  al- 
lowed to  discourage  any  one  from  giving  expression  to  what  appears 
to  be  inevitable  from  existing  trends. 

One  of  our  duties  as  milk  control  officials  is  to  constantly  endeavor  to 
think  our  problem  through,  even  to  anticipating  future  ideals  and  pol- 


81 
icies.  In  fact,  it  must  be  agreed  that  ability  to  do  this,  at  least  with 
a  reasonable  degree  of  accuracy,  but  always  with  open  minds,  is  one 
of  the  earmarks  of  an  adequate  understanding  of  our  duties.  If  we 
anticipate,  in  the  light  of  the  many  changes  that  have  been  constantly 
taking  place  in  the  past,  some  of  the  changes  that  are  most  sure  to 
occur  in  the  future,  we  are  more  likely  to  be  less  dogmatic  in  many  of 
our  demands.  We  shall  be  more  tolerant  of  the  points  of  view  of  the 
man  who  pays  all  of  the  costs  of  producing  milk  and  who,  in  addition, 
is  fortunate  to  have  even  a  narrow  margin  of  profit  as  a  reward  for 
his  long  hours  of  daily  toil.  We  shall  likewise  be  more  tolerant  of  the 
point  of  view  of  that  man  who  pays  the  distribution  costs.  We  shall 
also  have  a  greater  appreciation  of  the  fact  that  the  position  of  au- 
thority we  hold,  which  enables  us  to  enforce  demands,  is  absolutely 
no  assurance  that  these  demands  are,  therefore,  based  upon  demon- 
strated truths.  The  individual  who  questions  our  decisions  is  quite 
often  apt  to  be  right,  even  though  he  may  be  unable  to  go  further 
than  to  protest. 

The  difficulties  with,  which  we  are  confronted  are  the  result  of  com- 
plications arising  from  a  combination  of  factors  which  apply  to  milk 
in  a  way  not  at  all  characteristic  of  other  foods.  As  we  all  well  know, 
milk  is  a  highly  essential  food  produced  twice  or  more  times  daily 
under  a  wide  variety  of  conditions  which  may  subject  it  to  a  number 
of  possible  bacterial  contaminations.  In  addition  to  this,  the  physical 
and  chemical  nature  of  milk  makes  it  the  most  ideal  medium  for  the 
growth  of  most  micro-organisms.  Our  control  has  had  one  aim  pri- 
marily; namely,  to  reduce  to  a  minimum  all  possibilities  of  bacterial 
contamination  and  growth.  The  bacterial  relationship  introduces  dis- 
concerting complexities  in  measuring  quality  and  to  this  must  be 
added  other  complicating  factors  that  combine  to  make  up  quality, 
such  as  the  amount  of  fat  and  solids  not  fat,  flavors,  odors,  appear- 
ance and  sediment  content.  This  in  a  very  brief  way  recalls  to  our 
minds  the  complex  nature  of  the  problem  that  is  ours. 

The  present  control  policies  are  the  outgrowth  of  trial  and  error 
because  of  the  absence  of  concrete  knowledge  to  serve  as  a  guide  and 
because  of  differences  of  opinion  as  to  what  constituted  quality  in 
milk,  combined  with  the  fact  that  we  are  still  groping  for  a  workable 
means  of  measuring  quality. 

Like  many  other  movements,  the  need  of  milk  control  was  appre- 
ciated long  ago.  Ancient  sanitarians  specified  many  of  the  same  iden- 
tical requirements  that  are  being  stressed  at  the  present  time,  and 
while  much  has  been  added  to  our  knowledge,  particularly  during  the 
last  twenty-five  years,  yet  it  cannot  be  successfully  maintained  that 
we  have  since  added  to  our  ordinances  a  whole  lot  that  has  real  sig- 
nificance in  our  enforcement  procedures,  except  pasteurization  of  milk, 
the  tuberculin  testing  of  cows  and  a  more  or  less  rigid  medical  super- 
vision of  employees  in  the  case  of  certified  milk. 

According  to  records,  milk  has  occupied  an  important  place  in  the 
diet  of  man  for  many  centuries.  Several  Old  Testament  references 
show  that  it  was  used  extensively  as  a  food  long  before  the  Christian 
era,  but  there  is  no  evidence  of  any  knowledge  of  the  possible  dangers 
in  its  consumption.  This  is  not  surprising,  however,  when  one  con- 
siders that  to  the  ancient  mind,  disease  signified  that  the  inflicted  in- 
dividual was  ill  because  of  being  "possessed  of  devils."  In  other  words, 
diseases  were  thought  to  have  been  supernatural  in  origin  and  the  prob- 
lem was  to  drive  out  the  evil  spirits  or  to  appease  the  gods. 

Long  before  the  relationship  of  micro-organisms  to  disease  had  been 
conclusively  demonstrated,  however,  the  more  profound  thinkers  had 
reasoned  that  certain  epidemics  were  spread  through  the  consumption 
of  milk.  This  idea  was  probably  not  advanced  until  the  ancient  con- 
ception of  the  supernatural  origin  of  disease  had  given  away  to  a  more 


82 
plausible,  although  erroneous  theory  known  as  the  miasmatic  theory, 
which   dominated   thought   until   late    in   the   nineteenth   century.     The 
miasmatic  theory  was  in  brief  that  diseases  emanated  from  the  sur- 
roundings as  cellars,  manure  piles,  ground  waters  and  the  like. 

As  early  as  1599  reference  is  made  to  one  of  the  earliest  records 
showing  an  appreciation  of  the  possibilities  of'  danger  in  milk  con- 
sumption. This  occurred  in  Venice  when  the  senate  forbade,  under 
penalty  of  death,  the  sale  or  use  of  butter,  milk  or  cheese  because  of 
an  epidemic.  Again  in  1682  an  edict  was  issued  demanding  that  the 
milk  should  be  buried  because  of  an  epidemic  of  murrain  among  cows. 

In  an  encyclopedia,  published  in  1739,  were  some  interesting  state- 
ments regarding  the  producing  and  handling  of  milk.  A  translation 
of  part  of  this  statement  is  as  follows: 

"Milk  was  regarded  as  a  good  food  if  it  came  from  healthy  cows 
which  were  neither  too  young  nor  too  old.  The  food  value  of  milk  de- 
pends upon  the  quality  of  the  fodder;  since  the  cows  receive  only 
straw  in  winter  and  no  hay  it  is  less  palatable.  Good  milk  must  have 
a  white  or  yellow  color;  not  green  or  blue.  The  milking  cows  must 
not  only  be  fed  regularly  but  must  be  supplied  with  clean  litter." 

"It  is  important  that  the  milking  be  done  in  a  cleanly  manner  and 
that  the  milk  maids  who  handle  the  milk  likewise  be  clean.  The  cans 
and  utensils  should  also  be  kept  clean,  washed  and  scalded." 

"The  milk  must  be  strained  through  a  cloth  after  milking.  In  ad- 
dition, cleanliness  of  the  milk  room  and  milk  cellar  is  required,  be- 
cause milk  in  unclean  rooms  becomes  sour  quickly." 

An  ordinance  related  to  milk  was  passed  as  early  as  1742  in  Paris, 
and  is  very  likely  the  first  one  on  record.  This  regulated  the  feeding 
of  animals  used  for  milk  production,  including  cows,  goats  and  asses. 
The  feeding  of  spoiled  malt  and  any  poisonous  food  was  prohibited. 
The  milk  dealers  were  forbidden  to  sell  milk  that  was  watered  or 
colored  with  eggs,  or  that  was  sour  of  injurious  to  the  health.  * 

Johann  Petrius  Frank,  who  wrote  late  in  the  eighteenth  century  is 
given  credit  for  making  the  first  attempt  to  put  hygiene  on  a  scientific 
basis.  With  reference  to  milk,  he  says:  "Milk  should  not  be  handled 
in  zinc,  lead,  copper  or  brass  vessels.  In  Paris  where  milk  is  handled 
in  copper  vessels  frequently  whole  families  were  poisoned  by  verdi- 
gris." In  this  connection  it  might  be  stated  that  in  France  the  use  of 
lead  or  copper  vessels  in  the  handling  of  milk  was  forbidden  by  law. 

Frank  further  says  that  "those  who  sell  milk  should  have  clean, 
well-lighted  and  healthful  stables.  They  should  give  the  cows  fresh 
feed  or  pasture  them  v/hich  latter  method  gives  the  cows  healthful 
exercise.    Colostral  nor  watered  milk  should  not  be  sold." 

It  is  evident  from  these  several  accounts  that  many  of  the  require- 
ments for  sanitary  milk  production  and  distribution,  that  are  being 
emphasized  at  the  present  time,  were  established  nearly  two  centuries 
ago. 

An  appreciation,  however,  of  the  importance  of  milk  quality  de- 
veloped slowly  and  was  not  confined  to  members  of  the  medical  pro- 
fession. English  agricultural  publications  of  the  middle  of  the  eight- 
eenth century  call  attention  to  the  influence  of  turnips  and  cabbage 
upon  the  flavor  of  milk  and  to  the  possibility  of  the  transmission 
through  the  cow  of  drugs  and  metallic  substances. 

That  commercial  dairy  companies  were  also  early  interested  in  milk 
quality  is  evidenced  by  the  fact  that  the  Willowbank  Dairy  of  Glas- 
gow, Scotland  in  1809  made  an  effort  to  control  the  quality  of  its  own 
milk  supply.  This  idea  was  carried  further  in  1866  by  the  Aylesbury 
Dairy  Company  of  England,  which  was  first  to  advance  1?he  idea  of 
grading  milk.  This  company  recognized  two  grades,  probably  based 
upon  their  own  experience,  of  which  one  was  considered  suitable  for 
immediate  consumption  in  the  fresh  state;  the  other  unsuitable  and 
used  for  butter.  » 


83 

A  universal  appreciation  of  the  relation  of  milk  to  health  has  been 
slow  in  development.  Little  was  known  regarding  the  exact  cause  of 
diseases,  and  progress  in  health  matters  was  retarded,  not  only  be- 
cause of  the  lack  of  information  but  because  of  the  universal  belief 
in  such  theories  as  spontaneous  generation  or  the  miasmatic  theory  of 
disease;  both  of  which  persisted  in  the  public  mind  even  long  after 
scientific  investigation  had  demonstrated  them  to  be  fallacious. 

The  persistence  of  those  old  theories  is  well  illustrated  by  the  fol- 
lowing quotation  from  Groff's  article  in  1891  on  the  "Hidden  Causes 
of  Diseases."  "As  a  rule  the  most  dangerous  place  in  an  American 
home  is  the  cellar.  It  is  often  damp  and  too  often  not  clean.  Damp, 
foul  odors  day  by  day  arise  from  the  unventilated  and  dark  cellars, 
and  pass  to  every  room  of  the  house,  carrying  seeds  of  rheumatism, 
diphtheria,  pneumonia,  colds,  consumption  and  so  on  to  the  inmates. 
Kitchen  slops  and  garbage  are  doubtless  often  the  cause  of  malaria, 
diarrheas,  dysentery  and  more  serious  troubles  in  country  and  vil- 
lage homes." 

This  statement  came  from  a  physician  who  was  at  the  time  (1891) 
president  of  the  State  Board  of  Health  of  Pennsylvania.  It  was  under 
the  influence  of  .this  type  of  thinking  that  the  modern  principles  of 
sanitary  milk  control  originated.  Certified  milk  was  officially  recog- 
nized in  1893  and  the  sanitary  requirements  governing  the  produc- 
tion of  this  class  of  milk  originated  during  that  period  when  the  er- 
roneous theory  that  diseases  emanated  from  the  surroundings  existed. 

We  must  recognize  now,  that  our  point  of  view  in  this  respect  has 
changed  completely  and  we  must  also  admit,  therefore,  that  no  small  num- 
ber of  the  sanitary  requirements  still  being  demanded  have  aesthetic  value 
only  and  have  no  sanitary  significance  as  such,  aside  from  psychological 
influences.  It  may  be  that  we  shall  always  be  justified  in  stipulating  cer- 
tain demands,  at  least,  even  though  they  have  psychological  significance 
only.  But  we  must  present  them  in  this  light  and  guard  against  the  temp- 
tation to  distort  our  reasoning  in  order  to  justify  them. 

The  introduction  of  certified  milk  unquestionably  opened  a  new  era  in 
the  improvement  of  fluid  milk  supplies.  Its  inception  established  the 
principle  of  a  classification  based  upon  sanitation  which  had  real 
economic  significance. 

Sanitarians  soon  realized  that  the  requirements  for  the  production 
of  certified  milk  were  so  costly  as  to  demand  a  retail  price  per  quart 
that  was  prohibitively  high  for  most  consumers.  It  was  recognized, 
however,  that  there  was  a  place  in  the  market  for  this  most  expensive 
but  safest  raw  milk.  The  real  problem  was  to  make  available  a  safe 
milk  supply  produced  at  a  lower  cost.  Toward  this  end  numerous 
agencies  have  since  been  striving.  The  path  of  progress  has  been  be- 
set with  obstacles,  many  of  which  were  economic  in  nature,  but  de- 
spite the  difficulties  encountered,  the  health  department  in  city  after 
city  in  rapid  succession  undertook  the  task  of  safeguarding,  as  best  it 
could,  its  own  local  milk  supply. 

All  earlier  efforts  to  improve  milk  supplies  were  guided  by  ordi- 
nances patterned  after  the  requirements  for  certified  milk  production 
and  were  based  entirely  upon  specifying  certain  requirements  with 
which  the  producer  was  to  comply.  The  producer  had  no  choice  in  the 
matter,  even  though  he  paid  all  costs  of  production  entailed  by  these 
extra  demands.  Usually  no  legal  machinery  was  provided  for  an  ade- 
quate enforcement.  Control  officials  were  forced  to  rely  mostly  upon 
appeals  to  the  pride  of  the  producers  and  distributors  of  milk.  Diffi- 
culties in  enforcement,  however,  due  primarily  to  lack  of  organiza- 
tion, lack  of  funds  and  a  sympathetic  public  support,  led  officials  to 
consider  various  means  of  facilitating  the  administration  of  control 
and  of  stimulating  a  deeper  interest.  New  policies,  one  after  another, 
have  since  been  tried  out. 


84 

Koch's  development  in  1881  of  solidified  nutrient  media  made  the 
bacteria  count  possible.  In  1893  the  Chicago  Board  of  Health  was 
first  to  report  official  counts  upon  236  samples  of  milk.  According  to 
Rosenau,  the  first  attempt  to  enforce  a  fixed  bacteria  count  limit  was 
made  by  the  New  York  City  Board  of  Health  in  1900.  The  limit  was 
1,000,000  per  cubic  centimeter,  but  the  idea  was  abandoned  because 
it  was  found  "practically  impossible  to  enforce  such  a  standard  for 
the  City  of  New  York  on  account  of  the  complexity  and  the  enormous 
volume  of  the  milk  trade  of  that  city.  The  principal  difficulty  was  to 
place  the  responsibility  when  milk  was  found  to  contain  an  excessive 
number  of  bacteria,  as  the  milk  passed  through  so  many  hands  before 
it  was  delivered  to  the  consumer." 

In  1905  the  Boston  Board  of  Health  established  the  first  legal  limit 
at  500,000  per  cubic  centimeter. 

While  the  fundamental  principles  of  bacterial  control  were  recog- 
nized as  sound,  yet  the  limitations  of  bacteria  counts  soon  became  ap- 
parent. Neither  the  producer  nor  the  consumer  understood  their  sig- 
nificance and  since  the  control  officials'  comprehension  of  their  true 
significance  left  much  to  be  desired,  it  was  difficult  to  enlist  the  nec- 
essary interest  to  realize  the  success  that  was  hoped  for  by  the  more 
ardent  supporters  of  the  principle  of  bacterial  control. 

The  importance  attached  to  the  conditions  surrounding  the  produc- 
tion and  handling  of  milk  was  uppermost,  however,  in  the  minds  of 
the  rank  and  file  of  all  officials  interested  in  milk  control.  Difficulty 
in  enforcing  their  requirements,  even  after  being  written  into  an  or- 
dinance, proved  to  be  a  discouraging  handicap.  It  is  needless  to  elab- 
orate upon  some  of  the  reasons.  Lack  of  public  support  arose  no  doubt, 
from  lack  of  interest  because  the  consumer's  notion  of  milk  quality 
differed  entirely  from  that  held  by  the  medical  profession.  Lack  of 
laboratory  facilities  and  of  enforcement  personnel  were  other  limit- 
ing factors.  Inability  to  show  graphically  the  results  of  control  and 
of  progress  proved  also  a  serious  embarrassment. 

The  need  of  some  stimulating  procedure,  however,  was  universally 
recognized  and  the  thought  was  finally  conceived  that  some  mathe- 
matical expression  of  the  condition  surrounding  production  might  an- 
swer this  perplexing  question.  It  was  naturally  reasoned  that  if  such 
a  method  could  be  devised  it  would  serve  as  a  guide  to  all  and  as  a 
valuable  permanent  record  for  comparisons.  An  effort  to  meet  this 
need  was  made  when  the  now  familiar  dairy  barn  score  card  was  pro- 
posed in  1904.  It  is  unnecessary  to  describe  these  score  cards  at  this 
time.  Neither  is  it  necessary  to  elaborate  upon  their  advantages  and 
disadvantages.  This  method  of  expressing  conditions  mathematically 
was  unquestionably  an  outstanding  forward  step  in  the  direction  of 
better  milk  supplies. 

Much  to  the  surprise  of  the  originators  and  especially  of  the  ardent 
supporters,  the  numerical  dairy  barn  score  card  relatively  soon  fell 
into  disuse.  It,  too,  failed  to  stimulate  the  desired  interest  and  doubt- 
less the  fundamental  reason  was  as  above  stated,  that  the  concep- 
tion of  milk  quality  as  held  by  the  producer  and  the  consumer  corre- 
sponded in  no  way  to  that  of  milk  control  officials  in  whose  hands 
rested  the  responsibility  of  defining  sanitary  milk  requirements.  The 
fact  is  that  the  numerical  score  card  was  an  arbitrary  attempt  to 
measure  and  express  in  mathematical  terms  dairy  barn  conditions  and, 
as  was  discovered  later,  in  no  way  reflected  the  quality  of  the  milk 
because  many  items  were  purely  aesthetic  and  others  were  magnified 
out  of  all  proportions  to  their  true  significance.  Officials  representing 
health  departments  and  colleges  fell  into  the  error  of  assuming,  how- 
ever, that  there  was  a  definite  relation  between  the  numerical  barn 
score  and  the  quality  of  milk.  Many  officials,  in  fact,  were  so  sure  of 
this  correlation,  their  reasoning  being  based  upon  what  appeared  tp  be 


85 
logical  rather  than  upon  the  results  of  research,  that  they  even  thought 
milk  could  be  graded  accordingly. 

The  mention  of  "grades"  of  milk  introduces  the  latest  policy  that 
has  spread  throughout  the  United  States  since  its  official  adoption  in 
1911  at  New  York  City.  When  it  comes  to  discussing  this  policy,  es- 
pecially in  pointing  out  the  shortcomings,  I  am  fully  aware  of  the  fact 
that  I  may  be  treading  upon  the  pet  theories  of  many  interested  in 
milk  quality.  But  just  as  with  the  application  of  the  principle  of  bac- 
terial control  and  the  scoring  of  dairy  barns,  there  are  also  certain  in- 
herent limitations  in  this  principle  which  vast  numbers  are  reluctant 
to  admit  but  are  beginning  to  recognize.  Certain  indisputable  conse- 
quences are  inevitable,  irrespective  of  whether  or  not  we  enforce  or 
do  not  enforce  an  ordinance.  What  I  shall  say  on  this  particular  point 
applies  to  all  ordinances  in  which  an  endeavor  has  been  made  to 
"grade"  milk.  There  is  no  special  reason  for  believing  furthermore 
that  any  one  ordinance  is  significantly  superior  to  any  other  so  far  as 
obtaining  improved  milk  supplies  is  concerned. 

As  soon  as  it  became  apparent  during  the  latter  part  of  the  first 
decade  of  this  century  that  neither  the  bacterial  count  nor  the  numer- 
ical barn  score  stimulated  the  expected  interest  in  quality,  individuals 
interested  in  the  matter  turned  to  other  possible  policies. 

Attention  was  naturally  drawn  to  the  possibilities  of  grading  milk 
according  to  quality  because  of  the  fact  that  various  other  com- 
modities such  as  wool,  hay,  wheat  and  the  like  were  being,  apparently, 
successfully  graded.  The  grading  of  these  commodities  according  to 
fixed  and  easily  recognizable  standards  of  quality  made  it  possible 
for  the  customer  to  select  intelligently.  The  price  differences  which 
were  based  upon  grade  served  as  a  stimulus  to  the  producer  to  furnish 
a  better  quality  of  product.  Sanitarians  consequently  reasoned  that  if 
milk  could  also  be  graded  according  to  quality,  the  consumer  would 
very  likely  choose  the  better  grades  and  as  a  result  the  poorer  grades 
would  automatically  disappear  from  the  market. 

Commissions  were  appointed  to  define  milk  grades.  But  their  prob- 
lem was  far  more  difficult  and  complex  than  was  the  grading  of  apples, 
eggs,  hay  and  the  like.  The  universal  conception  of  quality  in  these 
products  is  based  upon  characteristics  that  are  visible,  more  or  less 
easily  measurable,  which  do  not  change  (or  if  they  do,  do  so  very 
slowly)  and  are  of  such  a  nature  as  to  make  regrading  possible,  if 
necessary.  The  grading  of  such  products  is  purely  economic,  the  public 
health  not  being  involved  at  all. 

Milk,  however,  is  a  liquid  in  which  the  factors  that  combine  to  make 
quality  are  constantly  changing  because  they  are  almost  entirely  bac- 
teriological and  chemical,  and  therefore  invisible.  Because  of  the  phy- 
sical and  chemical  nature  of  milk,  it  is  highly  perishable  unless  ex- 
treme care  is  exercised  in  handling.  The  judging  of  these  factors  re- 
quires elaborate  laboratory  procedures.  Moreover,  there  is  a  very  de- 
,  finite  public  health  problem  which  is  universally  recognized. 

To  circumvent  this  dilemma  these  milk  commissions  evidently  reasoned 
that  the  denning  of  different  conditions  surrounding  production,  com- 
bined with  maximum  bacteria  count  and  temperature  limits,  would 
grade  milk  as  satisfactorily  as  the  visible,  fixed  and  more  or  less 
easily  measurable  characteristics  made  it  possible  to  grade  apples,  for 
example,  and  would  equally  as  well  attract  the  interest  of  the  con- 
sumer and  producer. 

I  am  not  in  any  way  condemning  the  principle  of  grading  milk  but 
am  calling  attention  to  the  numerous  erroneous  assumptions  that  are 
presented  to  the  public  as  if  they  were  demonstrated  truths  based  upon 
scientific  studies.  I  am  also  pointing  out  that  judging  from  the  con- 
sumer's and  the  producer's  points  of  view,  the  present  day  application 
of  the  principle  of  grading  milk  is  proving  equally  as  inadequate  as 


86 

the  older  attempts  to  judge  milk  supplies  by  the  numerical  barn  score. 
Yet  we  are  making  unmistakable  progress  in  improving  the  quality  of 
milk  supplies  because  underneath  all  of  the  efforts  that  have  been  made 
we  have  been  steadily,  althought  at  times  with  discouragingly  slow 
speed,  spreading  the  gospel  regarding  the  few  essentials  that  are  nec- 
essary to  insure  milk  of  a  desirable  quality. 

The  fact  that  there  was  no  demonstrable  relation  between  the  barn 
conditions  and  the  actual  quality  of  the  milk  itself  was  shown  some  18 
years  ago.  The  publication  of  these  observations  proved  quite  dis- 
turbing in  sanitary  milk  control  circles,  but  there  has  since  been  a 
growing  tendency  in  the  direction  of  looking  at  the  question  of  milk 
control  from  the  point  of  view  of  the  essentials  only.  The  economics 
of  milk  production  demand  greater  attention  to  this  fact,  even  though 
it  must  be  admitted  that  it  is  not  easy  to  secure  an  agreement  upon 
what  is  essential  and  what  is  not. 

Must  we  not  sooner  or  later  make  up  our  minds  to  the  fact  that 
three  square  feet  or  more  of  light  in  one  barn  and  less  than  this  in 
another  does  not  make  two  grades  of  milk?  Neither  does  a  cement 
floor  in  one  stable  as  compared  with  wooden  floors  in  another  mean 
different  grades;  nor  does  whitewashing  of  stables,  clipping  of  cows, 
screening  and  a  number  of  others.  Some  maintain  that  in  their  ordi- 
nances they  have  included  a  different  combination  of  factors  for  one 
grade  than  for  another.  But  how  can  combinations  of  unrelated  factors 
better  the  situation?  Such  combinations  are  also  arbitrarily  decided 
upon  according  to  opinion  rather  than  according  to  demonstrated 
truths  and  to  advance  this  kind  of  an  argument  is  merely  throwing 
down  a  barrage  of  words  arranged  in  sentences  which  seem  to  express 
thoughts  that  appear  to  be  logical  and  therefore  difficult  for  the  pro- 
ducer or  the  consumer  to  fully  comprehend,  since  again  as  stated  above 
their  conception  of  quality  does  not  correspond  to  that  implied  by  the 
label. 

If,  instead  of  grading  apples  according  to  size,  color  and  the  like, 
we  graded  them  according  to  number  of  times  the  orchard  was  sprayed, 
the  type  of  tillage  practiced  and  the  type  of  container  in  which  they 
were  packed,  we  would  be  following  the  same  procedures  employed  in 
our  modern  attempts  to  grade  milk.  Suppose  eggs  were  graded — not 
according  to  color,  size  and  the  like — but  according  to  the  building  in 
which  they  were  laid.  Or,  suppose  students  should  be  rated — not  ac- 
cording to  the  scholastic  ability  manifested — but  according  to  the  build- 
ings and  equipment  which  make  up  their  surroundings.  I  am  not  belittling 
the  importance  of  surroundings,  but  when  we  place  so  much  emphasis 
upon  them  as  we  do  in  milk  control,  we  are  diverting  much  attention  from 
the  product  itself.  Fine  school  buildings  and  well  equipped  laborator- 
ies are  most  desirable,  but  we  must  not  forget  that  Pasteur  did  much 
of  his  great  work  in  an  "uninhabitable  garret."  If  we  should  base  our 
judgment  upon  surroundings  as  we  do  in  milk  control,  then  Pasteur 
was  a  failure  and  the  most  indifferent  student  of  our  present  day  an 
outstanding  success.  Altogether  too  many  of  our  efforts  in  milk  con- 
trol enforcement  divert  the  attention  of  the  producer  away  from  those 
few  factors  that  are  vital  to  milk  quality.  This  is  merely  a  change  in 
viewpoint,  but  one  thing  absolutely  certain  is  that  by  constant  direct- 
ing of  attention  to  the  product  milk  itself  and  to  the  factors  that  de- 
termine quality,  such  as  bacterial  control,  freedom  from  sediment, 
odors  and  flavors  and  freedom  from  dangers  of  infection,  a  dairyman 
becomes  a  better  dairyman,  he  learns  the  true  essentials  and  will,  in 
spite  of  himself,  gradually  adopt  better  methods.  He  will  keep  his 
cows  clean,  keep  the  stable  clean,  sterilize  the  utensils  and  properly 
cool  the  milk,  and  we  as  milk  control  officials  won't  have  to  continue 
attempting  to  do  the  impossible,  which  is  to  make  every  man  follow  the 
same  identical  procedure,  thereby  forbidding  even  the  most  intelligent 
dairymen  the  right  to  exercise  their  own  ingenuity. 


87 

My  ten  years  experience  in  extension  teaching  has  led  to  an  in- 
creasingly profound  respect  for  the  knowledge  and  the  sound  thinking 
of  the  great  majority  of  our  American  farmers.  Yet  in  the  adminis- 
tration of  too  much  of  our  sanitary  milk  control,  especially  that  of  the 
past,  there  is  the  unmistakable  implication  that  they  are,  as  a  class, 
of  a  comparatively  low  degree  of  intelligence.  We  must  not  forget  that 
the  dairyman  has  often  literally  put  us  on  the  defensive  because  of  the 
inconsistencies  in  our  demands  or  because  he  discovers  that  some  of 
our  claims  cannot  be  substantiated  by  facts.  Some  may  object  to  such 
a  frank  admission,  but  it  will  greatly  strengthen  our  cause  in  the  future 
to  face  the  truth,  rather  than  to  evade  our  own  mistakes. 

There  is  much  to  be  said  in  favor  of  the  policy  of  confining  all  of 
our  demands,  so  far  as  possible,  to  factors  that  are  a  part  of  the  milk 
itself.  If  a  dairyman  delivers  consistently  clean,  low  bacteria  count 
milk  of  good  flavor  from  healthy  cows,  I  am  wondering  if  it  is  anyone's 
business  as  to  just  what  is  done  on  the  dairy  farm.  There  are  limita- 
tions to  this,  no  doubt.  But,  if  a  dairyman  wishes  to  sterilize  by  means 
of  hypochlorites  or  by  prolonged  heating  in  water  at  ordinary  pasteur- 
ization temperature,  or  by  momentary  heating  at  much  higher  tem- 
peratures, or  even  by  the  use  of  proper  alkaline  solutions  at  lukewarm 
temperatures,  why  not  allow  him  to  follow  his  own  inclinations? 
There  are  a  number  of  other  illustrations  that  could  be  used,  but  this 
is  sufficient  for  the  point  I  have  in  mind.  If  we  insist  upon  every 
dairyman  following  our  specified  procedure,  there  is  naturally  bound 
to  be  resistance,  evasion  and  lessened  confidence.  How  would  we  enjoy 
having  someone  in  authority  insist  that  we  shave  every  morning  at  a 
specified  hour  and  that  we  use  only  the  old  straight  blade  razor?  We 
are  all  far  more  apt  to  use  most  efficiently  the  procedure  that  fits  best 
into  our  own  personal  scheme  of  things. 

Please  understand  that  I  am  not  making  these  comparisons  nor  de- 
veloping the  general  ideas  with  any  thought  of  disparaging  the  prin- 
ciple of  grading  milk.  We  shall  always  have  some  system  of  classify- 
ing milk,  but  as  public  health  officials  we — in  keeping  with  our  duties 
of  protecting  the  public  health — must  guard  against  the  ever  present 
and  sometimes,  I  fear,  almost  inevitable  danger  of  being  maneuvered 
into  the  anomalous  situation  of  appearing  to  approve  certain  practices 
which  have  economic  but  no  public  health  significance.  We  may  be 
increasing  the  cost  of  producing  milk  on  the  farm  or  of  handling  in 
the  plant,  by  insisting  upon  non-essential  but  more  or  less  costly  re- 
finements. If  we  are  absolutely  honest  with  ourselves,  it  would,  in- 
deed, prove  to  be  a  most  embarrassing  question  to  have  the  consumer 
ask  whether  or  not,  from  a  sanitary  point  of  view,  some  of  the  grades 
permitted  by  our  ordinances  were  actually  worth  two  cents  more  per 
quart  than  other  grades,  especially  if  asked  regarding  two  grades  of- 
fered for  sale  by  the  same  company.  The  usual  procedure,  in  order  to 
maintain  policies  when  confronted  with  such  a  question,  is  to  give  an 
evasive  answer  that  carries  no  definite  information  and  which  still 
leaves  the  questioner  in  a  quandary. 

Our  health  departments,  in  discharging  their  real  duty  to  the  con- 
sumer and  to  the  producer  too,  cannot  long  continue  under  the  present 
system  which  in  too  many  places  throughout  the  United  States  permits 
a  multiplicity  of  grades  that  are  based  upon  phraseology  rather  than 
upon  any  defensible  or  demonstrable  differences  in  milk  supplies  being 
graded.  In  one  case,  for  example,  three  so-called  grades,  Certified, 
Guaranteed  and  Grade  A  Raw,  were  reported  from  one  source  and 
selling  at  28,  20  and  14  cents  per  quart  respectively.  One  man  asked 
what  difference  it  made  so  long  as  all  of  the  milk  qualified  for  certi- 
fication. He  was  a  seller  of  milk  and  I  could  see  his  viewpoint.  But  as 
health  officials  we  are  justified  in  asking,  should  an  honestly  managed 
industry  expect  us  to  remain  in  silence  regarding  a  situation  which 


88 
makes  it  appear  that  we  support  the  implication  that  the  Certified  or 
the  Guaranteed  in  this  case  was  safer  than  the  A  raw  and  both  were, 
therefore,  worth  to  the  consumer  the  difference  of  14  and  6  cents  re- 
spectively? It  would  be  possible  for  me  to  multiply  such  illustrations 
in  the  field  of  ordinary  market  milk,  but  this  is  sufficient  to  bring  out 
the  point. 

If  we  are  to  continue  the  grading  principle  honestly,  all  concerned 
must  face  the  facts  squarely  and  as  soon  as  possible  make  the  neces- 
sary and  defensible  readjustments. 

Men  have  said  that  this  difficulty  is  traceable  to  lax  enforcement  of 
ordinances.  It  may  be  that  is  true  in  part,  but  the  health  department 
is  not  the  only  one  who  has  the  whole  responsibility  to  bear.  The  re- 
sponsibility is  borne  equally  by  the  producer  and  particularly  by  the 
distributor.  What  happens  as  soon  as  ordinances  are  actually  en- 
forced? All  cases  of  unhealthy  animals  and  humans  are  brought  un- 
der as  good  a  control  as  possible.  All  milk  containing  sediment  is 
eliminated  to  an  irreducible  minimum.  All  bacterial  counts  in  excess 
of  the  limits  are  reduced  to  a  low  percentage — 100  per  cent  being  im- 
possible. In  short,  all  carelessness  in  the  barn  or  milk  room  with  ref- 
erence to  cleanliness  or  to  the  cooling  of  the  milk  is  eliminated  so  far 
as  that  is  humanly  possible  and  here  again  we  cannot  expect  100  per 
cent  perfection.  As  soon  as  this  happens,  then  upon  what  basis  are  we 
to  grade  milk  from  a  sanitary  point  of  view?  If  an  ordinance  is  not 
enforced,  then  it  is  equally  difficult  to  substantiate  a  claim  that  there 
is  a  sanitary  difference  between  the  grades.  These  are  vitally  funda- 
mental questions  to  be  faced  frankly  by  all  concerned  in  control,  pro- 
duction and  in  distribution. 

We  are  beyond  a  shadow  of  doubt  confronted  with  the  certain  pros- 
pect of  a  more  rigid  enforcement  of  ordinances  all  over  the  United 
States.  The  enforcement  will  be  more  effective  in  some  places  than  in 
others.  As  a  result  of  more  rigid  enforcement,  we  are  gradually  com- 
ing to  fewer  classes  or  grades.  We  are  approaching  the  time  when  uni- 
versally, from  the  point  of  view  of  sanitary  milk,  there  will  be  but 
three  classes  of  milk  in  general,  namely,  Certified,  a  rigidly  controlled 
medically  supervised  Raw j  Milk,  and  a  high  quality  Pasteurized  Milk. 
From  the  point  of  view  of  public  health  these  are  all  that  health  offi- 
cials should  recognize.  In  most  places  there  will  be  but  two  classes  at 
the  most  and  in  many  but  one,  and  we  are  ultimately  not  going  to  split 
either  of  these  into  sub-grades  under  the  pretext  of  sanitation  because 
we  are  going  to  gradually  eliminate  to  an  irreducible  minimum  all 
carelessness.  This  cannot  be  done  100  per  cent  as  just  stated  and  those 
few  recurring  and  usually  temporary  cases  of  non-compliance  will 
fluctuate  so  much  from  one  individual  to  another  that  it  will  be  im- 
possible to  place  them  in  a  separate  class  as  was  the  original  intent  of 
the  grading  scheme.  In  the  best  controlled  Certified  supplies  there  are 
bound  to  occur  an  occasional  bacteria  count  even  considerably  in  ex- 
cess of  the  10,000  limit.  And  once  in  a  while  there  will  occur  a  lot  of 
milk  possessing  an  undesirable  flavor.  This  will  occur  also  in  the  best 
controlled  pasteurized  supplies.  It  has  always  happened  any  way  and 
is  most  likely  to  continue. 

Subdividing  any  of  the  above  classes  according  to  fat  content  for 
example  is  defensible,  but  this  is  an  economic  question  and  not  one 
for  public  health. 

The  duty  of  the  inspector  will  be,  or  if  properly  administered,  should 
be  always  in  the  direction  of  rendering  a  cooperative  service  based 
upon  the  dissemination  of  the  truth  and  upon  procedures  designed  to 
prove  and  locate  causes  of  trouble  and  thereby  win  the  confidence  of 
the  men  who  produce  and  distribute  the  milk.  There  is  no  more  dead- 
ening type  of  administration  than  that  in  which  the  milk  or  dairy  in- 
spector is  supposed  to  spend  most  of  his  time  tip-toeing  around  in  an 


89 
effort  to  catch  men  off  guard,  and  who  is  supposed  to  find  some  fault 
with  something  at  every  inspection. 

Sanitary  milk  control  is  a  real  responsibility,  the  execution  of  which 
depends  primarily  upon  an  educational  approach  and  upon  a  con- 
genial, cooperative  spirit  between  the  control  officials  and  the  industry. 
No  intelligent,  redblooded  individual  will  be  long  content  in  a  position, 
the  policies  of  which  consist  in  constantly  displaying  one's  police 
powers,  or  which  forbid  him  the  right  to  frankly  present  the  funda- 
mental truths. 

SANITATION   OF   FOOD  ESTABLISHMENTS 

Hermann  C.  Lythgoe,  Director 
Division  of  Food  and  Drugs 

It  can  within  certain  limits  be  said  that  we  are  just  beginning  to 
scratch  the  surface  of  our  work  regarding  sanitation  in  food  establish- 
ments. Some  years  ago,  when  we  were  finding  chemical  preservatives  in 
beer,  I  inquired  of  a  friend  of  mine,  closely  associated  with  the  brewery 
business,  as  to  why  such  material  was  being  used.  He  replied  that  Rome 
was  not  built  in  a  day,  and  that  the  employees  engaged  in  the  manu- 
facture of  beer  were  not  so  well  informed  upon  matters  relating  to  sani- 
tary science  as  those  of  us  who  had  the  advantage  of  a  technical  education. 

Our  advance  in  the  sanitary  control  of  food  handling  has  been  greatest 
in  relation  to  those  foods  which  are  most  liable  to  cause  serious  trouble 
if  handled  and  stored  under  unsanitary  conditions.  This  has  resulted  in 
a  tremendous  improvement  in  the  sanitary  production,  transportation, 
handling,  and  processing  of  milk,  which  has  been  carried  on  under  dis- 
tinctive laws  relating  to  that  substance. 

The  earliest  law  relating  to  sanitation  of  establishments  relating  to  food 
other  than  milk  is  found  in  the  law  which  gives  boards  of  health  of  cities 
and  towns  the  authority  to  make  regulations  relative  to  conditions  under 
which  articles  of  food  may  be  kept  or  exposed  for  sale  in  order  to  prevent 
contamination  thereof  and  injury  to  the  public  health.  This  law  i$  now  in 
existence  and  it  should  be  carefully  noted  that  it  contains  no  reference  to 
the  conditions  under  which  food  is  manufactured. 

Attempts  were  made  to  control  sanitary  conditions  of  food  establish- 
ments by  provisions  relative  to  licensing  of  the  industries.  For  example, 
— persons  carrying  on  an  establishment  for  the  manufacture  of  sausages 
or  chopped  meat  or  for  the  breaking  out  of  eggs  for  food  purposes  must 
obtain  from  the  board  of  health  of  the  town  where  the  industry  is  located 
a  license  to  carry  on  the  business.  Recently,  this  license  provision  has 
been  extended  to  the  manufacturers  of  ice  cream,  and  under  the  latter 
law,  the  boards  of  health  of  the  towns  are  authorized  to  make  regulations 
as  to  the  conditions  under  which  the  establishments  are  operated.  Slaugh- 
terhouses are  also  required  to  be  licensed  by  the  town  where  located. 
These  licenses  are  issued  by  the  Mayor  and  Aldermen  or  such  officers  as 
they  shall  delegate  or  by  the  Board  of  Selectmen  in  a  town  or  by  the 
Board  of  Health  if  any  in  towns  having  a  population  of  five  thousand. 

The  Department  of  Public  Health  deemed  it  advisable  to  recommend 
to  the  Legislature  of  1924,  an  act  providing  for  further  sanitary  control 
of  food.  This  resulted  in  the  passage  of  Chapter  50  of  the  Acts  of  1924, 
which  is  now  Section  305A  of  Chapter  94  of  the  General  Laws,  which 
provides  a  penalty  for  manufacturing,  preparing,  exposing,  storing, 
handling,  or  distributing,  etc.  food  in  or  from  an  unclean,  unsanitary,  or 
unhealthful  establishment,  etc.  or  under  unclean,  unsanitary,  or  unhealth- 
ful  conditions.  The  law  furthermore  provides  that  it  should  not  apply  to 
milk  or  any  other  articles  of  food  which  were  covered  by  the  statutes  above 
mentioned.  Under  this  law  we  then  had  an  opportunity  of  requiring  sani- 
tary conditions  to  exist  in  places  manufacturing  or  handling  food,  regard- 
ing which,  prior  to  that  time,  no  such  requirements  existed. 


90 

In  addition  to  these  laws,  there  is  a  special  law  relating  to  bakeries, 
which  is  enforced  by  the  State  Health  Department  and  by  the  local  Health 
Departments  acting  under  the  supervision  of  the  State  Health  De- 
partment. 

The  cold  storage  law  gives  this  Department  the  right  to  license  cold 
storage  warehouses  and  to  suspend  the  licenses  of  such  warehouses  or 
parts  thereof  which  do  not  conform  with  the  regulations  of  the  Depart- 
ment. Included  in  these  regulations  are  regulations  relative  to  sanitation, 
and  the  Department  in  the  past  has  closed  portions  of  warehouses  which 
were  being  operated  under  unsanitary  conditions. 

The  bulk  of  the  sanitary  inspections  relative  to  food  must  naturally  be 
made  by  the  boards  of  health  of  the  cities  and  towns,  primarily  because 
there  are  more  inspectors  per  capita  employed  by  the  cities  and  towns 
than  are  employed  by  the  State.  This  Department,  for  example,  employs 
but  nine  inspectors,  devoted  to  the  collection  of  milk,  food,  and  drug 
samples ;  to  the  inspection  of  pasteurization  establishments ;  to  the  inspec- 
tion of  cold  storage  warehouses;  to  the  inspection  of  slaughtering  con- 
ditions; to  the  inspection  of  conditions  under  which  local  slaughtering 
inspectors  do  their  work;  and  to  the  inspection  of  bakeries. 

The  Department  does  not  employ  a  person  devoted  exclusively  to  inspec- 
tions under  the  sanitary  food  law.  The  Department  endeavors  to  make 
an  inspection  of  the  bakeries  in  each  city  and  large  town  once  a  year. 
This  inspection  is  sometimes  made  in  company  with  the  local  inspector, 
and  sometimes  is  not.  In  all  cases,  a  letter  is  sent  to  the  board  of  health 
of  the  town,  informing  the  Board  in  detail  of  the  defects  found  and  direct- 
ing the  board  of  health  to  see  that  these  defects  are  corrected.  As  a  rule 
this  procedure  operates  in  a  very  satisfactory  manner.  Repeated  inspec- 
tions have  resulted  in  a  remarkable  improvement  in  the  sanitary  con- 
ditions under  which  bakeries  are  being  operated. 

When  the  law  first  went  into  effect  we  found  a  very  peculiar  attitude 
on  the  part  of  a  few  local  boards  of  health.  In  one  instance,  the  inspector 
of  this  Department  called  upon  the  local  board  of  health  by  previous 
arrangement  and  said  he  was  going  to  go  through  the  bakeries  of  that 
locality  with  their  inspectors..  Two  inspectors  accompanied  him.  They 
took  him  to  the  two  finest  bakeries  in  town.  After  they  came  out  of  the 
second  bakery  they  stepped  into  the  town  automobile  and  said,  "Good-by 
Doctor,"  and  went  away.  He  completed  the  rest  of  the  inspections  him- 
self and  from  the  reports  returned  by  our  inspector  it  was  very  evident 
that  the  local  men  had  good  reason  for  not  accompanying  the  inspector 
of  the  Department  to  the  rest  of  the  bakeries. 

Another  town  did  not  make  any  attempt  to  do  any  clean-up  work.  In 
that  particular  town  inspections  were  delayed  until  the  agent  of  the  board 
of  health  assured  us  that  the  conditions  were  satisfactory.  The  first  in- 
spection showed  conditions  to  be  far  from  satisfactory.  A  second  inspec- 
tion, made  some  months  later,  after  the  Board  had  been  informed  of  the 
results  of  the  first  inspection,  showed  no  improvement.  Direct  communi- 
cation with  the  chairman  of  the  board  of  health,  giving  him  a  copy  of 
both  reports  which  he  declared  the  Board  had  never  seen,  resulted  in  a 
promise  of  action.  Three  months  later,  another  inspection  was  made  in 
the  town,  and  the  inspector  reported  that  the  bakeries  were  almost  un- 
recognizable, due  to  the  radical  clean-up  policy  adopted  by  the  local  board 
of  health. 

One  of  our  inspectors  had  been  endeavoring  for  some  time  to  get  sani- 
tary conditions  improved  in  a  certain  slaughterhouse,  particularly  with 
reference  to  the  introduction  of  water  for  cleaning  purposes.  At  that  time 
the  conditions  were  controlled  entirely  by  the  local  board  of  health.  After 
the  passage  of  the  State  Sanitary  Food  Law,  the  inspector  called  upon 
the  proprietor  of  the  slaughterhouse  and  presented  him  with  a  copy  of 
this  law,  informing  him  that  under  this  law  the  State  Health  Department 
had  absolute  authority  to  proceed  against  him  if  the  sanitary  conditions 


91 
were  not  improved.   Upon  receipt  of  this  information  the  gentlemen  began 
immediate  improvement  of  the  sanitary  conditions. 

The  Department  has  made  very  few  prosecutions  under  the  Sanitary 
Food  Law,  and  then  only  under  conditions  which  the  Department  be- 
lieved to  be  absolutely  necessary  and  where  the  Department  had  evidence 
to  show  that  the  person  prosecuted  made  no  attempt  to  clean  up  the 
premises  after  he  was  requested  to  do  so  either  by  a  departmental  agent 
or  by  a  representative  of  the  board  of  health  of  the  town.  In  most  of 
these  cases,  the  Department  acted  at  the  request  of  the  local  officer,  who 
desired  some  assistance  from  persons  who  had  more  experience  than  he 
had  in  collecting  evidence  for  prosecution  before  the  courts. 

There  is  on  the  books  another  law  relating  to  sanitary  conditions 
specifically  in  relation  to  establishments  where  soft  drinks  are  prepared 
and  bottled.  These  establishments  are  licensed  by  the  local  boards  of 
health.  The  regulations,  however,  are  made  by  this  Department,  and 
additional  regulations  are  made  by  the  local  departments.  The  Depart- 
ment made  a  set  of  regulations;  sent  the  regulations  to  the  local  depart- 
ments, and  requested  the  local  departments  to  adopt  them.  As  a  rule  this 
was  complied  with  and  there  were  very  few  cases  where  the  local  depart- 
ment made  any  additional  regulations. 

The  Department  has  seen  fit  to  proceed  against  persons  operating  un- 
sanitary soft  drink  manufacturing  establishments,  and  in  one  case  which 
went  to  trial  and  resulted  in  a  conviction,  the  local  health  officer  requested 
such  action. 

Laws  of  this  type  are  very  difficult  to  enforce  because  of  the  different 
understanding  of  "cleanliness"  among  different  people.  One  person's 
idea  of  "sanitary  conditions"  may  mean  conditions  which  are  almost 
aseptic,  whereas  another  person's  idea  of  "sanitary  conditions"  may  mean 
conditions  which  are  to  most  of  us  almost  vile,  and  the  opinions  of  other 
persons  will  vary  between  these  two  extremes.  It  is  very  evident  that 
aseptic  conditions,  such  as  would  prevail  in  a  bacteriological  laboratory, 
cannot  prevail  in  establishments  operated  for  the  production  of  food.  It 
is  also  evident  that  such  establishments  can  be  operated  under  conditions 
of  common  decency  such  as  exist  in  the  kitchens  of  the  bulk  of  the  in- 
habitants of  the  State.  There  are  certain  fundamental  principles  which 
can  be  insisted  upon,  such  as  proper  location  of  the  toilets;  proper  pro- 
tection of  the  toilets  so  that  contamination  cannot  be  carried  from  them 
to  the  food;  proper  provision  for  washing  of  hands  of  employees  after 
using  toilets;  and  insistence  that  the  proprietor  of  the  establishment  see 
that  the  employees  properly  conduct  themselves  after  such  operations. 
The  establishment  of  such  relatively  simple  procedures  in  many  food  fac- 
tories is  an  extremely  difficult  proposition  on  the  part  of  the  health  officer. 

Sanitary  conditions  must  be  construed  differently  in  different  indus- 
tries. For  example,  the  conditions  existing  in  a  slaughterhouse  which 
may  be  considered  sanitary  can  readily  be  conceived  to  be  unsanitary  if 
they  exist  in  an  ice  cream  factory.  A  person  afflicted  with  tuberculosis, 
engaged  in  dipping  chocolates,  would  be  considered  to  be  violating  the 
Sanitary  Food  Law  by  preparing  food  under  unhealthful  conditions, 
whereas  the  same  person  could  be  employed  in  putting  labels  on  canned 
goods,  and  such  operation  could  be  considered  perfectly  healthful  as  far 
as  the  food  product  was  concerned. 

I  would  state  that  it  has  been  our  experience  that  a  person  violating 
the  Sanitary  Food  Law  will  as  a  rule  immediately  rectify  the  conditions 
on  being  requested  to  do  so  by  an  inspector  of  this  Department 

At  the  beginning  of  this  paper  I  mentioned  the  use  of  chemical  pre- 
servatives. Such  materials  have  been  used  from  the  earliest  records  of 
civilization.  It  is  often  wondered  why  the  early  European  explorers  were 
anxious  to  get  to  India  by  the  shortest  route.  The  answer  is,  "spices," 
which  were  used  for  the  preservation  of  food.  These  European  people 
did  not  have  refrigerators  operated  either  by  ice  or  electricity.   They  did 


92 

not  have  cold  storage  warehouses.  They  did  not  have  refrigerated  trans- 
portation cars,  such  as  we  have  today.  Their  meat  must  invariably  have 
been  eaten  within  a  very  short  time  of  the  animal's  being  killed,  or  it 
would  have  decomposed.  These  people  learned  that  the  application  of 
spices  as  well  as  salt  or  smoking  would  keep  the  meat  from  decompos- 
ing. In  modern  times  we  have  discovered  certain  more  powerful  anti- 
septics which  were  used  in  food,  some  of  which  are  today  tolerated. 
Nevertheless,  the  preservation  of  food  by  preservatives,  either  chemicals 
or  spices,  is  now  on  an  entirely  different  plane  from  what  it  was  thirty 
years  ago.  The  newer  chemical  preservatives  are  not  used  to  the  extent 
which  they  formerly  were  used.  Preservatives  like  sodium  benzoate  in 
catsup,  etc.  were  formerly  not  used  to  prevent  spoilage  of  the  food  in 
commercial  channels  but  to  prevent  spoilage  of  the  food  after  being 
opened  in  unsanitary  households. 

The  use  of  chemical  preservatives  has  been  greatly  restricted  by  the 
increased  use  of  pasteurization  in  food  products.  Thirty  years  ago,  the 
bulk  of  the  grape  juice  on  the  market  contained  chemical  preservatives. 
Now  none  of  it  contains  such  preservatives  because  the  product  after 
being  bottled  is  pasteurized  and  such  product  is  therefore  made,  trans- 
ported, and  sold  under  sanitary  conditions  because  of  the  killing  of  the 
bacteria,  yeasts,  and  moulds  which  would  cause  decomposition. 

Decomposition  in  food  stuffs  is  caused  by  the  growth  of  bacteria, 
yeasts,  and  moulds.  It  can  be  prevented  by  keeping  these  articles  out  of 
food,  or,  if  this  cannot  be  done,  by  keeping  the  food  at  such  temperature 
that  the  plants  in  question  will  not  grow.  These  plants  may  be  kept  out 
by  improvement  in  the  sanitary  conditons  under  which  the  articles  are 
manufactured.  Their  growth  can  be  stopped  by  improvement  in  the  sani- 
tary conditions  under  which  the  articles  are  stored  and  transported.  A 
comparison  between  conditions  as  they  exist  today  and  as  they  existed 
nearly  fifty  years  ago,  when  the  Massachusetts  Food  Law  first  went  into 
effect,  will  show  that  there  is  a  great  difference  between  the  former  un- 
sanitary conditions  and  the  present  very  satisfactory  sanitary  conditions. 

When  one  considers  the  enormous  amount  of  food  which  is  consumed 
by  persons  who  do  not  prepare  and  handle  the  same,  and  the  compara- 
tively few  cases  of  food  poisoning  due  to  infections  because  of  unsani- 
tary conditions,  it  is  very  evident  that  the  present  conditions,  while  not 
perfect,  are  extremely  satisfactory.  The  matter  of  sanitation  in  food  is 
primarily  one  of  education.  The  consumer,  as  well  as  the  manufacturer 
and  dealer  equally  is  required  to  be  educated.  Many  persons,  particularly 
milk  dealers,  have  complained  that  it  was  not  a  fair  proposition  to  require 
the  milk  dealer  to  so  handle  his  product  that  the  material  had  an  un- 
usually low  bacterial  count  and  then  for  the  householder  to  take  this 
clean  product  and  keep  it  in  the  house  under  conditions  which  would 
cause  it  to  spoil.   This  it  must  be  regretfully  admitted  is  a  fact. 

The  same  thing  is  true  in  relation  to  the  sanitation  of  food  other  than 
milk.  I  receive  many  complaints  during  the  course  of  the  year  relative 
to  alleged  sickness  being  caused  by  something  wrong  with  food.  I  in- 
variably look  with  suspicion  on  all  of  these  complaints,  my  suspicion  being 
that  the  complainant  has  some  ulterior  motive,  as  collecting  money  from 
an  insurance  company  for  a  sickness  alleged  to  have  been  caused  by  the 
food  in  question.  It  is  my  invariable  custom  in  these  cases  to  have  the 
conditions  investigated  at  once  by  an  inspector  of  the  Department,  and, 
strange  as  it  may  seem,  we  have  occasionally  found  unsanitary  conditions 
existing  in  the  factory  producing  the  food  alleged  to  have  caused  the 
sickness.  We  have  seen  fit  in  these  cases  to  proceed  against  the  establish- 
ment for  violation  of  the  law  relative  to  sanitation. 

I  would  cite  one  instance  relative  to  a  case  of  enteritis,  resulting  in  a 
complaint  that  it  was  caused  by  milk.  The  inspector  investigated  and 
ascertained  from  the  milk  dealer  that  he  had  had  two  complaints  only. 
He  ran  a  very  large  milk  route.    He  pasteurized  his  milk.    The  records 


93 

of  his  pasteurization  showed  correct  pasteurization.  The  appearance  of 
the  pasteurizing  vat  was  immaculate,  as  was  also  the  cooler  and  the  bottle 
filling  machine.  The  bottles  in  which  the  milk  was  placed  were  thoroughly 
sterilized,  and  on  the  surface  there  was  no  reason  for  the  trouble  which 
this  milk  was  said  to  have  caused.  The  inspector,  however,  requested  the 
proprietor  of  the  pasteurizing  establishment  to  disconnect  the  pipe  which 
connected  the  valve  with  the  pump.  This  pipe  was  in  a  vile  condition. 
The  proprietor  allowed  that  he  very  seldom  took  that  pipe  off.  After  the 
vat  was  cleaned  with  water,  some  of  the  water  would  remain  in  the  pipe 
under  conditions  whereby  bacterial  growth  would  be  induced.  The  milk 
was  pasteurized  and  the  valve  leaked  slightly,  some  of  the  milk  thereby 
getting  into  this  dirty  pipe,  and  owing  to  its  closeness  to  the  vat,  it  would 
be  warmed  somewhat,  thereby  inducing  an  increased  growth  in  the 
bacteria.  When  the  hot  milk  was  removed  from  the  vat,  this  first  portion 
was  carried  over  the  cooler  and  naturally  went  into  the  first  few  bottles. 
The  balance  of  the  hot  milk  killed  any  bacteria  which  might  have  been 
left  in  the  pipe,  and  the  resulting  milk  was,  of  course,  perfectly  satis- 
factory. Here  was  an  opportunity  for  something  to  go  wrong  and  infect 
only  a  few  bottles  of  milk.  Needless  to  say,  this  person  was  prosecuted 
and  fined. 

RELATION  OF  TYPHOID  CARRIERS  TO  FOOD  SUPPLY 

Gaylord  W.  Anderson,  Director 
Division  of  Communicable  Diseases 

The  unrecognized  typhoid  carrier  is  unquestionably  the  most  important 
factor  today  in  the  spread  of  typhoid  fever  in  Massachusetts.  Several 
years  ago,  when  typhoid  was  one  of  the  principal  causes  of  death,  water 
supplies  were  the  means  of  spreading  much,  if  not  most,  of  the  disease. 
With  the  development  of  the  science  of  sanitary  engineering  and  the  appli- 
cation of  its  knowledge  of  storage,  filtration  and  chlorination  of  water, 
typhoid  fever  spread  through  a  public  water  supply  has  practically  dis- 
appeared from  this  state.  Somewhat  similarly  with  the  steady  improve- 
ment in  the  conditions  surrounding  our  milk  production  and  the  increas- 
ing use  of  pasteurization,  milk  is  becoming  a  less  important  vehicle  for 
the  spread  of  typhoid,  even  though  we  can  by  no  means  say  that  further 
milk-borne  outbreaks  will  not  occur.  Occasional  cases,  the  exact  source  of 
which  is  usually  difficult  and  often  impossible  to  discover,  constitute  the 
greater  portion  of  our  present  day  typhoid.  The  development  of  our 
economic  system  has  been  such  that  very  few  of  us  know  in  detail  the 
history  of  the  food  which  we  put  into  our  mouths.  We  cannot  know  (and 
it  is  often,  perhaps,  better  for  our  appetites  at  least  that  we  should  not 
know)  what  hands  have  touched  it  before  it  came  to  us.  In  some  cases 
the  contact  may  have  been  intimate,  as  that  of  the  cook  who  fashions  the 
croquettes  or  prepares  the  salads,  or  it  may  have  been  very  fleeting.  In 
any  case,  however,  very  few  foods  can  be  truthfully  advertised  as  never 
touched  by  human  hands.  Yet  it  may  be  this  same  food,  attractive  to  look 
at  and  savory  to  taste,  that  is  ultimately  the  vehicle  for  the  spread  of 
typhoid  simply  because  it  has  been  handled  by  a  carrier. 

In  order  to  understand  the  role  that  the  carrier  plays  in  the  spread  of 
typhoid  and  the  problems  involved  in  our  attempts  at  control,  it  is  worth 
while  to  consider  briefly  what  is  known  as  to  the  carrier  conditions.  It  is 
usually  hard  to  convince  the  lay  person  that  an  individual  who  is  appar- 
ently perfectly  well  may  carry  in  his  or  her  body  the  germs  of  a  danger- 
ous disease.  Unfortunately,  it  is  often  even  more  difficult  after  accomp- 
lishing the  above  to  persuade  him  that  the  germs  do  not  mysteriously 
jump  from  the  carrier  to  anyone  who  comes  within  a  certain  range. 

The  majority  of  the  carriers  have  few  or  no  symptoms  attributable  to 
their  condition.  There  are  no  obvious  earmarks  by  which  they  may  be 
recognized.  An  English  authority  has  aptly  described  the  situation  when 


94 

he  said  that  we  would  have  no  typhoid  if  every  carrier  were  "stained 
blue."  It  is  because  they  are  not  "stained  blue,"  and  have  no  other  char- 
acteristic appearance,  that  we  often  fail  to  discover  their  carrier  condi- 
tion until  they  have  already  caused  infections.  And  unless  they  cause 
several  infections  which  can  be  correlated,  or  the  circumstances  surround- 
ing a  single  infection  are  clear  enough  to  point  the  way  for  carrier  in- 
vestigations, in  short,  unless  we  know  where  to  look  for  the  carrier,  he 
escapes  discovery. 

Several  circumstances  must  combine  to  bring  about  typhoid  infections 
from  a  carrier.  In  the  first  place,  the  organisms  must  be  shed  by  the 
•carrier  on  the  day  in  question.  It  is  well  known  that  for  one  reason  or 
another  living  typhoid  germs  may  not  appear  in  the  excreta  of  a  known 
carrier  at  various  times  only  to  reappear  at  a  subsequent  date.  It  is  this 
very  intermittency  of  excretion  that  is  responsible  for  the  overlooking  of 
certain  carriers,  and  that  makes  it  so  hazardous  to  rely  on  the  negative 
results  of  the  examination  of  a  single  stool  specimen. 

A  second  necessary  factor  in  the  chain  of  events  leading  to  an  infection 
is  that  the  hands  of  the  carrier  become  soiled  with  the  infectious  bowel 
or  bladder  discharges  and  that  the  organisms  be  incompletely  removed  by 
the  ordinary  washing  which  the  hands  are  given.  Unfortunately,  ther«" 
is  a  vast  difference  between  the  degree  of  cleanliness  necessary  to  remove 
bacteria  and  that  attained  by  our  everyday  hand  washing.  It  is  this 
difference  that  may  result  in  infection  spread  by  hands  which  are  appar- 
ently well-washed.  Time  also  is  apparently  a  factor,  because  certain  bac- 
teria, including  those  of  typhoid,  will  normally  die  in  a  sh®rt  time  if 
placed  on  the  human  skin. 

Granted  then  that  the  circumstances  on  a  given  day  are  such  that  the 
hands  of  the  carrier  have  been  freshly  soiled  by  infectious  bowel  dis- 
charges and  incompletely  cleansed,  it  is  still  necessary  for  further  infec- 
tion that  the  hands  be  brought  in  contact  with  food  which  is  to  be  eaten 
without  further  cooking  or  the  application  of  sufficient  heat  to  kill  the 
germs.  A  tremendous  variety  of  foods  have  at  one  time  or  another  been 
incriminated  as  having  carried  germs,  the  only  factor  common  to  all 
being,  apparently,  the  presence  of  sufficient  moisture  to  keep  the  germs 
alive  or  even  to  permit  of  their  further  growth. 

It  is  apparent  from  the  foregoing  that,  for  an  infection  to  result  from 
a  typhoid  carrier,  a  number  of  factors  must  have  interplayed  and  that, 
if  the  chain  of  events  is  broken  at  a  single  point,  infections  will  not  de- 
velop. Fortunately,  it  is  apparently  broken  most  of  the  time,  otherwise 
the  carrier  would  cause  infinitely  greater  damage  than  is  the  case.  It  is 
necessary,  however,  to  keep  in  mind  the  various  points  at  which  the 
chain  may  be  broken. 

Numerous  attempts  have  been  made  to  prevent  such  infections  through 
supervision  and  control  of  food  handlers.  It  is  impossible  to  measure  the 
relative  values  of  the  various  methods,  but  all  of  them  succeed  or  fail 
according  to  the  human  element  involved.  Routine  physical  examination 
of  food  handlers,  with  issuance  of  a  permit  or  certificate,  has  been 
attempted  in  some  places,  but  unfortunately,  as  administered  often  serves 
more  to  detect  physical  conditions  detrimental  to  the  health  of  the  indi- 
vidual employee  than  those  which  might  menace  the  public  health.  It  is 
true  that  such  measures  make  a  great  appeal  to  an  aesthetic  public,  but 
it  is  somewhat  questionable  whether  or  not  they  afford  a  measurable 
degree  of  protection  against  typhoid  fever,  inasmuch  as  their  success  or 
failure  depends  upon  the  honesty  of  the  applicant  for  a  license.  Certainly, 
there  will  inevitably  be  serious  errors  if  the  possibility  of  the  carrier  con- 
dition is  completely  dismissed  simply  because  the  applicant  denies  having 
had  typhoid  fever.  Even  though  the  denial  is  made  in  the  best  of  faith, 
there  is  still  the  possibility  of  the  person  who  has  become  a  carrier  in 
virtue  of  an  attack  of  typhoid  so  mild  as  to  escape  recognition.  That  such 
occurs  has  been  well  substantiated  by  the  experience  of  Massachusetts. 


95 

Selective  examination  of  food  handlers  has  been  adopted  by  certain 
organizations  instead  of  wholesale  superficial  inspections.  By  selective 
is  meant  concentration  upon  those  individuals  whose  occupation  brings 
them  in  intimate  contact  with  food.  There  is  obviously  a  tremendous 
difference  between  the  grocery  clerk  who  handles  canned  goods  and  the 
cook  who  prepares  the  food,  yet  both  are  food  handlers.  The  menace  to 
the  public  health  constituted  by  the  carrier  condition  in  the  one  is  vastly 
different  as  compared  with  that  in  the  other. 

Compulsory  examination  of  even  a  selected  group  is  at  best  difficult 
and  affords  a  false  sense  of  security,  owing  to  the  ease  of  evasion.  Its 
absence  does  not,  however,  relieve  the  individual  management  of  a  food 
handling  establishment  of  responsibility  for  guarding  against  the  em- 
ployment of  a  typhoid  carrier.  To  guard  against  such  employment  cer- 
tain establishments,  notably  dairies,  pasteurization  plants,  schools  and 
camps,  have  required  that  all  prospective  food  handlers  submit  stool  and 
urine  specimens  for  bacteriological  examination  before  employment.  The 
feasibility  of  such  a  requirement  has  been  abundantly  proven,  yet  un- 
fortunately it  is  frequently  not  applied  until  after  a  disastrous  experience 
with  an  outbreak  has  brought  the  problem  to  the  very  doorstep  of  the 
management. 

Numerous  instances  could  be  cited  in  which  outbreaks  might  have  been 
averted  had  a  responsible  management  required  such  examinations  of  its 
food  handlers.  Two  years  ago  a  large  summer  camp  for  girls  in  an  east- 
ern state  discovered  that  it  had  employed  a  carrier  as  cook  only  after 
over  fifty  of  the  girls  had  contracted  typhoid  fever,  some  six  or  seven  of 
whom  died.  In  spite  of  this  lesson,  dramatic  in  its  effect  and  clear  in  its 
teaching,  summer  camps  continue  to  employ  cooks  whose  only  recom- 
mendation is  an  employment  agency.  It  is  encouraging  to  note,  however, 
that  many  of  the  better  conducted  camps  are  becoming  alert  to  the  prob- 
lem and  are  insisting  that  carrier  examinations  be  made  before  employ- 
ment. In  Massachusetts  within  the  past  year  an  educational  establish- 
ment learned  from  sad  experience  that  it  had  employed  a  carrier  in  the 
lunch  room.  Only  three  years  prior  a  private  school  was  the  victim  of  a 
typhoid  carrier  working  as  the  cook.  Needless  to  say,  these  same  institu- 
tions, and  some  of  their  associates,  now  require  examination  of  prospec- 
tive food  handlers.. 

The  question  of  the  examination  of  the  food  handler  has  not  been  satis- 
factorily solved  on  a  community  basis,  nor  does  it  seem  likely  that  a 
thoroughly  satisfactory  solution  will  soon  be  found.  Nowhere  in  public 
health  are  theory  and  practicability  so  wide  apart.  Any  such  measure 
to  detect  carriers  must  be  administratively  satisfactory  without  being  so 
complicated  and  elaborate  that  it  degenerates  into  an  empty  formal  ges- 
ture. No  system  has  as  yet  been  devised  which  is  more  satisfactory  than 
individual  responsibility  on  the  part  of  the  employer  who  is  liable  for 
defects  in  the  service  which  he  renders.  It  is  encouraging  to  note  that 
employers  are  realizing  more  and  more  the  value  of  such  examinations 
and  many  of  them  are  requiring  such  as  prerequisites  to  employment. 

The  recognition  of  a  carrier  before  infections  have  been  caused  is,  of 
course,  the  ideal  protective  measure.  In  most  instances,  this  is  most 
readily  accomplished  during  the  convalescence  from  the  disease.  It  is 
obviously  unsound  and  lacking  in  foresight  to  permit  a  patient  recovering 
from  typhoid  to  return  to  his  normal  social  and  business  contacts  until 
it  is  certain  that  he  does  not  constitute  a  menace  to  his  associates.  By 
routine  culturing  of  all  typhoid  cases  before  their  release  from  official 
observation,  the  majority  of  our  carriers  could  be  detected  before  they 
have  caused  cases,  and  subjected  to  such  supervision  as  would  minimize 
the  possibility  of  spread  of  infection.  No  board  of  health  would  think  of 
discharging  from  quarantine  a  case  of  diphtheria  until  it  has  been  shown 
bacteriologically  that  the  patient  was  no  longer  harboring  diphtheria 
bacilli.    It  is  even  more  important  to  recognize  the  typhoid  carrier  state 


96 

for  this  may  persist  for  life,  whereas  the  diphtheria  carrier  is  at  worst 
usually  but  a  temporary  menace. 

It  is  not  to  be  inferred  that  all  typhoid  carriers  should  be  isolated 
away  from  their  fellow  men.  Nothing  would  be  more  unjust.  They  should, 
however,  so  conduct  themselves  that  they  do  not  spread  their  infection 
to  their  contacts.  A  typhoid  carrier  should  never  be  allowed  to  handle 
food  destined  for  public  consumption.  A  state  law  rightly  forbids  the 
employment  of  a  known  carrier  in  a  food  handling  capacity.  Obviously, 
the  housewife,  who  finds  herself  to  be  a  carrier,  cannot  be  expected  to 
refrain  from  cooking  for  her  family.  Such  would  be  economically  impos- 
sible. It  is  to  be  strongly  recommended,  however,  that  all  those  who 
must  eat  of  her  cooking  should  be  immunized  periodically  against  typhoid. 

The  carrier  who  does  not  handle  food  for  the  consumption  of  others 
is  usually  not  a  menace  to  the  public,  provided  the  excreta  are  properly 
cared  for.  The  realization  by  the  individual  that  he  is  a  carrier  usually 
prompts  him  to  take  those  ordinary  precautions  necessary  to  guard 
against  transmission  of  the  infection  to  his  associates.  His  occupation 
and  normal  routine  of  life  need  be  interefered  with  in  no  particular  so 
long  as  he  refrains  from  a  food  handling  profession. 

As  typhoid  fever  becomes  progressively  less  common,  fewer  carriers 
will  be  produced.  Constant  attention  to  the  convalescent  cases  to  detect 
those  individuals  who  continue  as  carriers,  and  constant  and  quiet  super- 
vision of  these  to  make  certain  that  they  refrain  from  engaging  in  the 
handling  of  food  for  consumption  of  others,  will  eventually  result  in  far 
less  food-borne  typhoid.  When  such  an  Eutopian  state  arrives  (and  its 
realization  seems  not  too  remote)  little  attention  need  be  given  to  the 
food  handler  as  a  carrier  of  typhoid.  Until  then,  however,  all  employers 
of  food  handlers  should  be  constantly  alert  for  possible  carriers  and 
should  insist  on  the  presentation  of  evidence  which  may  so  far  as  possible 
prove  that  a  prospective  employee  is  not  a  typhoid  carrier. 

SANITATION  OF  WAYSIDE  STANDS 

Walter  E.  Merrill,  Assistayvt  Sanitary  Engineer 
Division  of  Sanitary  Engineering 

The  wayside  stand,  or  roadside  market,  is  a  development  of  present 
day  life  which  is  closely  linked  with  the  growth  of  the  automobile  in- 
dustry. With  this  modern  method  of  rapid  transportation,  city  resi- 
dents are  today  able  to  travel  considerable  distances  from  their  homes 
into  the  country.  Naturally,  the  city  resident  wishes  to  obtain  the 
various  farm  products  as  fresh  as  possible.  A  farmer,  on  the  other 
hand,  appreciates  the  opportunity  to  obtain  a  better  price  than  if  he 
is  obliged  to  carry  his  products  to  the  city  market.  The  roadside  stand 
offers  the  solution  of  this  problem.  The  roadside  stand  offers  a  dual 
problem,  partly  agricultural  and  partly  one  of  public  health. 

Agricultural  Phase 

The  Massachusetts  Department  of  Agriculture  has  suggested  the 
following  definition: 

"A  farmer's  roadside  market  is  a  place  of  business  on  a  plot 
of  land  conveniently  located  by  a  travelled  road  where  sales 
are  made  direct  to  the  consumer  and  the  majority  of  the  prod- 
ucts are  farm  products  or  food  and  other  commodities  which 
the  farmer  and  his  family  have  produced  in  Massachusetts. 
These  Massachusetts  grown  goods  are  either  produced  on  the 
owner's  premises  or  purchased  direct  from  the  original  pro- 
ducer or  farmers'  cooperative  association." 


. 


97 

During  the  past  few  years  the  number  of  wayside  stands  along  our 
principal  roads  has  increased  tremendously.  Many  of  them  are  simple 
affairs  where  only  a  few  products  which  are  raised  on  the  farm  are 
displayed.  Others  are  more  elaborate  and  in  addition  to  vegetables, 
homemade  preserves,  tonics,  and  other  foodstuffs  are  offered  for  sale. 
In  some  cases  there  is  good  ground  for  suspicion  that  at  least  some 
of  the  goods  displayed  have  been  brought  out  from  the  city  market. 

Chapter  270  of  the  Acts  of  the  Legislature  for  the  year  1927,  en- 
titled "An  Act  to  Provide  for  Establishing  Grades  and  Standards  for 
Farm  Products,"  gives  the  Commissioner  of  Agriculture  the  power  to 
"establish  and  promulgate  official  grades  and  standards  for  farm 
products,  except  apples  and  milk,  produced  within  the  Commonwealth 
for  the  purposes  of  sale."  Under  this  Act  the  Commissioner  is  author- 
ized to  determine  or  design  brands  or  labels  for  identifying  such  farm 
products  packed  in  accordance  with  official  grades  and  standards  es- 
tablished. A  very  interesting  pamphlet  issued  by  the  Massachusetts 
Department  of  Agriculture  under  the  title  "More  Profit  for  the  New 
England  Farmer"  outlines  the  project  and  its  aims  and  what  has  been 
accomplished  so  far.  As  outlined  in  this  pamphlet,  the  following  six 
steps  have  been  taken  in  each  of  the  New  England  states: — 

(a)  Legislative  authority  has  been  granted  the  Commissioner  of 
Agriculture  to  establish  and  promulgate  voluntary  grades  and  stand- 
ards for  farm  products. 

(b)  The  Commissioner  of  Agriculture  has  been  given  authority  to 
adopt  a  suitable  label  for  identifying  such  products  graded  and  packed 
according  to  established  standards. 

(c)  The  Commissioner  of  Agriculture  has  been  given  the  necessary 
police  power  to  protect  these  grades  and  labels  from  violation  or 
misuse. 

(d)  A  permanent  New  England  organization  of  agricultural  com- 
modity interests  and  market  control  agencies  has  been  created  to  de- 
velop New  England  farm  marketing  plans  and  to  revise  and  amplify 
same  as  time  and  conditions  warrant. 

(e)  Cooperative  arrangements  have  been  made  with  the  State  Agri- 
cultural College  Extension  Service  providing  for  an  extensive  additional 
program  to  acquaint  producers  with  the  requirements  of  the  official 
grades  and  the  use  of  the  labels. 

(f )  Facts  are  being  gathered  pertaining  to  the  market  of  New  Eng- 
land products. 

The  number  of  grades  for  the  various  farm  products  which  have 
been  established  in  the  various  New  England  states  varies  consider- 
ably. Massachusetts  has  established  more  grades,  up  to  the  present 
time,  than  any  of  the  other  five  states.  The  commodities  for  which 
grades  have  been  established  are  as  follows:  eggs,  asparagus,  baby 
chicks,  hatching  eggs,  strawberries,  celery,  bunched  carrots,  beets, 
turnips  and  radishes. 

The  Department  of  Agriculture  has  designed  a  roadside  market  sign. 
Any  owner  of  a  roadside  market  may  apply  to  the  department  for  the 
lease  of  this  sign,  and  by  signing  a  lease  agreement  may  obtain  this 
sign,  provided  his  stand  meets  the  requirements  of  the  Department  of 
Agriculture.  The  sign  is  a  shield  of  dark  blue  background  color  with 
a  light-colored  border  bearing  the  words  "Bay  State  Farm  Products 
at  Roadside  Market"  and  also  indicating  that  these  products  are  super- 
vised by  the  Massachusetts  Department  of  Agriculture.  Under  the 
agreement  the  Department  of  Agriculture  has  the  right  to  revoke  the 
use  of  the  sign  at  any  time  for  failure  to  comply  with  the  provisions 
of  the  agreement. 

The  above  project  is  a  most  commendable  one  and  should  result  in 
raising  considerably  the  standard  of  the  roadside  market.    Heretofore 


98 
the  New  England  farmer  has  been  loathe  to  bother  with  the  grading 
of  his  products  but,  if  he  is  to  compete  with  the  other  sections  of  the 
country  where  these  practices  are  now  established,  he  must  come  to 
this  idea.  Although  the  program,  as  outlined  by  the  Department  of 
Agriculture,  aims  particularly  to  raise  the  quality  of  the  farm  products 
offered  for  sale,  it  should  also  help  to  raise  the  standard  of  sanitation. 
The  lease  agreement,  previously  referred  to,  states  that  "farm  road- 
side markets  displaying  the  official  sign  of  the  Department  of.  Agricul- 
ture shall  be  clean,  neat  and  attractive" ;  also  that  "the  market  shall 
be  inspected  periodically  with  special  reference  to  sanitations,  qual- 
ity of  product     .     .     ." 

Public  Health  Phase 

The  summer  camp  has  received  considerable  attention  in  the  past 
from  the  various  state  departments  of  health  but  the  tourist  camp 
and  the  wayside  stand  have  been  given  scant  attention  by  these  de- 
partments. Any  one  who  has  done  much  travelling  over  the  highways 
and  byways  of  this  state  realizes  the  great  difference  in  the  caliber 
of  our  wayside  stands.  At  some  of  them  conditions  are  excellent  but, 
sad  to  say,  in  numerous  cases  one  phase  or  another  of  sanitation  is 
badly  neglected.  Some  of  these  wayside  stands  are  mere  shacks;  others 
are  simply  tables  set  up  beside  the  road. 

Food  handlers  at  these  stands  are  subject  to  the  same  legal  regula- 
tion as  those  in  a  restaurant.  Under  Chapter  94  of  the  General  Laws 
of  Massachusetts  the  Commissioner  of  Public  Health,  on  his  own  in- 
itiative or  at  the  request  of  a  local  board  of  health,  may  require  any 
food,  handler  to  submit  to  a  thorough  examination  and  may  cause  the 
owner  to  discharge  this  person  if  he  is  found  to  be  afflicted  with  any 
disease  or  ailment  that  might  prove  detrimental  to  the  public  health. 
A  typhoid  carrier  at  a  wayside  stand  might  very  easily  be  the  cause 
of  an  epidemic  which  would  be  difficult  to  trace  to  its  source,  due  to 
the  scattered  territory  from  which  the  patrons  come. 

Certainly,  consideration  should  be  given  to  the  water  supply  at  the 
wayside  stand,  if  such  supply  exists.  If  all  these  supplies  could  be 
examined  at  the  present  time,  there  is  little  doubt  that  a  goodly  per- 
centage would  fail  to  meet  the  standard  required  in  a  water  supply  of 
good  quality.  In  some  cases  these  water  supplies  consist  of  old-fash- 
ioned dug  wells  which,  in  many  cases,  are  located  in  a  barnyard  or 
close  to  sources  of  pollution  and  are  not  adequately  protected  against 
the  entrance  of  surface  pollution  and  foreign  matter.  The  customer 
at  a  wayside  stand  should  be  able  to  ask  for  a  drink  of  water  with  the 
same  assurance  that  it  is  safe  to  drink  as  he  feels  when  he  draws  a 
glass  of  water  from  a  tap  in  his  own  home.  The  State  Department  of 
Public  Health  can,  upon  request,  examine  the  water  supply  at  a  way- 
side stand  but,  at  the  present  time  if  the  water  is  found  to  be  of  un- 
satisfactory quality,  there  is  no  direct  method  whereby  the  state  can 
compel  the  owner  of  the  stand  to  discontinue  use  of  this  water. 

The  appeal  of  the  old-fashioned  well  probably  has  blinded  most  of 
us  to  the  dangers  of  the  bucket  and  the  rope,  made  famous  by  the  old 
poem.  A  portion  of  a  parody  on  "The  Old  Oaken  Bucket"  might  be 
apropos  here: — 

"Just  think  of  it!    Mould  on  the  vessel  that  lifted 
The  water  I  drank  in  the  days  called  to  mind, 

Ere  I  knew  what  professors  and  scientists  gifted, 
In  the  water  of  wells  by  analysis  find. 

The  rotting  wood  fiber,  the  oxide  of  iron, 
The  Algae,  the  frog  of  unusual  size, 

The  water  impure  as  the  verses  of  Byron, 

Are  the  things  I  remember  with  tears  in  my  eyes. 


99 

"And  to  tell  the  sad  truth — though  I  shudder  to  think  it — - 

I  considered  that  water  uncommonly  clear, 
And  often  at  noon  when  I  went  there  to  drink  it, 

I  enjoyed  it  as  much  as  I  now  enjoy  beer. 
How  ardent  I  seized  it  with  hands  that  were  grimy, 

And  quick  to  the  mud-covered  bottom  it  fell; 
Then  reeking  with  nitrates  and  nitrites,  and  slimy 

With  monads  and  microbes,  it  rose  from  the  well." 

Another  phase  of  the  wayside  stand  as  related  to  sanitation  is  the 
restroom,  comfort  station,  or,  in  ordinary  parlance,  the  toilet.  This 
should  be  of  a  standard  of  cleanliness  that  no  one  need  hesitate  to  use 
it.  In  many  cases,  however,  one  finds  at  these  stands  an  old-fashioned 
country  toilet  with  conditions  so  disgustingly  dirty  that  one  pauses 
before  entering  it,  and  frequently  decides  against  doing  so.  There  is 
no  good  reason  why  the  toilet  at  a  wayside  stand  should  not  meet  the 
same  standard  that  is  expected  at  any  first-class  summer  camp. 

Other  phases  of  sanitation  to  be  considered  are  the  proper  disposal 
of  waste  material  from  the  wayside  stand  and  the  drainage  from  it. 
The  considerations  which  apply  to  the  summer  camp  would  apply 
equally  well  to  the  wayside  stand. 

Many  persons  feel,  possibly,  that  the  general  public  is  overburdened 
v/ith  State  Regulations.  Here,  however,  is  one  phase  of  modern  life 
which  might  well  be  submitted  to  regulations  from  state  or  other  au- 
thorities to  the  great  advantage  of  every  one. 

With  the  proper  cooperation  between  the  owner  and  the  state,  the 
wayside  stand  can  be  raised  to  a  new  level  whereby  greater  revenue 
will  be  obtained  by  the  producer,  the  general  public  will  obtain  a 
better  grade  of  product,  the  public  health  will  be  far  better  protected 
and,  lastly,  the  highways  will  be  made  more  attractive  by  a  type  of 
structure  that  will  be  an  asset,  and  not  a  liability,  to  the  natural  beauty 
of  its  surroundings. 

CAMP  SANITATION 

Walter  E.  Merrill,  Assistant  Sanitary  Engineer 
Division  of  Sanitary  Engineering 

Although  possibly  not  generally  recognized  as  such,  camping  is  today 
one  of  the  major  industries  of  the  State  of  Massachusetts.  Many  of  the 
camps  are  conducted  by  various  organizations  for  their  own  members. 
Other  camps  are  privately  owned,  operated  solely  for  financial  gain,  and 
are  open  to  any  one  willing  to  pay  the  prescribed  rate.  Another  class  of 
camps  is  the  tourist,  or  overnight,  camps,  the  population  of  which  is 
of  a  temporary  or  floating  nature.  A  considerable  number  of  the  cities 
and  towns  operate  municipal  camping  grounds,  primarily  for  campers 
carrying  their  own  tents  and  other  equipment;  in  some  cases  these  camps 
have  modern  sanitary  facilities,  in  others  the  equipment  is  limited, 
antiquated  and  not  satisfactory. 

In  years  gone  by  camps  were  located  with  little  thought  given  to  the 
requisites  of  sanitation,  such  as  a  pure  water  supply,  method  of  sewage 
disposal,  proper  drainage,  and  freedom  from  mosquitoes  and  other  pests. 
About  one  generation  ago  most  of  the  summer  camps  were  only  single 
dwellings  where  one  family  spent  their  vacation.  Practically  the  only 
large  camps  were  those  where  revival  meetings  were  held.  During  the 
first  quarter  of  the  twentieth  century  the  camp  movement  developed 
rapidly.  Gradually  camp  directors  and  the  general  public  have  awakened 
to  the  importance  of  providing  the  summer  camp  with  a  proper  sanitary 
environment.  Today  the  great  majority  of  those  engaged  in  this  ever- 
growing work  realize  the  absolute  necessity  of  giving  their  camp  100  per 
cent  protection  from  the  various  enemies  of  health.    The  children  who 


100 

attend  these  camps  are  accustomed  to  every  sanitary  protection  at  home, 
an  unpolluted  drinking  water,  a  modern  toilet,  freedom  from  flies  and 
mosquitoes,  et  cetera.  In  many  of  our  camps  are  gathered  those  who 
come  not  only  from  the  cities  and  towns  of  Massachusetts,  but  also  from 
many  other  states.  With  such  a  grouping  there  is  offered  great  opportun- 
ity for  the  spreading  of  epidemics  unless  the  health  of  the  campers  is 
carefully  safeguarded. 

During  the  summer  of  1930  the  Massachusetts  Department  of  Public 
Health  made  a  survey  of  163  camps  in  the  state.  Of  these  camps  68,  or 
42  per  cent,  were  privately  owned,  and  the  remaining  95  were  conducted 
by  various  organizations.  It  is  interesting  to  note  the  geographical  distri- 
bution of  the  camp  population.  Of  a  total  population  of  17,444  about  52 
per  cent  were  in  camps  located  in  the  easterly  part,  about  15  per  cent 
were  in  the  central  part,  and  the  remaining  33  per  cent  were  in  the  west- 
erly part  of  the  state.  The  above  figures  only  indicate  the  large  number 
of  people  that  go  to  camps  of  one  variety  or  another  that  were  included 
in  the  above  investigation.  It  is  probable  that  the  total  number  of  people 
who  visit  the  camps  of  Massachusetts  during  the  summer  is  close  to 
200,000. 

Massachusetts,  through  its  geographical  location  and  its  topography,  is 
admirably  adapted  for  camping  with  its  numerous  possibilities  for  recre- 
ation. For  those  who  so  desire  there  are  the  seaside  camps  with  their 
opportunities  for  sailing,  bathing,  and  fishing;  for  those  who  prefer 
life  in  the  country  there  are  the  interior  camps  with  the  opportunity  for 
hiking,  woodcraft  and  nature  study  and  horseback  riding.  In  the  moun- 
tainous country  of  the  westerly  portion  of  the  state  are  still  other  camps, 
many  located  on  inland  bodies  of  water  with  their  opportunities  for  some 
of  the  various  forms  of  recreation  already  named  and  the  further  oppor- 
tunity for  mountain  climbing. 

In  establishing  a  camp  which  will  serve  a  considerable  number  of  people 
it  is  advisable  that  thought  be  given  to  various  phases  of  sanitation 
before  settling  upon  a  specific  location.  Too  often  summer  camps  have 
been  located  in  a  haphazard  fashion  and,  as  they  developed,  it  has  been 
necessary  to  go  to  considerable  expense  which  might  well  have  been 
avoided  if  the  camp  had  been  properly  planned  in  the  beginning.  It  is 
recommended  that  the  advice  of  sanitary  engineers  experienced  in  such 
practice  be  sought  in  the  beginning  so  that  the  camp  may  be  properly 
located  and  laid  out. 

In  selecting  a  camp  site  some  of  the  phases  which  should  be  given 
careful  consideration  are  as  follows: 

1.  Accessibility. — Although  not  a  sanitary  problem,  accessibility  should 
be  a  prime  factor  in  the  selection  of  a  camp  site.  In  most  cases  it  is  im- 
portant that  those  coming  to,  and  leaving,  the  camp  should  be  within  easy 
reach  of  a  railroad  or  a  good  highway.  Transportation  of  food  supplies 
also  requires  that  the  camp  be  of  easy  access.  In  case  of  accident  or 
sickness,  unless  there  is  medical  attendance  at  camp,  it  might  be  neces- 
sary to  obtain  the  services  of  a  doctor  in. haste. 

2.  Drainage. — In  selecting  a  camp  site  particular  attention  should  be 
given  to  soil  conditions.  A  porous  soil,  preferably  on  a  side  hill,  provides 
opportunity  for  proper  drainage  of  a  camp  and  in  addition  may  be  of 
assistance  in  obtaining  a  good  water  supply  and  for  disposal  of  sewage. 

3.  Water  Supply. — Frequently  in  selecting  a  camp  site  little  thought 
is  given  to  the  possibility  of  securing  a  water  supply  of  good  quality  and 
in  sufficient  quantity.  A  camp  which  offers  all  the  other  advantages  is  of 
little  value  if  a  pure  water  supply  cannot  eventually  be  obtained.  Before 
proceeding  too  far  with  plans  for  a  camp  it  is  well  to  make  certain  that  a 
suitable  source  of  water  supply  can  be  obtained.  In  many  instances  such 
a  supply  may  be  obtained  from  the  ground,  either  from  a  spring  in  a 
mountain  side,  from  tubular  wells  driven  into  sand  and  gravel,  or  from 
dug  wells.   A  ground  water  supply  taken  from  rock  formation  may  prove 


101 

to  be  unsafe  as  pollution  has  been  known  to  travel  through  crevices  in 
the  rock  for  long  distances.  In  some  instances  a  safe  surface  water  supply 
may  be  obtained.  However,  a  surface  water  supply  is  easily  polluted  and 
before  a  camp  should  adopt  such  a  supply  those  in  charge  should  be 
practically  certain  that  they  will  be  able  to  protect  this  source  from 
pollution  in  the  future.  If  possible,  the  water  supply  should  be  made 
available  to  taps  in  the  camp,  eliminating  the  necessity  of  bringing  it  in 
utensils  from  the  source  of  supply,  during  the  course  of  which  handling 
the  water  may  become  polluted.  If  the  public  water  supply  is  available, 
then  connection  therewith  may  prove  to  be  the  best  solution  of  the  water 
supply  problem. 

U.  Sewage  Disposal. — The  method  of  disposing  of  the  sewage  of  a 
camp  usually  varies  with  the  size  of  the  camp.  In  any  event  all  sewage 
should  be  disposed  of  in  ground  that  is  lower  in  elevation  than  that  where 
the  water  supply  is  obtained,  and  at  a  considerable  distance  therefrom. 
For  a  small  camp  properly  maintained  pit  privies  may  provide  a  satis- 
factory method  of  disposal.  The  privies  should  be  so  constructed  that  flies 
and  other  insects  do  not  have  access  to  the  privy  vault.  The  privies  should 
be  so  located  that  no  odor  from  them  will  reach  the  camp.  For  small 
camps  it  is  common  practice  to  have  an  earthen  vault  6  to  8  feet  in  depth, 
depending  upon  the  height  of  ground  water,  disinfecting  the  contents 
effectively  with  chloride  of  lime  and  moving  the  privy  to  a  new  location 
when  the  material  in  the  vault  reaches  within  2  feet  of  the  surface.  Fresh 
earth  may  be  spread  over  the  contents  daily  in  order  to  reduce  the 
charge  of  odors.  When  a  pit  is  abandoned  it  should  be  filled  immediately 
with  dry  earth.  For  larger  camps  more  complicated  methods  of  sewage 
disposal  may  be  required;  among  these  are  the  sanitary  privy  which  has 
a  water-tight  receptacle,  the  chemical  toilet,  flush  toilets  with  cesspools, 
flush  toilets  with  a  septic  tank  and  sub-surface  disposal  drain,  and  in 
some  cases  the  flush  toilets  are  connected  to  a  combination  of  septic  tank 
and  cesspool.  It  is  always  advisable  to  make  a  connection  with  the  public 
sewers  if  possible,  and  when  considering  the  question  of  sewage  disposal 
this  possibility  should  be  investigated  first. 

The  principal  merit  of  a  septic  tank  lies  in  the  ease  with  which  the  efflu- 
ent can  be  disposed  of.  The  effluent  is  discharged  into  subsurface  pipes, 
laid  preferably  in  coarse  gravel  or  crushed  stone  with  open  joints  so  that 
the  material  will  seep  through  them.  Leaching  trenches  containing  open- 
jointed  tile  pipes  laid  in  coarse  gravel  or  crushed  stone  can  sometimes  be 
successfully  used.  It  is  important  that  the  subsurface  drains  shall  be  so 
designed  as  to  adequately  care  for  the  effluent.  The  length  of  these 
drains  will  depend  upon  the  quantity  of  sewage  and  the  nature  of  the  soil. 
The  average  person  has  the  idea  that  a  septic  tank  is  a  cure-all  for  every 
sewage  trouble;  this  is  not  true.  A  septic  tank  is  usually  considerably 
more  expensive  than  a  cesspool,  and  the  effluent  is  equally  dangerous. 

A  cesspool  is  usually  built  of  field  stone  laid  without  mortar  to  within 
2  feet  of  the  surface  above  which  point  the  stone  is  laid  in  cement,  curbed 
over,  and  provided  with  a  cover.  If  there  is  doubt  as  to  the  porosity  of 
the  soil  an  overflow  should  be  provided  through  a  tee  which  will  take  the 
liquid  from  a  foot  or  more  below  the  flow  line  and  discharge  the  liquid 
into  a  second  cesspool  or  leaching  drains.  Most  of  the  grease  which 
would  ordinarily  enter  the  cesspool  or  septic  tank  originates  in  the  kitchen 
sink.  This  grease  may  be  separated  from  the  other  wastes  by  a  grease 
trap.  This  trap,  should  have  a  capacity  of  at  least  7  or  8  gallons.  There 
are  several  types  of  grease  trap,  but  the  principle  is  the  same  in  all; 
grease  rises  to  the  surface,  and  the  outlet  pipe  extends  to  a  short  distance 
above  the  bottom  of  the  trap. 

5.  Garbage  and  Waste  Disposal. — In  the  early  days  of  camping  little 
attention  was  given  to  this  phase  of  sanitation.  In  many  cases  the  garb- 
age and  waste  material  were  merely  dumped  onto  the  surface  of  the 
ground  at  some  distance  from  the  camp.   Even  today  in  camps  which  are 


102 
laxly  conducted  this  practice  persists.  It  is  essential  that  garbage  and 
waste  material  be  kept  in  tightly  covered  receptacles  provided  for  that 
purpose.  It  is  preferable  that  metal  cans  be  used.  The  receptacles  should 
be  emptied  at  frequent  intervals,  at  least  twice  weekly.  The  contents 
should  be  burned  under  proper  supervision  or  disposed  of  in  some  other 
sanitary  manner  such  as  burying.  Rubbish  and  other  combustible  mater- 
ial may  be  disposed  of  by  burning  in  incinerators  provided  for  that  pur- 
pose. These  should  be  so  located  as  to  eliminate  danger  to  the  camp  from 
fire.  Fresh  garbage  may  be  disposed  of  to  farmers  or  others  for  feeding 
to  swine.  Garbage  and  waste  material  may  be  buried  under  two  or  three 
feet  of  earth,  but  it  is  essential  that  the  garbage  be  protected  from  flies 
and  other  vermin  by  covering  immediately,  otherwise  eggs  from  the  flies, 
etc.  may  hatch  out  and  the  maggots  crawl  to  the  surface. 

6.  Food  Sanitation. — This  phase  of  camp  life  is  one  of  its  most  import- 
ant phases.  The  milk  supply  should  come  from  a  source  of  known  purity. 
Milk  from  tuberculin-tested  cows,  or  pasteurized  milk,  should  be  insisted 
upon.  Bacteriological  examination  of  the  feces  and  urine  of  prospective 
food  handlers  should  be  insisted  upon  by  each  camp  to  guard  against  the 
possibility  of  the  employment  of  a  typhoid  carrier,  and  should  be  a  pre- 
requitite  to  employment.  The  cleanliness  of  the  kitchen  and  the  handling 
of  the  food  are  of  paramount  importance.  Dishes  should  be  properly 
sterilized  and  should  be  kept  in  some  receptacle  where  they  will  not  be 
exposed  to  dust  and  other  pollution. 

7.  Mosquito  and  Fly  Prevention. — The  mosquito  nuisance  is  much  more 
troublesome  than  the  fly  nuisance  but  usually  of  less  serious  consequence. 
The  only  variety  of  mosquito  in  Massachusetts  which  is  likely  to  cause 
serious  disease  is  the  Anopheles  which  is  the  type  of  mosquito  known  to 
transmit  malaria.  The  only  way  in  which  malaria  can  be  transmitted  is 
through  the  mosquito  biting  a  person  having  the  disease  and  then  biting 
a  second  person,  inoculating  the  latter  with  the  disease.  Due  to  the  small 
amount  of  malaria  in  this  state  the  danger  of  infection  from  the 
Anopheles  mosquito  is  relatively  small;  however,  aside  from  the  disease 
aspect  it  is  generally  desirable  to  eliminate  mosquitoes  from  a  camp  as 
they  are  not  pleasant  neighbors.  It  is  generally  practicable  to  make  a 
camp  or  community  relatively  free  from  mosquitoes.  The  remedies  are 
drainage,  the  use  of  oil,  or  by  a  combination  of  the  two  methods.  In  the 
case  of  swamps  where  it  is  impracticable  to  drain  the  standing  bodies 
of  water,  it  is  desirable  to  cover  the  surface  of  the  water  with  oil.  In 
the  case  of  large  salt  marshes,  drainage  ditches  to  provide  circulation  of 
the  tide  water  is  a  satisfactory  method  of  eliminating  mosquitoes.  A  good 
oil  for  use  in  mosquito  control  should  spread  rapidly  and  should  not 
evaporate  too  quickly.  Kerosene  may  be  used  to  good  advantage  or  a 
combination  of  heavy  oil  of  18°  gravity  and  a  light  oil  of  34°  gravity, 
used  in  the  proportion  of  4  to  1,  is  quite  effective.  There  is,  of  course, 
danger  to  fish  life  in  case  a  coating  of  oil  thick  enough  to  keep 
oxygen  from  the  fish  forms  on  the  surface,  or  the  oil  may  get  into 
the  gills  of  the  fish ;  also  the  oil  may  spread  to  some  point  where  bathing 
is  ordinarily  enjoyed,  and  render  the  conditions  unfit  for  bathing. 

The  house-fly  constitutes  an  important  phase  in  the  sanitary  control 
of  any  camp.  Its  prevention  is  very  difficult.  Statistics  show  that  many 
diseases  are  caused  by  the  carrying  of  contagion  from  fecal  matter  and 
garbage  to  food,  especially  milk.  The  fly  is  one  of  the  principal  agents 
m  the  carrying  of  such  contagion.  One  remedy  is  to  eliminate  the  breed- 
ing places  of  the  fly.  To  do  this  the  privy  should  be  made  fly-proof,  garb- 
age pails  securely  covered,  and  garbage  disposed  of  in  a  sanitary  manner. 

8.  Screening. — As  in  practically  every  case  it  will  be  found  impossible 
to  eliminate  mosquitoes  and  flies  entirely;  it  is  advisable  that  living 
quarters  and  dormitories  be  adequately  screened  and  that  certain  foods 
also  be  screened  from  flies  and  vermin.  In  a  tent  camp  where  the  ordin- 
ary type  of  wall  tent  is  used,  a  canopy  of  mosquito  netting  over  each  bed 
is  the  easiest  method  of  protection. 


103 

9.  Recreational  Opportunities. — Although  not  necessarily  of  sanitary 
significance,  the  opportunity  which  a  camp  affords  for  recreational  en- 
joyment is  naturally  of  vital  importance  as  a  health  factor.  If  the  chil- 
dren who  attend  our  camps  are  to  gain  health  and  strength  during  their 
stay  they  must  have  opportunity  for  various  forms  of  sport.  This,  how- 
ever, is  one  feature  which  the  average  camp  owner  is  not  likely  to  over- 
look. Some  of  the  lines  of  recreation  which  should  be  considered  are  the 
following:  bathing,  boating,  fishing,  opportunity  for  organized  play, 
hikes,  woodcraft  and  nature  study.  As  already  stated,  every  camp  cannot 
offer  all  of  these  advantages,  but  with  due  forethought  can  offer  most  of 
them.  For  bathing,  water  as  free  as  possible  from  pollution  should  be 
chosen;  disease  may  very  easily  be  spread  by  the  swimmer  swallowing 
polluted  water.  Freedom  from  weeds  is  also  a  point  worthy  of  considera- 
tion. A  sandy  bottom  is  desirable,  as  with  a  muddy  bottom  there  is 
danger  from  leeches. 

10.  Function  of  State  Department  of  Public  Health. — The  State  De- 
partment of  Public  Health  is  glad  to  furnish  to  camp  authorities  advice 
in  regard  to  water  supply,  sewage  disposal,  and  other  correlated  prob- 
lems which  they  encounter.  The  Department  is  not  authorized  to  design 
works  for  water  supply  or  sewage  disposal  but  can  advise  on  these 
matters.  For  a  camp  of  any  considerable  size  it  is  recommended  that  an 
engineer  of  experience  in  such  matters  be  consulted.  The  Department 
stands  ready  to  make  an  investigation  of  any  of  the  various  phases  of 
sanitation  previously  described  and  to  recommend  changes  or  additions 
in  the  plans  as  proposed.  By  a  more  complete  co-operation  between  the 
camp  owner  and  the  Department  it  will  be  possible  in  the  future  to  bring 
our  camps  to  a  standard  of  excellence  not  reached  heretofore. 

An  article  such  as  this  cannot  hope  to  do  much  more  than  call  atten- 
tion to  the  various  important  phases  of  camp  sanitation;  an  entire  chap- 
ter of  a  book  might  well  be  devoted  to  each  of  them.  A  valuable  book  en- 
titled "Camp  Sanitation"  has  been  issued  by  the  Boy  Scouts  of  America, 
and  any  one  interested  will  find  much  excellent  information  within  its 
covers. 

Appended  is  a  set  of  proposed  regulations  for  the  sanitary  control  of 
recreation,  health  and  tourists'  camps.  These  regulations  have  never 
been  adopted,  but  are  printed  so  that  the  reader  may  gain  an  idea  of 
what  might  be  expected  of  a  camp  under  a  state  licensing  system. 

Proposed  Minimum  Regulations  for  the  Sanitary  Control  of 
Recreation,  Health  and  Tourists'  Camps 

1.  Definition  of  Camp.  The  rules  and  regulations  hereinafter  made 
shall  apply  to  the  operation  of  camps  in  cities  and  towns  in  the  Common- 
wealth, whether  for  charity,  profit  or  other  purposes,  which  are  designed 
or  intended  as  recreation,  health  and  tourists'  camps,  excepting  private 
camps  owned  or  leased  for  individual  or  family  use,  or  camps  operated 
for  less  than  10  days  in  any  one  year. 

2.  Permits.  Boards  of  health  of  cities  and  towns  may  issue  permits,  as 
described  under  Section  ...  of  Chapter  111,  provided  these  rules  and 
regulations  are  complied  with. 

3.  No  permit  shall  be  granted  until  the  camp  management  has  furn- 
ished the  following  information  to  the  local  board  of  health: 

a.  Location  of  camp. 

b.  Name  of  management  and  the  Camp  Director  or  responsible  per- 
son in  charge,  with  his  or  her  permanent  address. 

c.  Approximate  date  of  opening  and  closing  of  camp. 

d.  Approximate  number  of  campers. 

e.  Name,  address  and  professional  qualifications  of  the  person  hav- 
ing medical  supervision  of  the  camp. 


104 

4.  Approval  of  Location.  No  camp  shall  be  established  until  the  loca- 
tion thereof  shall  have  been  approved  by  the  board  of  health  of  the  city 
or  town  in  which  the  camp  is  to  be  located. 

5.  Permits  for  Camps  on  Watersheds  of  Public  Water  Supplies.  No 
permit  shall  be  granted  for  a  camp  on  the  watershed  of  any  public  water 
supply  until  proper  sanitary  facilities  have  been  provided  which  shall  not 
be  in  violation  of  the  rules  and  regulations  for  the  sanitary  protection  of 
public  water  supplies  as  established  by  the  State  Department  of  Public 
Health. 

6.  Water  Supply.  Every  camp  shall  be  provided  with  a  water  supply 
of  good  sanitary  quality  and  of  sufficient  quantity,  approved  by  the  State 
Department  of  Public  Health.  Application  for  such  approval  must  be 
made  in  writing  prior  to  the  opening  of  the  camp.  License  to  operate 
may  be  granted  pending  the  receipt  of  approval.  Any  well  or  spring  of 
poor  or  questionable  quality  available  at  such  camps  shall  be  removed  or 
posted  as  unsafe.  Proper  pumps  or  overflow  pipes  shall  be  provided  for 
the  removal  of  water  from  any  well  or  spring  used  for  a  water  supply  at 
a  camp  and  such  wells  or  springs  shall  be  protected  from  pollution. 

7.  Sewage  Disposal.  Each  camp  so  located  that  public  sewerage  facil- 
ities are  available  shall  be  provided  with  suitable  flush  toilets,  and  every 
camp  not  so  located  that  public  sewerage  facilities  are  available  shall  be 
provided  with  septic  tanks,  chemical  closets  or  suitable  fly-proof  privies 
which  shall  be  maintained  in  a  clean  and  sanitary  condition.  There  should 
be  at  least  one  toilet  seat  to  every  twenty-five  campers;  a  ratio  of  one 
seat  to  fifteen  campers  would  be  more  desirable. 

8.  Pollution  of  Water  Supplies.  No  privy  or  other  receptacle  for  sew- 
age or  garbage  shall  be  located  within  200  feet  of  any  well  or  spring  used 
as  a  source  of  water  supply  at  a  camp  excepting  it  be  below  the  bottom 
of  such  well  or  spring. 

9.  Sources  of  Water  Supply,  etc.,  to  be  posted.  Signs  shall  be  posted  at 
each  camp  plainly  indicating  the  locations  of  the  source  or  sources  of 
water  supply  and  the  location  of  all  toilets  and  receptacles  for  the  dis- 
posal of  garbage  and  refuse. 

10.  Source  of  Milk  Supply.  The  milk  supply  of  the  camp  should  be 
pasteurized,  if  such  a  supply  is  available;  otherwise,  from  tuberculosis 
free  herds. 

11.  Disposal  of  Garbage,  etc.  Each  camp  shall  be  provided  with  tight 
covered  receptacles  for  rubbish,  garbage  and  refuse,  and  all  rubbish,  garb- 
age, and  refuse  including  waste  papers,  bottles  and  tin  cans  shall  be 
deposited  in  said  receptacles.  The  contents  of  these  covered  receptacles 
shall  be  removed  at  least  twice  per  week  when  the  camp  is  in  use  and 
burned  under  proper  supervision  or  disposed  of  in  some  other  sanitary 
manner. 

12.  Living  Quarters.  Living  quarters,  including  dormitories,  dining 
rooms,  kitchens,  laundries  and  other  shelters,  shall  be  properly  screened, 
rain-proof  and  raised  from  the  ground.  No  cook  or  other  food  handler 
with  a  history  of  having  had  typhoid  fever  shall  be  employed  or  continue 
to  be  employed  without  having,  or  having  evidence  of  having  had,  at 
least  two  negative  stool  and  urine  examinations. 

13.  Communicable  Diseases.  Cases  of  disease  declared  dangerous  to 
the  public  health  shall  be  reported  by  camp  authorities  to  the  local  board 
of  health.  Cases  shall  be  allowed  to  leave  the  camp  only  with  the  per- 
mission of  the  local  board  of  health.  The  more  important  of  these  diseases 
are:  anterior  poliomyelitis,  chicken  pox,  diphtheria,  dog-bite  (requiring 
anti-rabic  treatment) ,  dysentery,  encephalitis  lethargica,  epidemic  cerebro- 
spinal meningitis,  german  measles,  influenza,  lobar  pneumonia,  measles, 
mumps,  scarlet  fever,  septic  sore  throat,  smallpox,  tuberculosis  (all 
forms),  typhoid  fever  and  whooping  cough. 

14.  Caretakers.  At  least  one  caretaker  shall  be  employed  at  each  camp 
to  visit  said  camp  every  day  when  it  is  occupied  by  campers  or  picnickers, 


105 
and  the  caretaker  shall  keep  the  camp  and  its  equipment  in  a  clean  and 
sanitary  condition. 

15.  Maintenance  of  Sanitary  Conditions.  The  management  or  owner  of 
every  camp  shall  assume  responsibility  for  maintaining  the  camp  in 
proper  sanitary  condition  and  for  properly  maintaining  the  sanitary 
appliances. 

16.  Rules  and  Regulations  to  be  posted.  These  rules  and  regulations 
suitably  printed  shall  be  posted  in  conspicuous  places  at  each  camp  by 
the  management  thereof. 

HEALTHFUL  LIGHTING 

William  Firth  Wells 

Instructor  in  Sanitary  Science 
Harvard  School  of  Public  Health 

The  recent  emphasis  upon  the  apparently  mysterious  therapeutic 
and  bactericidal  effects  of  light  is  likely  to  fix  these  as  the  predom- 
inant health  factors  in  the  public  mind.  Granting  light  the  role  of  the 
great  purifier,  its  important  physiological  effects  and  curative  prop- 
erties, as  also  the  claims  of  irradiated  foods,  there  remains  in  the  field 
of  illumination  engineering  a  major  public  health  factor.  The  indi- 
rect benefits  of  good  lighting  on  health  are  out  of  all  proportion  to 
the  more  spectacular  direct  applications  of  light  to  disease,  or  even  to 
the  recorded  injury  and  death  resulting  from  faulty  lighting. 

Vision  provides  the  primary  channel  through  which  the  human 
being  receives  impressions  from  the  environment.  From  birth  to  death 
the  environment  is  being  constantly  explored  by  sight.  Education  is 
largely  a  process  of  visual  imagery,  and  our  picture  of  the  world 
about, — whether  direct,  or  through  pictures,  or  the  printed  word,  or 
even  the  spoken  language,  which  depends  for  its  effectiveness  upon  an 
appeal  to  visual  memory, — is  a  visual  impression.  It  is  not  surprising 
therefore  to  find  that  one-half  of  all  the  sensory  nerve  fibers  entering 
the  brain  are  visual,  and  considering  the  dependence  of  life  upon  the 
continuous  adjustment  of  the  individual  to  the  environment,  we  must 
recognize  the  protection  of  the  eye  as  a  public  health  problem  second 
only  to  life  itself. 

Until  community  life  becomes  complex  enough  to  have  a  public 
health  significance  light  comes  as  naturally  to  us  as  air,  for  such 
simple  purposes  as  may  be  needed.  Concentration  of  population,  how- 
ever, creates  artificial  conditions  of  existence.  Life  phases  formerly 
separated  in  time  by  daylight  or  darkness  depend  more  and  more  upon 
location.  Suitable  conditions  for  work,  play  and  sleep  are  more  diffi- 
cult to  secure  in  the  same  area,  and  so  industrial,  residential  and  rec- 
reational zones  are  established.  Congestion  drives  buildings  upward, 
further  limiting  both  light  and  air,  and  requiring  artificial  devices  to 
provide  the  primary  requisites  of  healthy  existence.  Public  health, 
faced  with  a  study  of  the  consequences,  discovers  hitherto  overlooked 
health  benefits  from  the  scientific  control  of  lighting. 

Artificial  lighting  cannot  be  passively  regarded  as  merely  an  ex- 
pedient in  community  development.  Removal  of  the  limitations  of  nat- 
ural lighting  gives  more  complete  control  of  our  environment  and 
thus  makes  more  healthful  living  conditions  possible.  For  fifteen  cen- 
turies the  candle  furnished  our  only  independence  from  sunlight,  but 
the  last  century  has  evolved  in  succession  the  gas  jet,  the  kerosene 
lamp,  the  gas  mantle,  the  arc  light,  the  incandescent  lamp  and  luminous 
tubes.  How  much  these  have  effected  modern  life  requires  little  mem- 
ory or  imagination.  The  possibilities  of  improving  conditions  of  health- 
ful living  can  only  be  disclosed  by  further  study.  Anyone  can  test  the 
degree  to  which  the  illuminating  engineer  can  meet  required  condi- 
tions by  witnessing  the  achievements  of  the  motion  picture.    Only  the 


106 

specification  of  the  physiologist  remains  to  be  elaborated  in  placing 
light  at  the  service  of  public  health. 

Economic  considerations  have  already  brought  about  fundamental 
improvements  in  lighting.  Although  contented  workers,  because  of 
more  agreeable  working  conditions,  reduced  eyestrain,  elimination  of 
accidents,  together  with  the  intangible  psychological  effects  of  cheer- 
fully lighted  surroundings,  are  a  distinct  asset  to  their  employer, — 
cutting  down  labor  turnover  and  compensation, — there  are  more  di- 
rect earnings  on  an  investment  in  good  lighting.  Making  the  dark 
hours  useful  and  raising  the  efficiency  of  the  workmen  has  increased 
production  from  ten  to  twenty-five  per  cent  with  no  other  addition  to 
plant  equipment  than  an  up-to-date  lighting  system  costing  but  one  to 
five  per  cent  of  the  payroll.  This  does  not  include  the  great  improve- 
ment in  the  quality  of  the  work  which  results  from  better  lighting  nor 
the  effective  supervision  it  makes  possible.  Spoilage  due  to  poor  light- 
ing is  said  to  cost  American  industry  more  than  $28,000,000  annually. 
Bad  lighting  was  responsible  for  nearly  25%  of  the  91,000  accidents  in 
1910.  Better  lighting  cut  this  percentage  more  than  a  third  in  the  next 
eight  years,  still  leaving,  however,  a  considerable  loss  of  time.  It  is 
estimated  that  a  million  dollars  in  wages  are  lost  annually  in  Massa- 
chusetts. 

While  these  figures  do  not  begin  to  measure  the  effect  of  lighting  on 
health,  they  serve  to  indicate  the  vast  importance  of  the  effect.  If 
employers  can  gain  so  much  in  lifting  the  strain  from  the  worker,  the 
benefit  to  the  worker  himself  must  be  evident.  The  first  effect  of  in- 
adequate lighting  is  eye-strain,  leading  to  a  slowing  down  of  the  work. 
Continuance  brings  permanent  impairment  with  ultimate  reduced  vis- 
ual efficiency.  Until  this  damage  eliminates  the  worker,  the  employer 
also  shares  the  loss  in  efficiency,  after  which  the  cost  is  borne  by  the 
worker.  It  then  concerns  the  public,  and  if  health  may  be  regarded 
as  a  positive  condition  of  life,  this  concern  is  a  problem  in  public 
health. 

SMOKE  NUISANCE 

David  A.  Chapman 

Director,  Division  of  Smoke  Inspection 

Massachusetts  Department  of  Public  Utilities 

For  years  people  felt  that  living  in  a  city  was  not  nearly  so  healthful 
as  living  in  the  country  -and  cast  around  for  the  causes.  It  is  inevit- 
able that  in  the  great  movement  for  better  health  which  arose  in  this 
country  at  the  beginning  of  this  century,  smoke,  which  had  often  been 
suspected,  should  take  its  share  of  the  blame.  For  the  air  in  our 
cities  would  be  as  pure  and  healthful  as  the  air  in  the  country  if  it 
were  not  for  the  pall  of  smoke  which  hangs  over  some  of  our  cities 
all  of  the  time  and  over  portions  of  some  of  them  part  of  the  time.  This 
menace  to  the  health  of  the  city  dweller  Was  not  regarded  seriously 
until  about  a  quarter  of  a  century  ago. 

At  that  period  some  of  our  most  eminent  and  public  spirited  physi- 
cians and  scientists  began  to  call  attention  to  very  serious  inroads  on 
the  health  of  city  dwellers  that  the  unrestricted  outpouring  of  smoke 
day  and  night  from  all  kinds  of  industrial  plants  was  making.  Effi- 
ciency experts  also  brought  in  a  heavy  indictment  against  the  smoke 
nuisance  in  the  cities  on  two  counts.  First,  because  of  the  great  in- 
jury done  by  smoke  to  buildings  and  the  furnishings  of  homes.  Second, 
because  of  the  excessive  waste  of  valuable  heating  units  by  faulty 
methods  of  combustion  and  improperly  constructed  boilers  and  chim- 
neys which  cause  smoke. 

Leading  medical  authorities  have  declared  from  time  to  time  that 
the  prevalence  of  smoke  in  the  cities  was  a  serious  menace  to  health 


107 
in  many  ways.  Their  statements  which  are  founded  on  extensive  re- 
searches are  of  primary  value  in  building  up  the  case  against  smoke 
aside  from  its  evil  effects  which  anyone  with  a  discerning  eye  can 
see,  chief  among  them  being  the  way  smoke  cuts  off  sunlight  which  is 
generally  recognized  as  necessary  to  the  maintenance  of  good  health. 
In  case  one  doubts  his  own  reasoning  he  has  the  words  of  Dr.  L.  Ver- 
non Briggs,  eminent  psychiatrist  and  a  pioneer  in  the  study  of  smoke 
abatement,  to  back  him  up.  At  a  Legislative  Committee  meeting  in 
1929  Dr.  Briggs  said: 

"Smoke  produces  serious  effects  upon  health  both  by  intercepting 
the  vitalizing  rays  of  the  sun  and  through  its  constant  inhalation.  Any- 
thing which  obscures  sunlight  and  contaminates  the  air  may  effect 
health.  Some  smoke  irritates  air  passages  and  is  supposed  to  favor  the 
development  of  respiratory  diseases.  Post-mortem  examinations  of 
bodies  has  disclosed  lungs  black  with  smoke  and  cinders,  and  that,  be- 
cause of  their  presence  in  the  air.  Because  of  this  Nature  is  unable  to 
throw  off  germs  of  influenza  and  tuberculosis." 

That  the  amount  of  sunlight  cut  off  by  the  smoke  pall  of  a  city  is  of 
no  small  account  was  recently  shown  in  New  York  City  by  the  experi- 
ments of  Dr.  James  E.  Ives  of  the  United  States  Public  Health  Service. 
Sunlight  recorders  placed  at  five  points  in  the  city  showed  a  loss  of 
31%  of  the  total  sunlight  through  smoke  alone. 

Dr.  Briggs  pointed  out  that  smoke  irritates  the  air  passages.  See 
what  it  does  to  those  subject  to  pulmonary  diseases.  Smoke  fumes 
cause  violent  coughing  which  may  result  in  hemorrhage  to  those  suf- 
fering from  diseased  lungs.  This  fact  was  pointed  out  by  a  Committee 
on  Hospitalization  of  the  American  Legion  when  discussing  the  situ- 
ation at  the  Chelsea  Naval  Hospital. 

Apart  from  the  irritating  effects  of  smoke  on  those  suffering  from 
pulmonary  diseases,  healthy  people,  too,  are  often  forced  by  smoke  and 
fumes  into  unhealthful  situations.  This  is  borne  out  by  the  words  of 
Dr.  Henry  A.  Christian,  physician  in  charge  of  the  Peter  Bent  Brigham 
Hospital.    Said  Dr.  Christian: 

"Pungent  and  disagreeable  fumes  float  into  our  houses.  At  night, 
they  are  often  particularly  bad.  If  this  continues,  it  will  increase  our 
disease  as  a  result  of  the  poor  hygiene  of  sleeping  behind  closed  win- 
dows, or  from  the  effects  of  breathing  in  irritating  fumes  if  the  win- 
dows are  left  open.  This  will  be  particularly  bad  for  our  citizens  who 
may  have  tuberculosis  and  for  whom  a  maximum  of  fresh  air  is  a  pre- 
requisite to  cure  or  arrest  of  the  disease." 

Increased  soot  will  increase  respiratory  disease,  especially  pneu- 
monia, as  shown  by  studies  conducted  in  Pittsburgh  and  elsewhere. 
The  oily  factor  in  soot  from  oil  burners  probably  will  increase  this 
hazard,  as  it  has  recently  been  shown  that  oil  droplets  in  the  lung  tis- 
sues produce  definite  pathological  conditions. 

Cancer,  the  most  dreaded  disease  of  the  present  age,  has  jumped 
into  the  front  rank  as  the  biggest  cause  of  death.  So  much  has  been 
written  and  so  little  is  known  about  this  scourge.  Can  it  be  possible 
that  smoke,  the  malefactor,  has  any  relation  to  the  prevalence  of  can- 
cer? Professor  Arthur  Edwin  Boycott  is  or  this  opinion.  He  believes 
that  it  is  caused  by  products  of  burnt  coal.  He  expressed  this  belief 
at  a  meeting  of  the  Royal  Society  of  Arts  held  in  London.  While  a  stu- 
dent at  Oxford,  Dr.  Boycott  studied  the  causes  and  cures  for  cancer, 
and  since  joining  the  faculty  of  the  University  of  London,  has  con- 
tinued to  make  experiments.  As  a  matter  of  practical  hygiene,  de- 
clared the  Professor,  one  should  avoid  irritation  in  all  forms  and  the 
case  against  the  products  of  burnt  coal  is  so  strong  that  it  is  evident 
that  the  smoke  nuisance  ought  to  be  stopped  without  further  delay. 

The  tarry  matter  and  the  sulphur  acids  are  most  dangerous  and  pro- 
duce catarrh  of  the  respiratory  tract,  bronchitis,   and  heart  failure. 


108 
As  an  authority  on  public  health,  Dr.  W.  A.  Brend  examined  the  main 
factors  in  infant  mortality  and  found  that  neither  poverty,  bad  hous- 
ing, insufficient  feeding,  defective  sanitation,  disease,  industrial  oc- 
cupations of  women  nor  malnutrition  of  mothers  can  be  regarded  as 
adequate  to  explain  the  excessive  difference  between  urban  and  rural 
mortality.  Brend  believes  that  the  noxious  influence  which  causes  the 
difference  is  a  "smoky  and  dusty  atmosphere,  and  that  as  a  cause  of 
infant  mortality  it  transcends  all  other  influences." 

In  this  State  there  are  health  regulations  providing  for  the  collec- 
tion and  disposal  of  abrasive  dust  created  in  connection  with  various 
industries.  However,  in  the  city  of  Boston,  there  are  boiler  plants  dis- 
charging into  the  atmosphere  large  quantities  of  fly  ash  of  a  silicatious 
composition  which  is  highly  abrasive,  the  product  of  pulverized  coal 
burning  plants. 

Beyond  a  doubt,  in  view  of  the  learned  opinions  and  evidence  at 
hand,  smoke,  irritating  fumes  and  abrasive  fly-ash  discharged  into  the 
air  we  breathe  form  a  very  definite  and  real  menace  to  health.  The 
statements  of  disinterested  physicians  being  founded  on  studies  and 
observations  extended  over  years  were  sufficient  to  convince  intelli- 
gent citizens  that  the  smoke  nuisance  in  our  cities  should  be  sup- 
pressed, for  its  suppression  meant  an  immense  gain  in  health  as  well 
as  in  the  appearance  of  our  cities.  And  yet  it  seems  strange  that  of 
the  three  necessities  of  life,  food,  air  and  water,  effective  legislation 
with  regard  to  purity  should  have  been  so  long  delayed  for  air,  al- 
though man  consumes  thirty-five  pounds  of  air  daily,  seven  times  as 
much  of  it  by  weight,  as  he  does  of  food  or  water. 

The  experience  of  the  Division  of  Smoke  Inspection  during  recent 
years  shows  clearly  that  much  of  the  increased  amount  of  smoke  noted 
and  complained  of  comes  from  the  burning  of  bituminous  coal  or 
heavy  fuel  oil  in  boilers  designed  solely  for  the  use  of  smokeless  fuel 
such  as  hard  coal  or  coke.  This  trend  toward  soft  coal  has  come  as  a 
natural  result  of  the  increasing  cost  of  hard  coal. 

Owners  found  that  soft  coal  could  be  burned  but  failed  to  realize  the 
damage  they  were  doing  to  surrounding  property  as  well  as  laying 
themselves  liable  to  a  fine  for  violating  the  smoke  laws. 

It  is  interesting  to  note  that  one  boiler  manufacturer  realized  that 
the  above  condition  might  result  if  we  may  judge  from  the  following 
statement  which  appears  in  his  catalogue: 

"This  boiler,  while  originally  designed  for  burning  hard  coals,  may 
be  operated  equally  well  with  bituminous  coal,  in  districts  where  there 
are  no  smoke  ordinances." 

It  is  to  be  hoped,  and  this  Division  feels  confident  that  we  shall  all 
note  a  material  reduction  of  the  smoke  pollution  in  the  air  we  have  to 
breathe  as  soon  as  manufacturers  of  boilers  and  the  public  at  large 
as  operators  of  heating  plants  are  educated  to  the  point  where  they 
realize  that  increased  efficiency  will  result  if  adequate  furnace  volume 
is  provided. 

THE  COMMUNITY  HEALTH  ORGANIZATION  IN 
MASSACHUSETTS  * 

W.  F.  Walker,  Dr.  P.  H. 

The  Commonwealth  Fund 

General  Health  Organization 

It  was  a  frequent  remark  of  Dr.  Eugene  Kelley,  former  Commissioner 
of  Health  in  Massachusetts  that  the  small  communities  in  the  State  pre- 
sented health  problems  for  which  there  was  then  no  satisfactory  admin- 
istrative solution.    There  has  existed  in  the  State  a  distinctly  decentral- 


*  Read   at  the   New   England   Health   Institute,    Portland,    Maine,    April,    1931. 


109 

ized  health  authority  based  on  the  right  of  local  self  government  in  prac- 
tically all  matters  which  has  been  extended  to  the  smallest  political  unit. 
Each  of  the  355  cities  and  towns  is  a  separate  administrative  unit  for 
public  health  purposes.  Undoubtedly  this  lack  of  organization  has  certain 
advantages  and  is  in  keeping  with  the  general  New  England  tradition 
that  each  community  must  at  all  cost  have  local  autonomy. 

In  the  early  days,  when  this  form  of  government  was  first  established, 
each  of  the  towns  or  local  units  concerned  was  discrete  and  there  was  a 
sufficient  stretch  of  unoccupied  or  sparsely  settled  territory  between 
urban  centers  to  act  as  a  natural  barrier  in  the  spread  of  communicable 
disease.  Because  of  the  infrequency  of  communication  these  units  seem 
to  have  functioned  reasonably  well  and  probably  encouraged  a  greater 
general  interest  among  the  population  in  health  protective  matters  than 
might  have  resulted  if  more  centralized  control  had  been  developed. 

Under  the  general  laws  of  the  state  as  amended  in  1924  boards  of 
health  of  these  all  too  numerous  units  may  make  any  reasonable  health 
regulations  and  are  authorized  to  draw  up  rules  and  regulations  having 
to  do  with  the  isolation  and  quarantine  and  control  of  contagious  disease. 
This  broad  regulatory  power,  without  simple  machinery  for  the  super- 
vision and  guidance  of  local  boards  in  its  exercise,  has  brought  about  a 
degree  of  confusion  which  is  readily  appreciated  when  it  is  known  that 
one  community  may  have  a  42  day  quarantine  period  for  scarlet  fever 
while  the  adjoining  community  holds  a  case  under  supervision  but  for 
21  days.  There  is  no  upper  or  lower  limit  to  the  range  of  regulations 
which  a  local  board  of  health  may  promulgate.  An  appreciable  percentage 
of  the  smaller  communities  have  no  local  health  regulations  of  any  kind 
and  many  communities  having  once  promulgated  such  regulations  have 
left  them  unchanged  for  ten  years,  though  during  this  time  considerable 
advance  has  been  made  in  medical  and  sanitary  science  and  in  what  may 
be  considered  sound  health  administration. 

The  Southern  Berkshire  Area 

The  effect  of  years  of  such  organization  can  be  visualized  by  referring 
to  the  conditions  in  the  particular  areas  under  consideration.  The  South- 
ern Berkshire  District,  comprising  the  southern  half  of  Berkshire  County, 
includes  15  towns  and  had,  according  to  the  1930  census,  a  population  of 
21,425.  The  towns  themselves  vary  from  200  people  in  Alford  to  slightly 
less  than  6,000  in  Great  Barrington,  with  a  population  per  square  mile 
ranging  from  nine  in  Sandisfield  to  152  in  Lee.  The  average  for  the 
district  is  forty-nine,  the  total  area  being  450  square  miles. 

Each  of  these  towns  has  a  specially  designated  board  of  health  or  em- 
powers the  selectmen  themselves  to  act  in  that  capacity  and  exercise  all 
the  authority  of  the  general  law.  In  addition  to  activities  carried  on 
under  these  agencies  the  town  school  committees  exercise  supervision 
over  the  health  of  school  children  and  employ  medical  and  nursing  serv- 
ice for  this  purpose. 

The  total  expenditure  by  the  boards  of  health  for  health  purposes — in- 
terpreted broadly  to  include  animal  and  sanitary  inspections  as  well  as 
medical  and  nursing  personnel,  laboratory  service,  etc. — amounts  to 
$11,800  or  $.55  per  capita.  The  school  committees  for  medical  and  nurs- 
ing service  spend  an  additional  $8,000  bringing  the  total  expenditure  of 
all  areas  through  official  channels  up  to  $19,800  or  nearly  $.92  per  capita. 
Even  with  this  fairly  generous  expenditure  through  official  channels,  none 
of  the  fifteen  boards  of  health  employs  full-time  personnel.  In  addition 
to  these  thirty  official  groups  participating  in  the  health  work  of  the  com- 
munity, eight  towns  have  visiting  nurse  associations  or  provide  for  a 
community  nurse  responsible  to  the  selectmen.  Through  these  non-official 
channels  it  is  conservatively  estimated  that  an  additional  $19,000  at  least, 
is  spent  on  health  work  and  sickness  care  through  community  effort, 
exclusive  of  the  amount  paid  local  registrars  for  the  recording  of  birth, 
death  and  marriage  certificates. 


110 

This  expenditure  provides  for  the  area  the  equivalent  of  eleven  nurses 
on  full-time  service,  one  full-time  and  one  part-time  milk  inspector,  a 
part-time  animal  inspector  in  each  town,  and  a  part-time  school  physician 
in  each  town.  Sometimes,  however,  the  same  individual  serves  more  than 
one  community.  It  also  provides  for  the  compensation  of  any  members 
who  act  officially  for  the  board  of  health  in  eight  towns.  Yet  it  does  not 
provide  a  coordinated  and  forward  looking  health  service  for  the  22,000 
people  in  the  district,  and  though  the  conditions  as  reflected  by  the  vital 
statistics  of  the  community  are  not  as  bad  as  are  found  in  most  rural 
areas  there  is  local  desire  and  unquestioned  opportunity  for  improvement 
in  the  health  protective  and  health  promotive  activities. 

The  proximity  to  the  district  of  Pittsfield  makes  possible  the  use  of 
certain  hospital  and  outpatient  facilities  which  are  a  real  factor  in  the 
health  set-up  of  the  community.  Fifty-two  patients  from  the  area  took 
advantage  of  the  outpatient  services  of  Pittsfield  hospitals  during  the 
y«ar,  chiefly  for  eye,  ear,  nose  and  throat,  orthopedic  and  venereal  disease 
services.  Seventy  per  cent  of  the  total  hospital  care  to  Southern  Berk- 
shire patients  was  rendered  by  Pittsfield  hospitals,  the  balance  being 
given  by  the  Fairview  Hospital  at  Great  Barrington. 

The  Nashoba  District 

The  Nashoba  district  comprises  fourteen  towns  having  a  total  popula- 
tion of  21,900,  but  is  somewhat  more  compact.  It  covers  an  area  of  but 
287  square  miles  with  an  average  density  of  population  of  seventy-six 
persons  per  square  mile,  varying  from  twenty-two  in  Dunstable  to  347 
in  Ayer,  with  only  five  of  the  towns  having  less  than  fifty  persons  per 
square  mile.  Here  there  are  the  same  official  agencies  for  public  health 
services  as  in  the  Southern  Berkshire  area;  the  boards  of  health  and 
selectmen  spend  $18,600  on  nursing  and  inspectorial  service,  commun- 
icable disease  control,  including  hospitalization,  general  administration 
and  miscellaneous  services,  including  dental  clinics.  The  school  com- 
mittees spend  a  total  of  $5,500  on  medical  and  nursing  services,  making 
the  total  spent  for  health  purposes  about  $24,000  or  $1.10  per  capita 
exclusive  of  the  expenditures  for  recording  vital  statistics  and  small 
amounts  spent  by  voluntary  agencies.  A  striking  difference  between  the 
two  districts  is  that  in  the  Southern  Berkshire  District  a  considerable 
amount  of  money  is  spent  on  nursing  service  by  voluntary  agencies,  chiefly 
through  the  Great  Barrington  Visiting  Nurse  Association,  which  serves 
five  towns  in  the  immediate  vicinity  of  Great  Barrington,  while  in  the 
Nashoba  District  there  is  relatively  little  service  by  private  health 
agencies. 

The  public  health  personnel  in  Nashoba  District  includes  nine  full-time 
nurses,  seven  of  whom  give  full-time  service  to  a  single  town  and  two 
divide  their  time  between  two  towns.  Three  towns  depend  upon  part-time 
service  to  meet  their  needs.  A  part-time  sanitary  inspector  in  one  town 
completes  the  trained  personnel  aside  from  the  part-time  service  of 
physicians  rendered  either  to  the  school  boards  or  to  the  boards  of  health. 
As  in  the  Southern  Berkshire  District,  the  citizens  of  the  Nashoba  area 
patronize  the  hospitals  of  the  surrounding  towns  to  a  considerable  extent. 
Thirty-two  per  cent  of  the  births  and  fifteen  per  cent  of  the  deaths  of 
residents  of  the  Nashoba  District  occur  in  the  hospitals  of  Lowell,  Leo- 
minster, Fitchburg,  Clinton,  Boston,  Waltham  and  Concord  in  Massachu- 
setts and  Nashua  in  New  Hampshire. 

The  status  of  health  activity  in  these  areas  at  the  moment  can  be  sum- 
marized by  their  scores  on  the  basis  of  the  Appraisal  Form  for  Rural 
Health  Work.  In  the  Southern  Berkshire  District  a  total  score  of  517 
points  of  a  possible  1,000  indicates  that  on  the  whole  the  health  machin- 
ery is  a  little  more  than  50  per  cent  adequate.  Because  of  a  considerable 
amount  of  prenatal  nursing  service  and  the  fact  that  physicians  in  general 
are  doing  an  unusual  amount  of  prenatal  work,  maternity  hygiene  stands 


Ill 

highest,  with  laboratory  and  infant  hygiene  and  communicable  disease 
control  following  in  this  order.  At  the  other  end  of  the  scale  we  see  sani- 
tation, school  hygiene,  popular  health  instruction  and  venereal  disease 
control  as  thoroughly  inadequately  provided  for. 

In  the  Nashoba  District  the  total  score  is  433  points  of  a  possible  1,000 
with  prenatal  and  infant  hygiene  and  communicable  disease  control  rank- 
ing at  the  top  and  preschool  hygiene,  tuberculosis  service,  popular  health 
instruction  and  venereal  disease  control  developed  to  less  than  20  per  cent 
adequacy. 

What  Is  to  Be  Done 

It  is  apparent  that  in  such  communities  there  is  no  lack  of  interest, 
that  there  is  a  possibility  of  adequate  financial  support.  The  crux  then, 
in  the  words  of  Dr.  Kelley,  is  a  lack  of  satisfactory  administration.  The 
failure  of  the  administrative  facilites  has  been  repeatedly  demonstrated 
in  the  face  of  epidemic  diseases.  The  way  to  better  administration  has 
already  been  pointed  in  the  State  in  the  field  of  education  where  for 
some  years  superintendency  districts  have  been  in  vogue  which  give 
trained  full-time,  capable  administration  to  the  schools  of  a  group  of 
towns. 

In  the  face  of  the  urgent  demands  of  war-time,  a  group  of  towns  in  the 
Nashoba  District  combined  to  pass  uniform  health  regulations  and  in 
other  ways  to  develop  common  protective  measures.  Following  an  out- 
break of  septic  sore  throat,  three  towns  in  the  Southern  Berkshire  Dis- 
trict combined  to  provide  an  adequate  milk  inspection  and  control  service. 
It  was  a  natural  sequel  to  consider  the  possibilities  of  organizing  a  group 
of  towns,  having  population  of  suitable  size,  and  with  sufficient  common 
interest  to  act  as  a  binder,  and  to  provide  from  State  and  outside  sources 
such  additional  personnel  as  seemed  necessary  to  form  a  nucleus  of  an 
organized  health  service  functioning  for  the  entire  area.  The  staff  would 
act  as  agents  of  the  individual  boards  of  health,  and  such  personnel  and 
support  as  could  be  demonstrated  to  the  town  to  be  in  its  best  interest 
would  gradually  be  attracted  to  this  nucleus. 

The  State  Program  in  Cooperation  with  the  Commonwealth  Fund 

The  possibilities  of  extending  this  form  of  organization  into  the  health 
field  and  eventually  providing  legal  stability  for  it  was  suggested  by  Dr. 
Bigelow  and  appealed  to  the  Commonwealth  Fund  as  a  project  which 
might  well  fit  into  the  program  of  its  Division  of  Public  Health.  This 
division  has  adopted  as  its  fundamental  principles: 

(1)  That  state  departments  should  directly  foster  and  guide  rural 
health  activities 

(2)  That  the  progressive  practice  of  medicine  is  the  foundation  of 
sound  health  work 

(3)  That  to  secure  maximum  results  physicians,   nurses,   teachers 
and  official  health  personnel  must  join  forces. 

In  carrying  out  this  program  two  related  lines  of  service  have  been 
planned.  One  provides  assistance  to  state  departments  of  health  in  setting 
up  field  supervision  for  rural  health  work  and  developing  adequate  local 
service  in  several  areas.  The  second  provides  assistance  to  schools  of 
medicine  in  the  same  state  in  promoting  special  training  for  rural  health 
service.  Special  grants  are  made  to  medical  schools  to  aid  in  the  teaching 
of  preventive  medicine  and  of  public  health,  both  to  undergraduate  medi- 
cal students  and  physicians  desiring  postgraduate,  brush-up  work.  Funds 
are  made  available  for  fellowships  both  for  undergraduate  students  who 
plan  to  engage  in  rural  practice  and  for  graduate  physicians  practicing 
in  the  State  and  particularly  in  those  areas  where  rural  health  units  are 
now  operating  under  the  program.  Similar  fellowships  for  nurses  and 
for  health  educators  and  other  health  personnel  are  offered  through  other 
institutions. 


112 

As  this  program  applies  specifically  to  Massachusetts  it  means  that  the 
State  Department  of  Health,  with  the  aid  of  the  Commonwealth  Fund, 
will  for  the  present  supply  to  the  Southern  Berkshire  District,  a  full-time 
health  officer,  a  supervising  nurse,  two  staff  nurses,  a  sanitary  inspector 
and  a  clerk.  The  boards  of  health  of  the  fifteen  towns  have  voluntarily 
come  together  and  endorsed  the  plan  of  cooperation  without,  for  this 
year,  assuming  any  financial  responsibility.  With  this  nucleus  of  full-time 
health  personnel,  in  addition  to  that  already  there,  and  with  the  coopera- 
tion of  both  official  and  voluntary  agencies  assured,  it  would  seem  not  too 
ambitious  to  expect  that  a  better  coordinated  service  could  be  developed, 
and  that  its  value  would  so  impress  the  communities  that  they  would  be 
willing  to  assume  the  financial  burden  which  it  involves.  It  also  is  be- 
lieved that  with  better  administration  there  may  very  likely  come  a 
greater  efficiency  of  operation  which  will  mean  that  for  the  same  or  only 
slightly  greater  health  expenditure  a  more  effective  and  better  balanced 
program  can  ultimately  be  carried  on.  The  use  of  part-time  nursing  ser- 
vice under  diverse  auspices  undoubtedly  introduces  inefficiences  which 
can  in  the  end  be  corrected. 

In  the  Nashoba  District  the  cooperative  program  provides  for  the  addi- 
tion of  a  full-time  health  officer,  a  senior  nurse,  and  one  staff  nurse,  a 
sanitary  inspector,  laboratory  technician  and  a  clerk  and  an  allowance  for 
part-time  medical  service.  This  is  likewise  considered  to  form  the  nucleus 
of  organized  service  which  will  extend  its  influence  on  the  basis  of  its 
proven  worth.  The  boards  of  health  have  come  voluntarily  together  to 
form  a  directing  body  for  the  guidance  of  the  work. 

Full-time  health  officers  have  been  employed  in  both  districts  and  the 
work  of  selecting  other  staff  members  and  the  actual  initiation  of  the  pro- 
gram is  well  along. 

Coordinating  Unit 

To  assist  the  State  Department  in  the  organization  of  work  in  the  two 
units  and  the  development  of  satisfactory  relationships  with  them,  and 
to  act  as  a  disseminating  agency  within  the  State  for  whatever  good  is 
developed  in  these  areas,  funds  have  been  provided  to  enable  the  State 
Department  to  employ  a  field  or  coordinating  unit.  This  consists  of  a 
physician  with  public  health  administration  experience,  sort  of  a  health 
officer  at  large,  a  public  health  nurse  well  versed  in  the  organization  and 
supervision  of  nursing  service  and  a  sanitary  engineer  of  good  training 
and  experience.  This  personnel  is  the  forerunner  of  the  permanent  staff 
in  the  communities,  developing  a  local  interest  for  a  better  organized 
service  and  assisting  in  keeping  the  programs  in  the  areas  balanced  and 
in  line  with  progressive  thinking.  Through  contact  with  other  parts  of 
the  state  they  will  be  able  to  spread  the  influence  of  the  work  in  the 
two  areas,  directly  and  effectively,  to  other  communities. 

Relation  to  Medical  Practice 

Another  very  real  part  of  the  project  is  the  granting  of  fifteen  scholar- 
ships for  four  months'  study  at  Harvard  with  courses  arranged  to  fit  each 
physician's  particular  needs.  Five  will  be  reserved  for  the  physicians 
of  each  of  the  two  districts  and  five  will  go  to  the  State  at  large.  These 
scholarships  are  particularly  designed  for  the  physicians  in  general  prac- 
tice in  rural  communities  who  wish  to  improve  their  grasp  of  the  best 
current  technique.  Instruction  will  be  given  to  those  subjects  which  are 
common  to  the  practice  of  medicine  with  emphasis  laid  on  problems  which 
are  troublesome  to  all  physicians. 

The  level  of  public  health  nursing  will  be  improved  by  the  giving  of 
two  scholarships  a  year  in  each  community  and  two  in  the  State  at  large 
for  study  not  to  exceed  four  months.  Through  a  loan  fund  for  under- 
graduate medical  students  at  Tufts,  physicians  will  be  encouraged  to 
seek  locations  in  rural  areas  and  thus  lower  the  average  age  and  raise 


113 

the  professional  level  of  rural  medical  practice.  Through  the  administra- 
tive arrangements  which  are  here  suggested,  namejy  the  grouping  of 
towns  into  health  districts,  local  health  service  should  be  improved  in 
quantity  and  quality.  By  means  of  the  program  of  medical  education, 
it  is  hoped  to  assist  the  rural  doctors  to  meet  the  needs  of  their  service 
more  effectively  and  to  be  in  position  to  participate  in  and  cooperate  with 
an  extended  and  well  balanced  public  health  program. 

THE  HEALTH  OFFICER  IN  THE  CONTROL  OF  GONORRHEA 

AND  SYPHILIS 

Nels  A.  Nelson,  M.  D. 

Assistant  Director, 

Division  of  Communicable  Diseases 

Foreword 

This  discussion  of  gonorrhea  and  syphilis  and  of  the  laws  of  Massa- 
chusetts pertaining  to  their  control  is  written  especially  for  the  health 
officers  of  this  State.  Gonorrhea  and  syphilis  are  very  different  in  their 
implications  from  all  other  diseases  dangerous  to  the  public  health,  and 
most  health  officers  are  baffled  by  the  problem  which  they  present. 

The  idealist,  sitting  safely  at  his  desk,  insists  that  there  is  no  reason 
why  these  two  diseases  should  not  be  managed  exactly  as  any  other  com- 
municable disease  is  managed.  He  argues  that  it  is  only  necessary  to  re- 
member that  gonorrhea  and  syphilis  are  diseases,  and  to  forget  their 
moral  implications  which,  in  many  cases,  do  not  apply.  But  the  health 
officer  who  must  ring  the  delinquent  patient's  doorbell  without  arousing 
the  curiosity  of  his  family,  or  who  has  just  advised  an  examination  to  an 
indignant  "source  of  infection,"  discovers  that  a  natural  human  desire 
to  avoid  discovery  of  sex  irregularity  is  not  so  easily  brushed  aside  by  an 
idealistic  wave  of  the  hand. 

However,  the  intelligent  health  officer  does  not  refuse  to  face  a  problem 
because  it  is  a  difficult  one.  He  cannot  close  his  eyes  to  the  fact  that  more 
than  half  the  women  who  have  gonorrhea  or  syphilis  have  been  infected, 
innocently,  through  marriage.  He  cannot  ignore  the  multitude  of  chil- 
dren who  are  born  with  syphilis  through  no  fault  of  their  own;  nor  the 
babies  who  have  been  blinded  by  gonorrhea.  So  while  he  is  quite  aware 
of  the  need  for  treading  cautiously  and  of  speaking  softly,  the  thoughtful 
health  officer  is  firm  in  his  determination  to  face  the  problem  squarely. 
He  knows  that  although  gonorrhea  and  syphilis  may  be  the  "wages  of 
sin"  to  some,  they  are  also,  like  diphtheria  and  infantile  paralysis,  the 
unfortunate  and  undeserved  lot  of  many  others. 

That  Massachusetts  health  officer  who,  as  he  willingly  hastened  to 
provide  care  for  a  baby  with  gonorrheal  ophthalmia,  remarked  that, 
"there  are  better  uses  for  the  taxpayer's  money  than  for  the  treatment 
of  the  good-for-nothing  men  and  women  who  get  gonorrhea,"  refused 
to  see  beyond  the  end  of  his  very  short  nose.  He  will  obstruct  progress 
in  his  own  community  for  a  time.  Eventually,  however,  he  will  like  all 
things,  pass  away,  and  his  town  will  be  free  to  catch  up  with  the 
procession. 

Gonorrhea 

Gonorrhea  is  a  germ  disease  involving  the  membranes  of  the  genital 
organs.  It  is  spread,  usually,  through  sexual  intercourse.  Its  symptoms 
appear,  as  a  rule,  within  a  week  after  exposure. 

In  the  male  the  parts  most  frequently  involved  are  the  urethra  (water 
passage),  the  base  of  the  bladder,  the  prostate  gland  and  the  lower  end 
of  the  testicles.  In  the  female  the  disease  attacks  the  urethra,  the  external 
genitalia  (private  parts),  the  vagina,  the  mouth  of  the  womb,  the  womb 
itself,  the  tubes,  the  ovaries  and  the  lining  of  the  pelvis.    Sometimes,  in 


114 

either  sex,  the  germs  enter  the  blood,  leading  to  a  severe  form  of  rheuma- 
tism and,  in  some  cases,  a  very  fatal  form  of  heart  disease.  Infection  of 
the  eye  often  results  in  serious  damage  to  vision  or  even  total  blindness. 

The  acute  stage  of  gonorrhea  is  of  relatively  short  duration  and  therein 
lies  the  danger.  When  the  annoying  symptoms  have  disappeared,  unless 
the  patient  has  been  carefully  instructed  in  the  nature  and  extent  of  the 
disease,  he  (or  she)  discontinues  treatment.  It  is  the  chronically  infected 
prostate  in  the  male  which,  while  it  produces  little  or  no  discharge,  is 
responsbile  for  most  of  the  spread  of  the  disease  by  men.  In  women,  the 
glands  of  the  urethra  and  of  the  mouth  of  the  womb  may  retain  the  in- 
fection for  months  and  even  years  with  little  or  no  consciousness  on  the 
part  of  the  patient  that  she  still  has,  or  ever  has  had,  gonorrhea. 

One  serious  obstacle  to  the  management  of  gonorrhea  is  the  difficulty 
of  finding  the  gonococcus  once  the  disease  has  passed  the  acute  stage. 
The  willingness  of  many  physicians  to  depend  entirely  upon  laboratory 
reports  (often  on  a  single  smear),  instead  of  searching  for  other  signs 
of  infection,  has  resulted  in  the  dismissal  of  too  many  persons  as  not 
infected,  and  in  the  too  early  discharge  of  many  others,  as  cured. 

Gonorrhea  in  the  male  is  not  often  the  disastrous  disease  that  it  is 
in  the  female.  In  some  cases  stricture  occurs  (scar  formation  in  the 
urethra)  which  requires  painful  dilations  throughout  life.  Persistent  in- 
fection of  the  prostate  may  have  a  similar  effect  upon  health  to  that  of 
infected  tonsils.  Infection  of  the  testicles  may  result  in  sterility.  But 
gonorrhea  in  the  female  is  disastrous  in  the  extreme.  Removal  of  all  the 
internal  generative  organs  (or  their  eventual  destruction  by  the  disease), 
sterility,  and  a  lifetime  of  incapacitating  "female  troubles"  with  their 
associated  neurasthenias,  have  become  the  lot  of  numberless  women, 
many  of  whom  do  not  realize  that  their  troubles  are  due  to  gonorrhea. 
Hundreds  of  little  girls  require  long  treatment  and  lose  months  from 
school  as  a  result  of  infection,  innocently  acquired  through  contact  with 
infected  adults. 

Consequently,  every  reasonable  procedure  which  will  prevent  the  spread 
of  gonorrhea  deserves  the  serious  attention  of  the  health  officer. 

Syphilis 

Syphilis  is  a  germ  disease  which  may  involve  the  entire  body  or  any 
part  of  it.  Although  it  usually  is  spread  through  sexual  intercourse, 
under  certain  conditions  it  may  be  acquired  through  such  non-sexual 
contacts  as  kissing,  handling  the  patient  or  using  articles  very  recently 
used  by  the  patient. 

The  first  sign  of  the  disease  appears  as  a  sore  (chancre)  which  develops 
at  the  place  where  the  germs  went  in  within  two  to  four  weeks  of  the 
date  of  exposure.  This  sore  may  appear  insignificant,  or  it  may  be  a  large 
ulcer.  It  is  often  missed,  especially  in  women.  The  chancre  may  contain 
thousands  of  the  germs  of  syphilis.  If  it  is  located  on  the  lip,  or  in  the 
mouth  or  on  any  exposed  part  of  the  body  it  is  extremely  dangerous  in 
non-sexual  contacts.  This  sore  may  remain  unhealed  for  many  days  or 
weeks  if  the  disease  is  not  treated.  Proper  treatment  will  heal  it  in  a 
few  days. 

If  the  disease  is  not  treated  or  is  inadequately  treated,  it  passes  into 
the  second  stage.  The  signs  of  this  stage  develop  from  three  to  six  weeks 
or  more  after  the  sore  appeared.  There  may  be  a  rash  on  the  body,  sores 
on  the  genitals  and  in  the  mouth,  sore  throat,  swollen  glands,  aching 
bones,  and  fever.  These  signs  may  be  so  mild  that  no  attention  is  paid 
to  them,  or  they  may  be  missed  entirely.  The  sores  on  the  genitals  and 
in  the  mouth  contain  thousands  of  the  germs  and  are  very  dangerous. 

Eventually  the  signs  of  the  second  stage  disappear,  slowly  without 
treatment,  but  in  a  few  days  with  proper  treatment.  But  if  treatment 
is  neglected  the  sores  may  reappear  at  intervals  of  weeks  or  months, 
in  some  cases  for  several  years. 


115 

If  the  disease  is  not  checked  by  adequate  treatment,  the  third  stage 
gradually  develops.  Signs  of  this  stage  may  appear  soon  after  the 
second  stage  has  disappeared,  but  usually  they  are  delayed  from  five 
to  ten  or  even  twenty  years  or  more.  Any  part  of  the  body  may  be  in- 
volved: the  skin,  bones,  heart  and  blood  vessels,  the  brain  or  the  spinal 
cord.  One  of  every  fourteen  persons  admitted  to  the  Massachusetts 
hospitals  for  mental  diseases  is  admitted  because  of  general  paralysis 
of  the  insane, — one  form  of  syphilis  of  the  brain.  It  costs  the  State  at 
least  $200,000  a  year  for  their  care.  It  is  probable  that  a  considerable 
part  of  the  heart  disease  of  middle  age  is  due  to  syphilis. 

Primarily  syphilis  (chancre),  if  treated  at  once  and  adequately,  is 
almost  always  curable.  If  the  disease  advances  to  the  second  stage,  the 
chance  of  cure  is  decreased  by  twenty  per  cent  or  more  although  its 
progress  may  be  arrested.  In  the  third  stage,  arrest  of  the  progress  of 
the  disease  is  all  that  can  be  assured  in  many  cases,  and  some  treat- 
ment may  be  necessary,  at  intervals,  throughout  the  patient's  life. 

Congenital  syphilis  is  the  result  of  syphilis  in  the  mother.  It  may 
be  evident  at  birth  in  the  form  of  exceedingly  dangerous  sores,  or  it 
may  be  discovered,  only  as  the  child  grows  older,  in  the  form  of  mental 
deficiency,  retarded  physical  development,  blindness,  deafness  and 
often  death.  Many  babies  with  syphilis  are  born  dead;  many  others 
die  shortly  after  birth  or  within  the  first  four  or  five  years  of  life.  A 
large  number  of  abortions  and  miscarriages  are  due  to  syphilis. 

Congenital  syphilis  can  be  prevented  by  adequate  treatment  of  the 
disease  in  the  mother  during  pregnancy.  Syphilis  in  pregnant  women 
usually  can  be  detected  only  by  the  use  of  the  Wasserman  test.  Con- 
sequently it  should  be  the  aim  of  the  health  officer  to  encourage  the 
routine  use  of  the  Wasserman  test  in  every  pregnancy. 

So  far  as  maximum  communicability  is  concerned,  the  primary  and 
secondary  stages  of  syphilis  are  the  most  dangerous.  The  patient  with 
syphilis  in  either  of  these  stages,  or  the  pregnant  woman  with  syphilis 
in  any  form,  who  discontinues  treatment  or  who  exposes  others,  should 
be  controlled  immediately.  Usually  resumption  of  treatment  will  be 
sufficient,  but  any  action  which  may  be  necessary  to  prevent  the  spread 
of  this  very  serious  disease,  should  be  taken  without  hesitation. 

The  Law 

Public  opinion  probably  never  will  permit  physicians  to  report  the 
name  of  a  patient  with  gonorrhea  or  syphilis  unless  the  patient  becomes 
unmanageable.  Therefore,  it  may  never  be  possible  to  control  these 
diseases  in  the  more  or  less  arbitrary  manner  in  which  other  diseases 
are  controlled. 

Fortunately  it  is  unnecessary  to  isolate  or  quarantine  most  people 
who  have  gonorrhea  or  syphilis.  The  patient  who  neglects  treatment 
usually  is  one  who  has  had  little  or  no  instruction  in  the  nature  of  the 
disease,  the  consequences  of  its  neglect,  its  adequate  treatment  and 
how  to  prevent  its  spread.  Of  course,  incorrigibility,  feeble-mindedness 
or  unusually  precocious  sex  impulse  must  be  dealt  with  in  some  cases, 
but  arbitrary  enforcement  of  the  law  may  be  reserved  almost  entirely 
for  this  smaller  group. 

Isolation,  except  as  an  emergency  measure  or  as  a  last  resort,  is  im- 
practicable. Even  if  all  cases  of  gonorrhea  and  syphilis  were  identi- 
fied to  the  health  officer,  it  would  be  unsound,  economically,  to  isolate 
thousands  of  people  for  weeks  or  months  or  even  years  when  strict 
observance  of  a  few  simple  rules  of  conduct  will  prevent  the  spread 
of  either  disease.  The  control  of  tuberculosis  is  proceeding  effectively 
through  the  use  of  methods  which  rarely  savor  of  compulsion.  In  or- 
dinary contacts  between  people  tuberculosis  is  far  more  communicable 
than  gonorrhea,  and  except  in  the  presence  of  exposed  lesions,  more 
communicable  than  syphilis. 


116 

However,  until  people  are  well  informed  concerning  these  diseases, 
and  until  every  patient  is  instructed  adequately  by  his  physician, 
there  will  be  lapses  from  treatment  and  work  for  the  health  officer. 

The  health  officer  who  can  convince  the  patient  that  it  is  for  his  own 
good  that  he  resume  treatment  will  accomplish  far  more  lasting  re- 
sults than  he  who  arbitrarily  commands  the  patient  to  do  so.  The 
public  health  nurse  who  ordered  a  suspected  source  of  infection  to  re- 
port to  a  doctor's  office  within  twenty-four  hours  under  penalty  of 
arrest,  so  antagonized  the  woman  that  she  stopped  visiting  the  physi- 
cian with  whom  she  already  was  under  observation; — and  there  has 
been  no  arrest! 

Compare  this  inconsiderate  and  disastrous  procedure  with  that  of 
the  health  officer  who,  with  unusual  tact,  secured  the  immediate  exam- 
ination of  a  notorious  prostitute  who  was  found  to  have  syphilis  in  its 
most  dangerous  form ;  brought  about  the  examination  of  her  unsuspecting 
husband  who  also  was  found  to  be  infected;  had  the  five  children  in 
the  family  examined;  and  discovered  six  of  the  woman's  male  com- 
panions, two  of  whom  were  found  to  have  syphilis!  Such  is  the  dif- 
ference between  the  iron  heel  of  authority  worn  by  some  officials  of 
small  calibre,  and  intelligent  management  by  the  health  officer  who 
has  the  welfare  of  both  the  individual  and  the  community  at  heart. 

On  occasion,  even  the  best  health  officer  will  be  obliged  to  reach 
for  a  club,  but  its  judicious  use  will  have  the  approval  of  public  opin- 
ion and  gain  the  respect  of  the  really  vicious  person  who  listens  to  no 
reason.  The  health  officer  of  one  Massachusetts  city  quickly  located 
and  removed  to  an  institution  a  woman  with  acute  secondary  syphilis 
who  had  fled  her  home  town  rather  than  to  accept  the  treatment  of- 
fered by  her  own  health  officer.  He  not  only  effectively  stopped  the 
further  spread  of  that  woman's  infection,  but  taught  her  that  beyond 
a  certain  point,  the  health  of  the  community  becomes  more  important 
than  the  unrestricted  liberty  of  the  individual. 

The  intelligent  health  officer  interprets  the  law  as  his  permission  to 
be  an  effective  servant.  A  board  of  health  quibbled  for  months  over 
whether  it,  or  the  board  of  public  welfare  should  be  responsible  for  the 
treatment  of  a  case  of  congenital  syphilis  with  involvement  of  the  eyes. 
When  the  child  could  no  longer  see,  the  board  of  health  suddenly  de- 
cided to  provide  the  necessary  care, — but  too  late;  the  disease  had 
progressed  too  far.  That  board  of  health  thought  more  of  what  the 
law  might  permit  it  to  evade  than  it  did  of  the  privilege  which  the  law 
conferred  upon  it  to  protect  the  health  of  the  individuals  which  consti- 
tute that  community.  Although  it  might  be  argued  that  the  disease 
was,  at  the  time,  non-communicable,  the  delay  resulted  disastrously, 
not  only  to  the  child,  but  also  to  the  community  in  terms  of  the  cost 
of  caring  for  a  blind  child. 

Following  is  a  discussion  of  the  general  laws  under  which  gonorrhea 
and  syphilis  have  been  declared  to  be  diseases  dangerous  to  the  public 
health,  the  regulations  of  the  Department  of  Public  Health,  and  the 
laws  under  which  local  boards  of  health  may  proceed  to  the  control  of 
these  two  dangerous  diseases: — 

GONORRHEA  AND  SYPHILIS  DECLARED  DANGEROUS  TO  THE 

PUBLIC  HEALTH 
Chapter  111,  Section  6,    The  Department  of  Public  Health  "shall  define 
what  diseases  shall  be  deemed  dangerous  to  the  'public  health." 

Gonorrhea  and  syphilis  were  declared  by  the  Department  to  be  dis- 
eases dangerous  to  the  public  health  on  December  18,  1917. 

The  Reporting  of  Gonorrhea  and  Syphilis 

Chapter  111,  Section  7.    The  Department  of  Public  Health  ".  .  .  .  may 
require  the  officers  in  charge  of  any  city  or  state  institution,  charitable 


117 

institution,  public  or  private  hospital,  dispensary  or  lying-in  hospital, 
or  any  board  of  health,  or  the  physician  in  any  town  to  give  notice  of 
cases  of  any  disease  declared  by  the  said  Department  to  be  dangerous 
to  the  public  health  .  .  ,  ." 
Chapter  111,  Section  112    (As  amended  by  Chapter  215).    "Gonorrhea 

and  syphilis shall  be  reported  to  the  local  boa7°d  of  health, 

either  directly  or  through  the  Department,  in  accordance  with  such 
rules  and  regulations  as  the  Department  may  make,  having  due  regard 
for  the  best  interests  of  the  public." 

Beginning  January  1,  1930,  the  Department  has  required  that  re- 
ports of  gonorrhea  and  syphilis  shall  be  made  through  the  Depart- 
ment. Since  the  names  of  the  patients  are  not  reported  except  in 
certain  cases,  the  reports  have  no  immediate  administrative  value. 
For  epidemiological  studies,  central  reporting  is  more  satisfactory 
than  to  have  the  reports  scattered  among  355  boards  of  health. 

REGULATIONS  OF  THE  DEPARTMENT 

(The  Regulations,  in  full,  will  be  found  in  the  Manual  of  Health  Laws, 
or  copies  may  be  had  on  request  to  the  Department.) 

1.  All  fo?-ms  and  stages  of  gonorrhea  and  syphilis  shall  be  reported. 
Gonorrhea  is  always  communicable,  in  sexual  intercourse  at  least.    It 

has  been  found  impossible  to  define  non-communicable  syphilis.  A  given 
case  may  be  communicable  at  one  time  and  not  at  another;  in  non-sexual 
contacts  at  one  time  and  only  in  sexual  intercourse  at  another.  A  woman 
with  syphilis,  regardless  of  its  non-communicability  to  other  persons,  may 
infect  her  unborn  baby  unless  treatment  is  adequate.  Consequently  it 
has  become  necessary  to  require  the  control  of  all  forms  of  syphilis. 

2.  Literature,  provided'by  the  Department,  may  be  given  to  the  patient 
by  the  physician. 

The  Department  has  literature  concerning  both  gonorrhea  and  syphilis, 
for  such  distribution. 

3.  //  the  patient  was  in  consultation  with  another  physician  over  the 
same  infection,  the  present  physician  shall  notify  the  first  of  the  patient's 
change  of  medical  adviser. 

This  is  necessary  in  order  that  the  first  physician  will  not  report  the 
patient  by  name  as  having  prematurely  discontinued  treatment. 

4.  Patients  who  discontinue  treatment  prematurely  are  to  be  reported, 
by  name  and  address,  to  the  Department. 

Many  of  the  patients  who  discontinue  treatment  have  not  been  properly 
or  adequately  instructed,  or  are  financially  unable  to  continue  treatment, 
or  have  become  discouraged  by  painful  treatments  or  the  long  time  re- 
quired for  cure.  Some  are  feebleminded,  some  are  incorrigible  and  some 
are  plainly  vicious.  These  patients  must  be  persuaded  to  resume  treat- 
ment. If  reasoning,  or  offer  of  free  treatment  (for  those  unable  to  pay) 
fails  to  move  them,  they  must  be  controlled  in  some  other  manner. 
Formal  summons  before  the  board  of  health  often  has  the  necessary  effect. 
Promise  of  isolation  usually  moves  the  most  stubborn,  but  actual  isola- 
tion may  be  necessary  in  an  occasional  case. 

5.  Persons  with  the  sores  of  early  syphilis  on  the  exposed  parts  of  the 
body  or  in  the  mouth,  if  engaged  in  occupations  requiring  close  contacts, 
such  as  barber,  hairdresser,  manicurist,  waiter,  waitress,  nursemaid, 
domestic,  etc.,  must  leave  their  occupations  until  the  sores  are  healed. 

There  is  no  reason  for  excluding  persons  with  gonorrhea  from  their 
occupations  since  that  disease  is  not  spread  among  adults  by  any  of  the 
ordinary,  non-sexual  contacts.  The  patient  with  syphilis  who  has  open 
sores  on  only  the  covered  parts  of  the  body  and  who  is  under  treatment, 
will  not  spread  infection  in  any  ordinary  contact  and  need  not  be  excluded 
from  work  if  treatment  is  continued,  since  new  sores  rarely  develop 
under  treatment.   But  the  patient  with  the  sores  of  early  syphilis  in  the 


118 

mouth  or  on  the  exposed  parts  of  the  body  may  be  very  dangerous  in 
such  contacts  as  may  occur  in  occupations  similar  to  those  indicated  in 
this  regulation.  When  the  sores  have  healed,  under  treatment,  the  patient 
should  be  permitted  to  return  to  his  occupation.  Treatment  must  be  con- 
tinued, however,  or  the  lesions  may  reappear  at  any  time. 

6.  The  names  of  such  sources  of  infection  as  can  be  identified  shall  be 
reported  to  the  Department  unless  tTiey  are  known  to  be  under  medical 
care. 

Careful  search  for  sources  of  infection  have  led  to  the  discovery  and 
the  control  of  many  cases  of  gonorrhea  and  syphilis.  Some  physicians 
complain  that  this  regulation  compels  them  to  become  "detectives"  of 
prostitution  and  "snoopers"  into  the  conduct  of  their  patients.  That  is 
an  absurd  and  flimsy  argument.  Those  same  physicians  would  consider 
that  health  officer  futile  who  isolated  the  case  of  typhoid  fever  reported 
to  him  but  neglected  the  search  for  the  carrier.  Sources  of  disease  are 
often  more  important  to  the  community  than  the  known  case.  The  latter 
is  under  control.  The  former  is  a  menace  so  long  as  he  remains  undis- 
covered. Sources  of  infection  often  are  unaware  of  their  own  infections. 
A  timely  warning  will  save  them  from  future  disaster  and  will  save 
others,  often  innocent,  from  infection.  It  is  peculiar  reasoning  which 
grants  the  right  of  treatment  to  the  patient  and  denies  both  treatment 
and  protection  from  infection  to  other  human  beings.  The  physician  will 
not  put  this  responsibility  upon  the  health  officer  by  disclosing  the  identity 
of  his  patient.  Therefore  the  physician,  being  the  only  person  who  knows 
the  patient,  is  the  only  person  who  can  see  to  it  that  the  others  involved 
are  warned.  He  can  do  this  either  through  the  patient,  or  failing  in  that, 
through  the  Department.  His  refusal  to  do  so  is  an  unfortunate  disregard 
of  the  principles  of  preventive  medicine. 

It  is  well  to  bear  in  mind  that  sometimes  the  alleged  "source  of  infec- 
tion" is  actually  the  victim  of  the  patient's  infection.  At  any  rate,  every 
"source  of  infection"  must,  at  some  previous  time,  have  been  the  victim 
of  infection.  This  fact  offers  the  fairer  method  of  approach.  The  indi- 
vidual may  always  be  informed  that  there  is  reason  to  believe  that  he 
(or  she)  may  have  been  exposed  to  gonorrhea  (or  syphilis)  and  that  an 
examination  is  advisable.  The  accusation  that  a  person  is  the  source  of 
another's  infection  may  not  only  be  unfair,  but  arouses  a  defensive 
indignation  which  closes  the  mind  to  advice.  But  to  have  been  the  victim 
of  another's  infection  is  a  different  matter,  and  more  frequently  leads 
to  the  physician. 

The  health  officer  must  be  prepared  for  some  disappointments  because 
of  inadequate  or  inexpert  examination  in  the  doctor's  office.  Unfortun- 
ately, and  especially  in  female  gonorrhea,  some  physicians  are  satisfied 
with  smears  (and  often  one  smear)  negative  for  the  gonococcus.  Those 
physicians  who  understand  this  disease  in  the  female  know  that  in  many 
cases  the  diagnosis,  or  at  least  the  suspicion  of  gonorrhea,  must  depend 
on  clinical  findings  and  history,  supported  at  best  by  laboratory  evidence 
of  pus  in  the  discharges.  Some  physicians  are'  satisfied  with  an  exam- 
ination of  the  male  external  genitalia.  The  infection  may  be  in  the  pro- 
state gland,  only  careful  examination  of  which  will  disclose  it. 

7.  The  Department  may  forward  a  report  of  a  case  having  prematurely 
discontinued  treatment,  or  of  a  source  of  infection,  to  the  board  of  health 
of  the  community  where  the  person  lives.  The  local  board  of  health,  in 
turn,  shall  report  the  result  of  its  investigation  and  action  to  the  Depart- 
ment. 

It  is  the  responsibility  of  the  local  board  of  health  to  prevent  the 
appearance  and  the  spread  of  diseases  dangerous  to  the  public  health  in 
its  community.  The  control  of  gonorrhea  and  syphilis  is  as  much  the 
problem  of  the  board  of  health  as  the  control  of  any  other  disease.  Once 
a  person  with  either  of  these  diseases  is  identified  to  the  health  officer, 
he  can  no  more  ignore  his  responsibility  for  such  action  as  may  be  neces- 


119 

sary  than  he  can  avoid  the  responsibility  for  action  in  case  of  any  other 
disease  reported  to  him.  The  difference  is  only  in  the  kind  of  action. 
In  gonorrhea  or  syphilis  it  is  usually  sufficient  to  explain  to  the  patient 
the  importance  (to  himself  as  well  as  to  others)  of  adequate  treatment, 
and  to  persuade  him  to  resume  treatment.  In  the  case  of  a  source  of 
infection,  he  must  advise  examination.  But  no  patient  can  be  compelled 
to  take  treatment  and  it  is  offered  only  as  an  alternative  to  arbitrary 
restriction  of  liberty.  If  persuasion  fails,  there  is  no  reason  why  the 
health  officer  should  hesitate  to  use  more  drastic  measures.  There  is 
ample  legislative  provision  for  such  action  (see  Control  of  the  Uncoopera- 
tive Patient).  Neither  is  there  any  reason  why  patients  should  be  per- 
mitted to  break  promise  after  promise  to  return  to  treatment,  for  weeks 
and  months  at  a  time.  If  the  spread  of  disease  is  to  be  prevented,  action 
must  immediately  follow  a  reasonable  opportunity  to  resume  treatment. 

The  Department  recognizes  that  the  probability  of  spreading  syphilis 
by  those  who  have  the  disease  in  its  late  stages  is  relatively  slight  in 
most  cases.  To  these,  resumption  of  treatment  is  advised  but  more 
drastic  action  is  not  recommended  except  in  the  case  of  pregnancy.  Every 
patient  who  can  be  kept  under  treatment,  however,  represents  an  eventual 
saving  to  the  community  in  terms  of  institutional  care  and  relief  for  the 
incapacitated  patient's  family. 

Persons  with  early  syphilis  (primary  or  secondary  stage)  must  be 
controlled  even  though  any  lesions  are  healed,  for  the  dangerous  sores 
may  reappear  at  any  time.  Gonorrhea,  being  at  all  times  communicable, 
must  be  controlled  in  every  case. 

The  return  report  of  the  local  board  of  health  to  the  Department  is  of 
very  real  value.  In  diphtheria  or  smallpox  and  most  other  reportable 
diseases  the  reporting  physician  sees  his  report  translated  into  action  by 
the  board  of  health.  In  the  case  of  gonorrhea  and  syphilis  the  physician 
sees  the  direct  result  of  his  report  only  if  the  patient  returns  to  him  for 
treatment.  But  if  the  patient  has  gone  to  another  physician  or  to  a  clinic, 
or  cannot  be  found,  the  physician  will  never  know  that  his  report  has 
served  any  useful  purpose,  unless  the  result  of  the  investigation  is  made 
known  to  him.  Further,  records  of  lost  patients  or  of  those  who  have 
changed  physicians  may  be  closed,  thus  removing  much  dead  material 
from  the  files.  And  if  the  patient  who  has  promised  to  return  to  treat- 
ment, fails  to  do  so,  the  physician,  having  received  a  report  of  this  prom- 
ise, can  inform  the  health  officer  of  this  failure. 

Unless  there  is  this  interchange  of  communications  and  full  cooperating 
between  the  official  and  the  treating  agency,  the  follow-up  becomes  in- 
effective. 

In  1930,  the  first  year  of  this  system  109  boards  of  health  investi- 
gated 2,476  cases  of  gonorrhea  and  syphilis.  This  is  gratifying  evidence 
of  the  willingness  of  Massachusetts  health  officers  to  accept  the  challenge 
of  these  two  diseases. 

The  Control  of  the  Uncooperative  Patient 

There  are  ample  laws  for  the  control  of  the  uncooperative  patient. 
Reference  to  some  of  them  follows: — (Since  Gonorrhea  and  syphilis  have 
been  declared  diseases  dangerous  to  the  public  health,  the  provisions  of 
these  laws  naturally  apply) . 

Chapter   111,    Section   92.    Provides   for   the   maintenance   of    isolation 
hospitals. 

Section  94.    provides  that  cities  and  towns  having  isolation  hospitals 
may  accept  patients  from  adjacent  cities  and  towns. 

Section  95.    Provides  for  the  removal  and  care  of  infected  persons, 
or  their  isolation  at  home,  if  necessary  for  the  safety  of  the  inhabitants. 
Section  96.    Provides  for  the  issuance  of  warrants  for  the  removal 
of  infected  persons. 


120 

Section  104.  Provides  that  the  selectmen  and  the  board  of  health 
shall  use  all  possible  care  to  prevent  the  spread  of  infection. 

Section  122.  Provides  for  the  destruction,  removal  or  prevention 
of  nuisances,  sources  of  filth  and  causes  of  sickness  and  shall  make 
regulations  for  the  public  health  pertaining  thereto.  The  courts  have 
ruled  that  cases  of  sickness  are,  in  effect,  causes  of  sickness  within  the 
meaning  of  this  section. 

Provision  of  Treatment  for  Indigent  Patients 

Chapter  111,  Section  116.  Provides  for  the  payment  of  reasonable  ex- 
penses by  the  community  where  certain  infected  persons,  who  are  un- 
able to  pay  for  treatment,  have  settlement,  or  by  the  State  Depart- 
ment of  Public  Welfare  if  the  person  has  no  legal  settlement. 

Section  32.  Provides  that  the  board  of  health  shall  retain  charge, 
to  the  exclusion  of  the  overseers  of  the  poor,  of  any  case  arising  under 
this  chapter,  in  which  it  has  acted. 

Chapter  121,  Section  12.  Provides  for  the  removal,  by  the  Department 
of  Public  Welfare,  of  certain  infected  persons  who  are  maintained,  or 
liable  to  be  maintained  by  the  Commonwealth. 

Chapter  111,  Section  117.  Provides  for  the  treatment,  either  in  a  hospital 
or  as  outpatients,  of ,  indigents  with  contagious  or  infectious  venereal 
diseases.  (Gonorrhea  and  syphilis  are  "contagious  or  infectious  ven- 
ereal diseases.") 

Section  118.  Provides  that  no  discrimination  shall  be  made  against 
the  treatment  of  venereal  diseases  in  the  outpatient  department  of  any 
general  hospital  supported  by  taxation  in  any  city  where  special  hos- 
pitals are  not  provided. 

Miscellaneous  Laws  Pertaining  to  Gonorrhea  and  Syphilis 

Chapter  111,  Section  119.  Provides  that  certain  records  of  venereal  dis- 
ease shall  not  be  made  public. 

Section  120.  Provides  for  the  destruction,  at  the  expiration  of  five 
years,  of  certain  venereal  disease  records. 

Chapter  112,  Section  12.  Provides  that  a  registered  physician  or  sur- 
geon may  disclose  the  infection  of  a  person  with  gonorrhea  or 
syphilis  to  any  person  from  whom  the  infected  person  has  received 
a  promise  of  marriage,  or  to  the  parent  or  guardian  of  such  person 
if  a  minor. 

Chapter  272,  Section  29.  Prohibits  certain  advertisements  which  call 
attention  to  a  person  from  whom,  or  an  office  or  place  at  which  in- 
formation, treatment  or  advice  may  be  obtained  concerning  diseases 
or  conditions  of  the  sexual  organs. 

Clinics 

Clinics,  subsidized  by  the  Department,  are  maintained  for  the  treat- 
ment of  those  who  have  gonorrhea  and  syphilis  and  are  unable  to  pay 
for  treatment,  at  Boston,  Brockton,  Fall  River,  Haverhill,  Holyoke, 
Lawrence,  Lowell,  Lynn,  New  Bedford,  Springfield,  and  Pittsfield. 
Clinics  at  Fitchburg  and  Worcester,  althought  not  subsidized  by  the  De- 
partment, accept  non-residents  for  treatment.  Patients  may  be  sent 
to  any  of  these  clinics  although  it  is  advisable,  if  the  cost  of  transpor- 
tation is  equal  to  or  greater  than  the  cost  of  treatment  with  some  local 
physician,  to  provide  for  treatment  with  the  latter.  There  is  no  reason 
why  every  city  or  town  should  not  contribute  toward  the  cost  of  treat- 
ing its  own  residents  who  are  unable  to  pay,  just  as  those  communities  are 
doing  in  which  the  clinics  are  maintained.  The  State  subsidy  in  no 
case  covers  the  entire  cost  of  maintaining  the  clinic,  and  in  many  cases 
amounts  to  only  a  fraction  of  the  cost. 


121 
Prostitution 

The  control  of  prostitution  is  a  police  problem  and  not  one  for  the 
board  of  health.  The  latter,  however,  can  cooperate  with  the  police  by 
calling  the  attention  of  the  latter  to  evidence  of  prostitution  or  of  other 
conditions  which,  although  subject  to  police  regulation,  may  lead  to 
the  spread  of  gonorrhea  and  syphilis. 

If  a  prostitute  is  known  to  be  infected  with  either  of  these  diseases, 
however,  and  continues  to  practice  her  profession,  there  is  no  reason 
why  she  may  not  be  isolated  for  the  protection  of  the  public  health, 
just  as  any  person  may  be  who  exposes  others  to  infection. 

Other  Problems  of  Control 

There  are  many  things  which  must  be  done  if  gonorrhea  and  syphilis 
are  to  be  controlled,  in  addition  to  managing  the  uncooperative  patient. 
They  are  summarized  briefly,  as  follows: — 

1.  Education  of  the  public  in  the  nature,  prevalence  and  methods  of 
control  of  gonorrhea  and  syphilis.  Probably  half  the  cases  never  come 
to  medical  attention.  Half  the  gonorrhea  that  reaches  the  doctor's 
office  is  six  months  or  more  past  the  date  of  infection  and  two-thirds 
of  the  syphilis  under  medical  care  is  in  the  late  stages.  Early  diagno- 
sis and  immediate  medical  attention  is  essential. 

2.  Altogether  too  many  patients  discontinue  treatment  prematurely. 
The  correction  of  this  situation  lies  both  in  public  education  and  in  in- 
sistence that  the  physician  spend  more  time  in  the  instruction  of  the 
patient. 

3.  Too  many  druggists  still  accept  the  serious  and  illegal  responsi- 
bility for  treating  or  prescribing  treatment  for  both  syphilis  and  gon- 
orrhea, but  especially  the  latter. 

4.  Many  areas  of  this  State  have  no  physician  willing  to  treat  gonor- 
rhea or  syphilis.  These  areas,  unfortunately,  are  often  far  removed 
from  clinics  or  from  communities  where  physicians  who  care  to  treat 
these  diseases  are  to  be  found.  Some  method  for  providing  adequate 
treatment  for  every  patient  must  be  devised. 

5.  Many  hospitals  still  refuse  to  admit  cases  of  gonorrhea  or  syphilis 
to  their  wards.   There  is  room  for  education  in  this  matter. 

6.  Newspapers  and  many  other  channels  of  public  information  are 
closed  to  material  concerning  gonorrhea  and  syphilis.  Only  an  aroused 
public  demand  can  correct  this  absurd  situation. 

7.  Probably  less  than  one-third  of  the  physicians  in  the  State  re- 
port their  cases  of  gonorrhea  and  syphilis.  An  intelligent  program  for 
the  control  of  these  diseases  depends  upon  the  thoroughness  of  our 
knowledge  concerning  them.  The  health  officer  is  often  in  a  position 
to  encourage  reporting. 

8.  Last,  but  not  by  any  means  least,  is  the  whole  problem  of  social 
hygiene,  sex  education  and  sex  character  building.  This  is  primarily 
the  concern  of  the  educational  resources  of  the  community,  but  its 
bearing  upon  the  eventual  control  of  gonorrhea  and  syphilis  is  so  great 
that  the  health  officer  can  hardly  hold  himself  aloof  from  participating 
in  the  general  program.  He  deals  with  one  of  the  major  results  of 
improper  and  inadequate  social  hygiene. 


122 


Editorial  Comment 


Then  and  Now?  The  following  excerpt  taken  from  "Public  Occurrences" 
for  Thursday,  September  25,  1690,  is  submitted 
through  the  kindness  of  Dr.  Henry  M.  Emmons  of  Boston. 

"Epidemical  fevers  and  Agues  grow  very  common  in  some  parts  of  the 
Country,  whereof,  though  many  die  not,  yet  they  are  sorely  unfitted  for 
their  employments,  but  in  some  parts  a  more  malignant  fever  seems  to 
prevail  in  such  sort  that  it  usually  goes  through  a  family  where  it  comes 
and  proves  mortal  unto  many.  The  Smallpox  which  has  been  raging  in 
Boston  after  a  manner  very  extraordinary  is  now  very  much  abated.  It 
is  thought  that  far  more  have  been  sick  of  it  than  were  visited  with  it, 
when  it  raged  so  much  twelve  years  ago.  Nevertheless  it  has  not  been  so 
mortal,  the  number  of  them  that  have  dyed  in  Boston  by  this  last  visita- 
tion is  about  three  hundred  and  twenty  which  is  not  perhaps  half  so  many 
as  fell  by  the  former.  General  in  June,  July  and  August. — It  infected 
some  children  of  mothers  that  had  themselves  undergone  the  disease  many 
years  ago,  for  some  such  were  now  born  full  of  the  Distemper.  It  is  not 
easy  to  relate  the  trouble  and  sorrow  that  poor  Boston  has  felt  by  this 
Epidemical  Contagion,  but  we  hope  it  will  be  pretty  nigh  extinguished 
by  that  time,  twelve  months  when  it  first  began  to  spread." 

This  makes  interesting  reading  and  it  is  well  in  these  days  of  phil- 
osophical skepticism  apparently  safe  from  smallpox  to  be  reminded  occa- 
sionally of  what  the  disease  has  been  and  may  be. 


Book  Notes 


Home  Guidance  for  Young  Children,  A  Parents'  Handbook  by  Grace 

Langdon,  Teachers  College,  Columbia  University.    Published  by  John 

Hay  Company,  New  York  City.   405  pp. 

This  handbook,  with  its  interesting  introduction  by  Lois  H.  Meek, 
Director  of  Child  Development  Institute,  Columbia  University,  is  read- 
able and  comprehensive.  It  emphasizes,  at  the  start,  the  enormous  im- 
portance of  parents  as  teachers  and  of  the  home  as  the  most  valuable 
"school"  the  child  will  ever  attend.  It  also  emphasizes  the  importance  of 
the  nine  prenatal  months  as  an  integral  part  of  the  child's  life,  a  period 
we  are  even  yet  inclined  to  look  upon  as  something  apart  and  not  really 
as  important  as  the  nine  months  after  birth. 

Especially  valuable  to  the  prospective  mother,  though  usually  omitted 
by  most  writers,  is  the  description  of  "what  to  expect  the  doctor  to  do" 
when  she  goes  for  her  first  prenatal  visit.  Many  women  do  not  know 
what  constitutes  adequate  prenatal  care  so  this  is  an  excellent  idea. 

A  little  more  emphasis  might  well  be  laid  on  the  reporting  of  symptoms 
during  pregnancy  to  the  doctor  as  this  is  one  important  item  in  preven- 
tion of  maternal  deaths.  The  first  year  after  birth  is  considered  in  detail 
both  from  the  point  of  view  of  the  mother's  needs  and  those  of  the  baby. 

Lactation  diet,  often  gone  over  lightly  or  omitted,  receives  the  atten- 
tion which  it  deserves. 

Almost  half  of  the  book  is  devoted  to  a  discussion  of  "the  educational 
aspects  of  a  child's  everyday  life"  which  covers  eating,  sleeping,  toileting 
and  play  in  detail.  Teaching  the  child  independence  in  all  these  essential 
activities  is  the  underlying  theme  and  it  is  extremely  well  done.  Learn- 
ing to  live  with  other  people  is  recognized  as  the  great  aim  in  every 
child's  training. 

A  summary  of  the  principles  of  children's  learning  and  of  parents'  atti- 
tudes and  an  excellent  bibliography  complete  the  book. 


123 
Prenatal  Care — U.  S.  Department  of  Labor,  Children's  Bureau,  Publi- 
cation No.  4.    Price  10c. 

This  new  booklet  on  prenatal  care  with  its  excellent  index,  glossary  and 
bibliography  is  certainly  the  most  valuable  publication  of  its  kind  obtain- 
able at  a  price  possible  for  every  parent. 

The  importance  of  early  examination  and  medical  supervision  is  empha- 
sized throughout  and  we  are  glad  to  see  that  the  absolute  necessity  of 
clean  delivery  is  stressed.  We  would  also  like  to  see  a  little  more  emphasis 
laid  on  the  necessity  of  experience  and  skill  in  medical  delivery  service. 
The  phrase  "competent  attendant"  will  only  mean  the  nurse  to  many 
mothers.  Good  prenatal  care  is  not  always  followed  by  skillful  delivery, 
as  we  know,  and  either  one  alone  is  not  going  to  help  much  to  give  us  a 
minimum  mortality. 

The  hygiene  of  the  nursing  mother  is  wisely  included  in  this  booklet, 
and  essential  diet  and  rest  habits  discussed  in  some  detail.  Cod  liver 
oil,  taken  under  the  doctor's  direction  is  advised  during  both  pregnancy 
and  lactation. 

A  section  is  devoted  to  the  handling  of  the  premature  baby  and  his 
special  problems,  and  is  a  valuable  addition.  (The  care  and  feeding 
of  normal  full-time  infants  are  covered  in  the  second  booklet  of  this 
series  entitled,  "Infant  Care.") 

The  father's  responsibility  and  cooperation  during  the  mother's  preg- 
nancy can  well  be  emphasized  more  in  such  publications  as  these — our 
Canadian  neighbors  far  outdo  us  there!  But  that  the  father's  part  is 
brought  in,  though  briefly,  under  Mental  Hygiene  is  a  beginning  at  least. 

Congratulations  are  due  to  those  who  compiled  this  small  book  and  we 
can  heartily  recommend  it  to  all  "expectant  parents." 

Year  Book  of  Obstetrics  and  Gynecology — Edited  by  Joseph  B.  DeLee 

and  J.  P.  Greenhill.   Year  Book  Publishers,  Chicago,  Illinois. 

This  useful  annual  covers  much  of  interest  to  all  who  deal  with  obstetric 
problems  and  who  are  anxious  to  keep  in  touch  with  the  latest  research 
and  treatment.  It  takes  up  also  diseases  of  the  newborn.  Particularly 
interesting  is  the  section  on  puerperal  septicemias  showing,  as  usual,  a 
great  diversity  of  medical  opinion  on  treatment. 

DeLee  comments,  "There  is  at  present  no  rational  treatment  for 
eclampsia."  All  the  more  reason  for  prevention,  which  by  the  way,  is  not 
touched  upon  in  this  discussion. 

Diligent  search  is  sometimes  necessary  to  find  the  topics  wanted  as  the 
index  is  not  any  too  reliable. 


124 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  January,  February,  and  March,  1931,  samples 
were  collected  in  149  cities  and  towns. 

There  were  1,181  samples  of  milk  examined,  of  which  205  were  below 
standard;  from  14  samples  the  cream  had  been  in  part  removed,  and  27 
samples  contained  added  water.  There  were  26  samples  of  Grade  A  milk 
examined,  20  samples  of  which  were  above  the  legal  standard  of  4.00% 
fat,  and  6  samples  were  below  the  legal  standard. 

There  were  858  samples  of  food  examined,  of  which  129  were  adul- 
terated. These  consisted  of  2  samples  sold  as  butter  which  proved  to 
be  oleomargarine;  1  sample  of  clams  which  contained  added  water;  1 
sample  of  cream  not  labeled  in  accordance  with  the  law;  1  sample  of 
dried  fruits  which  contained  sulphur  dioxide  and  was  not  properly 
labeled;  47  samples  of  eggs,  18  samples  of  which  were  sold  as  fresh 
eggs  but  were  not  fresh,  24  samples  of  cold  storage  eggs  not  marked, 
and  5  samples  were  decomposed;  4  samples  of  maple  syrup  which  con- 
tained cane  sugar;  48  samples  of  sausage,  11  samples  of  which  con- 
tained a  compound  of  sulphur  dioxide  jiot  properly  labeled,  36  samples 
contained  starch  in  excess  of  2  per  cent,  2  samples  of  which  also  con- 
tained a  compound  of  sulphur  dioxide  not  properly  labeled,  and  1  sample 
was  decomposed;  18  samples  of  hamburg  steak,  17  samples  of  which 
contained  a  compound  of  sulphur  dioxide  not  properly  labeled,  and  1 
sample  was  decomposed ;  1  sample  of  chicken  meat,  1  sample  of  chicken 
juice,  2  samples  of  spiced  ham,  and  1  sample  of  lunch  meat,  all  of 
which  were  decomposed;  1  sample  of  minced  meat  which  contained 
benzoate;  and  1  sample  of  spinach  which  contained  a  trace  of  arsenic. 

There  were  45  samples  of  drugs  examined,  of  which  15  were  adul- 
terated. These  consisted  of  2  samples  of  ether  for  anaesthesia,  1 
sample  of  which  contained  aldehyde  and  peroxide,  the  other  contained 
aldehyde ;  and  13  samples  of  spirit  of  nitrous  ether,  all  of  which  were 
deficient  in  active  ingredient. 

The  police  departments  submitted  1,291  samples  of  liquor  for  exam- 
ination, 1,271  of  which  were  above  0.5%  in  alcohol.  The  police  depart- 
ments also  submitted  19  samples  of  narcotics,  etc.,  for  examination,  5 
of  which  were  morphine,  1  heroin,  1  sample  was  a  solution  which  con- 
tained approximately  1  per  cent  of  mercuric  chloride,  1  sample  of  gray 
powder  which  was  fed  to  a  mouse  with  no  apparent  harmful  results, 
4  samples  of  liquids,  1  containing  alcohol  but  in  which  no  other  poisons 
were  found,  1  containing  oil  of  juniper,  1  containing  ethyl  alcohol  and 
caffeine,  and  another  consisting  of  commercial  anti-freeze  methanol; 
1  sample  of  grapes  was  examined  for  heavy  metals ;  1  sample  of  cigar- 
ettes was  examined  for  added  drugs;  1  sample  of  pills  was  found  to 
contain  acetyl-salicylic  acid;  and  4  samples  contained  narcotics. 

There  were  1,181  bacteriological  examinations  made  of  milk. 

There  were  67  bacteriological  examinations  made  of  soft  shell  clams, 
19  samples  in  the  shell,  all  of  which  were  unpolluted,  and  48  samples 
shucked,  36  of  which  were  unpolluted,  and  12  were  polluted.  There 
was  1  bacteriological  examination  made  of  hard  shell  clams,  shucked, 
which  was  unpolluted.  There  were  2  bacteriological  examinations  made 
of  razor  clams  in  shell,  which  were  unpolluted. 

There  were  69  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  69  cities  and  towns  visited  for  the  inspection  of  pasteur- 
izing plants,  and  146  plants  were  inspected. 

There  were  97  convictions  for  violations  of  the  law,  $2,180  in  fines 
being  imposed. 

John  Florini  of  North  Adams,  Louis  Sykes  of  Norwood,  Charles 
Roumas  of  Beverly,  and  William  Mattison  of  Hubbardston,  were  all 
convicted  for  violations  of  the  milk  laws.  John  Florini  of  North  Adams 
appealed  his  case. 


125 

William  E.  Finn  of  Middleborough;  First  National  Stores,  Incorpo- 
rated of  Framingham ;  Charles  Crocker  of  Everett;  Baker  Market  Com- 
pany, Incorporated,  and  Lewis  P.  Vanasse  of  Fall  River;  Cann's  Sea 
Grill,  Incorporated,  Frederick  L.  Scheu,  and  New  England  Provision 
Company,  all  of  Boston;  Mayflower  Meat  Market  Incorporated,  Strauss 
Roth  Stores,  Incorporated,  John  Devine,  and  William  H.  Allison,  all  of 
Lynn;  Alex  Goldstine  of  Worcester;  William  Almond  of  New  Bedford; 
Roy  E.  Harris  of  Newburyport;  Enrico  Moro  and  Charles  Thurber,  2 
cases  each,  of  Attleboro ;  Strauss  Roth  Stores,  Incorporated,  and  George 
Walker  of  Salem;  Henry  Staveley  of  Fitchburg;  Primo  Diozzi  and  Nich- 
olas Macero  of  Somerville;  Bernard  Keiser,  Vincent  Carlin,  David  B. 
Levitt,  and  Harry  Rulnick,  all  of  Springfield;  Robert  MacGibbon  of 
Quincy;  Sol  Sawyer  of  Taunton;  Alfred  Rayner  and  Michael  Zasadzin- 
ski  of  Holyoke;  Robert  Stringer  of  Lowell;  Sweet's  Market  Incorpo- 
rated, Stark  Supply  Company,  Louis  Segal,  Blair's  Foodland  Incorpo- 
rated, Abraham  Cohen,  Benjamin  Gross,  Barnett  Racoff,  and  Mary  Rob- 
inson, all  of  Roxbury;  David  Albert  and  Charles  A.  Parker  of  North 
Andover;  Harry  Kramer  of  Hudson;  and  Louis  Rudnick  of  North 
Adams,  were  all  convicted  for  violations  of  the  food  laws.  Cann's  Sea 
Grill  Incorporated  of  Boston;  William  E.  Finn  of  Middleborough; 
Strauss  Roth  Stores,  Incorporated,  of  Salem;  Stark  Supply  Company, 
Abraham  Cohen,  Barnett  Racoff,  and  Mary  Robinson,  all  of  Roxbury; 
and  Charles  Thurber,  1  case,  of  Attleboro,  all  appealed  their  cases. 

McKesson  Eastern  Drug  Company  and  James  F.  Guerin  of  Wor- 
cester; McKesson  Eastern  Drug  Company,  2  cases,  of  Boston;  and  Er- 
nest B.  McClure  of  Somerville,  were  all  convicted  for  violations  of  the 
drug  laws. 

Arthur  G.  Pechilis  of  Ipswich;  Frank  Manzi  of  Worcester;  Nicholas 
Bezis  of  Salem;  Frank  Caterino  and  Primo  Diozzi  of  Somerville;  Earl 
F.  Crawford  of  Framingham ;  Jacob  Richter  of  Roxbury ;  John  T.  John- 
son of  Quincy;  Antone  Garcia  and  Manuel  P.  Santos  of  New  Bedford; 
The  Gloria  Chain  Stores  Incorporated  of  Newton;  and  Harry  Berkat- 
sky,  Thomas  Equatowich,  Patrick  Fallon,  Morris  Gilburg,  Growers  Out- 
let Incorporated,  Katherine  Korol,  Bessie  Levy,  Bessie  Widlansky, 
Patsy  Algiro,  Leon  Colapietro,  and  Abraham  Keyser,  all  of  Spring- 
field, were  all  convicted  for  violations  of  the  cold  storage  laws. 

The  Massachusetts  Mohican  Company,  2  cases,  and  Growers  Outlet, 
Incorporated,  2  cases,  both  of  Springfield;  George  Snyder  of  Lynn; 
Hyman  Weinstein  of  Waltham;  Samuel  Bender,  2  cases,  and  Rose 
Steinberg  of  Roxbury;  Manhattan  Food  Stores  Company,  Incorporated, 
of  Somerville;  and  Albert  Shore  of  Worcester,  were  all  convicted  for 
violation  of  the  false  advertising  law.  Growers  Outlet,  Incorporated, 
of  Springfield  appealed  one  case. 

Earl  F.  Carlon,  3  cases,  of  West  Springfield;  W.  T.  Jones  Company 
of  Chelsea;  George  Zervas  of  Ipswich;  Benjamin  V.  Conant  of  Dan- 
vers;  and  Wilbur  P.  Elliott  of  Lynn,  were  all  convicted  for  violations  of 
the  pasteurization  law.  W.  T.  Jones  Company  of  Chelsea  appealed  their 
case. 

Albert  Halberstadt  of  Newtonville  was  convicted  for  violation  of  the 
sanitary  food  law. 

Fred  Severance  of  Gill;  Samuel  August  of  Northampton;  and  Abra- 
ham Cohen  of  Turners  Falls,  were  convicted  for  violations  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  orig- 
inal packages  from  manufacturers,  wholesalers,  or  producers : 

One  sample  of  milk  which  contained  added  water  was  produced  by 
Manog  Mihranian  of  Methuen. 

One  sample  of  cream  not  labeled  in  accordance  with  the  law  was  ob- 
tained from  David  Holmes  of  Athol. 


126 

One  sample  of  dried  fruit  which  contained  sulphur  dioxide  not  prop- 
erly labeled  was  obtained  from  United  Fruit  Stores  of  Worcester.  _ 

One  sample  of  clams  which  contained  added  water  was  obtained 
from  Atlantic  Fish  Company  of  Boston. 

One  sample  of  minced  meat  which  contained  benzoate  was  obtained 
from  Benjamin  Feinburg  of  Lynn. 

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

12  samples,  from  William  Almond  of  New  Bedford;  2  samples  each, 
from  Charles  A.  Parker  and  David  Albert  of  North  Andover;  G.  J. 
Joubert  of  Adams;  David  Levitt  of  Springfield;  and  Robert  Stringer 
of  Lowell ;  and  1  sample  each,  from  New  York  Style  Provision  Company 
of  Westfield;  Stengel's  Delicatessen,  Vernon  R.  Porter,  C.  F.  Anderson 
Market,  Incorporated,  and  Arthur  G.  Vose,  all  of  Brockton;  Wade 
Maloof  and  George  Corey  of  Lawrence;  Greenville  Market  of  Roxbury; 
Alex  F.  Vitkowski  of  Gardner;  Telesfor  Milowski  of  Turners  Falls; 
Robert  MacGibbon  of  Quincy;  William  H.  Allison  of  Lynn;  John  Woj- 
taszek  of  Adams;  and  Charles  Thurber  of  Attleboro. 

Sausage  which  contained  a  compound  of  sulphur  dioxide  not  prop- 
erly labeled  was  obtained  as  follows: 

1  sample  each,  from  Independent  Beef  Company  of  Somerville;  New 
England  Provision  Company  of  Boston;  Simon  Jegelewicz  of  Westfield; 
Eastern  Provision  Company  of  Fall  River;  Eugene  Barthel  of  Gardner; 
George  Corey  of  Lawrence;  and  from  Market,  983  South  Water  Street, 
New  Bedford. 

Two  samples  of  sausage  which  contained  starch  in  excess  of  2  per 
cent,  and  also  contained  a  compound  of  sulphur  dioxide  not  properly 
labeled  were  obtained  from  George  Corey  of  Lawrence. 

One  sample  of  sausage  which  was  decomposed  was  obtained  from 
West  End  Market  of  Maiden. 

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

1  sample  each,  from  Paul  Babel  of  Norwood;  Harry  Kramer  of  Hud- 
son; Great  Atlantic  &  Pacific  Tea  Company  of  Methuen;  Louis  Rud- 
nick  of  Adams;  Wellworth  Market,  Blair's  Market,  Incorporated,  Ben- 
jamin Gross,  Abraham  Sweet,  Louis  Market,  Hammond  Market,  Wash- 
ington Public  Market;  Starke  Supply  Company,  Incorporated,  and  Cam- 
den Market,  all  of  Roxbury;  Phillip  Kaller  and  Robert  Cravitz  Market 
of  New  Bedford ;  Adler's  Market  of  Taunton ;  and  Harry  Brody  of  All- 
ston. 

One  sample  of  hamburg  steak  which  was  decomposed  was  obtained 
from  Deitch  &  Foster  of  Boston. 

Maple  Syrup  which  contained  cane  sugar  was  obtained  as  follows: 
1  sample  each,  from  Curtis  Lunch  of  Roxbury,  Wellworth  Service  Store, 
Incorporated,  of  Framingham,  and  Plaza  Lunch  of  New  Bedford. 

There  were  eleven  Confiscations,  consisting  of  51Y2  pounds  of  decom- 
posed cooked  chickens;  248  pounds  of  decomposed  chickens;  787  pounds 
of  decomposed  turkeys;  588  pounds  of  decomposed  cooked  hams;  24 
pounds  of  decomposed  cooked  luncheon  meat;  30  pounds  of  miscellan- 
eous cooked  pork;  12  pounds  of  decomposed  cooked  pork  tongue;  453 
pounds  of  decomposed  pork  trimmings;  30  pounds  of  decomposed 
luncheon  tongues;  and  the  carcass  of  one  hog,  weighing  200  pounds, 
affected  with  hog  cholera. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  December,  1930: —  181,830  dozens  of 
case  eggs;  325,870  pounds  of  broken  out  eggs;  704,165  pounds  of  but- 
ter; 2,326,848y2  pounds  of  poultry;  3,962,388^  pounds  of  fresh  meat 
and  fresh  meat  products;  and  2,011,742  pounds  of  fresh  food  fish. 

There  was  on  hand  January  1,  1931: — 834,630  dozens  of  case  eggs; 
1,691,423  pounds  of  broken  out  eggs;  5,356,975  pounds  of  butter;  4,- 


127 

614,412  pounds  of  poultry;  8,769,1601/2  pounds  of  fresh  meat  and  fresh 
meat  products;  and  17,724,896  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  January,  1931 : —  147,300  dozens  of 
case  eggs;  160,306  pounds  of  broken  out  eggs;  564,964  pounds  of  but- 
ter; 1,874,280  pounds  of  poultry;  9,553,395  pounds  of  fresh  meat  and 
fresh  meat  products;  and  1,537,667  pounds  of  fresh  food  fish. 

There  was  on  hand  February  1,  1931: —  145,440  dozens  of  case  eggs; 
1,282,919%  pounds  of  broken  out  eggs;  3,960,326  pounds  of  butter; 
5,522,837  pounds  of  poultry;  15,570,265y2  pounds  of  fresh  meat  and 
fresh  meat  products ;  and  14,220,942  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  February,  1931 : —  527,100  dozens  of 
case  eggs;  321,640  pounds  of  broken  out  eggs;  497,321  pounds  of  but- 
ter; 1,768,297  pounds  of  poultry;  6,563,249  pounds  of  fresh  meat  and 
fresh  meat  products;  and  1,104,732  pounds  of  fresh  food  fish. 

There  was  on  hand  March  1,  1931: —  458,400  dozen  of  case  eggs; 
l,079,08iy2  pounds  of  broken  out  eggs;  2,698,405  pounds  of  butter; 
6,121,882  pounds  of  poultry;  18,862,476  pounds  of  fresh  meat  and 
fresh  meat  products;  and  10,215,495V2  pounds  of  fresh  food  fish. 


128 
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 
Water  and  Sewage  Lab- 
Biologic  Laboratories   . 

Division  of  Food  and  Drugs 


Division  of 

oratories 

Division  of 


Division  of 
Division  of 
Division  of 


Child  Hygiene 
Tuberculosis 
Adult  Hygiene 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Director, 

Gaylord  W.  Anderson,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 

Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  Pittsfieid. 


Publication  op  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
BM.     6-'31.     Order  2589. 


«$y?/f- 


THE 
COMMONHEALTH 


Volume  18 

No.  3 


JULY-AUG.-SEPT. 
1931 


Lobar  Pneumonia 


Foreword  George  H.  Bigelow,   M.D. 

Epidemiology   of    Pneumonia  M.    J.    Rosenau,    M.D. 

Diagnosis  of  Lobar  Pneumonia  Frederick  T.  Lord,  M.D. 
Prophylaxis  and  Treatment  of  Lobar 

Pneumonia  Edwin  A.   Locke,   M.D. 

Serum  Therapy  in  Type  I  Lobar  Pneumonia  W.  D.  Sutliff,  M.D. 

Pneumococcus    Type   Determination  Edith    Beckler,    S.B. 

Antipneumococcic   Serum  Benjamin  White,   Ph.D. 

Nursing  Care  of  the  Pneumonia  Patient  Walborg  Peterson,  R.N. 

The  Massachusetts  Pneumonia  Plan  Roderick   Heffron,   M.D. 


MASSACHUSETTS 
DEPARTMENT  OF  PUBLIC  HEALTH 


<a- 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  op 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

page 

Foreword,  by  George  H.  Bigelow,  M.D.   .....  131 

The  Epidemiology  of  Pneumonia,  by  M.  J.  Rosenau,  M.D.  .  132 

The  Diagnosis  of  Lobar  Pneumonia,  by  Frederick  T.  Lord,  M.D.  .  134 
The  Prophylaxis  and  Treatment  of  Lobar  Pneumonia,  by  Edwin 

A.  Locke,  M.D 141 

Serum  Therapy  in  Type  I  Lobar  Pneumonia,  by  W.  D.  Sutliff, 

M.D. 152 

Pneumococcus  Type  Determination,  by  Edith  Beckler,  S.B.  .          .  162 

;  Antipneumococcic  Serum,  by  Benjamin  White,  Ph.D.  .          .          .  164 
I  Nursing  Care  of  the  Pneumonia  Patient,  by  Walborg  Peterson, 

R.N 168 

■  The  Massachusetts  Pneumonia  Plan,  by  Roderick  Heffron,  M.D.  .         172 

j 

Morbidity  Survey  Among  Individuals  Receiving  Out-Door  Relief 
in  Cambridge,  by  Marie  R.  Giblin,  Anne  A.  Boris  and 

Sadie  Minsky 174 

Red  Cross  Health  Work  in  Massachusetts,  by  Harding  L.  White         178 
Pediatric  Education — Report  of  Subcommittee  on  Medical  Educa- 
tion, by  Borden  S.  Veeder  ......         180 

News  Notes 

Mothers'  Classes 180 

American  Society  for  Control  of  Cancer  —  Educational  Ma- 
terial   181 

International  Hospital  Association       .....         181 
Book  Notes 

The  Child  from  One  to  Six 182 

The  Principles  and  Practice  of  Hygiene     ....  182 

Report  of  Division  of  Food  and  Drugs,  April,  May  and  June,  1931         183 


FOREWORD 

George  H.  Bigelow,  M.D. 

Commissioner  of  Health, 

Massachusetts  Department  of  Public  Health 

Prominent  among  the  principal  causes  of  death,  lobar  pneumonia 
each  year  exacts  a  heavy  toll  among  our  wage  earning  population.  Al- 
though certain  other  conditions  may  claim  more  victims  because  of 
their  frequent  occurrence  in  the  declining  years  of  life,  lobar  pneu- 
monia all  too  frequently  strikes  at  the  prime  of  physical  vigor  and  the 
height  of  economic  ability.  Its  ravages  are  more  serious  in  their  ef- 
fect on  the  public  economy  than  are  those  of  many  of  the  diseases 
which  are  today  demanding  a  high  place  in  public  attention.  Few 
public  health  problems  are,  therefore,  more  rich  in  possibilities  than 
an  attempt  to  avoid  this  tremendous  annual  loss  of  life  and  economic 
wealth. 

Many  serious  attempts  have  been  made  to  add  to  our  knowledge  of 
pneumonia  and  much  has  been  learned  that  should  be  made  available 
in  its  treatment.  Patient  laboratory  workers  have  studied  the  large 
group  of  pneumococci  and  have  cleared  up  much  that  was  formerly 
obscure.  Their  studies  have  pointed  the  way  for  the  production  of 
sera  to  be  used  in  the  treatment  of  pneumonia.  The  most  encourag- 
ing of  the  sera  that  have  been  used  has  been  the  concentrated  pneu- 
mococcus  antibody  solution.  Suitable  for  use  in  pneumonia  of  Types 
I  and  II,  clinical  trials  have  shown  that  in  many  instances  marked 
improvement  has  followed  its  administration. 

The  Department  of  Public  Health  has,  in  past  years,  manufactured 
in  its  Antitoxin  and  Vaccine  Laboratory  this  concentrated  antipneu- 
mococcus  serum.  So  long  as  it  has  remained  an  experimental  product, 
its  use  has  necessarily  been  limited  to  certain  institutions  where  its 
value  might  well  be  studied.  Its  administration  has  been  attended  with 
results  so  satisfactory  that  it  has  seemed  desirable  to  extend  its  use 
so  far  as  possible  without  losing  sight  of  the  fact  that  further  study 
is  necessary.  The  expense  of  its  manufacture  has  prevented  its  possi- 
ble distribution  on  the  same  basis  as  other  sera.  Its  cost,  when  pur- 
chased, has  virtually  denied  it  to  many  that  might  best  profit  from  its 
use. 

Through  the  generosity  of  the  Commonwealth  Fund  of  New  York 
City,  the  Department  of  Public  Health  is  now  enabled  to  carry  on  an 
intensive  study  of  the  production  and  use  of  this  concentrated  pneu- 
monia serum.  It  has  been  the  hope  of  the  Department  that  in  this  way 
the  study  which  would  have  otherwise  been  impossible  may  be  so  ex- 
panded that  the  serum  may  eventually  be  available  for  the  treatment 
of  cases  of  lobar  pneumonia  in  all  sections  of  Massachusetts.  Valu- 
able only  if  given  in  the  early  stages  of  the  disease,  it  is  our  hope  that 
through  the  service  made  possible  for  this  study  the  serum  may  be 
made  available  for  those  cases  that  are  seen  in  the  home  by  the  fam- 
ily physician  and  not  simply  for  those  that  have  so  far  progressed 
that  they  have  reached  the  hospital  stage. 

The  Department  has  been  extremely  fortunate  to  have  in  connec- 
tion with  this  study  the  advice  and  guidance  of  many  who  have  had 
extensive  experience  with  various  aspects  of  pneumonia.  As  a  part 
of  this  study,  we  have  been  able  to  bring  together  here  a  series  of  ar- 
ticles on  pneumonia  which  give  a  comprehensive  view  of  the  present 
status  of  our  knowledge  of  the  disease.  It  is  our  privilege  to  be  able 
to  place  a  copy  of  these  articles  in  the  hands  of  every  physician  in  the 
state  and  it  is  our  hope  that  they  may  be  of  material  assistance  to  him 
in  the  attempt  to  limit  so  far  as  possible  the  heavy  toll  of  pneumonia. 


132 
THE  EPIDEMIOLOGY  OF  PNEUMONIA 

M.  J.  Rosenau,  M.D. 

Department  of  Preventive  Medicine  and  Hygiene 

Harvard  Medical  School 

Pneumonia  is  not  a  single  disease,  but  comprises  a  group  of  varied 

infections.   Pneumonia  may  be  primary  or  secondary;  it  may  be  lobar 

or  lobular  (bronchopneumonia).    Many  different  microorganisms  may 

cause  a  massive  inflammation  of  the  lungs,  but  the  term  "pneumonia" 

which  we  are  now  thinking  of  is  restricted  to  an  infection  with  the 

pneumococcus  which  is  the  most  frequent  cause  of  pneumonitis.   Even 

with  this  limited  definition,  pneumonia  is  not  a  single  disease  but  a 

group  of  specific  infections,  because  there  are  a  number  of  different 

types  of  pneumococci  with  quite  different  immunological  traits.     The 

classical  fixed  types  have  become  more  numerous  with  further  study, 

although  Types  I,  II  and  III  are  still  the  most  important  and  fatal  with  us. 

This  is  indicated  in  the  following  table. 

Incidence  of  Various  Types  of  Pneumococci  in  Healthy  Persons, 
in  Cases  of  Pneumonia  and  Resulting  Mortality 


Carriers  among  the 

Percentage  of  all 

Case  Fatality, 

Type 

General  Population, 

Pneumococcic 

Per  Cent 

Per  Cent 

Lobar  Pneumonia 

Type  I 

1.8 

33. 

25. 

Type  II 

5.1 

81. 

32. 

Type  III 

8.4 

12. 

45. 

Type  IV 

41.8 

24. 

16. 

Massachusetts  has  its  full  quota  of  pneumonia,  as  might  be  expected 
in  this  climate.  The  following  table,  prepared  by  the  Massachusetts 
State  Department  of  Public  Health,  gives  the  recent  figures. 


LOBAR 

Year 

Population 

Cases  x  ( including 

Deaths 

BRONCHO 

UN- 

"undefined" 

Deaths 

DEFINED 

pneumonias) 

Deaths 

1921 

3935743  2 

4080 

1749 

2311 

74 

1922 

3991333  2 

5194 

2238 

3066 

106 

1923 

4046923  2 

4759 

2166 

3455 

147 

1924 

4102513  2 

4552 

1817 

2382 

127 

1925 

4158103  2 

5544 

2274 

2832 

90 

1926 

4170556 8 

5134 

2315 

2702 

94 

1927 

4191638  8 

4279 

1909 

2095 

60 

1928 

4212720  8 

4785 

2106 

2443 

57 

1929 

4233802  3 

5287 

2154 

2694 

48 

1930 

4254885  8 

4332 

1816 

2150 

67 

1  Impossible  to  give  cases  per  year  of  bronchopneumonia,  since  bron- 
chopneumonia is  not  a  reportable  disease. 

2  Estimated  as  of  July  1st  from  the  censuses  of  1920  and  1925. 
8  Estimated  as  of  July  1st  from  the  censuses  of  1925  and  1930. 


Pneumonia  is  one  of  the  most  prevalent  and  fatal  of  all  acute  dis- 
eases. It  occurs  in  all  climates,  but  takes  its  greatest  toll  in  the  change- 
able and  trying  cold  season  of  the  temperate  zones.  The  disease  occurs 
most  frequently  in  the  winter  and  early  spring  months.  There  is  com- 
paratively little  during  the  summer  time. 

About  10  per  cent  of  deaths  from  all  causes  in  the  U.  S.  registration 
area  are  due  to  pneumonia,  all  forms,  of  which  60  per  cent  are  lobar 
and  undefined  pneumonia  and  40  per  cent  bronchopneumonia.  Ac- 
cording to  the  U.  S.  Mortality  Statistics,  pneumonia  appears  to  be  on 
the  decline,  but  this  may  be  more  apparent  than  real  on  account  of 
errors  and  incompleteness  of  registration  and  diagnosis. 


133 

Pneumonia  attacks  all  agds.  The  incidence  is  most  marked  in  both 
extremes  of  life,  infancy  and  old  age,  when  the  flame  flickers  feeblest. 
Pneumonia  also  attacks  the  strong  and  robust  in  early  adult  life,  but 
under  these  circumstances  the  chances  of  recovery  are  relatively  fa- 
vorable. Pneumonia  is  a  frequent  complication  of  measles  and  influ- 
enza. It  often  complicates  any  weakening  disease.  As  a  terminal  in- 
fection, it  frequently  closes  the  final  scene. 

The  infection  is  spread  directly  from  man  to  man.  The  pneumococcus 
does  not  thrive  in  the  outer  world,  and  man  therefore  must  be  regarded 
as  its  source  and  reservoir.  Pneumonia  is  a  contact  infection.  It  is  spread 
by  cases  and  carriers.  The  epidemiology  of  pneumonia  at  first  glance  does 
not  seem  to  be  that  of  a  contagious  disease.  It  does,  however,  clearly 
belong  to  the  great  group  of  contact  infections  spread  by  secretions  from 
the  mouth  and  nose.  The  disease  shows  marked  individuality,  the  chief 
feature  of  which  is  its  feeble  tendency  to  focal  concentration.  It  is  diffi- 
cult to  trace  the  epidemiological  connection  between  one  case  of  pneu- 
monia and  the  next.  Carriers  are  exceedingly  common.  The  vagaries  of 
the  disease  can  be  explained  by  the  fact  that  a  person  contracts  pneumonia 
only  in  the  presence  of  the  infection  plus  susceptibility.  Predisposing 
causes  and  accessory  factors  play  an  important  role  in  determining  the 
disease. 

Among  the  accessory  factors  are  alcoholism,  exposure,  fatigue,  trauma, 
and  local  irritation.  Pneumonia  frequently  complicates  measles,  influenza, 
whooping  cough,  typhoid  fever  and  other  diseases.  It  is  common  as  a 
terminal  infection  in  chronic  heart  disease,  pulmonary  tuberculosis, 
Bright's.  disease,  diabetes  and  other  debilitating  affections.  Unbalanced 
diets  undermine  resistance  to  the  pneumococcus,  for  pneumonia  is  a  fre- 
quent complication  of  scurvy  and  rickets.  Bad  air,  irritating  fumes  and 
gases,  and  dust  are  well  recognized  predisposing  causes  of  pneumonia. 

Pneumonia  belongs  to  a  group  of  diseases  which  are  the  most  prevalent 
and  damaging  of  the  infections  to  which  flesh,  is  heir.  The  acute  infec- 
tions of  the  respiratory  tract  prevail  more  especially  in  temperate,  cool 
and  variable  climates,  but  also  occur  in  warm  latitudes  and  even  in  the 
tropics.  As  a  group,  the  respiratory  infections  are  less  well  understood 
and  hence  less  controllable  than  the  intestinal  diseases.  The  respiratory 
diseases  are  responsible  for  60  per  cent  of  sickness  and  20  per  cent  of 
deaths.  Pneumonia,  as  well  as  the  other  diseases  in  this  group  are  spread 
chiefly  through  the  discharges  from  the  mouth  and  nose,  and  usually  by 
rather  direct  personal  contact  with  cases  and  carriers,  sometimes  by  drop- 
let infection,  or  indirectly.  Infection  may  be  contracted  in  food  or  drink, 
by  hand-to-mouth  contamination,  or  by  things  that  have  been  recently 
mouthed,  such  as  cups,  spoons,  toys,  etc. 

Pneumonia  in  Massachusetts  causes  more  deaths  than  any  other  infec- 
tious disease  with  the  exception  of  tuberculosis.  Tuberculosis  rates  are 
declining,  while  pneumonia  holds  its  own.  Up  to  the  present  time  rela- 
tively little  attention  has  been  paid  and  practically  no  work  done  on  a 
state-wide  basis,  or  any  measures  adopted  in  an  effort  to  attempt  to  con- 
trol the  spread  of  pneumonia.  The  State  Department  of  Public  Health 
is  now  making  a  comprehensive  and  thorough  study  of  this  question,  under 
the  able  supervision  of  Dr.  Roderick  Heffron. 

The  prevention  of  pneumonia  is  still  baffling  for  lack  of  understanding 
of  some  of  the  fundamental  factors  in  the  epidemiology  of  the  disease. 
We  cannot  boast  of  success  with  an  infection  which  is  one  of  the  chief 
causes  of  death.  We  should  think  of  pneumonia  very  much  as  we  think  of 
diphtheria,  whooping  cough  and  influenza,  that  is,  as  an  infection  which 
is  spread  from  man  to  man  through  the  secretions  of  the  mouth  and  nose. 
Preventive  measures  must  regard  pneumonia  as  a  communicable  infection. 


134 
THE  DIAGNOSIS  OF  LOBAR  PNEUMONIA 

Frederick  T.  Lord,  M.D. 
Boston,  Mass. 
Pneumonia  due  to  the  pneumococcus  differs  from  pulmonary  infection 
with  other  organisms  in  an  explosive  onset,  usual  massive  lung  involve- 
ment, short  course,  abrupt  termination  in  favorable  cases  and  relatively 
rapid  restoration  of  the  involved  area  to  normal. 

General  Clinical  Description 

The  history  of  a  preceding,  mild,  acute,  upper  respiratory  infection 
such  as  accompanies  a  "cold"  can  usually  be  obtained.  This  does  not  differ 
from  an  ordinary  "cold"  until  the  patient  is  stricken  with  the  more  serious 
illness.  The  onset  is  commonly  abrupt  with  coincident  pain  in  the  side, 
cough  and  chill  or  chilliness.  The  cough  is  at  first  dry  and  painful,  but 
rapidly  becomes  productive  and  the  expectoration  is  usually  rusty  and 
tenacious  within  twenty-four  hours.  The  chill  may  last  a  half  hour  or 
longer.  The  temperature  rises  rapidly  and  may  reach  102  to  104  within  a 
few  hours.  The  pulse  and  respiration  rate  are  elevated,  the  latter  out 
of  proportion  to  the  former.  The  patient  may  be  less  uncomfortable  lying 
on  the  affected  side.  The  alae  nasi  dilate  with  inspiration.  The  face  is 
likely  to  be  flushed  and  the  lips  increasingly  cyanotic  as  the  disease 
progresses.  Herpetic  lesions  are  common  on  the  lips  and  about  the  mouth, 
but  seldom  appear  before  the  second  or  third  day.  Within  the  first  twenty- 
four  hours  the  physical  signs  are  usually  limited  to  slight  dulness,  dimin- 
ished and  bronchial  breathing  and  fine,  moist,  consonating  rales  with  long 
breath  or  cough.  In  some  cases  at  this  early  period  the  lungs  are  nega- 
tive, but  the  physical  signs  are  usually  outspoken  by  the  second  or  third 
day  with  limited  motion  of  the  affected  side  and  over  the  involved  area 
dulness,  bronchial  breathing,  increased  voice,  aegophony,  increased  whis- 
per and  increased  tactile  fremitus.  Unless  masked  by  diffuse  bronchitis, 
crepitant  rales  can  usually  be  heard  over  the  involved  part  of  the  lung 
during  the  early  period  of  the  illness,  but  are  likely  to  be  absent  while 
the  disease  is  at  its  height.  The  extent  of  the  involved  area  increases  in 
typical  cases  to  embrace  the  greater  part  or  the  whole  of  one  lobe.  In 
atypical  cases,  however,  the  physical  signs  may  be  uncertain  for  a  time  or 
remain  so  throughout  the  illness.  In  cases  terminating  favorably  the 
temperature  falls  by  crisis  or  lysis  in  from  five  to  ten  days,  with  such 
indications  of  beginning  resolution  as  a  change  of  the  rusty  sputum  to  a 
more  purulent  and  less  tenacious  expectoration,  a  more  resonant  percus- 
sion note  and  reappearance  of  the  fine,  consonating  rales  (redux  crepitus). 

The  course  of  the  disease  is  very  variable.  All  grades  of  severity  may 
be  observed.  In  the  mildest  cases,  the  patient  may  be  fairly  comfortable 
throughout,  without  pain,  the  cough  not  discomforting,  the  sputum  scanty 
or  absent  and  the  pulse  and  temperature  only  little  elevated.  The  tempera- 
ture may,  in  rare  instances,  begin  to  fall  by  the  third  or  more  often  by 
the  fifth  day  in  mild  cases.  Predictions  regarding  the  outcome  are,  how- 
ever, unsafe  and  the  condition  may  change  rapidly  from  apparent  safety 
to  great  gravity.  Changes  for  the  worse  are  more  often  gradual,  however, 
and  indicated  by  delirium,  restlessness,  insomnia,  greater  cyanosis,  more 
rapid  pulse  and  respiration  and  extension  of  the  involved  area.  In  gen- 
eral, the  severity  of  the  constitutional  symptoms  is  more  reliable  as  a 
prognostic  indication  than  the  extent  of  the  pneumonia.  Bilateral  or 
multiple  lobar  involvement  is  somewhat  less  favorable  than  a  unilobar 
process.  Septicaemia  or  a  positive  precipitin  test  in  the  urine  makes  the 
outlook  more  serious.  Youth  and  vigor  are  favorable  factors.  From  the 
sixth  to  the  twentieth  year  the  mortality  is  about  6%  and  rises  steadily 
as  age  advances  reaching  about  26%  from  31  to  40,  nearly  40%  from  41 
to  50  and  may  amount  to  65%  above  60.  The  outlook  varies  in  the  differ- 
ent types  of  infection. 


135 
Clinical  Varieties  of  Lobar  Pneumonia 

Abortive  Pneumonia.  In  rare  instances,  the  disease  runs  a  very  short 
course.  Typical  pneumonia  of  a  duration  of  one  day  has  been  reported  by 
a  number  of  observers.  One  case  of  two  and  a  second  of  three  days  dur- 
ation occurred  among  200  cases,  none  of  which  were  serum  treated,  at 
the  Massachusetts  General  Hospital. 

Central  Pneumonia.  The  solidification  begins  at  the  lung  root  and 
spreads  slowly  toward  the  periphery.  Physical  signs  may  be  absent  for 
several  days  or  even  throughout  the  illness.  Such  other  features,  however, 
as  an  acute  onset  with  chill,  rusty  sputum,  increased  rate  of  respiration, 
leucocytosis  and  the  X-ray  examination  usually  permit  a  diagnosis. 

Migratory  Pneumonia.  In  some  cases  the  pneumonic  process  spreads 
from  one  lobe  to  another,  resolution  taking  place  at  one  place  while  the  in- 
filtration progresses  elsewhere.  Thus  all  the  lobes  of  one  or  both  lungs 
may  be  successively  invaded  and  a  lobe  previously  attacked  may  be  rein- 
fected. Such  a  course  has  been  termed  erysipelatous.  The  illness  is  likely 
to  be  protracted  and  severe.  In  some  degree  many  pneumonias  belong  in 
this  group  as  shown  by  the  frequency  with  which  at  autopsy  there  is  ex- 
tension from  one  to  a  neighboring  or  another  lobe. 

Lobar  Pneumonia  in  Children.  Lobar  pneumonia  is  uncommon  before 
the  second  year.  During  childhood  an  initial  chill  is  less  common  than 
in  later  life  and  convulsions,  delirium  or  stupor  may  usher  in  the  attack. 
Nausea  and  vomiting  are  more  common  than  in  adults.  Expectoration  is 
usually  absent  under  five  years  of  age.  The  temperature  is  likely  to  be  at 
a  higher  level  and  the  pulse  rate  proportionally  more  rapid  than  in  later 
years.  Physical  signs  of  consolidation  may  not  appear  until  late  in  the 
course  of  the  disease  and  the  diagnosis  may  be  in  doubt  for  several  days. 
An  explosive  onset,  with  fever,  cough,  rapid  respiration,  expiratory  grunt 
and  leucocytosis  may  be  the  only  definite  indications.  The  white  count  is 
in  general  more  elevated  than  in  adults.  Roentgen-ray  examination  is  im- 
portant in  determining  the  nature  of  the  pulmonary  process.  The  outlook 
is  more  favorable  than  in  adults.  Delayed  resolution  is  less  often  ob- 
served.  Empyema  and  otitis  media  are  more  common  than  in  adults. 

Relation  of  the  Clinical  Aspects  to  the  Type  of  Infection 

It  is  impossible  to  determine  the  type  of  infection  by  other  than  labora- 
tory means.  Nevertheless,  the  clinical  aspects  may  furnish  suggestive 
evidence.  In  general,  the  grouping  of  initial  symptoms  in  a  typical  ex- 
plosive onset,  though  common  to  all  types  of  acute  pneumococcus  lobar 
pneumonia,  is  more  often  observed  with  Type  I  and  Type  II.  An  insidious 
onset,  without  chill,  pain  or  rusty  sputum  is  more  frequently  observed 
in  pneumococcus  infections  other  than  Type  I  and  Type  II.  Pneumonia 
developing  after  operation,  or  as  a  complication  of  circulatory  disturb- 
ance, or  in  elderly  persons  is  not  likely  to  be  due  to  Type  I  or  Type  II. 
When  the  age  of  the  patient  is  taken  into  consideration  the  number  of 
successful  predictions  of  the  type  is  increased  because  of  the  frequency 
with  which  Type  I  occurs  in  youth.  Of  585  cases  of  lobar  pneumonia  in 
adults  under  30,  Cecil,  Baldwin  and  Larsen  (Arch.  Int.  Med.  40 :  253-280 
(Sept.  1927)  found  that  246  (42%)  were  Type  I  infections. 

Special  Diagnostic  Aids 

Leucocyte  Count.  A  polynuclear  leucocytosis  is  present  in  over  90  per 
cent  of  cases.  It  occurs  as  early  as  the  chill  or  a  few  hours  later  and 
persists  throughout  the  disease.  There  is  no  constant  relation  between 
the  degree  of  leucocytosis  and  the  severity  of  the  infection,  but  the  mor- 
tality is  relatively  high  in  patients  without  leucocytosis.  The  white  count 
falls  more  slowly  than  the  temperature  and  in  favorable  cases  reaches 
normal  within  a  week  to  ten  days  after  defervescence.  Delayed  resolu- 
tion or  complications  due  to  suppuration  are  usually  accompanied  by  an 
elevation  of  the  leucocyte  count. 


136 

Roentgen-ray  Examination.  This  is  of  value  in  confirming  the  results 
of  physical  examination  and  the  demonstration  of  central  or  multiple  in- 
volvement not  otherwise  to  be  found.  The  increased  density  due  to  lobar 
pneumonia  is  usually  somewhat  uneven  and  mottled  with  ill-defined  mar- 
gins but  may  be  homogeneous  and  sharply  limited.  Comparison  of  succes- 
sive films  may  show  increased  radiance  of  previously  dense  areas  as  an  in- 
dication of  resolution  which  may  begin  in  the  central  part  and  extend 
eccentrically  toward  the  periphery  or  more  commonly  in  several  places  at 
the  same  time.  Evidence  of  resolution  may  be  obtained  by  x-ray  at  a  time 
when  neither  the  physical  signs  nor  the  temperature  curve  indicate  the 
proximity  of  crisis. 

A  complicating  collapse  of  the  lung  may  be  indicated  by  an  even  in- 
crease of  density  of  the  involved  region.  Collapse  of  an  entire  lower  lobe 
may  be  recognized  by  the  presence  of  a  dense  homogeneous  shadow  in  the 
cardiophrenic  angle  with  sharply  defined  outer  border  declining  from  the 
root  downward  and  outward  to  the  diaphragm.  Collapse  of  the  middle 
lobe  presents  a  dense  homogeneous  shadow  in  the  right,  lower  lung  field 
with  a  sharply  defined  nearly  horizontal  upper  and  vertical  outer  border. 
In  addition,  with  unilateral  atelectasis  there  is  elevation  of  the  correspond- 
ing leaflet  of  the  diaphragm,  narrowing  of  the  intercostal  spaces  and  in- 
creased downward  inclination  of  the  ribs  on  the  affected  side  and  dis- 
placement of  the  heart  and  mediastinum  toward  the  lesion.  X-ray  exam- 
ination is  important  in  the  detection  of  pleural  effusion.  Small  amounts 
of  free  fluid  obliterate  the  costophrenic  angle.  Larger  amounts  present  a 
homogeneous  increase  of  density  in  the  lower  part  of  the  lung  field,  with 
ill-defined,  upper  border  reaching  its  highest  level  in  the  outer  aspect  of 
the  lung  field.  Encapsulated  effusions  are  of  even  density  with  sharply 
defined  margins  and  may  occur  at  any  place,  but  are  more  commonly  basal 
or  in  the  region  of  the  interlobar  septa. 

The  roentgen-ray  findings  with  bronchopneumonia  differ  from  those 
with  lobar  pneumonia  in  the  more  patchy  character  of  the  areas  of  in- 
creased density,  greater  frequency  of  multiple  foci  and  wider  separation 
of  the  involved  regions.  An  area  of  increased  density  due  to  confluent 
bronchopneumonia  cannot  be  differentiated  by  the  x-ray  alone  from  that 
due  to  lobar  pneumonia. 

Importance  of  Early  Diagnosis 

The  complex  of  initial  symptoms  fortunately  leaves  little  room  for 
doubt  as  to  the  nature  of  the  developing  illness.  Chill  or  chilliness,  stitch 
in  the  side,  rapid  elevation  of  temperature,  cough  and  rusty  sputum  are 
almost  distinctive  of  lobar  pneumonia  and  it  is  unnecessary  to  wait  for 
physical  signs  of  consolidation  before  proceeding  to  the  determination  of 
the  type  of  the  pneumococcus  infection  and  the  administration  of  anti- 
serum. 

Determination  of  the  Type  of  Pneumococcus  Infection 

Inasmuch  as  the  clinical  features  do  not  serve  to  distinguish  the  type 
of  pneumococcus  infection,  resort  must  be  made  to  the  laboratory.  Such 
initial  symptoms  as  chill,  stitch  in  the  side,  rapid  elevation  of  tempera- 
ture, cough  and  rusty  expectoration  are  sufficiently  suggestive  to  make 
immediate  determination  of  the  type  of  infection  desirable.  Examination 
of  the  sputum  is  the  most  readily  available  method  and  a  specimen  is 
almost  always  obtainable  in  adults,  if  the  physician  is  sufficiently  insist- 
ent. The  sputum  should  come  from  the  deeper  parts  of  the  air  passages 
and  be  collected  in  a  clean,  wide-mouthed,  sterile  bottle.  A  microscopic 
examination  for  pneumococci  and  other  organisms  should  be  made  in  all 
cases.  Care  should  be  taken  to  select  the  more  suspicious  particles.  A  small 
mass  of  rusty,  tenacious  material  should  be  washed  free  of  adherent  mu- 
cus in  sterile  salt  solution  or  bouillon.  Thin  smears  are  fixed  in  the  flame 
in  the  ordinary  manner,  stained  by  Gram's  method  and  counter-stained 


137 

with  bismark  brown.  All  specimens  should  also  be  investigated  for  tuber- 
cle bacilli  as  a  routine.  The  mere  presence  of  pneumococci  in  the  sputum 
is  of  little  moment  in  the  diagnosis  as  these  organisms  are  normal  inhabi- 
tants of  the  mouth.  Determination  of  the  type  of  pneumococcus  infec- 
tion is  essential  in  all  cases.  Methods  for  the  identification  of  types  are 
described  elsewhere.  A  small  amount  of  sputum  suffices  for  the  mouse 
test.  The  Sabin  microscopic  slide,  agglutination  test  is  time-saving  as 
compared  with  macroscopic  tube  tests,  but,  if  possible,  as  much  as  two  to 
ten  cubic  centimeters  of  sputum  should  always  be  obtained  and  the  type 
of  infection  can  then  be  immediately  tested  also  by  the  Krumwiede  pre- 
cipitation method.  If  sputum  cannot  be  obtained,  a  blood  culture  may  give 
the  desired  information,  but  is  positive  in  only  about  a  third  of  the  cases. 
A  diagnosis  of  type  may  be  made  by  a  precipitin  test  on  the  urine,  but  the 
test  is  positive  only  in  the  presence  of  severe  infections.  A  precipitin 
test  can  also  be  done  on  the  blood  serum.  It  is  positive  only  in  unusually 
severe  cases  late  in  the  course  of  the  disease. 

Diagnostic  Importance  of  Persistence  of  Fever  After  the  Time  Of  Its 
Expected  Decline  Or  Re-elevation  of  Temperature  After  Defervescence 

Defervescence  is  usually  by  crisis  in  which  the  temperature  returns  to 
normal  within  twelve  to  twenty-four  hours.  A  defervescence  which  takes 
place  during  twenty-four  to  thirty-six  hours  is  termed  a  protracted  crisis. 
As  the  disease  approaches  its  termination  there  may  be  a  rapid  fall  in 
the  temperature  followed  by  a  rapid  rise.  Such  a  drop  in  the  temperature 
is  spoken  of  as  a  pseudo-crisis.  Defervescence  by  crisis  is  more  common 
in  children,  in  vigorous  adults  and  when  the  disease  runs  a  brief  course. 
Complications  occur  less  frequently  in  cases  terminating  by  crisis.  When 
the  fall  in  the  temperature  lasts  longer  than  thirty-six  hours  it  is  spoken 
of  as  lysis.  It  is  more  often  observed  in  the  aged,  the  subjects  of  chronic 
disease  and  in  the  presence  of  complications  which  are  four  times  more 
common  in  cases  terminating  by  lysis  than  by  crisis.  A  protracted  course 
or  febrile  disturbance  after  defervescence  is  most  often  due  to  serofib- 
rinous or  purulent  pleurisy,  migratory  pneumonia,  organizing  pneumonia 
or  otitis  media.  Such  other  causes  as  pericarditis,  endocarditis,  phlebitis, 
or  meningitis  are  less  common.  Lung  abscess  rarely,  if  ever,  follows  true 
lobar  pneumonia. 

Differential  Diagnosis 

Patients  with  atypical  onsets  at  times  present  a  difficult  diagnostic 
problem.  Variation  from  the  characteristic  picture  is  not  uncommon  in 
children  and  the  aged.  Terminal  lobar  pneumonia  in  debilitated  subjects 
or  those  with  arteriosclerosis,  chronic  heart  lesions,  kidney  disease  and 
diabetes,  may  readily  be  overlooked  and  central  pneumonia  may  be  in 
doubt  for  several  days. 

Obstruction  atelectasis  may  complicate  lobar  pneumonia.  It  is  most 
often  observed  in  infants  and  children,  but  may  occur  at  any  age.  Bron- 
chial plugging  from  retained  tenacious  secretion  is  the  most  common 
cause.  Its  development  is  favored  by  the  maintenance  for  a  long  period 
of  one  position  such  as  lying  constantly  on  one  side.  Ineffectual  expulsion 
of  bronchial  secretion  and  absorption  of  air  in  the  part  of  the  lung  sup- 
plied by  the  occluded  passage  is  doubtless  the  explanation.  In  a  review 
of  the  x-ray  films  of  forty-seven  patients  with  lobar  pneumonia  at  the 
Massachusetts  General  Hospital,  Holmes,  King  and  I  found  evidence  of 
varying  and  usually  slight  degrees  of  atelectasis  in  twenty-three.  Massive 
collapse  is  uncommon.  Of  558  cases  of  pneumonia  personally  examined 
there  was  a  complicating  lung  collapse  involving  a  sufficiently  large  area 
to  lead  to  clinically  demonstrable  cardiac  displacement  in  fourteen  (2.5%). 
Of  these  nine  had  lobar  and  five  bronchopneumonia. 

There  are  usually  no  symptoms  which  can  with  certainty  be  ascribed  to 
the  atelectasis,  but  the  lung  collapse  may  contribute  to  the  dyspnea.  In 
some  cases,  collapse  with  closed  bronchus  can  be  demonstrated  and  usually 


138 

at  the  base  posteriorly  by  such  signs  as  dulness,  diminished  or  absent 
breathing,  diminished  voice,  without  aegophony,  diminished  or  absent 
whisper  and  tactile  fremitus.  Such  signs  should  not  be  confused  with 
those  due  to  pleural  effusion.  The  x-ray  is  important  in  the  recognition 
of  atelectasis. 

Onset  with  Abdominal  Pain.  Abdominal  pain  occurs  in  about  six  per 
cent  of  cases  and  as  an  initial  symptom  may  lead  to  the  confusion  of 
pneumonia  with  such  acute  abdominal  affections  as  gall  stones  or  appendi- 
citis. The  pain  is  usually  referred  to  the  upper  but  may  be  felt  in  the 
lower  quadrants  of  the  abdomen.  Spasm  and  tenderness  may  accompany 
the  pain.  The  lower  six  intercostal  nerves  supply  the  abdominal  wall 
with  sensation  and  the  eleventh  the  abdominal  wall  over  the  region  of  the 
appendix. 

Meningismus.  In  children  and  at  times  in  adults  there  may  be  a  pre- 
dominance of  cerebrospinal  symptoms  with  severe  headache,  vomiting, 
iritability,  delirium  or  coma,  involuntary  loss  of  urine  and  feces,  stiff- 
ness or  retraction  of  the  neck  and  spine  and  inability  normally  to  extend 
the  leg  with  the  thigh  flexed  (Kernig's  sign).  Paralyses  and  localized 
convulsive  movements  are  lacking.  The  pupils  and  eye  grounds  are  nor- 
mal. The  cerebrospinal  fluid  may  be  under  increased  pressure,  but  rises 
normally  with  jugular  compression.  The  fluid  is  clear,  sterile  and  with- 
out increase  in  cells.  The  content  of  globulin,  protein,  non-protein  nitro- 
gen, sugar  and  chlorides  and  the  gold  sol  are  normal.  Careful  daily  ex- 
amination of  the  lung  will  usually  disclose  the  pulmonary  character  of 
the  infection.  The  symptoms  due  to  meningeal  irritation  usually  subside 
at  the  time  of  or  shortly  after  defervescence. 

Pleurisy  with  Effusion.  Fibrinous  pleurisy  over  the  involved  part  of 
the  lung  or  a  wider  area  is  almost  constant  with  lobar  pneumonia.  Small 
sero-fibrinous  effusions  are  more  common  than  purulent  exudates.  Empy- 
ema occurs  clinically  in  about  four  per  cent  of  cases.  Dry  pleurisy  may  be 
indicated  by  the  presence  over  the  affected  region  of  a  friction  rub  which 
does  not,  however,  exclude  free  or  encapsulated  fluid  elsewhere.  Over  free 
effusions,  there  is  usually  dulness,  diminished  bronchial  breathing,  dimin- 
ished voice,  aegophony,  increased  whisper  and  diminished  or  absent  tactile 
fremitus.  Dulness  in  the  paravertebral  region  on  the  affected  side  with 
pleural  effusion  and  relative  resonance  in  this  region  with  pneumonia  may 
be  of  value  in  differentiating  the  two  conditions.  Grocco's  paravertebral 
dulness  on  the  opposite  side  is  of  little  diagnostic  value  with  small  effu- 
sions. Displacement  of  the  heart  away  from  the  effusion  is  important  evi- 
dence for  large  but  of  little  value  for  small  effusions.  In  rare  instances  the 
heart  is  displaced  toward  the  effusion  in  consequence  of  massive  collapse 
of  the  lung  on  the  side  corresponding  to  the  accumulation  of  fluid.  En- 
capsulated empyema  may  be  difficult  of  detection  from  physical  signs 
alone.  Circumscribed  dulness  with  diminished  breathing,  voice  and 
tactile  fremitus  may  be  suggestive.  The  breathing  is  not  likely  to  be 
bronchial  or  the  voice  aegophonic  unless  the  sacculated  fluid  is  large  in 
amount.  Roentgen-ray  examination  is  of  great  value  in  the  early  detec- 
tion of  pleural  effusion  and  in  locating  an  encapsulated  empyema.  The 
nature  of  the  effusion  complicating  pneumonia  can  be  determined  by  ex- 
ploratory puncture  and  the  examination  of  the  fluid. 

Determination  of  the  Character  of  Pleural  Fluid 

This  is  usually  impossible  without  exploratory  puncture,  but  certain 
suggestive  features  may  be  mentioned.  Small  amounts  of  pleural  fluid 
occurring  as  a  complication  or  sequel  of  lobar  pneumonia  are  usually  sero- 
fibrinous in  character  and  sterile.  Large  metapneumonic  effusions  are 
likely  to  be  purulent.  In  children  under  five  years  of  age  the  chances  are 
much  in  favor  of  empyema.  The  clinical  manifestations  though  of  little 
value  in  individual  cases  are  in  general  more  severe  with  pus,  with  higher 
and  more  irregular  fever,  chills,  sweats,  loss  of  weight  and  strength, 
pallor  and  leucocytosis. 


139 

Exploratory  Puncture.  This  should  be  done  under  local  anaesthesia. 
With  free  effusion  the  exploration  should  be  made  over  the  suspected  area, 
usually  in  the  7th  intercostal  space  in  the  region  of  the  angle  of  the 
scapula.  This  site  has  the  advantage  that  being  in  a  dependent  region  if 
pus  is  found  and  operation  is  desirable  surgical  drainage  can  be  estab- 
lished at  or  near  the  point  of  puncture.  Encapsulated  effusion  should  be 
sought  under  guidance  by  x-ray  examination. 

In  addition  to  the  determination  of  the  presence  of  pleural  fluid,  the 
operator  should  note  any  unusual  thickness  of  the  pleural  or  pulmonary 
tissue  or  undue  resistance  encountered  during  the  introduction  of  the 
needle. 

Samples  of  the  fluid  obtained,  no  matter  how  small  the  amount  should 
be  saved  for  examination. 

Examination  of  Pleural  Fluids.  The  gross  character  of  the  fluid  (ser- 
ous, serofibrinous,  hemorrhagic,  fibrinopurulent,  purulent,  etc.)  should  be 
noted.  With  clear  or  cloudy  fluids  the  specific  gravity  should  be  taken.  In 
general,  transudates  have  a  relatively  low  specific  gravity,  1010  or  lower 
for  hydraemic  fluids  and  1010  to  1015  for  venous  transudates,  while  the 
specific  gravity  of  exudates  is  usually  1018  or  higher.  Cultures  from  the 
fluid  should  be  made  at  once  on  a  fresh  blood  agar  plate  and  in  bouillon  to 
which  a  small  amount  of  rabbit  or  human  serum  is  added  by  expressing 
a  small  amount  of  fluid  from  the  syringe  used  in  the  exploratory  punc- 
ture. Thin  smears  should  be  stained  for  tubercle  bacilli,  by  Gram's  stain 
for  other  organisms  and  by  Wright's  blood  stain  for  cellular  elements. 

Examination  of  serofibrinous  fluids.  The  microscopic  examination  of 
fluids  of  this  character  should  be  done  as  soon  as  possible  after  with- 
drawal. Spontaneous  coagulation  and  the  entanglement  of  cells  in  the 
meshes  of  fibrin  may  be  prevented  by  mixing  the  fluid  with  an  equal 
volume  of  sterile  1%  sodium  citrate  in  0.85%  sodium  chloride  solu- 
tion. A  red  and  white  count  are  desirable  on  bloody  fluids  to  deter- 
mine the  quantitative  relation  between  these  elements  and  permit  a 
decision  regarding  the  extent  to  which  the  white  cells  may  be  ascribed 
to  effused  blood.  In  the  differential  count  of  the  white  cells,  a  predom- 
inance of  polynuclear  neutrophiles  may  in  general  be  regarded  as  an 
indication  of  a  severe  infection.  An  excess  of  lymphocytes  in  exuda- 
tive fluids  may  be  taken  to  indicate  a  less  intense  inflammation.  Pre- 
dominance of  endothelial  cells  in  fluids  of  low  specific  gravity  is  sug- 
gestive of  a  passive  transudate. 

Examination  of  Purulent  Exudates.  Operation  should  not  be  done  until 
the  pus  has  been  examined.  Cultures  should  be  taken  as  with  serofi- 
brinous fluids.  Stained  smears  should  be  examined  for  tubercle  ba- 
cilli and  other  organisms.  If  the  smear  shows  no  organisms  and  cul- 
tures are  sterile  the  empyema  may  be  tuberculous  and  guinea  pig 
inoculation  should  be  done  by  injecting  a  small  amount  of  the  fluid 
under  the  skin  of  the  animal. 

Determination  of  the  Type  of  Pneumococcus  Infection  in  Pleural  Fluids. 
Specific  precipitin  tests  with  diagnostic  antipneumococcic  sera  may  be 
done  on  the  clear  supernatant  fluid  obtained  after  standing  or  centri- 
fugalization.  Two-tenths  cubic  centimeters  of  each  type  of  appropri- 
ately diluted  (the  proper  dilution  is  indicated  on  the  bottle  for  each  type) 
diagnostic  serum  are  transferred  by  means  of  graduated  sterile  pip- 
ettes to  small  test  tubes.  An  equal  amount  of  the  clear,  supernatant, 
pleural  fluid  is  carefully  layered  over  the  diagnostic  sera  in  each  tube 
by  allowing  the  fluid  to  flow  down  the  inside  of  the  tilted  tube.  The 
type  of  pneumococcus  is  indicated  by  an  almost  immediate  precipitin 
reaction  in  the  tube  containing  the  homologous  serum.  Incubation  is 
unnecessary.  The  method  has  the  advantage  that  unlike  the  aggluti- 
nation test  contamination  with  other  organisms  does  not  interfere  with 
the  reaction.  In  supernatant  fluids  containing  pneumococci,  agglutina- 
tion tests  may  be  done  by  the  macroscopic  method  or  the  microscopic 


140 

slide  agglutination  test  of  Sabin.  A  bile  test  for  solubility  should  also 
be  set  up  in  the  series. 

Bearing  on  Treatment  of  the  Character  of  the  Pleural  Fluid  and  Other 

Factors 

The  examination  of  pleural  fluids  is  essential  in  deciding  the  appro- 
priate treatment.  With  sterile  exudates,  thoracentesis  is  the  procedure 
of  choice.  Turbid  fluids  containing  merely  an  excess  of  polynuclear 
neutrophiles  and  pneumococci  are  on  the  border  line  between  serofi- 
brinous and  purulent  exudates  and  repeated  punctures  may  suffice  for 
a  time.  With  frankly  purulent  pneumococcus  effusion,  more  radical 
measures  are  indicated.  During  the  acute  stage  of  the  disease,  thor- 
acotomy with  costatectomy  is  to  be  avoided  on  account  of  risk  at  this 
time  of  a  radical  operative  procedure  and  the  danger  of  collapse  of  the 
unadherent  lung  on  opening  the  thorax.  Closed  suction  drainage  by  a 
trocar  thoracotomy  has  the  advantage  of  slow  evacuation,  avoidance  of 
a  large  operation  wound  and  largely  eliminates  the  danger  of  open 
pneumothorax.  Thoracotomy  with  costatectomy  is  the  operation  of 
choice  for  purulent  pneumococcus  effusions  when  the  empyema  cavity 
is  walled  off  by  sufficiently  firm  adhesions  to  prevent  lung  collapse 
when  the  thorax  is  opened. 

Delayed  Resolution 

The  signs  of  consolidation  usually  persist  for  a  few  days  to  a  week 
after  the  crisis.  In  rare  instances  resolution  is  delayed  beyond  this 
interval  and  may  result  in  organizing  pneumonia  by  replacement  with 
connective  tissue  in  consequence  of  an  upset  of  the  local  ferment-anti- 
ferment  balance.  A  delay  of  resolution  beyond  three  weeks  may  in 
general  be  regarded  as  evidence  of  developing  pulmonary  induration. 
An  x-ray  examination  is  essential  in  such  cases.  Pulmonary  tubercu- 
losis and  pleurisy  with  effusion  must  be  excluded  before  the  diagnosis 
of  delayed  resolution  can  be  made. 

Bronchopneumonia 

The  differentiation  of  lobar  pneumonia  from  bronchopneumonia  is 
not  ordinarily  difficult.  The  latter  is  usually  secondary  and  occurs  as 
a  complication  of  an  existing  respiratory  infection  without  chill,  pain 
in  the  side,  rapid  rise  of  temperature  or  rusty  sputum.  The  tempera- 
ture is  more  irregular  and  the  physical  signs  less  definite  than  with 
lobar  pneumonia.  Widely  scattered,  moist  rales  may  be  the  only  physi- 
cal signs  or  there  may  be  multiple  small  areas  of  consolidation.  Def- 
ervescence is  by  lysis,  resolution  is  slow  and  there  is  a  tendency  to 
relapse. 

A  variety  of  bacterial  incitants  is  concerned  in  the  etiology  of  bron- 
chopneumonia. Pneumococci  of  other  types  than  I  and  II  are  the  most 
common  invaders.  Among  others,  streptococci,  influenza  bacilli  and 
staphylococci  may  also  be  a  cause.  The  distinction  between  typical 
pneumococcus  lobar  pneumonia  and  bronchopneumonia  due  to  these 
or  other  organisms  may  ordinarily  be  made  from  the  secondary  nature 
of  the  process  in  the  latter,  the  atypical  character  of  the  symptoms  and 
the  bacteriologic  examination.  In  the  uncommon  instances  in  this 
group  in  which  the  pneumonia  is  primary,  greater  difficulty  may  be  en- 
countered. It  is  difficult  to  correlate  the  clinical  picture  with  the  bac- 
teriologic findings,  but  hemolytic  streptococcus  pneumonia  may  fol- 
low measles  or  septic  sore  throat.  The  mortality  is  high  and  empyema 
is  a  frequent  complication.  Staphylococcus  aureus  pneumonia,  accord- 
ing to  Chickering  and  Park  (J.  A.  M.  A.  72:  617  (Mar.  1,  1919)  is  char- 
acterized by  the  production  of  multiple  small  abscesses  and  the  ex- 
pectoration of  a  peculiar  "anchovy  sauce"  sputum. 

With  pulmonary  infarction  the  initial  complex  of  symptoms  closely  re- 
sembles that  with  lobar  pneumonia,  with  chill  or  chilliness,  pain  in 


141 

the  side,  cough  and  bloody  sputum,  but  chill  is  less  common  than  with 
lobar  pneumonia.  Bloody  sputum  may  appear  within  a  few  hours  of 
the  onset  or  be  delayed  for  two  to  three  days.  The  blood  may  be  in  the 
form  of  bloody  streaks,  but  is  more  commonly  intimately  mixed  with 
the  sputum  and  of  a  dark  red  color.  Particles  of  sputum  washed  in 
bouillon  or  sterile  salt  solution  may  fail  to  show  bacteria  in  stained 
preparations  or  in  cultures.  In  contrast  to  the  rapid  elevation  of  tem- 
perature with  lobar  pneumonia,  the  fever  rises  gradually  and  reaches 
a  maximum,  seldom  exceeding  103 °F,  only  after  a  day  or  two.  In  some 
cases  there  is  a  musty  odor  to  the  breath.  Dyspnea  and  cyanosis  may 
be  a  striking  feature  if  a  large  branch  of  the  pulmonary  artery  is 
plugged.  The  physical  signs  are  the  same  as  with  lobar  pneumonia 
and  dry  pleurisy  or  pleurisy  with  bloody  effusion  may  be  present.  A 
moderate  leucocytosis  is  often  observed.  The  temperature  falls  by  lysis 
in  favorable  cases  and  the  physical  signs  slowly  disappear.  Though 
it  is  not  uncommon  for  pulmonary  infarction  to  occur  as  a  complica- 
tion of  latent  venous  thrombosis  and  for  the  venous  involvement  to 
become  manifest  some  time  after  the  infarction  has  taken  place,  the 
attendant  circumstances  may  suggest  the  correct  diagnosis.  An  ap- 
propriate symptom  complex  occurring  after  operation  or  delivery,  with 
uterine  sepsis  with  or  without  relation  to  childbirth,  and  with  sinus 
thrombosis  in  connection  with  otitis  media  or  mastoid  disease  is  likely 
to  be  due  to  pulmonary  infarction  rather  than  to  lobar  pneumonia. 

An  acute  tuberculous  pneumonia  may  present  serious  diagnostic  diffi- 
culty and  the  differentiation  from  pneumococcus  pneumonia  may  be 
impossible  in  the  first  few  days  of  the  illness.  There  may  be  suggestive 
features  in  the  story,  such  as  a  family  history  of  tuberculosis  or  known 
opportunity  for  contagion,  hemoptysis  out  of  a  clear  sky,  a  primary 
pleurisy  or  adenitis  with  resulting  cervical  scars.  Cough  and  failing 
health,  evening  rise  of  temperature  and  night  sweats  may  precede  the 
acute  illness.  The  initial  complex  of  symptoms  is  likely  to  be  atypical, 
but  may  be  abrupt  with  chill,  rapid  rise  of  temperature,  stitch  in  the 
side  and  cough  and  dyspnea  with  the  development  of  signs  of  consol- 
idation as  with  croupous  pneumonia.  The  sputum  may  be  rusty,  but  is 
more  often  purulent  with  blood  in  streaks  or  masses  rather  than  in 
homogeneous  admixture.  It  is  less  tenacious  and  viscid  than  with 
croupous  pneumonia.  There  may  be  signs  of  apical  disease  on  physi- 
cal examination  and  by  x-ray  a  fine  or  coarse,  mottled  increase  of  den- 
sity above  the  anterior  portion  of  the  third  rib.  Repeated  examination 
of  the  sputum  for  tubercle  bacilli  may  be  necessary  before  the  diag- 
nosis can  be  established. 

THE  PROPHYLAXIS  AND  TREATMENT  OF  LOBAR  PNEUMONIA 

Edwin  A.  Locke,  M.D. 

Boston,  Massachusetts 

Prophylaxis 

The  contagiousness  of  pneumonia  is  well  established  and  control  of 
the  disease  is  impossible  without  the  most  careful  attention  being 
given  to  methods  of  protection  of  the  uninfected. 

Repeated  investigations  have  established  the  fact  that  normal 
healthy  individuals  often  harbor  pneumococci  types  III  and  IV,  usually 
of  relatively  low  virulence,  in  the  upper  respiratory  passage  and  these 
are  in  consequence  often  spoken  of  as  the  mouth  organisms.  In  the 
case  of  those  in  close  contact  with  the  pneumonia  patient  a  very  con- 
siderable percentage  show  the  presence  of  virulent  pneumococci  in 
their  mouths  and  of  the  same  type  as  the  patient.  The  Rockefeller 
studies  (1)  show  an  incidence  of  Types  I  and  II  in  the  mouths  of 
healthy  individuals  in  attendance  on  patients  with  pneumonia  of  13 
and  12  percent  respectively.    A  further  and  very  significant  fact  was 


142 
established  by  these  same  studies;  namely,  that  such  carriers  often 
harbor  the  types  I  and  II  in  their  mouths  or  nasal  secretions  for  as 
long  a  period  as  3  to  4  weeks.  The  length  of  the  period  during  which 
the  infecting  organism  remains  in  the  sputum  of  the  patient  varies 
from  a  few  days  following  the  onset  of  the  disease  to  as  many  months. 
The  evidence  appears  to  strongly  favor  the  assumption  that  at  least  in 
the  cases  of  type  I  and  II  pneumonia,  the  infection  is  from  without  and 
that  the  organism  gains  entrance  to  the  body  through  the  air  passages. 
These  epidemiological  facts  indicate  the  prominent  part  which  the 
human  carrier  probably  plays  in  the  dissemination  of  the  disease.  The 
first  principle  then  in  the  prophylaxis  of  pneumonia  is  genuine  isola- 
tion of  the  patient.  The  family  and  friends  must  always  be  impressed 
with  the  grave  danger  of  intimate  contact  with  the  sick  individual.  The 
sole  source  of  danger  is  obviously  the  secretions  from  the  lungs  and 
upper  air  passages.  The  sputum  should  be  disinfected,  the  best  method 
being  to  use  paper  napkins  or  cloths  which  can  be  burned.  All  soiled 
linen  and  dishes  should  be  sterilized  by  boiling. 

•  Prophylaxis  on  the  other  hand  is  very  definitely  concerned  with  the 
general  condition  of  the  individual  in  so  far  as  it  effects  his  natural  re- 
sistance to  infection.  Such  factors  as  fatigue,  exposure  to  cold  and 
wet,  worry,  illness,  loss  of  sleep  and  dissipation  tend  to  increase  the 
susceptibility  to  infection  and  may  thus  play  a  real  role  in  the  epidem- 
iology of  pneumonia.  Of  particular  importance  is  the  presence  of  an 
acute  upper  respiratory  tract  infection.  Cecil,  Baldwin  and  Larsen 
(6)  found  such  secondary  type  of  pneumonia  to  be  present  in  46.7 
percent  of  their  1654  cases  observed  in  the  Bellevue  Hospital.  The 
neglect  of  the  common  cold  in  other  words  figures  prominently  in  the 
etiology  of  pneumonia. 

The  work  of  Lister  (11)  in  South  Africa,  Cole  and  his  coworkers  (1) 
at  the  Rockefeller  Institute  and  Cecil  and  Steffen  (7)  has  established 
the  possibility  of  producing  an  active  immunization  in  both  animals 
and  man  against  the  various  types  of  pneumococci  which  suggests  an 
effective  means  of  prevention  of  pneumonia.  The  blood  serum  of  in- 
dividuals rendered  immune  by  this  method  can  readily  be  shown  to 
contain  agglutinins,  opsonins  and  protective  substances  but  the  im- 
munity is  probably  of  relatively  short  duration ;  i.  e.,  seldom  more  than 
eight  to  ten  months.  A  practical  test  of  this  method  was  made  by  Cecil 
and  Austin  (5)  who  obtained  very  striking  results  at  Camp  Upton  in 
1918  through  the  vaccination  of  12,519  soldiers  against  the  pneumococ- 
cus. 

The  high  degree  of  protection  against  the  fixed  types  of  pneumococci 
afforded  by  such  inoculations  seems  to  promise  an  effective  means  of 
dealing  with  large  masses  of  individuals  in  times  of  epidemics  as  in 
the  case  of  the  army  camps.  So  far  as  the  general  public  is  concerned 
the  extremely  low  incidence  of  pneumonia  clearly  indicates  that  such 
a  method  of  protection  is  quite  impracticable  since  a  very  large  number 
would  be  subjected  to  a  somewhat  heroic  method  of  protection  against  an 
extremely  small  hazard.  With  his  chances  of  contracting  pneumonia 
so  very  slight  it  is  certain  that  the  average  individual  would  not  sub- 
mit to  the  procedure.  Park  (19)  in  his  recent  Harben  Lectures  states 
that  the  results  of  prophylactic  vaccination  against  pneumonia  seem 
favorable  but  raises  the  objection  that  with  thirty  fixed  types  of  pneu- 
mococci it  would  be  impossible  to  provide  a  sufficient  amount  of  each 
in  a  single  dose  to  be  effective  in  producing  immunity. 

Treatment 

In  spite  of  an  ever  increasing  literature  on  the  treatment  of  pneu- 
monia the  careful  student  of  the  subject  cannot  fail  to  be  impressed 
with  the  fact  that,  except  for  the  introduction  of  serum  therapy,  no 
striking  advance  has  been  made  in  the  past  few  decades.    The  prin- 


143 
cipies  of  treatment  have,  it  is  true,  become  more  erystalized  as  the 
foundations  on  which  they  rest  have  gradually  shifted  from  empiricism 
to  pathologic  physiology.  Even  so,  the  task  of  definitely  and  concisely 
outlining  a  scheme  of  routine  treatment  is  a  most  difficult  one  and 
always  open  to  criticism  since  so  much  must  depend  on  the  personal 
experience  of  the  writer. 

Furthermore,  as  has  been  so  often  emphasized,  accurate  judgment 
regarding  the  value  of  any  method  of  treatment  of  an  acute,  infectious, 
self  limited  disease  like  pneumonia  is  uncertain.  Its  course  is  charac- 
terized by  sudden  and  unexpected  changes  which  often  seem  impossi- 
ble to  explain  otherwise  than  as  directly  due  to  the  therapeutic  agent 
employed.  This  difficulty  in  forming  sound  judgments  justifies  us  in 
assuming  an  attitude  of  skepticism  regarding  the  merits  of  any  new 
treatment  for  pneumonia. 

Specific  Serum  Therapy 

Since  the  action  of  the  specific  serum  as  well  as  the  method  of  its 
administration  are  fully  discussed  in  another  chapter,  I  shall  attempt 
only  a  brief  clinical  estimate  of  the  value  of  the  so-called  "refined 
pneumococcus  antibody"  and  "unrefined  antipneumococcus  serum" 
(Park). 

1.  Antipneumococcic  Serum  (Cole).  —  The  results  of  the  brilliant 
series  of  laboratory  investigations  conducted  by  Cole  and  his  associ- 
ates at  the  Rockefeller  Institute  for  Medical  Research  in  producing  a 
type  specific  immune  serum  against  the  pneumococcus  have  been 
abundantly  confirmed  clinically.  It  remained  for  the  clinician  to  deter- 
mine the  extent  of  its  value  as  a  practical  measure  in  the  treatment  of 
pneumonia.  The  original  antipneumococcic  serum  of  Cole  or  its  de- 
rivatives has  been  used  for  more  than  a  decade  in  many  of  our  leading 
American  hospitals  and  the  accumulated  experience  permits  us  to 
speak  with  a  considerable  degree  of  authority  regarding  its  place  in 
the  therapy  of  pneumonia.  In  man  as  in  animals  the  Type  I  serum  will 
sterilize  the  blood,  so  far  as  the  homologous  infection  is  concerned, 
provided  the  injections  are  given  early  in  the  course  of  the  disease. 
Later  the  amount  of  protective  substance  (antibodies)  necessary  to 
establish  a  balance  in  the  blood  is  too  great  to  be  supplied  by  means  of 
the  immune  serum.  Symptomatically  also  the  case  with  Type  I  infec- 
tion is  often  greatly  improved  following  the  giving  of  serum  intra- 
venously. Finally  the  favorable  action  of  the  serum  is  shown  in  a  low- 
ering of  the  mortality  rate.  Here,  too,  the  favorable  cases  are  essen- 
tially confined  to  those  treated  within  the  first  three  days  of  the  dis- 
ease. Cole's  figure  for  the  deaths  in  a  large  series  of  treated  cases  is 
10.5  percent.  Similar  figures  from  many  hospitals  indicate  a  definite 
influence  in  lowering  the  case  fatality  rate  but  none  are  so  low  as 
those  of  Cole. 

We  may  then  summarize  the  possibilities  of  the  therapeutic  use  of 
antipneumococcic  serum  in  pneumonia  as  follows:  if  the  serum  is  of 
a  high  potency,  homologous  with  the  infection,  administered  within 
the  first  three  days  of  the  disease,  and  in  very  large  doses,  it  is  to  a 
considerable  degree  effective  in  Type  I  infections.  Homologous  serum 
for  Type  II  possesses  only  slight  value  and  for  Type  III  none. 

In  spite  of  these  results  the  Type  I  antipneumococcic  serum  of  Cole 
has  very  generally  fallen  into  disuse  and  justly  we  believe  in  conse- 
quence of  obvious  disadvantages.  First,  the  serum  is  of  such  low  titre 
that  an  unreasonably  large  amount  is  necessary  in  order  to  insure  ade- 
quate dosage  of  antibodies.  Second,  the  technical  difficulties  in  its  ad- 
ministration are  a  real  obstacle  to  its  general  use.  Third,  very  severe 
reactions  and  especially  serum  sickness  are  common.  These  limitations 
have  made  it  impossible  to  advocate  the  use  of  the  serum  except  in  the 
best  research  hospitals.  We  have  then,  as  is  so  well  expressed  by  Park 


144 
and  Cecil,  a  perfectly  sound  theoretic  basis  for  specific  serum  therapy 
in  Type  I  and  II  pneumonia  but  on  the  practical  side  still  lack  a  serum 
free  of  defects. 

2.  "Refined  Pneumococcus  Antibody". — The  preparation  of  this  pneu- 
mococcus  antibody  solution  marks  a  very  important  forward  step  in 
the  specific  therapy  of  the  disease.  The  object  has  been  first  to  rid  the 
serum  of  the  reaction  producing  substance  and  second,  to  free  the 
antibody  from  the  horse  serum  in  order  that  concentration  might  be 
possible.  Huntoon  (10)  succeeded  in  preparing  a  water  solution  of 
antibody  for  Type  I,  II,  and  III  pneumonia  of  the  same  proportion  as 
in  the  unrefined  serum  but  with  only  a  minute  trace  of  horse  serum 
and  only  a  very  small  quantity  of  bacterial  protein.  Notwithstanding 
the  small  amount  of  protein  present  the  solution  gave  frequent  and 
violent  chills  as  well  as  very  high  temperature.  Several  fatal  cases 
immediately  following  injections  have  been  reported.  The  effects  of 
the  antibody  solution  appeared  to  be  the  same  as  of  the  whole  serum. 
After  a  thorough  testing  in  many  of  our  best  hospital  clinics  it  was 
discarded  as  too  dangerous  to  be  of  practical  value. 

Felton  has  in  recent  years  developed  a  similar  refined  antibody  solu- 
tion for  Types  I  and  II  but  one  which  almost  entirely  obviates  the  un- 
favorable reactions  just  mentioned.  It  is  at  the  same  time  approxi- 
mately ten  times  as  potent  as  the  unrefined  serum.  More  recently  Fel- 
ton has  been  able  to  accurately  standardize  his  solution  so  that  it  can 
actually  be  given  in  doses  expressed  in  terms  of  units.  Figures  from 
many  clinics  are  already  at  hand  concerning  their  results  with  this 
remedy  and  indicate  that  it  not  only  eliminates  the  possibility  of  the 
severe  reactions  so  often  seen  with  the  use  of  the  original  antipneu- 
mococcus  serum  and  Huntoon's  concentrate  but  gives  better  results 
than  either.  The  problem  of  the  specific  treatment  of  pneumonia  is  by 
no  means  solved  but  very  satisfactory  advance  has  taken  place  during 
the  past  few  years.  We  now  have  at  hand  for  the  first  time  an  immune 
agent  which  is  essentially  free  from  danger  to  the  patient  and  with 
technique  of  administration  which  is  relatively  simple.  The  evidence 
of  benefit  with  early  treatment  is  unmistakable.  While  we  do  not  feel 
that  the  time  has  arrived  when  the  refined  antibody  solution  (Felton) 
should  be  distributed  generally  to  the  profession  it  does  seem  emi- 
nently desirable  that  it  should  be  made  available  through  a  selected 
group  of  our  best  hospitals  in  the  state.  It  is  my  personal  conviction 
that  the  importance  of  early  administration  of  the  serum  is  so  para- 
mount that  there  is  ample  justification  for  routine  injection  as  soon  as 
the  diagnosis  of  pneumonia  is  made  and  before  typing  can  be  done. 

Symptomatic  Treatment 

Notwithstanding  the  success  of  the  specific  therapy  during  recent 
years  and  its  promise  of  much  wider  application  in  the  future  the  im- 
portance of  the  direct  treatment  of  symptoms  has  not  in  any  sense 
diminished.  Indeed  the  success  of  the  antipneumococcic  serum  de- 
pends to  no  small  degree  on  the  efficiency  with  which  the  individual 
symptoms  are  relieved  and  the  general  needs  of  the  sick  individual 
are  met.  The  problem  in  pneumonia  is  primarily  one  of  an  infection  but 
so  far  as  the  symptomatic  treatment  is  concerned  one  must  seek  a  ra- 
tional basis  in  the  pathological  physiology  resulting  from  the  bacterial 
invasion. 

Means  and  Barach  (13)  have  published  an  admirable  discussion  of 
the  functional  disturbances  in  pneumonia  and  the  indications  which 
they  afford  for  treatment.  They  emphasize  the  so-called  "respiratory 
battle"  as  the  fundamental  feature  of  pneumonia.  As  a  result  of  many 
factors  but  chief  among  them  the  increased  metabolism,  acidosis,  de- 
ficient rate  of  blood  flow  and  anoxemia  a  condition  of  hyperpnea,  or 
increased  pulmonary  ventilation,  develops.    At  the  same  time  then,  ac- 


145 
cording  to  these  authors,  we  have  functional  demands  on  the  lungs 
which  are  far  above  the  normal  and  a  respiratory  mechanism  with  les- 
sened efficiency.  The  latter  is  largely  the  result  of  "extensive  consol- 
idation, pain,  excessive  bronchial  secretions,  edema  (usually  cardiac) 
of  the  uninflamed  alveoli,  pleural  or  pericardial  effusion  and  acidosis" 
(Norris  (16)  )  and  accounts  for  the  dyspnea.  I  shall  discuss  the  gen- 
eral treatment  of  pneumonia  primarily  on  the  basis  of  this  respiratory 
load. 

The  general  management  of  the  case  is  of  the  utmost  importance. 
In  but  few  other  diseases  does  the  quality  of  the  nursing  count  so 
much.  As  this  is  the  subject  for  discussion  in  another  chapter  of  this 
report  I  shall  not  take  up  the  details  regarding  the  sick  room  or  the 
general  hygiene  of  the  patient  except  to  condemn  the  practice  of  using 
local  applications  to  the  chest  such  as  poultices,  counterirritants, 
bandages,  and  jackets.    They  are  useless  and  often  harmful. 

Aerotherapy  has  been  a  subject  for  much  discussion  and  the  ex- 
treme views  so  generally  held  a  decade  or  two  ago  regarding  the  ad- 
vantages of  open  air  treatment  have  happily  been  very  much  modified. 
Pure,  fresh  air,  is  indeed  of  very  vital  importance  but  to  insure  these 
qualities  it  is  not  necessary  that  it  should  be  of  low  temperature.  A 
temperature  below  60  degrees  is  undesirable  as  it  so  often  irritates 
the  inflamed  bronchial  mucous  membranes,  causing  cough.  Again 
the  very  frequent  necessity  for  exposure  of  the  patient  in  the  course 
of  general  treatment  means  discomfort  as  well  as  some  danger  if  the 
room  temperature  is  low. 

Diet — This  does  not  form  a  very  important  part  of  the  treatment  of 
pneumonia  since  the  disease  is  of  such  short  duration  that  there  is  no 
real  problem  in  the  maintenance  of  nutrition.  Nor  are  the  digestive 
functions  as  a  rule  seriously  disturbed.  Even  the  increased  caloric 
demands  incident  to  the  pyrexia  and  the  protein  loss  need  give  no  con- 
cern unless  the  disease  is  prolonged.  Anorexia  especially  in  the  early 
stages  is  apt  to  be  marked.  Fluids  and  semisolids  should  form  the 
bulk  of  the  diet  and  may  include  milk  and  simple  milk  dishes  (matzoon, 
Koumys,  zoolak,  buttermilk,  eggnogs)  cream,  butter,  starches  such  as 
gruels,  macaroni,  rice,  toast,  stale  bread,  cooked  cereals,  and  baked  or 
mashed  potato,  eggs,  custards,  broths,  beef  juice,  scraped  beef,  minced 
chicken,  farinacious  soups,  fruit  juices  and  cooked  fruits.  Care  should 
be  exercised  lest  the  diet  contain  an  excess  of  either  sugar  in  any  form 
or  fats,  in  the  former  case  the  danger  being  tympanitis  and  in  the  latter 
a  diarrhoea.  Of  vastly  greater  importance  is  the  maintenance  of  a  high 
fluid  intake  of  at  least  2,000 — 3,000  c.c.  per  diem.  Some  form  of  fluid 
should  be  offered  to  the  patient  every  hour  or  two.  Milk,  buttermilk, 
barley  water,  soups,  fruit  juices  (well  diluted),  simple  aerated  waters, 
even  a  moderate  amount  of  black  coffee  should  be  allowed. 

Hydrotherapy — There  is  no  more  essential  single  item  in  the  program 
of  treatment  in  pneumonia.  It  is  hardly  less  so  than  in  typhoid  but  un- 
fortunately this  valuable  measure  is  often  neglected.  The  exact  form  in 
which  the  water  is  applied  is  of  small  importance  so  long  as  the  technique 
of  the  particular  type  of  bath  is  accurately  followed — the  cold  chest  com- 
press (Barach),  the  sheet  bath,  cold  sponge,  and  alcohol  rub.  With  high 
fever  and  the  persistence  of  toxaemia  the  baths  should  be  given  every 
3  to  4  hours.  The  objective  signs  of  favorable  reaction  of  the  baths  are 
almost  always  definite.  The  cyanosis  disappears,  dyspnoea  is  relieved, 
cardiovascular  tone  is  improved,  fever  lowered,  respiration  stimulated, 
elimination  increased,  delirium  lessened  and  the  patient  is  relaxed  often 
dropping  off  into  a  sound  sleep. 

Oxygen — The  indication  for  oxygen  therapy  is  the  presence  of  anoxemia 
or  deficient  oxygen  saturation  of  the  blood  as  evidenced  by  the  presence 
of  cyanosis  and  commonly  hyperpnea  also.  The  more  or  less  dramatic 
results  which  usually  follow  immediately  the  administration  of  0=  namely, 


146 
the  disappearance  of  the  cyanosis,  slowing  of  the  respiratory  rate  and 
accompanying  decrease  of  the  hyperpnea,  lessening  of  the  pulse  rate,  relief 
of  the  nervous  symptoms,  and  giving  of  greater  comfort  to  the  patient 
unfortunately  suggest  a  somewhat  greater  importance  of  this  procedure 
than  it  merits.  Very  exhaustive  studies  in  recent  years  by  Stadie  (21) 
Barach  (2)  Binger  (3)  and  Palmer  (17)  of  the  effects  of  oxygen  therapy 
in  pneumonia  patients  with  acute  anoxemia  seem  definitely  to  prove  its 
value  although  with  evidences  of  an  influence  on  the  case  fatality  rate 
which  is  by  no  means  in  keeping  with  the  objective  results  enumerated 
above. 

A  high  mortality  is  associated  with  those  cases  showing  a  high  degree 
of  arterial  oxygen  unsaturation,  i.e.  under  80  per  cent  (normal  =  95  per 
cent) .  This  marked  anoxemia  is  not  in  itself  the  cause  of  the  high  fatality 
rate  but  rather  the  underlying  condition  producing  the  deficient  oxygen 
saturation.  Barach  has  particularly  emphasized  the  importance  of  such 
factors  as  age  of  the  patient,  type  of  pneumococcus,  day  of  disease  and 
bacteremia  as  those  chiefly  concerned  in  determining  the  mortality  but 
concludes  that  the  beneficial  effects  of  oxygen  therapy  are  definitely 
established.  Palmer  says  "knowing  the  profound  disturbances  resulting 
from  uncomplicated  anoxemia,  we  must  conclude  that  effective  oxygen 
therapy  alleviates  a  part  of  the  load  under  which  the  organism  is  labor- 
ing in  pneumonia." 

Three  methods  of  administration  have  proved  effective;  1)  the  oxygen 
chamber  devised  by  Stadie,  2)  the  Roth-Barach  tent,  and  3)  the  nasal 
catheter.  The  first  is  a  highly  specialized  type  of  equipment  which  is 
available  in  only  a  few  research  institutions.  The  portable  oxygen  tent 
has  during  the  past  few  years  come  into  quite  common  use  in  our  hos- 
pitals but  is  too  expensive  and  cumbersome  for  general  employment  in 
the  home.  With  the  tent  a  constant  supply  of  fresh,  cool  air  with  40 — 60 
per  cent  oxygen  can  be  provided  indefinitely.  Palmer  finds  the  nasal  cath- 
eter method  effective  if  a  rate  of  flow  is  maintained  far  above  that  ordin- 
arily used.  He  finds  that  a  flow  of  2  liters  per  minute  will  insure  about 
30  per  cent  of  oxygen  which  he  regards  as  the  "lower  limit  of  effective 
oxygen  administration."  The  percentage  of  oxygen  can  be  increased  mod- 
erately by  the  use  of  a  double  nasal  catheter.  Palmer  regards  the  old  tube 
and  funnel  apparatus  as  useless. 

Alcohol. — Unfortunately  an  authoritative  opinion  regarding  the  value  of 
alcohol  in  pneumonia  cannot  be  given.  There  is  general  agreement  that 
in  the  case  of  the  chronic  alcoholic  the  use  of  alcohol  in  some  form  is  in- 
dicated and  in  generous  quantities.  Furthermore  we  know  that  alcohol 
in  moderate  amounts  is  not  only  a  food  but  one  which  is  very  readily 
metabolized.  My  own  clinical  experience  convinces  me  that  in  many  cases 
alcoholic  preparations  (whiskey,  brandy  or  champagne)  are  distinctly 
valuable  adjuvants  in  the  treatment  of  pneumonia  especially  in  the  toxic 
type,  the  aged,  and  in  those  cases  where  little  or  no  food  is  taken. 

Vaccine  Therapy. — The  purpose  of  this  method,  so  often  advocated,  is 
to  stimulate  the  production  of  antibodies  in  the  blood  but  the  immune 
response  is  only  slight  and  the  results  of  clinical  experience  are  far  from 
convincing.  The  opinion  of  Zinsser  (23),  however,  makes  us  hesitate  to 
dismiss  the  procedure  as  useless.  He  says  "we  believe  that  the  develop- 
ments of  the  last  few  years  have  revealed  certain  immunological  condi- 
tions in  pneumococcus  infection  which  may  be  considered  as  furnishing 
a  rational  basis  for  the  use  of  specific  vaccines  in  pneumonia,  a  matter 
which  hitherto  has  rested  on  a  purely  empirical  basis."  Until  more  con- 
vincing evidence  of  its  favorable  action  is  forthcoming  we  may  fairly  con- 
sider that  the  therapeutic  value  of  pneumococcus  vaccine  in  pneumonia 
has  not  been  established. 

The  use  of  homologous  convalescent  serum  cannot  be  recommended. 

Cardio-Vascular  symptoms  are  often  prominent  in  pneumonia  and  the 
treatment  of  these  constitutes  a  very  vital  part  of  the  general  therapeutic 


147 
program.  About  this  subject,  however,  has  centered  a  lively  controversy 
for  many  years  particularly  regarding  the  use  of  digitalis.  Many  advo- 
cate the  routine  and  early  use  of  digitalis  in  pneumonia  at  all  ages,  others 
contend  that  the  drug  should  be  given  as  a  routine  measure  only  to  those 
past  middle  life  while  still  others  restrict  its  use  to  those  cases  with 
cardiac  failure.  A  common  practice  has  been  to  partially  digitalize  the 
heart  early  in  the  course  of  the  disease  in  order  to  insure  prompt  response 
to  digitalis  in  case  of  acute  cardiac  failure.  Some  have  gone  so  far  as  to 
reserve  digitalis  solely  for  those  showing  auricular  fibrillation  or  flutter. 
Likewise  there  is  a  considerable  difference  of  opinion  regarding  the  dos- 
age to  be  employed. 

The  facts  regarding  the  role  of  the  heart  and  circulation  in  the  path- 
ology of  pneumonia  are  now  quite  generally  established.  In  fatal  cases 
dilation  of  the  right  heart  is  usually  found  at  necropsy  and  in  a  consider- 
able percentage  of  severe  cases  some  degree  of  dilatation  can  be  demon- 
strated clinically.  The  actual  anatomical  alterations  in  the  myocardium 
are  insignificant  and  seemingly  not  sufficient  to  cause  heart  failure.  Many 
years  ago  Newburgh  and  Porter  (15)  proved  that  the  heart  muscle  re- 
mains functionally  unimpaired  in  pneumonia  and  loses  its  efficiency  only 
when  subjected  to  the  toxic  effects  of  the  pneumonic  blood.  Contrary  to 
a  rather  common  belief  death  in  pneumonia  is  seldom  the  result  of  cardiac 
failure  but  rather  to  septicaemia.  Nevertheless,  the  maintenance  of  an 
effective  circulation  is  of  the  utmost  importance  to  the  individual  with 
pneumonia  and  every  means  at  our  disposal  to  support  the  heart  and  pre- 
serve good  vascular  tone  should  be  employed. 

The  recent  work  of  Wyckoff,  DuBois  and  Woodruff  (22)  at  the  Bellevue 
Hospital  on  the  therapeutic  value  of  digitalis  in  pneumonia  goes  far 
toward  settling  the  controversy  over  the  use  of  this  drug.  Among  their 
835  cases  95  percent  had  normal  sinus  rhythm  and  less  than  5  percent 
showed  auricular  fibrillation  or  auricular  flutter.  They  find  almost"  no 
evidence  of  benefit  from  digitalis  except  in  a  few  cases  of  these  two  con- 
ditions and  particularly  emphasize  the  possibilities  of  harm  in  the  routine 
use  of  digitalis  in  pneumonia.  A  further  consideration  of  great  moment 
is  also  brought  out,  namely,  that  in  pneumonia  one  cannot  without  detri- 
ment to  the  patient  give  digitalis  until  the  appearance  of  mild  toxic  symp- 
toms as  is  the  rule  in  the  usual  case  of  congestive  heart  disease. 

The  argument  that  in  pneumonia  the  right  ventricle  is  under  varying 
degrees  of  strain  and  is  aided  by  digitalis  carries  some  conviction. 

A  study  of  the  literature  and  my  own  experience  leave  me  with  definite 
convictions  regarding  the  use  of  digitalis  in  pneumonia  as  follows:  1) 
There  is  no  justification  for  the  routine  use  of  digitalis  in  all  cases  as  is 
the  custom  in  so  many  hospitals.  If  given  in  full  doses  in  this  manner 
there  is  considerable  danger  of  actual  detriment  to  the  patient.  2)  There 
is  no  rational  basis  for  the  routine  use  of  digitalis  even  in  the  aged.  3) 
The  administration  of  digitalis  should  be  restricted  primarily  to  the  cases 
showing  congestive  heart  failure.  It  also  finds  a  useful  place  in  the  cases 
with  auricular  fibrillation  or  flutter  though  many  of  these  cases  recover 
without  digitalis.  4)  When  given  the  greatest  caution  should  be  exercised 
to  avoid  even  the  early  toxic  symptoms. 

If  sudden  decompensation  occurs  a  standard  tincture  should  be  given 
in  dram  doses  every  four  hours  for  three  doses  then  minims  XV  three 
times  daily  as  needed  to  maintain  the  digitalis  effects.  Under  ordinary 
conditions  when  digitalis  is  indicated  it  is  best  to  employ  one  of  the 
standardized  preparations  of  the  dried  digitalis  leaves  (pills  of  1%  grains 
or  .1  grams  each)  giving  2  or  3  pills  (.2 — .3  grams)  3  times  daily  for  2 
days.  Less  accurate  but  usually  satisfactory  results  can  be  obtained  by 
the  use  of  a  standard  tincture  in  doses  of  1  dram  every  6  to  8  hours  for 
3  doses  and  then  minims  XV  twice  or  three  times  daily  as  needed.  When 
the  situation  is  critical  and  immediate  results  are  imperative  digitalis 
may  be  given  intravenously  in  the  form  of  a  standardized  solution  in  doses 


148 
corresponding  to  .3  or  .4  grams  of  the  leaves  and  repeated  in  2  to  3  hours 
if  necessary. 

Strophanthus  is  warmly  advocated  by  Meara  and  others  because  of  its 
very  prompt  action  in  cardiac  emergencies  but  it  should  never  be  given 
in  a  case  where  digitalis  has  been  administered  just  previously.  Several 
instances  of  sudden  death  following  its  use  are  recorded.  The  usual  dose 
in  strophanthin  gr.  1/160-1/180  (4—0.00075  gm.)  dissolved  in  2  drams 
of  normal  salt  solution  and  given  intramuscularly  or  intravenously. 
Ouabain  (crystalline  Strophanthus)  may  be  used  in  the  same  manner  in 
doses  of  1/160  (0.0004  gm.).  The  action  of  strophanthin  is  but  little 
more  prompt  than  digitalis  if  the  latter  is  given  intravenously  and  be- 
cause of  the  danger  attending  its  use  it  seems  to  me  of  little  value. 

Other  so-called  cardiac  stimulants  like  caffein,  camphor  and  strychnine 
are  of  much  less  or  doubtful  value  and  should  be  used  only  as  adjuvants  to 
digitalis.  They  do  not  act  on  the  heart  muscle  directly  but  may  aid  the 
circulation  indirectly  by  virtue  of  their  action  on  other  tissues.  The  ac- 
tion of  caffein  is  mixed  and  somewhat  variable  but  according  to  the  best 
authorities  undoubtedly  in  the  end  aids  slightly  to  increase  the  per  minute 
output  of  blood.  An  immediate  improvement  in  the  quality  of  the  pulse 
with  an  accompanying  rise  in  blood  pressure  often  follows  its  use  but  these 
effects  unfortunately  are  of  very  brief  duration.  A  much  more  important 
action  of  caffein  is  its  effect  as  a  cerebro-spinal  stimulant  especially  the 
respiratory  centre  resulting  in  an  increase  of  both  the  depth  and  frequency 
of  respiration.  It  is  this  action  which  makes  caffein  a  very  valuable  rem- 
edy occasionally  in  the  presence  of  a  grave  collapse  in  the  course  of  pneu- 
monia. The  drug  should  not  be  given  in  the  excited  or  delirious  cases.  The 
sodio-benzoate  of  caffein  is  best  given  hypodermically  when  prompt  re- 
sults are  desired  in  doses  of  3  to  lx/z  grains. 

Camphor  has  long  been  considered  to  possess  almost  unique  powers  as 
a  cardiac  stimulant  in  cases  of  cardiac  failure  occurring  in  infectious 
diseases.  Among  German  clinicians  camphor  is  held  in  high  esteem  as  a 
cardiac  stimulant.  During  the  past  few  decades  the  drug  has  fallen  into 
almost  complete  disuse  in  the  United  States  which  would  seem  justified  by 
the  negative  results  of  various  clinical  investigations  regarding  its.  action. 
The  work  of  Marvin  and  Soifer  (12)  seems  conclusively  to  show  that 
camphor  possesses  no  merit  whatsoever  as  a  remedy  for  congestive  heart 
failure. 

The  only  value  to  be  attached  to  strychnine  as  a  member  of  this  group 
is  that  of  a  general  stimulant  since  it  has  no  effect  on  the  heart  directly. 

Adrenalin  (epinephrin)  is  a  powerful  vasamotor  stimulant  but  un- 
fortunately its  action  is  very  transitory.  The  indications  for  its  use  are 
as  an  emergency  measure  in  cases  with  cardiac  collapse  and  should  be 
given  intravenously  in  doses  of  3-4  minims  repeated  once  or  twice  at 
intervals  of  a  few  minutes. 

In  pneumonia,  as  in  all  infectious  diseases,  there  are  to  a  varying  degree 
toxic  effects  on  the  heart  muscle  but  in  addition  various  other  factors, 
mechanical  and  otherwise,  may  combine  to  increase  the  cardiac  embarrass- 
ment. Any  relief  from  this  additional  burden  is  probably  of  greater  im- 
portance than  cardiac  stimulation.  Venesection  finds  a  very  definite  place 
in  the  treatment  of  acute  dilatation  of  the  right  heart  and  the  removal  of 
a  few  hundred  c.c.  of  blood  in  such  an  emergency  usually  gives  very  strik- 
ing relief.  In  addition  to  this  mechanical  relief  in  cardiac  dilatation  Peter- 
son and  Levinson  (20)  emphasize  the  theoretical  importance  of  this  meas- 
ure in  depleting  "the  circulation  of  a  certain  amount  of  presumably  toxic 
material."  These  authors  further  suggest  another  advantage  of  this  pro- 
cedure concerned  with  the  so-called  ferment-antiferment  balance  in  the 
consolidated  lung.  Proteolysis  of  the  pneumonia  exudate  seems  to  be  the 
result  of  an  increase  of  the  enzymes  protease  and  ereptase  derived  from 
the  polymorphonuclear  leucocytes  over  the  antiferment  of  the  tissue 
fluids.   By  depleting  the  tissues  of  antiferment,  venesection  would  appear 


149 
to  aid  in  bringing  about  such  a  desired  balance.  The  relief  of  meteorism 
and  the  regulation  of  the  bowels  are  certain  to  act  favorably  on  the  cardiac 
mechanism.  Reasonable  control  of  an  harassing  cough  or  the  judicious 
use  of  sedatives  in  the  presence  of  restlessness  and  excitability,  the  free- 
dom from  all  care  and  excitement  of  any  kind,  can  accomplish  much  in 
easing  the  burden  on  the  heart. 

No  single  procedure  concerned  with  the  care  of  the  pneumonic  patient 
contributes  more  to  the  support  of  the  heart  and  circulation  than  hydro- 
therapy.  This  is  discussed  above. 

Tympanites — The  chief  gastro-intestinal  symptoms  are  constipation  and 
meteorism  and  the  control  of  these  conditions  is  most  vital.  Tympanites 
is  unfortunately  very  common  as  a  direct  result  of  toxaemia  and  in  turn 
when  present  definitely  favors  the  increase  of  the  toxaemia  through  the 
absorption  of  putrefactive  products  from  the  intestines  as  well  as  mechan- 
ically contributing  to  the  dyspnoea.  From  the  very  first  the  bowels  should 
be  watched  and  regulated  by  salines  or  one  of  the  mild  catharics  and,  if 
needed,  by  enemas.  By  such  means  paresis  of  the  colon  and  distension 
can  almost  invariably  be  prevented.  If  it  does  occur  prompt  and  if  neces- 
sary drastic  measure  for  relief  must  be  taken.  Hot  fomentations  and 
turpentine  stupes  usually  afford  sufficient  relief.  The  rectal  tube  may 
help  to  bring  away  gas  but  is  seldom  sufficient  without  some  form  of 
enema.  One  of  the  simple  types  of  enemata  may  suffice  but  usually  a 
rather  drastic  form  is  required  such  as  pure  glycerine  of  1  or  2  ounces 
(Shattuck),  turpentine  (1  ounce  in  1  pint  of  soap  suds)  or,  in  my  exper- 
ience most  effective  of  all,  an  injection  of  1  pint  of  a  mixture  of  equal 
parts  of  warm  milk  and  molasses. 

Pituitrin  %  to  1  c.c.  hypodermically  sometimes  meets  with  a  very 
prompt  response  although  on  the  whole  the  results  are  much  less  striking 
than  in  cases  of  abdominal  distension  after  operation.  In  desperate  cases 
physostigmin  salicylate  (eserin)  1/60  grain  subcutaneously  and  repeated 
in  a  few  hours  acts  favorably.  The  emulsion  of  asafetide  3-5  ounces  given 
as  an  enema  may  relieve  when  all  other  methods  have  failed. 

An  adequate  amount  of  fluid  lessens  the  tendency  to  distension.  With 
the  first  appearance  of  the  condition  the  fats  and  sugars  in  the  diet  should 
be  carefully  supervised. 

Toxaemia — The  two  most  effective  methods  of  controlling  toxaemia  are 
hydrotherapy  and  the  ingestion  of  a  generous  amount  of  fluids.  Careful 
regulation  of  the  bowels  is  likewise  important.  If  the  patient  is  very  toxic 
an  intravenous  injection  of  a  few  hundred  c.c.  of  a  10  percent  solution  of 
glucose  will  sometimes  give  great  relief.  Hypodermoclysis  or  proctoclysis 
are  indicated  when  the  ingestion  of  fluids  is  insufficient. 

Delirium  and  other  nervous  symptoms — Constant  attention  on  the  part 
of  the  nurse  is  most  necessary  as  the  delirious  patient  may  at  any  moment 
make  some  violent  movement  which  jeopardizes  his  condition.  The  best 
sedative  in  the  presence  of  either  delirium  or  insomnia  is  hydrotherapy 
and  the  response  is  often  astonishing.  An  ice  bag  to  the  head  is  often 
grateful.  In  the  presence  of  these  symptoms  sedative  and  hypnotic  drugs 
find  an  important  place.  Bromides,  chloral  hydrate,  barbital  preparations 
and  paraldehyde  are  useful.  Opiates  are  of  less  service  and  their  admin- 
istration is  by  no  means  an  innocuous  procedure.  In  the  amounts  neces- 
sary to  control  delirium  or  great  restlessness  morphine  has  a  very  definite 
depressing  effect  on  the  respiratory  centre  and  a  perhaps  more  significant 
effect  on  the  gastro-intestinal  tract.  The  appetite  is  dulled,  nausea  and 
vomiting  are  frequent,  and  most  serious  of  all  intestinal  peristalsis  is 
greatly  diminished  with  the  almost  inevitable  appearance  of  tympanites 
and  obstinate  constipation.  The  procedures  necessary  to  relieve  these  con- 
ditions induced  by  morphine  are  extremely  exhausting  to  the  sick  pneu- 
monia patient. 

The  recent  researches  of  Davis  (9)  on  the  action  of  morphine  in  pneu- 
monia do  not  altogether  support  this  position.   He  found  that  in  the  doses 


150 
ordinarily  used  the  depression  of  the  pulmonary  ventilation  and  decrease 
of  the  arterial  oxygen  saturation  was  but  slight  and  not  sufficient  to  con- 
traindicate  its  use  for  severe  pain  or  delirium.  In  cases  with  extensive 
involvement  and  pulmonary  oedema,  on  the  other  hand,  the  danger  of  a 
serious  depression  of  the  respiration  with  resulting  anoxemia  of  an  ex- 
treme grade  are  always  present.  Davis  says  that  if  morphine  is  admin- 
istered in  this  type  of  case  it  must  be  combined  with  oxygen  therapy. 

Pain — If  severe,  pain  may  assume  considerable  importance  because  of 
its  interference  with  the  respiratory  and,  to  a  lesser  degree,  the  cardiac 
functions  and  also  with  sleep.  Simple  strapping  is  less  useful  than  a  well 
fitted  taut  cotton  binder  since  the  latter  can  be  adjusted  at  any  time  or 
removed  and  reapplied  if  the  occasion  arises.  On  the  other  hand  strapping 
has  the  obvious  advantage  that  it  can  be  restricted  to  a  unilateral  area 
which  we  desire  to  mobilize.  Dry  heat  and  the  ice  bag  locally  over  the  site 
of  pain  are  worthy  of  a  trial  but  I  believe  that  poultices  and  counter- 
irritants  should  be  applied  with  the  greatest  caution  if  at  all.  When  in 
the  presence  of  agonizing  pain  an  anodyne  becomes  necessary  codeine  is 
usually  inadequate  and  morphine  should  be  given  freely. 

Cough — To  a  considerable  degree  cough  is  desirable  as  it  represents 
nature's  effort  to  remove  the  accumulated  bronchial  secretions  and  should 
not  in  consequence  be  suppressed  by  drugs  unless  it  becomes  harassing. 
Expectorants  are  of  no  value.  If  the  cough  is  of  pleural  origin  relief  often 
follows  the  measures  taken  to  control  the  pain.  Among  the  many  drugs 
recommended  for  cough  only  codeine  and  morphine  merit  recognition. 

Collapse — This  event  so  often  develops  and  especially  at  the  time  of 
crisis  that  it  is  worthy  of  brief  discussion.  Judicious  treatment  may  tide 
the  patient  over  and  save  life.  Under  such  critical  circumstances  we 
should  feel  fully  justified  in  the  application  of  desperate  measures  when 
milder  remedies  fail.  Absolute  quiet  and  the  application  of  dry  heat  in 
some  form  to  the  body  surface  should  first  of  all  be  provided.  Aromatic 
spirits  of  ammonia,  1  dram  or  x/2  to  1  ounce  of  brandy  or  whiskey  should 
be  given  if  at  hand  since  they  cause  an  immediate  though  transitory  re- 
flex stimulation  of  the  heart  and  medullary  centres.  The  inhalation  of 
ammonia  or  smelling  salts  acts  in  the  same  manner.  Adrenalin  (epine- 
phrin)  is  the  most  powerful  vasomotor  stimulant  increasing  the  heart 
beat  and  very  strikingly  the  blood  pressure  and  should  be  given  as 
promptly  as  possible,  intramuscularly  15  minims  (1  c.c.)  or  if  the  symp- 
toms of  collapse  are  alarming,  intravenously  drop  by  drop  until  4  or  5 
have  been  injected.  Caffeine  sodio-benzoate  5-7.5  grains  may  be  given 
hypodermically.  It  is  under  these  circumstances  that  the  administration 
of  strophanthin  1/120  grains  into  a  muscle  or  vein  seems  fully  justified 
if  the  patient  has  not  been  receiving  digitalis.  Anoxemia  is  almost  in- 
variably present  and  indicates  oxygen  therapy. 

Alkali — In  many  quarters  the  administration  of  large  amounts  of  alkali 
(sodium  bicarbonate  chiefly)  in  pneumonia  is  warmly  recommended  and 
there  is  at  least  a  theoretic  basis  for  this  method.  Acidosis  is  recognized 
as  one  of  the  causes  of  the  increased  respiratory  load  in  pneumonia  and 
hence  one  of  the  common  causes  of  dyspnoea.  Palmer  (18)  and  Means  and 
Barach  (13)  have  shown  conclusively  that  during  the  febrile  stage  of  this 
disease  the  available  alkali  in  the  blood  is  often  moderately  reduced.  It 
is  contended  that  the  preservation  of  the  acid-base  equilibrium  in  the 
blood  may  be  of  considerable  moment.  This  is  readily  maintained  by  the 
administration  of  large  doses  of  some  form  of  alkali.  Not  only  is  the 
acidosis  corrected  if  present  but  indirectly  the  efficiency  of  the  respira- 
tion is  increased  especially  as  concerns  the  excretion  of  carbon-dioxide. 
Means  and  Barach  warn  against  the  danger  of  producing  an  alkalosis  and 
recommend  that  only  sufficient  sodium  bicarbonate  be  given  to  render  the 
urine  alkaline  (usually  4-8  gm.  daily)  and  that  the  subsequent  dosage  be 
just  sufficient  to  preserve  a  slight  alkaline  reaction. 

Glucose — One  of  the  newer  procedures  which  offers  some  promise  of 
merit  is  the  intravenous  injections  of  concentrated  glucose    (20-50  per- 


151 

cent) .  The  glucose  provides  calories  in  a  very  available  form  and  in  the 
presence  of  a  very  inadequate  food  intake  in  many  cases  may  be  of  great 
assistance.  It  must  be  kept  in  mind  also  that  as  a  result  of  the  pyrexia 
the  metabolism  is  accelerated  and  the  caloric  needs  considerably  increased. 
The  indications  for  the  application  of  this  method  would  seem  to  be  in 
the  toxic  type  of  case  where  the  fluid  and  food  intake  is  apt  to  be  at  a 
minimum. 

Chemotherapy — The  large  number  of  drugs  for  which  a  more  or  less 
specific  action  in  pneumonia  is  claimed  and  for  which  imposing  mortality 
statistics  are  often  presented  as  evidence  of  their  value  is  the  clearest 
evidence  that  there  are  none  which  possess  genuine  specific  properties. 
Many,  however,  are  of  value  in  the  symptomatic  treatment  of  pneumonia 
and  may  play  even  a  conspicuous  part  in  the  therapeutic  program. 

Quinine  in  various  form  has  been  very  widely  used  for  the  past  two 
decades  especially  in  Germany  and  by  many  is  considered  a  true  specific. 
It  is  claimed  that  the  drug  has  remarkable  pneumococcidal  powers  both 
in  vitro  and  in  vivo.  Morgenroth  and  Levy  (14)  in  1911  first  investigated 
the  action  of  quinine  on  pneumococcus  and  other  infections  because  of  its 
known  activity  against  certain  protozoa.  The  German  reports  on  the 
results  from  this  form  of  chemotherapy  are  for  the  most  part  extremely 
favorable. 

Optochin  (ethyl-hydrokuprein)  a  quinine  derivative,  was  formerly  used 
almost  exclusively  but  has  more  recently  been  largely  given  up  because  of 
the  dangers  of  amaurosis.  Several  newer  quinine  preparations  have  re- 
placed optochin  the  most  commonly  used  being  quinine-urethane  (quinine 
hydrochloride  .5  gm.,  urethane  .5  gm.,  water  5  c.c.)  and  given  intra- 
muscularly twice  daily.  In  the  United  States  pneumoquin-base,  so-called, 
is  the  form  of  quinine  most  commonly  used.  Four  grains  are  given  by 
mouth  four  or  five  times  daily  for  15  doses  and  with  each  dose  five  ounces 
of  milk  to  enhance  its  absorption  (Cross  (8)  ).  The  effectiveness  of  qui- 
nine therapy  is  confined  to  the  first  two  or  three  days  of  the  disease. 
Cahn-Bronner  (4)  in  1927  published  a  very  complete  report  of  ten  years 
experience  with  parenteral  quinine  injections  in  croupous  pneumonia.  His 
method  consists  in  the  daily  intramuscular  injection  of  quinine  hydro- 
chloride .5  gm.  for  3-4  days.  He  claims  a  marked,  symptomatic  improve- 
ment, average  shortening  of  the  course  by  50  percent,  and  a  definite 
lowering  of  mortality  in  early  treated  cases  (7  percent  in  treated  and 
20.5  in  untreated  cases.) 

The  reports  from  American  clinics  and  in  particular  the  Rockefeller 
Institute  for  Medical  Research  on  the  value  of  the  salts  of  quinine  in  the 
treatment  of  pneumonia  have,  for  the  most  part,  been  unfavorable  and  in 
consequence  this  method  cannot  be  advocated. 

REFERENCES 

1.  Avery,  0.  T.,  Chickering,  H.  T.,  Cole,  R.  and  Dochez,  A.  R.:  Acute 
Lobar  Pneumonia.  Prevention  and  Serum  Treatment,  Monograph  of  the 
Rockefeller  Institute  for  Medical  Research,  No.  7:  1917. 

2.  Barach,  A.  L. :  Oxygen  Therapy  in  Pneumonia,  N.  Y.  State  J.  Med. 
29:  985-995,  1929. 

3.  Binger,  C.  A.  L. :  Anoxemia  in  Pneumonia  and  Its  Relief  by  Oxygen 
Inhalation,  J.  Clin.  Investigation  6 :  203-219,  1928. 

4.  Cahn-Bronner,  C.  E.:  Ten  Years  of  Quinine  Therapy,  Therap.  d. 
Gegenw.  68 :   97-103,  1927. 

5.  Cecil,  R.  L.,  And  Austin,  J.  H. :  Results  of  Prophylactic  Inocula- 
tion Against  Pneumococcus  in  12,519  Men,  J.  Exper.  Med.  28:  19-41,  1918. 

6.  Cecil,  R.  L.,  Baldwin,  H.  S.,  and  Larsen,  N.  P.:  Lobar  Pneu- 
monia, A  Clinical  and  Bacteriologic  Study  of  2,000  Typed  Cases,  Arch 
Int.  Med.  40 :  253,  1927. 

7.  Cecil*  R.  L.,  and  Steffen,  G.  I. :  Vaccination  of  Monkeys  Against 
Pneumococcus  Type  I  Pneumonia  by  Means  of  Intratracheal  Injection  of 


152 

Pneumococcus  Type  I  Vaccine,  Pub.  Health  Rep.,  Wash.  37:  2735-2744, 
1922. 

8.  Cross,  F.  B. :  Principles  and  Applications  of  Numoquin-Base 
(Ethyl-tiydrocupreine)  in  Treatment  of  Lobar  Pneumonia,  M.  J.  and  Rec 
126:  271,  1927;  354,  1927. 

9.  Davis,  J.  S.  Jr.  :  Effect  of  Morphine  on  Respiration,  J.  Clin.  Invest. 
6:  187-202,  1928. 

10.  Huntoon,  F.  M. :  Pneumococcus  Antibody  Solution  Specific  Against 
Types  I,  II  and  HI,  Transactions  of  Section  on  Pathology  and  Physiology, 
Am.  Med.  Assoc,  102-112,  1922. 

11.  Lister,  F.  S.:  An  Experimental  Study  of  Prophylactic  Inocula- 
tions Against  Pneumococcal  Infection  in  the  Rabbit  and  in  Man,  Publica- 
tion No.  8  of  the  South  African  Institute  for  Medical  Research,  1916. 

12.  Marvin,  H.  M.,  and  Soifer,  J.  D. :  The  Value  of  Camphor-In-Oil 
as  a  Cardiac  Stimulant,  J.  A.  M.  A.  83 :  94,  1924. 

13.  Means,  J.  H.,  and  Barach,  A.  L. :  The  Symptomatic  Treatment  of 
Pneumonia,  J.  Am.  Med.  Assoc.  77:  1217-1223,  1921. 

14.  Morgenroth,  J.,  and  Levy,  R. :  Chemotherapie  der  Pneumokok- 
kminfektion,  Berl.  Klin.  Woch.  48:  1560,  1911. 

15.  Newburgh,  L.  H.,  and  Porter,  W.  T. :  The  Heart  Muscle  in  Pneu- 
monia, J.  Exp.  Med.  22 :  123-128,  1915. 

16.  Norris,  G.  W. :  The  Causes  and  the  Control  of  Dyspnea  in  Disease 
of  the  Lungs,  Am.  J.  M.  S.  163:  157,  1922. 

17.  Palmer,  R.  S.:  Oxygen  Therapy  in  the  Treatment  of  Pneumonia, 
etc.,  N.  E.  J.  Med.  200:  330-332,  1929. 

18.  Palmer,  W.  W. :  Acidosis  and  Acid  Excretion  in  Pneumonia,  J. 
Exper.  Med.  26:  495,  1917. 

19.  Park,  W.  H.:  Pneumonia;  Haben  Lectures,  1930,  J.  State  Med. 
39:  125-140,  187-203,  1931. 

20.  Petersen,  W.  F.,  and  Levinson,  S.  A. :  The  Therapeutic  Effect  of 
Venesection;  With  Particular  Reference  to  Lobar  Pneumonia,  J.  Am.  M. 
Assoc,  78:  257,  1922. 

21.  Stadie,  W.  D.:  Oxygen  of  Arterial  and  Venous  Blood  in  Pneu- 
monia and  Its  Relation  to  Cyanosis,  J.  Exper.  Med.  30:  215,  1919. 

22.  Wyckoff,  J.,  DuBois,  E.  F.,  and  Woodruff,  I.  G.:  The  Thera- 
peutic Value  of  Digitalis  in  Pneumonia,  J.  A.  M.  A.  95 :  1243-1247,  1930. 

23.  Zinsser,  H.:  An  Immunological  Consideration  of  Pneumonia  and 
a  Discussion  of  the  Rational  Basis  for  Vaccine  Therapy,  N.  E.  J.  Med. 
200:  853,  1921. 

SERUM  THERAPY  IN  TYPE  I  LOBAR  PNEUMONIA 

W.  D.  Sutliff,  M.D. 
Boston  City  Hospital 

Serum  therapy  of  Type  I  lobar  pneumonia  has  been  used  by  a  limited 
number  of  American  clinicians  over  a  period  of  fourteen  years  following 
the  publication  in  1917  of  the  Rockefeller  Monograph  Number  7  by  Avery, 
Chickering,  Cole,  Dochez  (1).  There  has  been  lively  discussion  of  the 
merits  of  antipneumococcic  serum  therapy,  but  it  has  not  been  generally 
adopted.  The  search  for  effective  modes  of  treatment  has  been  continued 
and  carried  into  many  fields,  such  as  vaccine  therapy,  chemotherapy,  and 
physiotherapy,  but  antipneumococcic  serum  has  continued  to  receive  con- 
siderable attention.  It  has  found  many  supporters  among  students  of  the 
subject,  because  it  is  based  upon  a  sound  experimental  foundation. 

It  has  appeared  to  some  that  a  therapy  experimentally  sound  and  applied 
successfully  by  individual  men,  may  have  failed  in  general  application 
merely  through  technical  difficulties.  Felton's  (2)  serum  was  designed  to 
be  free  from  the  disadvantages  of  the  whole  horse  serum  used  by  earlier 
workers,  while  retaining  the  same  therapeutic  effectiveness. 

A  description  of  some  of  the  experiments  that  indicate  the  mechanism 
of  the  serum's  action,  and  a  description  of  some  of  the  clinical  effects  ob- 


153 

tained,  together  with  an  account  of  the  technique  required  in  the  use  of 
Felton's  concentrated  antipneumococcic  serum  are  given  below.  Only  the 
therapy  of  lobar  pneumonia  due  to  the  Type  I  pneumococcus  will  be  con- 
sidered because  of  the  conflicting  reports  as  to  the  effectiveness  of  such 
serum  in  the  treatment  of  infections  due  to  serological  strains  of  pneu- 
mococci  other  than  Type  I. 

Mode  of  Action  of  Antipneumococcic  Serum 

The  observation  that  pneumococci  are  immunologically  distinct  is  funda- 
mental to  the  application  of  specific  serum  therapy  in  lobar  pneumonia. 
(3).  As  many  as  thirty-two  different  serological  types  of  pneumococcus 
have  been  identified  by  Cooper  and  her  coworkers  (4)  as  occurring  in  lobar 
pneumonia.  Type  I  is  the  most  frequent  single  type,  however,  and  is  the 
"typical"  pneumococcus  of  Neufeld.  Type  I  has  been  found  in  about  30 
per  cent  of  all  pneumonia  cases  by  Dochez  and  Gillespie  (5),  Cole  (6), 
and  Cecil  (7). 

Study  of  the  nature  of  type  specificity  has  afforded  a  rational  basis  for 
the  relationship  between  type  specificity  and  the  therapeutic  usefulness  of 
antipneumococcic  serum.  Avery  and  his  colleagues  Dochez,  Heidelberger 
and  Goebel  (8)  (9)  (10),  and  others,  have  found  that  pneumococci  are 
all  made  up  of  a  protein  that  is  common  to  all  types  and  which,  therefore, 
is  species  specific;  and  that  the  protein  is  combined  with  a  carbohydrate 
which  is  different  for  each  type  and  therefore  type  specific.  The  type- 
specific  carbohydrate  is  found  to  be  a  constituent  of  the  organism  and  to 
be  given  off  during  growth  into  the  surrounding  medium.  The  term  "sol- 
uble specific  substance,"  which  is  frequently  abbreviated  to  "SSS,"  has 
been  applied  to  the  type-specific  carbohydrates.  Looked  at  from  the  aspect 
of  the  importance  of  "SSS"  to  the  organism,  it  can  be  said  to  lend  to  the 
organism  its  type-specific  biological  characters  and  its  virulence.  The 
combinatino  between  the  protein  and  "SSS"  constitutes  the  antigen  which 
induces  the  formation  of  type-specific  antibodies  when  injected  into  the 
animal  body. 

The  specific  antiserum  prepares  virulent  organisms  for  phagocytosis  by 
leucocytes.  It  is  probably  by  favouring  phagocytosis  of  the  pneumococcus 
that  the  serum  protects  animals  against  infection.  The  fate  of  an  animal 
or  man  infected  with  pneumococci  is  determined  by  the  interaction  of 
"SSS"  and  specific  antiserum.  An  excess  of  "SSS"  breaks  down  the  de- 
fences of  an  animal  by  neutralizing  the  phagocytosis-promoting  powers  of 
the  animal's  blood  plasma  and  body  fluids.  An  excess  of  specific  antiserum 
enables  phagocytosis  of  the  organisms  to  take  place.  The  relationship  of 
antibodies  to  recovery  in  lobar  pneumonia  has  been  determined  by  observ- 
ing the  time  of  appearance  of  natural  antibodies  in  the  course  of  the 
disease,  and  by  observing  the  effect  of  the  administration  of  specific  im- 
mune serum  on  the  course  of  the  disease.  There  is  little  question  that 
antibodies  appear  about  the  time  of  improvement  in  uncomplicated  lobar 
pneumonia  and  fail  to  appear  in  patients  in  whom  uncomplicated  disease 
progresses  unfavourably.  The  effect  of  antibodies  administered  to  patients 
suffering  from  pneumococcus  Type  I  lobar  pneumonia  indicates  that  the 
serum  is  therapeutically  useful.   Such  a  clinical  study  is  described  below. 

Results  of  Serum  Therapy*.  (11) 

Several  attempts  have  been  made  to  determine  whether  concentrated 
antipneumococcic  serum,  made  by  Felton's  method,  actually  saves  lives 
when  used  in  lobar  pneumonia  in  man.  This  has  been  done  by  treating 
alternate  patients  in  the  municipal  hospitals  of  New  York  and  Boston, 
and  comparing  the  fatality  rate  of  the  serum  treated  group  with  the 
fatality  rate  of  the  group  that  received  no  serum.  Table  I  contains  the 
death  rates  from  Type  I  lobar  pneumonia  obtained  in  such  controlled 


*  The  data  following   are  printed   with   permission  of  the   Journal   of   the  American   Medical 
Association. 


154 
clinical  therapeutic  trials.   They  show  that  antipneumococcic  serum  has  a 
consistently  beneficial  effect.   It  is  noteworthy  that,  as  with  other  immune 
measures,  the  best  results  in  two  of  the  series  were  obtained  following 
treatment  early  in  the  disease. 

In  order  to  judge  the  effectiveness  of  the  concentrated  antiserum 
in  each  individual  patient  it  is  necessary  to  know  what  symptomatic 
effects  may  be  expected  from  the  administration  of  the  serum.  The 
relatively  small  number  of  treated  patients  described  below  was  ob- 
served together  with  an  alternate  control  series  for  symptomatic 
changes.    The  course  of  the  disease  in  the  serum-treated  patients  was 


DURATION   TO  TYPE  DETERMINATION    (DAYS) 


Chart  1. — The  duration  of  Type  I  lobar  pneumonia  as  measured  by 
the  number  of  days  before  the  occurrence  of  a  marked  and  sustained 
drop  in  temperature  to  or  nearly  to  normal.  This  and  the  following 
chart  shows  on  the  left  the  duration  of  the  disease  in  days  and  along  the 
base  line  the  number  of  days  after  the  onset  of  the  disease  until  the  pneu- 
mococcus  type  was  determined.  The  curves  join  points  which  represent 
the  average  of  the  duration  of  the  acute  disease  in  patients  grouped  accord- 
ing to  the  interval  from  the  onset  until  the  pneumococcus  type  was  deter- 
mined. The  diagonal  line  beginning  at  O  divides  the  portion  of  the  dis- 
ease before  the  determination  of  the  pneumococcus  type  (below  the  line) 
from  the  portion  of  the  disease  after  the  determination  of  the  pneumococ- 
cus type  (above  the  line).  Specific  therapy  was  instituted  in  half  the 
patients  at  the  time  represented  by  this  line.  Each  dot  represents  a 
patient  treated  specifically  and  each  cross  a  patient  not  given  specific 
therapy. 


155 
shortened  and  altered  often  enough  so  that  it  is  probable  that  physi- 
cians  who   treat   very   few   pneumonia    cases    can   personally    see    evi- 
dence of  the  favorable  effect  of  the  serum. 

Each  alternate  case  in  a  group  of  fifty-nine  Type  I  lobar  pneumonia 
cases  received  concentrated  antipneumococcic  serum  prepared  accord- 
ing to  the  method  of  Felton,  and  all  the  patients  were  carefully  ob- 
served to  detect  signs  of  clinical  improvement.  The  changes  in  the 
course  of  the  disease  that  seemed  most  reliable  because  they  were  most 
objective  and  at  the  same  time  seem  most  significant,  were  (1)  the 
duration  of  the  acute  stage  of  the  disease;  (2)  the  course  of  the 
bacteremia;  and  (3)  the  presence  or  absence  of  pulmonary  extensions 
of  the  infection. 

Duration:  In  chart  1  temperature  changes  were  used  to  indicate  the 
duration  of  the  disease. 

It  is  apparent  that  the  serum  treated  cases  (represented  by  dots) 
showed  improvement  at  a  fairly  regular  and  comparatively  short  inter- 
val after  pneumococcus  type  was  determined  and  specific  treatment 
was  begun.  It  is  also  clear  that  in  the  cases  in  which  concentrated  an- 
tibody was  not  given  (represented  by  crosses)  improvement  set  in  at 
irregular  and  usually  longer  intervals  after  the  determination  of  the 
pneumococcus  type.  Specifically,  seventeen  of  eighteen  treated  pa- 
tients showed  a  marked  fall  in  temperature  within  thirty  hours  after 
the  type  of  pneumococcus  was  determined  and  treatment  was  begun. 
Only  one  of  the  treated  patients  had  a  high  fever  for  a  longer  period 
than  the  average  untreated  patient.  While  five  of  the  untreated  pa- 
tients had  a  short  drop  in  temperature  within  thirty  hours  after  the 
type  was  determined,  and  four  showed  the  same  change  before  the 
average  treated  patients,  the  remaining  ten  are  scattered  widely  on 
the  chart.  The  curves  in  Chart  1,  showing  the  average  duration  be- 
fore the  occurrence  of  a  sustained  drop  in  temperature,  indicate  per- 
haps even  more  clearly  the  difference  in  the  duration  of  the  disease  in 
treated  and  in  untreated  patients.  The  patients  who  received  concen- 
trated antibody  early  in  the  disease  had,  on  the  average,  a  fall  in  tem- 
perature to  nearly  normal  from  20  to  24  hours  after  they  were  typed 
and  treated,  while  the  untreated  patients  showed,  on  the  average,  a 
similar  temperature  drop  from  48  to  144  hours  after  the  determina- 
tion of  the  pneumococcus  type.  In  cases  which  came  under  observa- 
tion after  the  fourth  day  of  the  disease,  there  was  no  great  difference 
in  the  average  course  of  the  disease  in  treated  and  untreated  patients. 

In  Chart  2,  temperature  is  considered  together  with  other  symp- 
toms. The  acute  disease  is  taken  to  persist  until  all  elevations  of  tem- 
perature as  well  as  acute  symptoms  have  disappeared.  It  is  seen  that 
eleven  of  the  eighteen  serum  treated  patients  were  well  within  thirty 
hours  after  the  pneumococcus  type  determination,  which  represents 
approximately  the  beginning  of  treatment.  It  is  likewise  apparent  that 
twelve  of  the  eighteen  specifically  treated  patients  were  well  before  the 
average  untreated  patient.  On  the  other  hand,  only  four  of  the  fifteen  un- 
treated patients  were  well  within  the  first  thirty  hours  after  the  pneu- 
mococcus type  determination,  and  only  five  of  the  untreated  were  well 
before  the  average  treated  patient,  three  of  the  latter  being  patients  first 
observed  on  the  sixth  and  seventh  days  of  the  disease.  As  in  the  first 
chart,  the  beneficial  effect  of  antibody  treatment  is  seen  only  in  patients 
treated  early;  in  this  case,  those  treated  on  or  before  the  fifth  day  of 
the  disease. 

Summarizing  the  effect  of  concentrated  antibody  treatment  on  the  dur- 
ation of  Type  I  lobar  pneumonia,  it  may  be  said  that  definite  improvement 
was  quite  regularly  present  in  this  group  of  serum  treated  patients  within 
thirty  hours  after  antibody  administration.  The  treated  patients  showed 
a  shorter  average  duration  of  their  illness  than  did  the  untreated  patients. 
The  difference  in  favor  of  the  serum  treated  patients  was  greatest  in 


156 
those  treated  earliest  in  the  disease  and  decreased  progressively  as  treat- 
ment was  delayed. 

Bacteremia.  The  result  of  blood  culture  is  known  to  be  of  considerable 
prognostic  significance.  The  presence  of  bacteremia  early  in  the  course  of 
the  disease  is  considered  an  indication  of  a  severe  infection,  while 
the  presence  of  a  bacteremia  on  the  fourth  day  or  later  in  the  course 
of  the  disease  is  an  unfavorable  prognostic  sign.    Seven  of  the  treated 


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DURATION   TO   TYPE    DETERMINATION    (DAY5) 

Chart  2. — The  duration  of  type  I  lobar  pneumonia  as  measured  by 
the  number  of  days  required  for  complete  disappearance  of  fever  and 
symptoms. 


patients  had  a  bacteremia  when  they  were  first  seen.  The  effect  of  serum 
treatment  on  the  bacteremia  was  striking.  All  six  patients  who  had  more 
than  one  blood  culture  taken  had  negative  cultures  after  serum  treatment. 
These  may  be  compared  with  the  six  untreated  patients  whose  first  blood 
cultures  were  positive.  Only  two  of  these  untreated  patients  subsequently 
had  negative  blood  cultures. 

The  development  of  bacteremia  was  apparently  prevented  by  the  admin- 
istration of  serum.  No  treated  patient  with  an  originally  negative  blood 
culture   developed   a   positive   culture,   whereas   four   of   ten    untreated 


157 
patients  whose  first  blood  cultures  were  negative  later  had  positive  cul- 
tures (one  was  found  positive  on  culture  of  heart's  blood  at  autopsy). 

Pulmonary  Extensions.  The  extension  of  the  inflammatory  process  to 
a  new  area  in  the  lungs  is  a  clinical  condition  that  is  characteristic  of  a 
pneumonic  process  that  is  progressing  unfavorably.  The  clinical  signs  of 
extension,  such  as  continued  bloody  sputum  and  prolongation  of  the 
course  of  the  disease  or  relapse,  aided  in  making  this  diagnosis.  No  cases 
were  considered  as  showing  extension,  however,  unless  the  new  area  of 
consolidation  was  clearly  demonstrated  by  physical  signs  and  by  Roentgen 
examination.  Among  the  treated  patients  no  extensions  were  detected 
subsequent  to  the  administration  of  specific  serum.  Among  the  untreated 
patients,  extensions  occurred  in  four  otherwise  uncomplicated  cases. 

Summarizing  the  objective  evidence  of  the  effect  of  the  administration 
of  concentrated  antibody  to  patients  with  Type  I  lobar  pneumonia,  it 
appears  that  (1)  the  duration  of  the  disease  was  shortened  on  the  average 
from  one  to  two  days  in  patients  treated  on  or  before  the  fourth  day;  (2) 
the  bacteremia  cultures  disappeared  after  serum  treatment,  and  no  pa- 
tients developed  positive  blood  cultures  after  such  treatment;  and  (3)  ex- 
tension of  the  infection  to  new  portions  of  the  lungs  occurred  among  the 
untreated,  but  not  among  the  treated  patients. 

Method  of  Serum  Administration 

Early  Diagnosis.  From  the  description  of  the  results  of  serum  therapy 
it  is  obvious  that  early  institution  of  treatment  is  of  the  utmost  import- 
ance. Procedures  that  lead  to  eliminating  unnecessary  delays  in  recog- 
nizing the  disease,  or  in  securing  material  for  bacteriological  diagnosis,  or 
in  the  identification  of  the  pneumococcus  type  in  the  laboratory  aid  in  the 
administration  of  antipneumococcus  serum  at  the  earliest  possible  moment. 

The  diagnosis  of  lobar  pneumonia  is  not  difficult.  Type  I  lobar  pneu- 
monia, in  particular,  is  apt  to  run  a  characteristic  course.  The  more 
significant  points  in  making  the  diagnosis  are:  (1)  The  history  of  an 
acute  onset  following  a  previous  "cold",  the  onset  being  marked  by  a 
chill,  pain  in  the  thorax,  prostration,  and  tenacious,  bloody  sputum,  red 
with  fresh  blood  or  brown  with  methemoglobin ;  (2)  the  physical  signs 
of  a  single,  well-localized  consolidation  in  the  lungs.  Not  all  these  symp- 
toms and  signs  are  always  present.  The  signs  of  consolidation  may  be 
equivocal  or  absent,  especially  early  in  the  disease.  In  doubtful  cases  the 
nature  of  the  sputum  is  a  most  valuable  sign. 

A  specimen  of  sputum  is  useful,  not  only  in  the  physical  diagnosis  of 
the  disease,  but  it  is  also  the  best  material  from  which  to  determine  the 
serological  type  of  the  pneumococcus.  It  is  possible  to  secure  a  sample  of 
sputum  from  nearly  every  patient  when  one  appreciates  its  value.  It  is 
wise  to  request  a  sample  of  sputum  early  in  the  course  of  the  examination 
as  the  movements  during  examination  are  sometimes  sufficient  to  produce 
coughing.  If  the  patient's  mouth  is  dry,  a  swallow  of  water  facilitates 
the  raising  of  sputum.  When  the  patient  does  not  cough,  a  few  demon- 
strations by  the  examiner  will  frequently  cause  a  sympathetic  impulse. 
The  sample  of  sputum,  once  observed  for  its  diagnostic  value,  should  be 
sent  to  the  laboratory  no  matter  what  its  character.  If  it  is  not  typically 
pneumonic,  but  if  the  symptoms  are  those  of  lobar  pneumonia,  efforts 
should  continue  to  be  directed  toward  securing  a  more  typical  specimen. 
The  relief  of  pain  by  a  swathe,  a  local  application,  or  an  analgesic,  or  the 
administration  of  an  expectorant  may  aid  in  finally  obtaining  a  typically 
pneumonic  specimen  of  sputum.  The  type  of  pneumococcus  can  be  deter- 
mined within  3  to  10  hours  by  the  Sabin  method,  which  is  described  else- 
where. 

If  sputum,  for  any  reason,  cannot  be  obtained,  a  sterile  cotton  swab 
applied  to  the  pharyngeal  wall  may  be  cultured  for  pneumococcus.  This 
requires  from  18  to  36  hours.  Another  source  of  material  for  pneumococ- 
cus typing  is  the  urine,  which  in  rather  ill  patients  frequently  gives 


158 
specific  precipitin  reaction,  when  mixed  with  antipneumococcic  serum. 
The  type  of  infection  may  be  determined  by  this  method  within  one  half 
hour.  The  blood  culture  is  also  of  value.  The  latter  two  procedures,  aside 
from  their  aid  in  determining  the  type  of  the  infecting  pneumococcus,  are 
also  valuable  prognostically. 

Dosage  of  antiserum.  The  potency  of  the  serum  is  measured  in  terms 
of  its  protective  value  for  mice  by  means  of  a  test  devised  by  Felton.  The 
Felton  unit  is  based  upon  the  determination  of  the  amount  of  serum  that 
will  protect  a  majority  of  mice  injected  with  a  certain  standard  dose  of 
living  pneumococci,  when  compared  to  the  protective  dose  of  a  standard 
serum. 

During  the  administration  of  concentrated  serum  by  the  authors  quoted 
in  Table  1,  generally  impressions  have  been  gained  which  guide  the  choice 
of  the  dosage  of  serum  expressed  in  Felton  units.  Cecil  and  Sutliff  (12) 
recommend  100,000  units  during  the  first  24  hours  of  treatment,  while 
Park  (13)  recommends  from  50,000  to  100,000  units  during  the  same 
period. 

There  is  little  question  that  individual  patients  differ  markedly  in  their 
requirements,  but  at  the  present  time  there  is  no  method  for  measuring 
these  requirements.  The  amount  of  serum  needed  may  increase  with  the 
duration  of  the  disease  before  treatment  is  begun,  as  the  experiments  of 
Goodner  suggest.  Bacteremic  patients  can  be  thought  to  require  larger 
amounts  of  antibody  than  patients  whose  blood  is  sterile.  Whether  a 
standard  dose  is  used  for  all  patients,  or  whether  the  dosage  is  varied  for 
different  patients  according  to  clinical  indications,  administration  early 
in  the  disease  will  have  a  marked  influence  on  the  success  of  treatment. 
Other  things  being  equal,  an  adequate  amount  of  serum  should  be  given 
as  early  as  possible,  and  this  implies  that  the  full  dosage  should  be  given 
as  quickly  as  safety  permits.  Supplementary  dosage  may  be  indicated  in 
a  certain  number  of  patients,  since  the  level  of  passively  transferred  anti- 
body, as  well  as  of  foreign  protein  in  the  blood  serum,  falls  rapidly  within 
the  first  24  hours  after  administration  to  one  half  their  original  concen- 
tration. 

At  the  present  time  the  adoption  of  a  standard  dose  of  about  100,000 
units  to  be  administered  as  early  as  possible  in  the  course  of  the  disease 
is  the  method  of  choice.  Other  considerations  modify  the  actual  technique 
of  serum  administration.  Since  it  is  usually  desired  to  use  the  syringe 
with  needle  as  the  simplest  mode  of  intravenous  administration,  from 
20  to  50  cc.  are  the  largest  amounts  of  serum  convenient  for  a  single  dose. 
The  giving  of  a  preliminary  amount,  5  cc,  is  wise  as  a  test  of  the  possi- 
bility of  untoward  reaction.  A  delay  of  two  hours  between  doses  seems 
advisable  because  chills  or  other  reactions  may  occur  within  this  time. 

Serum  reactions.  In  connection  with  the  administration  of  concen- 
trated antipneumococcic  serum,  and  in  fact  the  intravenous  administra- 
tion of  any  foreign  substance,  reactions  of  various  types  occur.  On  the 
whole,  pneumococcic  antibody  concentrated  by  the  method  of  Felton  sel- 
dom produces  untoward  reactions.  The  possible  types  of  reaction  may  be 
listed  as  (1)  immediate  reactions  with  gastric  and  with  circulatory  symp- 
toms; or  with  urticarial  and  asthmatic  symptoms;  (2)  thermal  reactions; 
and  (3)  serum  sickness. 

The  immediate  reactions  (1)  are  the  greatest  source  of  anxiety  because 
of  occasional  reports  of  fatalities  that  have  followed  immediately  after 
serum  was  given.  But  immediate  reactions  observed  during  the  past  two 
years  in  the  use  of  Felton's  concentrated  serum  have  run  a  mild  course. 
They  have  shown  the  following  symptoms:  The  immediate  reaction  in 
which  circulatory  symptoms  predominate  is  characterized  by  flushing  of 
the  face,  feeling  of  weakness,  with  rapid  pulse,  perspiration,  and  some- 
times with  desire  to  go  to  stool,  nausea  or  pains  in  neck  or  back.  The  im- 
mediate reaction  of  the  asthmatic  or  urticarial  type  manifests  itself  as 
follows:    From  three  to  fifteen  minutes  after  the  injection  of  serum,  the 


159 

patient's  respiratory  rate  becomes  more  rapid,  dyspnea  becomes  marked 
and  the  patient's  face  is  flushed.  Urticaria  is  usually  present,  although 
frequently  limited  to  a  few  scattered  wheals  that  may  easily  pass  un- 
noticed. Subjective  anxiety  or  feeling  of  compression  over  the  chest  may 
occur,  and  sometimes  precordial  pain.  Urticaria  may  appear  alone.  When 
such  reactions  have  followed  the  administration  of  Felton's  antibody 
they  seem  to  have  been  associated  with  certain  lots  of  antiserum.  They 
have  decreased  in  frequency  as  the  technical  details  of  the  concentration 
of  serum  have  become  better  understood.  They  have  seemed  not  to  be  a 
serious  phenomenon. 

Reactions  of  the  asthmatic  and  urticarial  type,  due  to  previous  serum 
administration  have  been  best  described  by  von  Pirquet  and  Schick  (14), 
who  named  the  type,  "accelerated  reactions,"  and  considered  them  a  form 
of  serum  sickness.  An  extensive  experience  with  such  reactions  convinced 
these  authors  that  they  did  not  lead  to  serious  consequences.  Immediate 
reactions,  following  the  use  of  concentrated  antipneumococcic  serum,  have 
occurred  without  apparent  relation  to  previous  serum  administration,  al- 
though, since  the  symptoms  are  similar,  some  of  the  reactions  observed 
may  have  been  of  this  type. 

Despite  the  experience  of  the  past  two  years  that  immediate  reactions 
are  harmless,  it  is  of  course  possible  that  they  may  be  severe.  On  the  other 
hand,  mild  reactions  in  chronically,  as  well  as  in  acutely  ill,  patients  may 
explain  some  of  the  serious  results  reported.  Severe  reactions  may  prob- 
ably also  be  produced  by  disregarding  the  common  caution  which  should 
be  observed  in  intravenous  therapy,  that  the  first  injection  should  be  made 
slowly;  any  symptoms  noted;  the  injection  discontinued;  and  the  admin- 
istration of  large  amounts  of  the  toxic  material  thus  avoided. 

The  administration  of  horse  protein  to  an  individual  who  is  consti- 
tutionally hyper-sensitive  to  this  protein  may  be  the  cause  of  some  fatali- 
ties in  serum  administration.  Park  (15)  estimated  their  frequency  as  1 
in  70,000  patients.  We  have  seen  no  individuals  of  this  type.  The  ophthal- 
mic test,  depending  upon  the  absorption  of  very  small  amounts  of  thera- 
peutic serum  from  the  conjunctiva,  has  been  used  in  the  hope  that  it  will 
be  positive  in  persons  with  a  very  high  degree  of  sensitivity  and  thus  in 
persons  liable  to  have  severe  reactions.  A  simpler  precaution  that  is 
probably  of  more  value  is  the  elicitation  of  a  history  of  specific  hyper- 
sensitiveness  to  horse  emanation.  A  description  of  the  routine  precau- 
tionary methods  is  given  below. 

Thermal  reactions  (fever  usually  accompanied  by  a  chill)  may  be  pro- 
duced by  any  type  of  intravenous  injection.  They  occur  about  one  hour 
after  injection  of  the  material.  They  have  been  reported  as  occurring  in 
15.4  per  cent  of  the  cases  treated  by  Cecil  and  Sutliff  (12)  and  12.5  per 
cent  of  a  small  series  of  cases  treated  by  Sutliff  and  Finland  (11).  Those 
observed  with  Felton's  antibody  have  been  mild  and  not  associated  with 
hyperpyrexia  (more  than  106°F).  They  require  no  special  treatment,  be- 
side ensuring  the  comfort  of  the  patient  by  means  of  blankets  and 
warmth,  and  observations  for  possible  hyperpyrexia. 

Serum  sickness  is  a  familiar  occurrence  after  all  types  of  serum  admin- 
istration. It  begins  about  seven  days  after  the  administration  of  serum. 
It  is  characterized  by  lymphadenopathy,  fever  increase  of  leucocytes  to 
10,000  or  12,000,  urticaria  which  may  itch  badly,  and  arthritis.  The  dur- 
ation is  usually  from  one  to  four  days.  The  incidence  of  serum  sickness 
is  related  to  the  total  amount  of  serum  administered.  Cecil  and  Sutliff 
(12)  report  that  among  patients  receiving  less  than  50  cc.  of  serum  the 
incidence  was  4.9  per  cent  and  among  those  receiving  more  than  50  cc. 
of  serum,  27.2  per  cent.  Sutliff  and  Finland  (11)  observed  serum  sick- 
ness in  29  per  cent  of  the  patients  in  their  series. 

A  serial  story  of  the  sei;um  treatment  of  a  patient  follows.  When  the 
patient  is  first  seen,  the  examiner  attempts  to  make  a  definite  clinical 
diagnosis.    When  this  is  possible,  a  specimen  of  sputum  is  obtained,  and 


160 
the  Sabin  method  is  used  for  determining  the  type  of  pneumococcus. 
Blood  is  taken  for  culture,  and  when  the  patient  is  seriously  ill,  a  speci- 
men of  urine  is  obtained  for  the  precipitin  test.  If  a  Type  I  pneumococcus 
is  found,  specific  serum  therapy  is  immediately  instituted.  The  patient 
is  questioned  as  to  a  history  of  sensitivity  to  horse,  or  other  animal  eman- 
ations, hay-fever,  food  idiosyncracies,  asthma,  eczema  in  childhood,  and 
previous  serum  therapy.  The  ophthalmic  test  is  performed;  one  or  two 
drops  of  the  therapeutic  serum  being  placed  in  the  conjunctival  sac,  and 
observed  for  30  minutes  for  the  possible  development  of  a  conjunctival 
injection.  If  there  is  positive  evidence  of  sensitivity  to  horse  protein,  it 
is  likely  that  serum  cannot  be  administered  in  sufficient  dosage  to  be  of 
value.  If  there  is  history  of  an  allergic  condition  not  specifically  horse 
serum  sensitization,  and  if  there  is  a  negative  ophthalmic  reaction,  the 
usual  method  of  serum  administration  is  used  with  especial  care  to  inject 
the  first  dose  of  serum  slowly. 

The  serum  is  first  warmed  to  body  temperature  by  placing  the  rubber- 
stoppered  vial  in  warm  water  for  5  to  10  minutes.  A  venous  puncture  is 
made  in  the  cubital  fossa  and  the  serum  is  injected  slowly,  5  to  15  minutes 
being  taken  for  the  total  dose.  The  first  dose  is  5  cc.  in  amount.  Succeed- 
ing doses  of  serum  are  given  in  the  same  way  at  two  hour  intervals,  until 
the  total  amount  of  serum  has  been  administered. 

Summary  and  Conclusions 

Experimental  work  has  developed  a  conception  of  the  specific  carbo- 
hydrate of  pneumococcus  and  its  relation  to  protective  antibodies  which 
affords  a  rational  basis  for  the  use  of  type  specific  antiserum  in  Type  I 
lobar  pneumonia.  This  experimental  evidence  has  led  to  a  continuous 
effort  to  make  serum  treatment  for  lobar  pneumonia  practical. 

Felton's  concentrated  antibody  has  given  satisfactory  results  in  the 
hands  of  several  workers,  from  the  point  of  view  of  the  saving  of  human 
life,  and  from  the  point  of  view  of  symptomatic  improvement  in  a  con- 
secutive series  of  cases.  This  concentrated  antibody,  by  reason  of  its  com- 
parative freedom  from  side  actions,  and  its  relative  ease  of  administration 
seems  to  fill  the  practical  requirements  for  the  specific  serum  treatment 
of  Type  I  lobar  pneumonia. 

The  limitations  of  the  action  of  specific  antiserum  follow  naturally  from 
the  study  of  its  action.  It  is  type  specific,  it  is  useful  only  in  Type  I  pneu- 
monia, it  is  decisively  effective  only  early  in  the  disease. 

The  type  specific  action  of  the  serum  is  of  course  a  limitation,  but  it  is 
also  the  principle  upon  which  the  therapy  is  built.  It  seems  at  present 
possible  only  to  attack  pneumococcus  infections  caused  by  different  strains 
as  separate  and  distinct  problems. 

It  is  fortunate  that  Type  I  pneumococcus  lobar  pneumonia  is  the  most 
frequent  of  the  types,  constituting  30  per  cent  of  all  cases  in  hospital 
practice.  Since  lobar  pneumonia  is  so  frequently  a  cause  of  death  as  to 
rank  high  in  all  statistics,  a  specific  treatment  of  one  out  of  every  three 
cases  is  still  numerically  of  considerable  importance. 

The  antiserum  is  decisively  effective  only  in  the  first  four  days  of  the 
infection.  This  has  been  explained  in  two  ways,  either  one  of  which  may 
be  correct.  (1)  The  toxic  changes  after  the  first  few  days  of  the  disease 
may  already  be  irreparable,  even  though  the  "SSS"  is  neutralized  by  the 
injected  antibodies.  (2)  The  accumulation  of  "SSS"  in  the  lung  may  be- 
come so  great  as  to  make  any  possible  concentration  of  antibodies  in- 
effective. 

The  use  of  specific  therapy  in  Type  I  lobar  pneumonia  does  not  in  any 
way  lessen  the  importance  of  general  measures,  such  as  medication  and 
nursing  procedures  that  have  a  known  value  in  the  treatment  of  the  dis- 
ease. But,  due  to  the  repeated  question  as  to  whether  the  intravenous  ad- 
ministration of  serum  is  a  source  of  disturbance  and  discomfort  to  the 
patient,  a  comparison  of  the  exertion  and  disturbance  caused  by  pro- 


161 
cedures  commonly  employed  with  those  attending  the  use  of  serum  may 
not  be  out  of  place.  Enemas  are  employed  by  some  physicians  with  good 
effect.  A  sponge  bath,  or  alcohol  rub  is  used  for  cleanliness,  and  some- 
times to  reduce  an  unduly  elevated  temperature,  and  in  any  case  the  linen 
of  the  bed  is  changed  daily  or  oftener  when  diaphoresis  is  free.  Even 
when  these  procedures  are  skillfully  done  the  exertion  on  the  part  of  the 
patient  is  manifestly  greater  than  that  attending  the  intravenous  adminis- 
tration of  serum.  When  intravenous  injections  are  carefully  made  they 
will  not  disturb  the  patient  physically,  and  should  cause  no  fright.  A 
certain  liability  to  systemic  reactions  exists,  as  indicated  in  the  discussion 
above,  but  it  is  reduced  to  a  minimum  in  serum  made  at  present  by 
Felton's  method. 

A  rule  which,  more  than  any  other,  insures  gratifying  results  in  the  use 
of  specific  antipneumococcic  therapy  in  Type  I  lobar  pneumonia  is  that 
one  should  be  ever  on  the  alert  to  make  a  positive  diagnosis  early  in  the 
disease.  Insistence  upon  a  personal  observation  of  the  sputum  is  prob- 
ably the  most  trustworthy  single  procedure  in  the  early  recognition  of 
lobar  pneumonia. 

When  a  patient  is  treated  adequately  within  the  first  four  days  of  the 
onset  of  the  disease,  the  symptomatic  response  is  usually  striking  and  one 
can  feel  that  about  a  50  per  cent  saving  of  life  is  being  obtained. 

TABLE  I. 

Mortality  of  Type  I  Lobar  Pneumonia  Treated  with  Concentrated 

Antibody  (Felton)  Compared  with  the  Mortality  of  Simultaneous 

Control  Series  without  Serum  Therapy. 


Absolute 
Cases 

Serum  Treated 

Number     Per  Cent 
Deaths        Deaths 

Not 
Absolute 
Cases 

Treated  with 
Number 
Deaths 

Serum 
Per  Cent 
Deaths 

Cecil  et  al1 
Cases  less  than 
3   days  duration 

239 
103 

48 
12 

20.1 
11.7 

234 
97 

73 
26 

31.2 
26.8 

Park  et  al2 
Cases  less  than 
3  days  duration 

58 
29 

13 
6 

22.0 
21.0 

54 
28 

19 
10 

35.0 
36.0 

Finland3 
Cases  less  than 
3  days  duration 

80 
42 

17 
"       4 

21.3 
9.5 

70 
16 

22 
6 

31.4 
37.5 

REFERENCES 

1.  Avery,  O.  T.,  Chickering,  H.  T.,  Cole,  R.,  and  Dochez,  A.  R. : 
Rockefeller  Institute  Monograph.    No.  7,  1917. 

2.  Felton,  L.  D. :  The  concentration  of  antipneumococcus  serum. 
Jour.  Am.  Med.  Ass'n.  94:  1893-1896  (June  14)  1930. 

3.  Neufeld,  F.,  and  Haendel  :  Weitere  Untersuchung  ueber  Pneumok- 
okken  Heilsera.  III.  Mitteilung.  Ueber  Vorkommen  und  Bedeutung  atypi- 
scher  Varietaeten  des  Pneumokokkus.  Arb.  aus.  d.k.  Gesundheitsamte. 
34:293,  1910. 

4.  Cooper,  G. :    Personal  communication. 

5.  Dochez,  A.  R.,  and  Gillespie,  L.  J. :  A  biologic  classification  of 
pneumococci  by  means  of  immunity  reactions.  Jour.  Am.  Med.  Ass'n. 
61:727,  1931. 

6.  Cole,  Rufus:  Lobar  pneumonia.  Nelson's  Loose  Leaf  Medicine, 
Vol.  1,  207,  1920. 

7.  Cecil,  R.  L.,  Baldwin,  H.  S.,  and  Larsen,  N.  P. :  Lobar  pneumonia. 
A  clinical  and  bacteriological  study  of  two  thousand  typed  cases.  Arch. 
Int.  Med.  40 :253-280,  1927. 

8.  Dochez,  A.  R.,  and  Avery,  O.  T. :  The  elaboration  of  specific  soluble 
substance  by  pneumococcus  during  growth.  Jour.  Exp.  Med.  26:477,  1917. 


162 

9.  Avery,  0.  T.,  and  Heidelberger,  M.:  Immunological  relationships 
of  cell  constituents  of  the  pneumo coccus.  Jour.  Exp.  Med.  42 :367,  1925. 

10.  Lord,  F.  T.,  and  Persons,  E.  L. :  Certain  aspects  of  mouse  protec- 
tion tests  for  antibody  in  pneumococcus  pneumonia.  Jour.  Exp.  Med. 
53:151,  1921. 

11.  Sutliff,  W.  D.,  and  Finland,  Maxwell:  Type  I  lobar  pneumonia 
treated  with  concentrated  pneumococcic  antibody  (Felton).  Jour.  Am. 
Med.  Ass'n.,  96:465,  1931. 

12.  Cecil,  R.  L.,  and  Sutliff,  W.  D.:  The  treatment  of  lobar  pneu- 
monia with  concentrated  antipneumo coccus  serum.  Jour.  Am.  Med.  Ass'n. 
91:2035-2042,  (Dec.  29)   1928. 

13.  Park,  W.  H. :   Personal  communication. 

14.  von  Pirquet  and  Schick  :  Die  Serum  Krankheit,  Deuticke,  Leip- 
zig, 1905. 

15.  Park,  W.  H.,  Williams,  A.,  Krumwiede,  C:  Pathogenic  micro- 
organisms,  p.  301,  9th  edition,  1929,  Lea  and  Febiger,  New  York. 

PNEUMOCOCCUS  TYPE  DETERMINATION 

Edith  Beckler,  S.  B. 
Bacteriological  Laboratory ,  State  House,  Boston,  Massachusetts. 

Pneumococci  are  organisms  that  often  are  identified  by  their  morph- 
ology and  staining  reaction.  A  pneumococcus  is,  typically,  a  lancet-shaped 
coccus,  appearing  in  pairs,  usually  surrounded  by  a  definite  capsule.  It  is 
Gram-positive.  Variations  occur  in  the  morphology,  as  some  strains  are 
more  spherical  than  others,  and  chain  formation  may  occur.  The  capsule, 
also,  is  subject  to  variation  in  size  or  may  be  absent. 

Although  pneumococci,  found  in  saliva,  were  described,  as  early  as  1880, 
by  Pasteur  and  Sternberg,  working  independently,  they  were  not  associ- 
ated with  lobar  pneumonia  until  1886.  During  that  year,  Frankel  and 
Weichselbaum  each  demonstrated  the  pneumococcus  as  the  causative  or- 
ganism of  pneumonia. 

The  earlier  workers  did  not  indicate  that  they  considered  the  pneu- 
mococcus as  other  than  a  single  organism.  Later  workers,  Neufeld,  in 
Germany,  and  Cole  and  his  associates  at  Rockefeller  Hospital,  showed  that 
the  so-called  pneumococcus  was  a  group  of  pneumococci,  which  could  be 
divided  into  types.  By  means  of  serological  tests,  it  was  possible  to  classify 
three  types  called  the  "fixed"  types,  I,  II  and  III;  all  others  were  placed  in 
a  group  called  type  or  group  IV.  Recent  work  has  led  to  a  subdivision  of 
the  pneumococci  of  this  group  into  several  other  fixed  types. 

On  account  of  serum  therapy,  it  is  desirable  to  determine  the  type  of 
pneumococcus  present  in  every  case  of  pneumonia. 

The  following  named  specimens  may  be  sent  to  the  laboratory  to  be 
examined  for  type  of  pneumococcus:  sputum,  blood,  spinal  fluid,  pleural 
fluid  and  urine.  Sputum  specimens  are  the  most  common  and  are  to  be 
recommended  in  cases  of  lobar  pneumonia.  The  sample  of  sputum  should 
come  from  the  deeper  air  passages  and  should  be  free  from  contaminating 
mouth  bacteria.  If  possible,  not  less  than  5  cubic  centimeters  should  be 
sent.  All  specimens  should  be  sent  in  sterile  containers  with  no  dis- 
infectant of  any  sort.  The  fresher  the  specimen  when  it  reaches  the  labor- 
atory, the  better  the  chances  of  cultivating  a  pneumococcus.  Suitable  con- 
tainers for  specimens  may  be  obtained  at  the  Bacteriological  Laboratory, 
Room  527,  State  House,  Boston,  Mass. 

All  specimens  are  examined  either  for  living  pneumococci  or  for  a 
product  of  growth  of  the  pneumococci,  found  in  the  surrounding  medium. 
This  product  of  growth  is  called  precipitable  substance  or  precipitin 
antigen. 

By  means  of  serological  tests  the  pneumococci  are  classified  as  Types  I, 
II  and  III,  the  so-called  fixed  types  and  Group  IV,  a  heterogeneous  group 
of  pneumococci.  For  purposes  of  research,  this  group  may  be  further 
classified  into  fixed  types. 


163 

Two  methods  of  pneumococcus  type  determination  may  be  used  for 
sputum:  (1)  mouse  inoculation  and  (2)  demonstration  of  precipitable 
substance,  usually  known  as  the  coagulation  method  of  Krumwiede. 

The  time  required  for  the  determination  of  type  varies  greatly  for 
different  specimens  of  sputum.  A  well  marked  reaction  may  be  obtained, 
by  means  of  the  Krumwiede  method,  within  an  hour  after  the  receipt  of 
the  specimen  at  the  laboratory.  On  the  other  hand,  a  mouse  inoculation 
method  may  consume  from  3  to  24  hours.  The  laboratory  may  try  several 
methods  on  the  same  specimen  but  can  make  no  prediction  as  to  the  time 
required  for  the  type  determination.  All  reports  are  sent  as  early  as  is 
consistent  with  accuracy. 

A  brief  outline  of  laboratory  methods  is  given  below. 

1.    Mouse  Methods 

A  white  mouse  is  inoculated,  intraperitoneal^,  with  0.5  to  1  c.c.  of 
washed  and  ground  sputum. 

Two  methods  of  differentiation  of  type  of  pneumococcus  are  then  pos- 
sible: (a)  the  stained  slide  microscopic  agglutination  test,  often  called 
the  Sabin  method,  and  (b)  the  macroscopic  tube  agglutination. 

(a)  The  procedure  for  the  microscopic  typing  is  as  follows:  3  or  4 
hours  after  inoculation,  a  small  amount  of  the  mouse's  peritoneal  fluid  is 
withdrawn  with  a  sterile  capillary  tube  or  hypodermic  syringe.  A  minute 
drop  of  this  fluid  is  expelled  upon  each  of  four  partitions  marked  off  on  a 
glass  slide.  The  first  drop  is  mixed  with  a  loopful  of  saline  for  control 
and  the  others  with  a  loopful  of  diagnostic  serums  types  I,  II  and  III, 
respectively.  The  serums  are  slightly  diluted  to  prevent  group  agglutina- 
tion. The  smears  are  spread  out,  dried  and  Gram  stained.  Examination  is 
made  with  the  oil-immersion  lens.  If  an  agglutination  of  organisms, 
seen  to  be  pneumococci,  takes  place  with  one  of  the  type  serums  a  report 
can  be  made  that  the  organism  is  of  the  corresponding  type.  A  diagnosis 
of  Group  IV  is  made  if  no  reaction  occurs  in  any  of  the  smears.  If  the 
pneumococci  are  not  present  in  sufficient  numbers  for  a  satisfactory  test 
this  procedure  is  repeated  every  hour  until  a  diagnosis  can  be  made. 
After  the  death  of  the  mouse  the  type  may  be  confirmed  by  the  macro- 
scopic tube  agglutination  test. 

(b)  The  macroscopic  tube  agglutination  test  is  performed  in  from  5 
to  24  hours  (averaging  8)  after  inoculation  of  the  mouse.  If  the  mouse 
has  not  died,  an  exploratory  puncture  is  made  and  if  pneumococci  are 
numerous,  the  animal  is  chloroformed.  It  is  then  autopsied  with  aseptic 
precautions.  The  skin  of  the  abdomen  is  laid  back  and  a  longitudinal  slit, 
just  large  enough  to  admit  the  tip  of  a  sterile  bulb  pipette,  is  made  in 
the  abdominal  wall.  A  loopful  of  the  peritoneal  exudate  is  streaked  at 
once  on  one-half  of  a  blood  agar  plate.  The  peritoneal  cavity  is  washed 
thoroughly  with  3  or  4  c.c.  of  sterile  normal  saline,  the  washings  being 
put  into  a  centrifuge  tube.  Then  the  thoracic  cavity  is  opened  and  a  loop- 
ful of  heart's  blood  is  taken  and  streaked  upon  the  other  half  of  the  blood 
agar  plate.  The  peritoneal  washings  are  centrifuged  at  low  speed,  to 
throw  down  body  cells,  and  then  at  high  speed  to  throw  down  the 
pneumococci.  The  supernatant  liquid  from  the  second  centrifuging  is 
decanted  and  tested  for  the  precipitin  antigen.  The  sediment,  which  con- 
sists of  the  organisms,  is  resuspended  in  salt  solution  to  give  a  some- 
what turbid  suspension.  This  suspension  of  pneumococci,  in  0.2  c.c. 
amounts,  is  mixed  with  equal  amounts  of  types  I,  II  and  III  serums  in 
agglutination  tubes.  Another  tube,  containing  0.4  c.c.  suspension  and  0.1 
c.c.  ox-bile,  is  set  up  to  demonstrate  the  bile  solubility  of  the  pneumococci. 

Agglutination  of  a  fixed  type  is  shown  with  the  corresponding  serum. 
Distinct  flaking,  with  a  clearing  of  the  supernatant  liquid,  should  be  seen. 
If  there  is  no  agglutination  it  is  a  Group  IV  pneumococcus.  The  agglutin- 
ation test  is  checked  with  the  precipitin  test  made  by  mixing  the  clear 
supernatant  liquid  from  the  second  centrifuging  with  the  three  fixed  type 
serums.   Usually,  there  is  sufficient  soluble  precipitable  substance  in  this 


164 
diluted  peritoneal  fluid  to  give  a  precipitin  ring  test  if  the  liquid  is  layered 
over  the  serum. 

For  these  macroscopic  tube  tests,  readings  are  made  within  two  hours 
after  incubation  at  55  °C,  observations  being  made  after  15,  30,  60  and 
120  minutes.  On  account  of  the  possible  presence  of  group  agglutinins 
and  precipitins  in  the  serums,  cross  reactions  may  occur  after  prolonged 
incubation. 

The  cultures  made  from  the  heart's  blood  and  the  peritoneal  fluid  are 
used  for  confirmatory  tests.  If  the  pneumococcus  belongs  to  Group  IV, 
further  microscopic  agglutination  tests  are  made  with  all  the  fixed  type 
serums  of  that  group  that  are  available  for  diagnostic  purposes. 

2.    The  Krumwiede  Test  for  Precipitable  Substace  in  the  Sputum. 

This  method  is  tried  on  every  specimen,  if  sufficient  amount  is  received, 
as  it  is  the  quickest  method  of  all. 

From  3  to  10  c.c.  of  sputum  are  transferred  to  a  centrifuge  tube  which 
is  immersed  in  a  water  bath  containing  boiling  water.  When  the  sputum 
is  coagulated,  the  clot  is  broken  up  with  a  glass  rod.  If  less  than  1  c.c. 
of  liquid  is  obtained,  sufficient  saline  is  added  to  make  up  this  amount. 
The  tube  is  replaced  in  the  water  bath  and  the  contents  stirred  several 
times.  Then  the  tube  is  placed  in  the  centrifuge  and  centrifuged  at  high 
speed  for  about  15  minutes.  The  clear  supernatant  liquid  is  layered  over 
an  equal  amount  of  each  of  the  three  type  serums,  used  undiluted.  The 
reaction  usually  occurs  immediately  but  if  it  does  not,  the  tubes  are 
placed  in  the  incubator  at  45  °C.  Frequent  observations  are  made  within 
one  hour,  which  is  the  maximum  time  for  incubation. 

If  no  reaction  is  obtained  with  any  of  the  three  serums,  one  proceeds 
with  a  mouse  test. 

When  it  is  not  possible  to  get  a  good  specimen  of  sputum,  a  sample  of 
urine  may  be  examined  for  the  precipitin  antigen. 

The  urine,  cleared  by  centrifugation,  or,  at  times,  concentrated,  is 
layered  over  the  serums  as  in  any  precipitin  test. 

Urine  examination  is  not  advised  as  a  substitute  for  sputum  typing. 
Urine  may  fail  to  show  a  reaction  even  when  the  patient  has  an  infection 
with  a  fixed  type  pneumococcus. 

Other  substances,  such  as  spinal  fluid  from  cases  of  pneumococcus  men- 
ingitis, blood  and  pleural  fluid  are  either  tested  at  once,  or  inoculated 
into  a  mouse  or  a  suitable  culture  medium,  like  Avery  broth. 

When  the  pneumococcus  is  not  found  in  a  specimen,  other  organisms 
are  identified,  as  far  as  possible.  The  presence  of  hemolytic  streptococci, 
streptococcus  viridans,  Pfeiffer's  bacillus,  Friedlander's  bacillus,  staphy- 
lococci, etc,  is  reported. 

Since  the  laboratory  is  prepared  to  make  exhaustive  tests  on  the  speci- 
mens submitted  for  examination,  physicians  are  urged  to  procure  good 
samples  so  that  accurate  results  may  be  obtained  with  no  loss  or  waste  of 
time.  Specimens  should  be  sent  to  the  laboratory  as  promptly  as  possible, 
preferably  by  messenger.  It  should  be  borne  in  mind  that  pneumococci 
are  short-lived  and  may  undergo  autolysis  within  a  few  hours.  The  most 
successful  results  are  obtained  with  fresh  specimens. 

ANTIPNEUMOCOCC1C  SERUM 

Benjamin  White,  Ph.D. 
Director,  Division  of  Biologic  Laboratories, 
Massachiisetts  Department  of  Public  Health. 
In  the  years  before  the  biologic  classification  of  pneumococci,  the 
preparation  of  antipneumococcic  serum  was  based  largely  upon  empiri- 
cism.    It  was  not  until  1909  that  Neufeld  and  Handel  announced  that 
pneumococci   immunologically  fell  into  two  classes —  one  a  compact 
group  which  they  held  to  be  typical  pneumococci,  and  the   other,  a 
heterogeneous  group  made  up  of  many  sub-groups  or  types.    By  using 
these  "typical  pneumococci"  (which  we  now  designate  as  Type  I)  they 


165 
were  able  to  produce  a  serum  which  was  found  to  have  not  only  specific 
antibodies  for  pneumococci  of  the  typical  group  when  tested  in  the 
laboratory,  but  which  had  definite  curative  action  in  those  human  cases 
of  lobar  pneumonia  where  the  infecting  organism  was  of  this  definite 
type.  From  his  observations  Neufeld  concluded  that  successful  serum 
therapy  depended  upon  having  a  serum  of  high  potency,  specific  for 
the  type  of  the  infecting  pneumococcus ;  upon  giving  the  serum  intraven- 
ously in  large  amounts  so  that  a  high  concentration  of  pneumococcus 
antibody  was  present  in  the  body  at  a  given  time,  and  upon  adminis- 
tering the  serum  in  the  early  stages  of  the  disease. 

In  1913  Dochez  and  Gillespie  announced  a  further  biologic  classifi- 
cation of  pneumococci  into  four  types,  of  which  Type  IV  was  later 
found  to  be  a  heterogeneous  group  of  many  types.  Still  more  recently 
Cooper  has  subdivided  group  IV  into  thirty  separate  types,  and  undoubt- 
edly further  study  will  disclose  additional  types.  Lobar  pneumonia, 
therefore,  must  now  be  looked  upon  not  as  a  clinical  entity,  but  as  a 
disease  of  considerable  bacteriologic  and  immunologic  variation. 

The  facts  that  justify  the  preparation  of  antipneumococcic  serum  as 
well  as  our  faith  in  its  curative  action,  and  those  which  explain  its 
limitations  are  these:  The  injection  into  suitable  animals  of  pneu- 
mococci produces  an  active  immunity  in  such  an  animal  to  the  particu- 
lar type  of  pneumococcus  injected.  The  serum  of  such  an  immune  ani- 
mal is  found  to  contain  antibodies  such  as  agglutinins,  precipitins, 
tropins  and  complement-fixing  and  protective  antibodies,  and  these 
antibodies  are  specific  for  pneumococcus  and  still  more  so  for  the 
particular  type  employed  in  immunizing  the  animal.  Such  a  serum 
when  mixed  with  many  thousand  infecting  doses  of  virulent  pneu- 
mococci will  prevent  the  infection  of  a  susceptible  animal  into  which 
such  a  mixture  is  injected,  or  if  the  serum  is  injected  in  proper 
amounts  a  short  time  after  an  experimental,  and  otherwise  fatal,  in- 
jection of  pneumococci  has  been  made,  it  will  modify  or  abort  the  in- 
fection. Here  again  the  serum  must  correspond  immunologically  to 
the  type  of  pneumococcus  causing  the  infection.  These  facts,  there- 
fore, warrant  our  practice  of  actively  immunizing  horses  and  of  using 
such  an  immune  serum  in  the  treatment  of  lobar  pneumonia  in  human 
beings. 

There  are  other  facts,  however,  that  must  be  borne  in  mind.  One  is 
that  such  a  serum  contains  antibodies  for,  and  can  only  be  efficacious 
against,  the  type  or  types  of  pneumococcus  used  in  immunizing  the 
horse,  and,  therefore,  if  the  case  of  lobar  pneumonia  is  due  to  a  differ- 
ent type  of  pneumococcus  the  serum  can  not  be  expected  to  have  any 
curative  value.  Another  fact  is  that  the  protective  action  of  this  serum 
does  not  follow  the  law  of  multiple  proportions  and,  therefore,  if  the 
infection  is  a  heavy  one  no  amount  of  serum,  however  large,  will  pre- 
vent death.  From  experimental  data  we  know  that  we  can  produce  a 
serum  of  comparatively  high  immunologic  titre  for  Type  I  pneumococ- 
cus, but  in  the  case  of  Type  II  a  serum  of  less  potency  is  the  best  we 
can  accomplish,  while  against  Type  III  no  way  has  yet  been  found  to 
produce  a  serum  having  any  appreciable  protective  action.  For  the 
many  other  types  effective  serums  can  undoubtedly  be  prepared,  but 
because  of  the  number  of  these  types  (some  thirty  at  the  present  time) 
it  has  not  been  practicable  to  make  corresponding  serums  for  all  of 
them. 

I.     Preparation  of  Antipneumococcic  Serum 

1.  Immunization  of  Horses.  Horses  may  be  immunized  against  a 
single  type  or  against  two  or  more  types  of  pneumococci.  It  is  the 
usual  practice  to  use  a  strain  of  Type  I  or  Type  II  alone,  or  a  strain 
of  each  of  these  two  types  together.  Pure  cultures  of  high  virulence 
for  mice  are  grown  in  broth,  and  at  the  height  of  growth  are  cen- 
trifuged  out  of  the  broth  and  killed  either  with  formalin  or  by  a  mod- 


166 
erate  degree  of  heat.  Standardized  and  gradually  increasing  amounts 
Of  these  killed  pneumococci  are  injected  intravenously  into  the  horse 
on  three  successive  days,  and  after  an  interval  of  a  week  a  similar 
series  of  injections  is  made.  This  procedure  is  repeated  until  the  serum 
of  the  horse  shows  a  satisfactory  content  of  protective  antibodies. 
The  horse  is  bled  at  intervals  of  three  to  four  weeks,  the  blood  is  al- 
lowed to  clot  and  the  serum  drawn  off  under  aseptic  precautions. 

2.  Unconcentrated  Serum.  If  the  unconcentrated  serum  is  to  be  used, 
a  preservative  (0.35  per  cent  Trikresol)  is  added  and  the  serum  al- 
lowed to  age  in  the  cold  for  at  least  two  months.  Its  sterility  is  tested 
by  the  method  recommended  by  the  National  Institute  of  Health,  and 
the  serum  is  then  bottled  and  the  sterility  of  the  final  containers  tested. 
Potency  tests  are  carried  out  in  a  manner  to  be  described.  Such  a 
serum  contains  from  eight  to  ten  per  cent  of  serum  proteins  and  since 
this  serum  is  usually  administered  in  doses  of  one  hundred  cubic  centi- 
meters or  more,  it  causes  serum  sickness  in  a  large  percentage  of 
patients. 

3.  Concentrated  Serum.  There  are  several  methods  used  for  the  refine- 
ment of  antipneumococcic  serum,  and  they  all  have  as  their  purpose  the 
concentration  of  specific  antibodies  as  well  as  the  elimination  of  non- 
immune serum-proteins  which  give  rise  to  shock,  thermal  reactions 
and  serum  sickness.  One  of  the  first  preparations  of  concentrated 
serum  was  the  "Pneumococcus  Antibody  Solution"  of  Huntoon.  He  and 
his  coworkers,  modifying  and  utilizing  the  specific  absorption  method 
of  Gay  and  Chickering,  produced  a  preparation  that  contained  in  con- 
centrated form  the  specific  pneumococcus  antibodies  present  in  the 
original  serum.  Although  Huntoon  succeeded  in  removing  the  other 
serum  proteins  to  a  remarkable  degree,  his  antibody  solution  was  said 
to  give  severe  thermal  reactions,  so  clinicians  have  turned  to  serum 
concentrated  by  chemical  means. 

Avery  first  showed  that  the  protective  antibody  could  be  separated 
from  the  other  proteins  of  antipneumococcus  serum  by  fractional  pre- 
cipitation with  ammonium  sulphate,  but  beyond  establishing  this  fact 
he  did  not  develop  a  routine  method  for  the  concentration  of  this 
serum.  The  extended  studies  by  Felton  have  given  us  two  methods 
which  have  been  generally  employed  in  making  the  various  prepara- 
tions of  concentrated  antipneumococcic  serum,  or  concentrated  anti- 
body solution,  which  have  been  used  in  the  majority  of  clinical  ob- 
servations. 

The  Felton  method  usually  employed  before  the  announcement  of 
his  alcohol  method,  consisted  in  adding  the  whole  antipneumococcic 
serum  to  an  equal  volume  of  distilled  water  at  70  to  80°C.  and  then 
precipitating  out  the  antibodies  with  neutral  sodium  sulphate  at 
35  to  40°C.  This  precipitate  was  dialyzed  to  free  it  from  the  sulphate. 
When  in  solution  it  was  acidified  and  centrifuged  to  precipitate  ex- 
traneous protein.  The  desired  antibodies  left  in  solution  were  then  iso- 
lated by  pouring  the  solution  into  cold  distilled  water,  whereupon  they 
separated  out.  This  precipitate  was  dissolved  in  3  per  cent  sodium 
chloride  solution  containing  0.2  to  0.4  per  cent  phenol  as  a  preserva- 
tive, the  solution  was  filtered  through  a  Berkefeld  (bacteria  proof) 
filter,  tested  for  sterility  and  potency,  bottled,  again  tested  for  steril- 
ity and  distributed  in  15  c.c.  vials,  labelled,  according  to  the  National 
Institute  of  Health's  regulation,  "Antipneumococcic  Serum,  Concen- 
trated," or  often  as  "Pneumococcus  Antibody  Solution." 

Felton  has  recently  described  a  different  method  which  he  considers 
to  be  an  improvement  over  his  former  procedure.  Instead  of  making 
his  initial  precipitation  of  antibodies  with  sodium  sulphate  he  now 
uses  alcohol  in  a  concentration  of  15  to  20  per  cent  at  a  temperature 
of  about  zero  C.    This  precipitate  is  washed  in  chilled  water,  and  then 


167 
dissolved  in  sodium  chloride  solution  containing  0.4  per  cent  phenol 
as  a  preservative.    The  antibody  solution  is  filtered  through  a  Berke- 
feld  filter,  tested  for  sterility  and  potency,  bottled  and  again  tested 
for  sterility  and  distributed  under  the  names  already  given. 

Concentrated  antipneumococcic  serum  prepared  by  either  of  the  Fel- 
ton  methods  contains  the  specific  pneumococcus  antibodies,  largely 
freed  from  other  serum  proteins  and  rarely  contains  more  than  10  to 
12  per  cent  of  solids.  It  is,  therefore,  far  less  likely  to  give  rise  to 
serum  sickness  than  the  unconcentrated  serum  and  in  clinical  use  it 
is  found  to  be  well  borne  by  the  pneumonia  patient. 

4.  Standardization  of  Antipneumococcic  Serum.  At  the  present  time 
there  are  two  methods  used  for  testing  the  potency  of  antipneumoc- 
cic  serum.  These  are  the  method  recommended  by  the  National  Insti- 
tute of  Health  and  that  recommended  by  Felton.  They  both  have  as 
their  purpose  the  determination  of  the  amount  of  protective  antibody 
contained  in  a  given  volume  of  serum,  which  is  accomplished  by  find- 
ing whether  a  definite  amount  of  serum  will  protect  albino  mice 
against  a  standard  dose  of  a  virulent  culture  of  pneumococcus.  In 
both  methods  a  standard  control  serum  is  included  in  the  tests  for 
comparison  with  the  serum  being  tested.  Determinations  of  Types  I 
and  II  antibodies  are,  of  course,  made  separately. 

In  the  Felton  method  the  potency  of  any  given  lot  is  determined  by 
comparing  the  highest  dilution  of  the  sample  which  will  protect  at 
least  two  of  three  mice  for  twenty-four  hours  against  a  standard 
amount  of  virulent  culture  of  pneumococci  with  the  highest  dilution  of 
the  control  serum  which  will  give  the  same  degree  of  protection.  The 
determined  potency  is  stated  in  units. 

This  concentrated  antipneumococcic  serum  or  concentrated  antibody 
solution  is  usually  given  an  expiration  date  of  about  six  months  but  the 
sooner  after  its  preparation  date  it  is  used  the  greater  its  potency  should 
be  and  the  less  likely  it  is  to  produce  immediate  constitutional  reactions. 
Because  this  serum  is  of  equine  origin  great  care  should  be  taken  before 
and  during  its  administration  in  order  to  avoid  anaphylactic  shock,  and 
the  precautions  advised  in  the  circular  of  directions  accompanying  the 
product  should  always  be  observed. 

5.  Curative  Action  of  Antipneumococcic  Serum.  This  serum  is  anti- 
bacterial and  not  antitoxic.  Although  the  details  of  its  curative  action 
in  lobar  pneumonia  are  not  fully  known,  we  do  know  that  it  has  no  direct 
killing  effect  on  pneumococci.  It  is  assumed  upon  good  evidence  that  its 
content  of  protective  antibody  is  the  index  of  its  therapeutic  potency  and 
that  tropins  and  agglutinins  may  contribute  to  its  antagonistic  action 
against  the  infecting  pneumococci. 

6.  Administration  of  Antipneumococcic  Serum.  Although  directions 
for  the  administration  of  this  serum  are  given  elsewhere  in  this  number 
of  "The  Commonhealth,"  certain  facts  may  be  emphasized  here.  It  has 
been  possible  to  produce  a  potent  serum  for  Type  I  pneumococcus  infec- 
tions and  in  a  lesser  degree  for  Type  II  infections,  but  so  far  it  has  been 
impossible  to  prepare  a  serum  of  satisfactory  potency  for  Type  III  infec- 
tions. Although  specific  serums,  either  monovalent  or  polyvalent,  for  the 
other  types  of  pneumococci  are  being  made,  their  preparation  and  use  are 
still  in  the  experimental  stage.  Therefore,  for  patients  suffering  from 
lobar  pneumonia  due  to  Type  I  or  Type  II  infection  either  monovalent  or 
bivalent  Type  I  or/and  Type  II  serum  should  be  used.  Serum  treatment 
should  begin  as  soon  as  the  clinical  diagnosis  of  lobar  pneumonia  is  made 
but  it  should  be  stopped  if  a  type  determination  shows  that  the  infecting 
pneumococcus  is  of  any  type  other  than  I  or  II.  Furthermore,  since  it  is 
necessary  to  have  the  antibodies  in  the  blood  in  a  high  concentration  and 
before  an  overwhelming  number  of  pneumococci  are  present  in  the  body, 
the  serum  should  be  given  in  as  large  doses  as  are  compatible  with  the 


168 
well-being  of  the  patient,  always  intravenously  and  at  the  earliest  possible 
moment  in  the  course  of  the  disease.    It  is  doubtful  if  the  serum  can  be 
efficacious  when  administered  after  the  fourth  day. 

7.  Serum  Treatment  of  Pneumococcus  Meningitis.  In  case  of  menin- 
gitis caused  by  pneumococci,  the  administration  of  concentrated  anti- 
pneumococcic  serum  is  indicated,  and  its  administration  should  be  gov- 
erned by  the  same  considerations  as  apply  to  the  administration  of  anti- 
meningococcic serum  in  meningococcus  meningitis.  It  may  be  given  both 
intraspinally  and  intravenously  but  it  can  only  be  expected  to  be  of  pos- 
sible value  in  cases  due  to  Types  I  or  II  pneumococci. 

It  should  be  remembered  that  antipneumococcic  serum  is  still  in  an 
early  stage  of  its  development,  and  that  because  of  its  very  nature,  as 
well  as  the  nature  of  the  disease  against  which  it  is  employed,  its  use  and 
effects  are  somewhat  limited.  When  used,  however,  in  suitable  cases  and 
according  to  the  latest  directions,  it  is  an  agent  of  curative  value  in  cases 
of  lobar  pneumonia  due  to  infections  with  Types  I  and  II  pneumococci. 

Antipneumococcic  serum  for  Types  I  and  II  pneumococci,  concentrated  by  the  methods  of 
Felton  is  now  being  manufactured  at  the  Massachusetts  Antitoxin  and  Vaccine  Laboratory 
under  a  grant  from  the  Commonwealth  Fund  of  New  York  City  and  is  available  only  for 
hospitals  and  physicians  cooperating  in  the  special  Pneumonia  Study  and  Service.  This  product 
is  also  manufactured  by  some  of  the  commercial  laboratories  and  can  be  purchased  from  their 
district  branches  or  local  distributors. 

NURSING  CARE  OF  THE  PNEUMONIA  PATIENT 

Walborg  Peterson,  R.  N. 

Head  Nurse,  7th  floor,  Baker  Memorial  Hospital, 

Boston,  Massachusetts. 

It  is  considered  that  efficient  nursing  care  is  one  of  the  essential  fea- 
tures in  the  treatment  of  pneumonia.  Perhaps  there  is  no  disease  in 
which  a  nurse  plays  a  more  important  role  than  during  its  short  course 
of  a  week  or  ten  days,  not  only  by  giving  good  nursing  care  but  by  being 
constantly  on  the  alert  to  detect  any  change  until  the  danger  of  compli- 
cations is  passed.  The  early  recognition  of  any  new  symptom  enables 
the  physician  to  control  its  development  and  also  to  prescribe  the  neces- 
sary treatment. 

From  the  very  beginning  of  the  disease  the  nurse  should  maintain  a 
calm  manner  and  radiate  reassurance  to  both  the  patient  and  other  mem- 
bers of  the  family.  A  great  many  of  the  lay  people,  anticipating  a  fatal 
outcome,  are  more  or  less  apprehensive  in  regard  to  this  disease.  There- 
fore, her  chief  efforts  should  be  to  keep  the  patient  perfectly  quiet  and  the 
surrounding  atmosphere  as  cheerful  and  comfortable  as  possible.  The 
general  principles  of  the  nursing  care  are:  rest,  administration  of  fluids, 
proper  elimination  and  relief  of  any  pain  or  distressing  symptoms.  The 
treatment  prescribed  by  the  physician  is  in  relation  to  the  symptoms 
which  are  present  or  which  develop.  Many  people  are  unable  to  receive 
hospital  care  but  equally  favorable  results  are  obtained  in  the  home.  The 
important  thing  to  remember  if  the  patient  is  treated  at  home  is  that 
his  bed  be  in  a  room  with  cool  and  fresh  air  but  free  from  drafts,  noises 
and  household  cares.  Because  pneumonia  is  an  infectious  disease,  the 
nurse  should  observe  very  careful  precaution  technique  and  prevent 
spreading  to  others  and  herself.  The  sputum  may  be  destroyed  and  the 
bed  linen,  towels,  dishes  and  utensils  boiled. 

In  many  instances  a  sudden  chill  occurs  before  the  physician  arrives. 
The  chill  followed  by  the  abrupt  rise  in  temperature  is  usually  the  pre- 
liminary symptom  of  lobar  pneumonia.  The  chill  may  be  controlled  to 
some  extent  with  the  application  of  heat  in  various  forms,  such  as  blank- 
ets, hot  water  bags  and  hot  drinks.  The  temperature  should  be  taken  soon 
after  the  chill  and  every  four  hours  thereafter.  In  order  to  insure  accur- 
acy while  the  fever  persists  it  is  important  that  the  temperature  be  taken 
rectally  because  of  coughing  and  mouth  breathing.   The  temperature  runs 


169 

a  course  between  102  to  104  degrees  until  the  crisis  or  lysis  appears.  The 
rise  in  temperature  in  bronchial  pneumonia  is  more  gradual  and  its  course 
is  more  irregular.  The  pulse  and  respirations  are  very  rapid  and  in  pro- 
portion to  the  degree  of  temperature.  They  should  be  watched  very  care- 
fully for  any  variation  and  reported  immediately  if  any  change  occurs. 

Pleurisy  is  a  condition  which  is  present  soon  after  the  onset  of  the 
disease.  Every  effort  should  be  made  to  relieve  the  pleuritic  pain  as  it 
not  only  causes  general  discomfort  but  also  adds  considerably  to  the  res- 
piratory embarrassment.  A  chest  swathe  may  be  made  from  firm  outing 
flannel  and  applied  for  immobilization  of  the  chest.  Shoulder  straps  of 
bandage  should  be  used  to  help  keep  the  binder  in  place.  As  it  has  a 
tendency  to  loosen  very  easily  and  then  become  wrinkled,  it  is  necessary 
to  adjust  it  frequently.  Adhesive  strapping  applied  to  the  affected  area 
by  the  physician  sometimes  gives  more  relief.  Local  application  of  heat 
is  often  used  to  great  advantage.  This  may  be  applied  in  the  form  of  a 
hot  water  bag,  mustard  plaster  or  mustard  paste.  If  a  mustard  paste 
is  ordered  it  may  be  made  in  the  following  manner:  for  an  adult  use  4 
dessert  spoons  of  flour,  2  dessert  spoons  of  mustard,  1  dessert  spoon  of 
cottonseed  or  olive  oil.  For  a  child  the  proportion  should  be  4  dessert  spoons 
of  flour  to  1  dessert  spoon  of  mustard.  Mix  the  flour  and  mustard  together 
and  add  the  oil,  then  add  enough  lukewarm  water  to  make  a  paste.  A  piece 
of  cheese  cloth  or  soft  cloth  about  10  x  7  inches  is  good  for  applying  this. 
Spread  the  mixture  on  one  half  of  the  cloth,  allowing. about  one  half  inch 
of  the  edges  to  fold  over  the  paste,  then  cover  the  paste  with  the  other 
half  of  the  cloth.  Apply  to  the  patient's  affected  area,  allowing  it  to  re- 
main there  for  15-30  minutes.  The  skin  should  be  observed  at  frequent 
intervals  for  reddening  or  blistering,  and  if  such  occurs  remove  mustard 
paste  immediately.  If  these  procedures  fail  to  give  the  desired  relief, 
codeine  or  morphine  is  indicated  and  should  be  given  frequently  to  con- 
trol the  distress.  The  cough  is  very  troublesome  to  the  patient,  but  it 
is  necessary  to  a  certain  degree  to  raise  the  sputum.  The  color  and  con- 
sistency of  the  sputum  serves  a  great  purpose  in  determining  the  diag- 
nosis. During  the  early  stages  of  the  disease  a  specimen  should  be  sent 
to  a  laboratory  for  examination  and  typing.  The  sputum  of  lobar  pneu- 
monia, often  scanty  at  first,  is  a  rusty  color  and  very  tenacious.  In  the 
bronchial  type,  it  is  more  purulent  and  the  quantity  is  often  greater.  The 
twenty-four  hour  amount  should  be  carefully  measured  and  reported  to 
the  physician  daily.  The  cough  is  often  quite  persistent  throughout  the 
illness,  which  adds  decidedly  to  the  patient's  restlessness.  It  should, 
therefore,  be  controlled  with  respiratory  sedatives  as  much  as  possible. 
Cough  syrups  with  codeine  may  be  given  as  often  as  every  two  hours,  but, 
if  ineffective,  morphine  or  larger  doses  of  codeine  should  be  given  by 
mouth  or  subcutaneously  until  relief  is  obtained.  Opiates  should  be 
avoided  if  the  cough  is  too  productive  as  it  has  a  tendency  to  lessen  the 
cough  reflexes  and  prevents  expectoration.  Herpes  or  fever  blisters, 
often  present  on  the  lips  and- nose  may  be  treated  with  white  vaseline  or 
cold  cream  to  lips,  and  drops  of  liquid  albolene  or  Russian  oil  to  each 
nostril  as  often  as  necessary. 

As  the  disease  develops  the  dyspnea  becomes  more  marked.  It  is  char- 
acterized by  the  short,  rapid  and  often  grunting  respirations,  which  may 
be  greatly  exaggerated  when  pleurisy  is  present.  This  dyspnea  may  be 
relieved  to  a  certain  degree  by  elevation  of  the  patient  in  bed.  The  head 
and  knees  are  raised  so  that  he  is  practically  in  a  sitting  position.  Any 
device  which  will  give  the  necessary  inclining  support  such  as  an  ordinary 
kitchen  chair,  suit  bag  or  packing  box,  will  serve  the  purpose  when  a 
Gatch  bed  or  back  rest  is  not  available.  The  chair,  for  instance,  may  be 
placed  on  top  of  the  mattress  in  such  a  fashion  that  the  pillows  rest  on 
the  back  of  the  chair.  It  may  be  kept  in  position  by  tying  the  legs  of  the 
chair  to  the  bedstead.  Often  more  satisfactory  results  are  obtained  by 
placing  the  chair  between  the  mattress  and  the  spring.    Sufficient  pillows 


170 
may  be  used  for  comfort  and  support  of  the  head  and  knees.  All  efforts 
should  be  used  to  prevent  the  patient  from  slipping  down  in  bed  as  it 
adds  considerably  to  his  discomfort.  A  bolster,  made  by  rolling  a  pillow 
into  a  diagonally  folded  sheet,  may  be  placed  under  the  patient's  thighs 
and  tied  to  either  side  of  the  bed.  In  most  cases  this  simple  procedure 
furnishes  very  gratifying  results  in  maintaining  the  proper  position.  The 
bedclothing  should  be  warm  but  lightweight.  Ordinarily  the  patient  per- 
spires quite  freely  so  that  an  adequate  supply  of  linen  should  be  kept  on 
hand  to  provide  for  frequent  changing.  Flannel  nightgowns  provide  the 
greatest  warmth  and  comfort.  Sometimes  it  is  impossible  to  keep  the 
bedclothing  over  the  patient's  shoulders,  not  only  because  of  his  upright 
position  in  bed,  but  also  because  of  his  periods  of  restlessness.  It  is  there- 
fore necessary  that  a  shoulder  blanket  or  shawl  be  placed  about  the 
patient's  shoulders  for  added  protection. 

Absolute  rest  is  essential  as  long  as  any  fever  persists.  Any  physical 
effort  which  may  fatigue  the  patient  should  be  eliminated  as  much  as 
possible.  Daily  baths  may  be  given,  but  the  patient  should  be  guarded 
against  the  slightest  exertion,  having  every  move  made  for  him.  Alcohol 
sponges  are  necessary  when  the  temperature  is  103-104  degrees,  and 
may  be  given  as  often  as  every  four  hours.  This  not  only  aids  in  reduc- 
ing the  temperature  but  also  produces  a  sedative  effect.  He  should  be 
turned  at  frequent  intervals  for  back  rubbing  and  gentle  massage  in 
order  to  prevent  too  continuous  pressure  on  the  bony  prominences. 
Hygiene  of  the  mouth  must  be  carefully  watched  by  using  mild  antiseptic 
mouth  solutions  after  each  nourishment.  The  patient  is  never  allowed  to 
become  restless  at  night  as  sleep  is  essential.  Luminal  or  allonal  is  often 
very  efficacious.  If  he  does  not  respond  well  to  these  mild  sedatives  or 
if  delirium  and  pain  are  present  morphine  should  be  given  at  frequent 
intervals. 

Solid  foods  are  not  necessary  during  this  brief  illness  and  are  poorly 
borne  by  the  patient.  However,  it  is  desirable  to  give  an  adequate  amount 
of  fluids  and  carbohydrates  in  an  easily  assimilable  form — chiefly  as 
liquids.  The  liquid  diet  should  consist  of  water,  milk,  and  fruit  juices 
which  may  be  varied  as  much  as  possible.  The  amount  of  liquid  allowed 
the  patient  during  the  twenty-four  hours  should  not  exceed  100-120 
ounces.   The  output  of  urine  should  be  carefully  estimated  daily. 

Distention  is  a  condition  which  is  most  always  present  and  requires 
constant  attention.  If  the  distention  becomes  severe  it  causes  increased 
respiratory  disturbances  and  also  general  discomfort.  It  is  imperative  to 
control  this  condition  as  much  as  possible.  If  the  patient  does  not  have 
a  daily  bowel  movement  an  enema  should  be  given.  Sometimes  mild 
cathartics  are  given  in  small  doses  and  at  frequent  intervals  with  excel- 
lent result.  If  castor  oil  is  ordered  it  may  be  prepared  in  a  manner  in 
which  it  may  be  thoroughly  disguised  by  mixing  the  juice  of  one  orange 
to  the  amount  of  castor  oil  ordered  and  adding  a  pinch  of  bicarbonate  of 
soda.  This  entirely  changes  the  consistency  from  an  oily  substance  to  a 
light  and  foamy  preparation.  For  further  relief  of  the  distention  a  purga- 
tive enema  may  be  necessary.  If  a  milk  and  molasses  enema  is  ordered, 
use  six  ounces  of  each.  Warm  the  milk  and  add  the  molasses  slowly.  The 
patient  should  retain  this  from  a  half  to  one  hour  if  possible.  In  an  hour 
a  plain  water  enema  should  be  given.  An  enema  of  two  ounces  each  of 
magnesium  sulphate,  glycerine  and  water  sometimes  produces  excellent 
gas  results.  Stuping  is  also  a  method  by  which  the  distention  may  be 
relieved.  During  the  process  of  stuping  a  rectal  tube  should  be  inserted 
to  allow  for  the  escape  of  gas.  Use  four  parts  of  cottonseed  oil  or  olive 
oil  to  two  parts  of  turpentine  and  apply  with  a  small  absorbent  applicator 
to  the  abdomen.  Then  wring  the  stupe  cloth  from  hot  water  and  apply 
to  abdomen.  Care  should  be  used  to  avoid  burning  patient.  The  stupe 
may  be  replaced  by  another  hot  one  as  soon  as  the  previous  one  has  cooled. 
This  process  may  continue  from  15  to  20  minutes  and  also  may  be  repeated 


171 
every  hour  until  relief  is  obtained.   The  turpentine  mixture  should  never 
be  applied  more  than  once  in  24  hours  on  account  of  blistering  the  skin 
and  absorption.   If  the  patient  finally  does  not  respond  to  this  treatment, 
subcutaneous  injections  of  pituitrin  or  physostigmin  are  necessary. 

Cyanosis  is  nearly  always  present,  sometimes  in  a  very  mild  degree.  It 
is  caused  by  the  lack  of  the  proper  supply  of  oxygen  to  the  lungs.  If  it 
becomes  severe  the  administration  of  oxygen  is  indicated,  which  may  be 
given  with  a  small  nasal  catheter.  The  greatest  relief  is  obtained  from 
the  oxygen  tent.  Definite  improvement  is  observed  almost  instantly.  The 
patient's  breathing  is  less  labored,  the  quality  of  his  pulse  improves  and 
his  restlessness  diminishes.  The  amount  of  oxygen  supply  to  the  tent  is 
regulated  by  the  physician  and  carefully  watched  by  the  nurse.  It  is  not 
necessary  to  remove  the  tent  while  fluids  are  being  given. 

The  patient  should  be  watched  carefully  for  any  circulatory  disturb- 
ances. In  case  there  are  any  signs  of  irregularity  or  weakness  of  the 
pulse  it  should  be  reported  to  the  physician  at  once.  Stimulants  such  as 
digitalis  or  caffeine  are  frequently  given  by  mouth  or  by  subcutaneous 
methods.  When  digitalization  is  necessary  the  nurse  should  watch  care- 
fully for  toxicity,  evidenced  by  vomiting  and  dropping  of  pulse  to  60  or 
below.  Alcoholic  stimulants  are  often  given  in  small  amounts  and  at 
frequent  intervals. 

Pneumonia  usually  has  a  characteristic  ending  by  crisis  or  lysis.  The 
patient  appears  before  the  crisis  occurs  as  though  he  were  on  the  verge 
of  collapse,  when  rather  rapidly  there  is  a  marked  drop  in  tempera- 
ture, the  pulse  and  respirations  are  correspondingly  lowered  and  on  the 
whole  he  looks  much  better  and  seems  more  comfortable.  Sometimes  the 
temperature  has  a  less  spectacular  drop,  coming  down  gradually  by  lysis. 
This  occurrence,  whether  by  lysis  or  crisis,  means  that  the  patient  has 
acquired  the  necessary  immunity  to  conquer  the  disease.  If  the  patient 
does  not  have  the  customary  lysis  or  crisis  he  has  not  become  immune, 
and  the  pneumonia  spreads  and  there  is  evidence  of  extreme  toxemia. 
Death  usually  results. 

If  the  patient  has  Type  I  or  Type  II  pneumonia,  serum  treatment  is  in- 
dicated and  is  given  very  early  in  the  disease.  It  often  causes  a  crisis  soon 
after  administration.  The  patient  should  be  watched  very  carefully  fol- 
lowing the  injections  for  any  signs  of  urticaria,  increased  dyspnea, 
asthmatic  breathing  or  any  other  untoward  reaction. 

Although  he  may  seem  cured  it  is  imperative  to  watch  carefully  for  any 
symptoms  of  relapse.  If  the  temperature,  after  being  normal  for  several 
days,  rises  suddenly  and  pulse  and  respirations  are  increased  it  should 
be  reported  at  once.  If  he  complains  of  any  pain  or  soreness  in  either 
leg  accompanied  with  slight  rise  in  temperature,  phlebitis  should  be 
suspected  and  reported  immediately  to  the  physician.  Otitis  media  is 
often  a  secondary  condition  characterized  by  earache,  tenderness  around 
the  ear  or  a  discharge.  Empyema  is  a  very  common  complication  and  any 
sign  of  it  should  be  reported. 

The  period  of  convalescence  is  of  tremendous  value  as  the  patient  has 
been  through  a  very  severe  illness  and  his  strength  has  been  exhausted. 
He  should  be  kept  quiet  in  bed  for  a  week  or  so,  or  until  the  physician 
feels  that  it  is  safe  for  him  to  get  up.  If  he  can  be  put  out  of  doors  con- 
veniently it  will  be  of  great  benefit  to  him.  When  he  is  ready  to  sit  up 
the  periods  should  be  short  at  first,  then  gradually  increased,  so  that  the 
patient  may  not  become  overtaxed  and  be  subjected  to  the  danger  of  a 
relapse. 


172 
THE  MASSACHUSETTS  PNEUMONIA  PLAN 

Roderick  Heffron,  M.D. 

Field  Director,  Pneumonia  Study  and  Service 
Massachusetts  Department  of  Public  Health 

In  the  State  of  Massachusetts  there  are  few  diseases  that  cause  as 
many  or  more  than  2000  deaths  a  year,  and  of  those  diseases  there  is 
only  one  that  has  received  little  intensive  study  by  this  Department,  and 
that  is  lobar  pneumonia.  Lobar  pneumonia  causes  more  deaths  annually 
in  this  State  than  any  other  infectious  disease,  excepting  pulmonary 
tuberculosis. 

Large  sums  of  money  have  been  spent  in  studying  many  of  the  common 
and  often  less  fatal  diseases  and  in  devising  adequate  methods  for  their 
treatment,  control  and  prevention.  Approximately  90%  of  our  lobar 
pneumonias  are  caused  by  pneumococcus  infections.  Up  to  the  present 
time,  there  are  relatively  few  known  administrative  measures  that  can 
be  taken  that  in  any  way  control  or  prevent  lobar  pneumonia.  It  is  for 
this  reason  that  it  was  deemed  wise  a  few  years  ago  to  devote  such  funds 
as  were  available  to  the  one  phase  of  handling  this  problem  that  seemed 
most  promising — namely,  the  treatment  of  cases  of  lobar  pneumonia  with 
specific  antipneumococcic  serum.  For  this  reason  a  few  years  ago,  the 
State  Department  of  Public  Health  at  its  Antitoxin  and  Vaccine  Labora- 
tory at  Forest  Hills  began  the  manufacture  and  distribution  of  such  sera 
for  the  treatment  of  patients  ill  with  lobar  pneumonia.  Cole,  Cecil,  Park 
and  others  have  shown  rather  conclusively  the  benefits  derived  from  the 
use  of  specific  immune  sera  in  the  treatment  of  many  cases  of  lobar  pneu- 
monia. It  was  further  shown  that  to  be  effective  the  serum  must  be  given 
early  in  the  course  of  the  disease  (during  the  first  four  days  of  the  ill- 
ness) and  that  the  serum  is  effective  only  when  patients  are  ill  with  a 
Type  I  or  Type  II  pneumococcus  infection. 

Such  a  plan  of  limiting  the  use  of  this  serum  to  cases  of  Type  I  or  Type 
II  pneumococcus  pneumonia  treated  early  in  the  course  of  their  illness 
necessitated  the  establishment  of  a  laboratory  that  could  complete  a  pneu- 
mococcus typing  within  a  few  hours  of  receiving  the  specimen.  Con- 
sequently, a  typing  station  was  established  by  the  bacteriological  lab- 
oratory of  the  State  Department  of  Public  Health  in  the  State  House  at 
Boston  which,  because  of  its  distance  from  the  outlying  communities  of 
the  State,  militated  against  the  early  use  of  antipneumococcic  serum  in 
cases  of  pneumococcus  lobar  pneumonia  in  these  remote  areas  as  usually 
physicians  were  not  called  to  see  their  patient  until  two  or  three  days 
had  elapsed  and  by  the  time  sputum  had  been  sent  to  the  State  House, 
typed  and  the  report  returned  to  the  physician,  it  was  usually  too  late  to 
give  the  serum  with  any  hope  of  benefit. 

About  two  years  ago,  the  State  began  the  manufacture  and  distribu- 
tion of  Felton's  concentrated  antipneumococcic  serum  which  because  of 
its  effectiveness,  its  ease  of  administration,  freedom  from  chill  reactions, 
and  lessening  of  serum  sickness  had  much  to  recommend  it.  Clinical 
trial  has  since  shown  the  value  of  such  sera  as  evidenced  by  the  writings 
of  Cecil,  Park,  Baldwin,  Sutliff,  and  others.  This  Department  attempted 
to  have  case  records  filled  out  by  the  physicians  using  such  sera  concen- 
trated at  the  State  Antitoxin  and  Vaccine  Laboratory  and  received  152 
reports  of  cases  so  treated.  In  view  of  the  great  cost  of  this  serum  in  its 
final  concentrated  form,  it  seemed  that  from  the  public  health  standpoint 
the  expense  of  producing  antipneumococcic  serum  was  out  of  proportion 
to  its  then  limited  use  in  relation  to  other  biological  products. 

It  was  felt  that  if  we  were  in  possession  of  more  knowledge  regarding 
the  epidemiology  of  this  disease,  could  speed  its  clinical  and  bacteriolog- 
ical diagnosis  and  the  early  commencement  of  serum  treatment;  if  we 
better  understood  the  immunological  principles  underlying  serum  produc- 
tion and  could  produce  a  more  potent  and  highly  concentrated  serum,  and 
if  means  could  bo  found  to  place  this  serum  at  the  command  of  the  practi- 


lis 

tioner  in  the  field  where  treatment  could  be  begun  earlier  we  could  soon 
learn  whether  this  method  of  treating  pneumonia  was  practical  on  a  State- 
wide basis. 

Inasmuch  as  such  valuable  information  would  effect  other  states  in  their 
pneumonia  program,  it  was  decided  to  secure  if  possible,  financial  aid 
from  some  philanthropic  foundation.  A  plan  was  drawn  up  for  an  elab- 
orate study  of  this  disease  and  was  submitted  to  the  officers  of  the  Com- 
monwealth Fund  of  New  York  City.  The  plan  was  accepted  by  that 
Foundation  and  they  have  granted  this  Department  an  annual  sum  of 
money  for  a  period  of  three  years  with  a  tentative  agreement  of  addi- 
tional support  for  another  two  years  if  the  results  of  the  first  three  years' 
study  merit  its  continuance. 

The  pneumonia  study  in  this  State  is  being  carried  on  with  the  aid  of 
a  special  Advisory  Committee  composed  of  Doctors  Edwin  S.  Calderwood, 
Arthur  Cushing,  Roger  I.  Lee,  Edwin  A.  Locke,  Frederick  T.  Lord,  Robert 
N.  Nye,  Arthur  E.  Parkhurst,  Joseph  H.  Pratt,  Milton  J.  Rosenau,  Wilson 
G.  Smillie,  and  George  L.  Walker. 

This  Committee  has  decided  that  certain  hospitals  should  be  selected 
because  of  the  service  they  could  render  pneumonia  cases  in  their  respec- 
tive areas.  The  hospitals  selected  must  have  or  agree  to  have  a  special 
pneumonia  service  which  shall  select  the  proper  cases  for  treatment,  have 
pneumococcus  typing  done,  and  serum  treatment  begun  with  the  least 
possible  delay,  and  follow  treated  cases  with  suitable  laboratory  work, 
such  as  blood  counts  and  cultures  and  any  other  bacteriologic  or  path- 
ologic examinations  that  may  be  necessary.  Detailed  clinical  histories 
and  case  reports  are  returned  to  us  on  special  record  blanks  supplied  by 
this  Department  for  all  cases  treated. 

The  plan  is  to  have  various  laboratories  conveniently  located  over  the 
State  chosen  as  pneumococcus  typing  centers.  The  technicians  of  these 
laboratories  will  be  trained  at  the  expense  of  the  Pneumonia  Service  Fund 
in  the  proper  methods  of  pneumococcus  typing.  In  addition,  the  bacterio- 
logical laboratory  of  the  State  Department  of  Public  Health  will  continue 
to  do  pneumococcus  typing  free  of  charge  to  all  physicians  in  the  State. 

Further,  in  order  that  the  most  recent  advances  in  the  diagnosis  and 
treatment  of  lobar  pneumonia  may  be  made  generally  available  to  all 
physicians,  a  one  day  pneumonia  course*  is  being  offered  by  Harvard 
Medical  School  through  its  courses  for  graduates.  This  course  has  been 
given  in  Boston  this  fall  and  will  be  offered  in  other  cities  in  the  State 
wherever  there  is  sufficient  demand.  The  curriculum  includes  a  discussion 
of  the  epidemiology,  clinical  diagnosis,  surgical  complications,  and  treat- 
ment of  the  disease  with  special  attention  paid  to  methods  of  bacterio- 
logical diagnosis,  the  importance  and  newer  technique  of  pneumococcus 
typing  and  serum  treatment. 

In  a  given  location  which  is  to  be  served  by  the  typing  station  in  that 
area  a  few  local  physicians  will  be  selected  by  our  Advisory  Committee  on 
pneumonia  to  serve  as  our  clinical  collaborators  or  consultants.  The 
selected  physicians  will  have  the  concentrated  antipneumococcic  serum  for 
distribution  to  the  proper  cases.  Every  physician  in  the  area  who  has  an 
already  diagnosed  or  suspected  case  of  lobar  pneumonia  in  his  practice 
may  call  in  anyone  of  these  consultants  who  will  give  him  the  serum  for 
his  patient.  The  consultant  called  in  may  charge  his  usual  fee  for  such 
a  consultation  but  if  the  patient  is  unable  to  pay  his  fee,  a  small  uniform 
fee  will  be  paid  to  the  consultant  for  his  services  from  the  special  Pneu- 
monia Service  Fund.  In  return  for  the  serum,  which  is  supplied  free  of 
charge  (and  enough  for  one  patient  costs  roughly  about  one  hundred 
dollars)  detailed  and  uniform  records  of  all  cases  so  treated  are  to  be  re- 
turned to  this  office. 


*  For  information  regarding  the  one  day  course  on  lobar  pneumonia  offered  by  the  Harvard 
Medical  School  through  its  Courses  for  Graduates  in  connection  with  this  Pneumonia  Study  and 
Service  apply  to  the  "Assistant  Dean,  Courses  for  Graduates,  Harvard  Medical  School,  240 
Longwood  Avenue,  Boston,  Massachusetts." 


i?4 

In  addition  to  bringing  serum  to  the  patient  the  local  consultant  called 
will  see  that  the  initial  serum  treatment  is  given,  that  the  sputum  or  urine 
is  typed,  blood  studies  made  and  that  the  attending  physician  is  familiar 
with  the  technic  of  administering  further  doses  of  serum. 

It  is  hoped  that  during  the  next  five  years  by  the  development  and 
extension  of  such  a  consulting  service  it  will  be  possible  to  train  a  large 
number  of  clinicians  in  the  newer  methods  of  early  diagnosis  and  serum 
treatment  of  lobar  pneumonia  and  that  these  physicians  will  pass  on  their 
information  to  others,  so  that  in  the  end  we  may  have  a  large  number  of 
physicians  sufficiently  acquainted  with  the  necessity  of  early  and  accur- 
ate bacteriological  diagnosis  and  methods  of  serum  treatment  that  anti- 
pneumococcic  serum  may  be  used  generally  throughout  the  State. 

A  portion  of  the  funds  are  being  expended  on  a  statistical  and  an  epi- 
demiological survey  of  lobar  pneumonia  in  this  State  and  it  is  hoped  that 
upon  the  completion  of  this  work  we  shall  have  sufficient  added  informa- 
tion to  make  feasible  sound  administrative  measures  directed  toward  the 
prevention  and  control  of  this  disease. 

Finally,  intensive  investigation  is  being  carried  out  on  a  study  of  anti- 
pneumococcus  immunity  and  serum  production  at  our  Antitoxin  and 
Vaccine  Laboratory  in  Forest  Hills.  Research  already  begun  on  the 
various  methods  of  concentrating  antipneumococcus  serum  and  testing 
its  potency  is  being  continued  and  expanded.  By  further  investigation 
along  allied  lines  it  is  hoped  that  a  method  will  be  found  for  producing  a 
higher  degree  of  immunity  in  experimental  animals,  especially  horses, 
and  that  a  more  potent  and  concentrated  serum  may  be  produced. 

The  cost  of  the  concentrated  serum  now  being  manufactured  and  dis- 
tributed by  this  department  to  supply  the  hospitals  and  consultants 
selected  by  our  Advisory  Committee  to  cooperate  with  us  in  this  work  is 
being  paid  from  our  special  Pneumonia  Service  Fund,  so  generously 
given  us,  as  before  mentioned,  by  the  Commonwealth  Fund  of  New  York 
City. 

While  it  is  regretted  that  concentrated  antipneumococcic  serum  can  not 
yet  be  offered  for  general  distribution,  principally  because  of  its  great 
cost,  it  is  felt  that  by  limiting  the  supply  to  those  cooperating  in  this 
study,  we  will  make  faster  progress  in  developing  safe  and  sound  criteria 
for  its  use. 

In  brief  then,  the  purposes  of  the  Pneumonia  Study  are: 

1.  To  study  the  epidemiology  of  lobar  pneumonia  in  this  State. 

2.  To  promote  more  prompt  clinical  and  bacteriological  diagnosis  of 
the  disease. 

3.  To  encourage  and  facilitate  earlier  and  more  general  therapeutic 
use  of  concentrated  serum. 

4.  To  study  and  improve  methods  of  serum  production. 

5.  To  correlate  the  studies  on  serum  production  with  the  results  follow- 
ing its  clinical  use. 

6.  To  devise  procedures  for  serum  treatment,  and  administrative 
measures  for  the  prevention  and  control  of  this  disease. 

MORBIDITY  SURVEY  AMONG  INDIVIDUALS  RECEIVING 
OUT-DOOR  RELIEF  IN  CAMBRIDGE 

Marie  R.  Giblin,  Anne  A.  Boris,  and  Sadie  Minsky 
Division  of  Adult  Hygiene 
An  intensive  morbidity  study  was  conducted  by  the  Massachusetts  De- 
partment of  Public  Health  in  the  year  ending  December  1,  1929,  among 
the  families  who  were  receiving  financial  aid  from  the  Cambridge  Depart- 
ment of  Public  Welfare.  This  study  was  inaugurated  at  the  request  of 
the  Cambridge  Department  of  Public  Welfare  which  desired  to  learn 
whether  or  not  the  families  under  their  care  had  more  sickness  than  the 
general  population. 


175 

The  Massachusetts  Department  of  Public  Health  has  made  morbidity- 
surveys  in  several  communities  by  home  visits,  obtaining  information  on 
sickness  occurring  within  a  year  previous  to  the  home  visit.  The  Depart- 
ment desired  to  determine  the  relative  value  of  such  morbidity  data  and 
to  compare  it  with  that  obtained  by  several  visits. 

Cambridge,  a  city  with  a  population  of  129,590  individuals,  is  located 
in  Metropolitan  Boston  and  presents  conditions  similar  to  the  City  of 
Boston  itself.  At  the  beginning  of  the  survey,  301  families  were  receiv- 
ing financial  aid  from  the  City  of  Cambridge.  Records  were  secured  at 
the  first  visit  from  279  of  these  families.  Information  throughout  the 
following  year  was  obtained  from  257  families,  although  some  of  these 
did  not  remain  on  the  books  of  the  Public  Welfare  throughout  the  entire 
period.  This  group  comprised  1062  individuals,  an  average  of  4.1  per 
family.  The  United  States  was  the  birthplace  of  80.8  per  cent  of  the 
individuals,  Ireland  5.1  per  cent,  Canada  4.8  per  cent,  Italy  3.2  per  cent, 
Portugal  2.3  per  cent,  and  all  other  countries  3.8  per  cent. 

Table  I. — Age-Sex  Distribution  of  Population 


Age  Group 

Ntjmbeb  of  Individuals 

Percentage 

Distribution 

Cambridge  Survey 

Percentage 
Distribution 

(Years) 

Male 

Female 

Total 

Massachusetts 
1920 

0-9 

10-19  

20-29  

30-39  

40-49  

50-59  

60-69  

70-79  

80+ 

149 

205 

15 

12 

10 

5 

10 

6 

3 

0 

159 

204 

43 

94 

67 

20 

28 

26 

2 

4 

308 

409 

58 

106 

77 

25 

38 

32 

5 

4 

29.0 
38.5 
5.5 
10.0 
7.3 
2.4 
3.6 
3.0 
0.5 

19.3 

16.5 

17.4 

15.8 

13.1 

9.3 

5.4 

2.4 

0.7 

Unknown    .... 

Total  .... 

415 

647 

1,062 

99.8 

99.9 

The  age  distribution  (Table  I)  differed  materially  from  that  of  Massa- 
chusetts in  1920.  The  surveyed  group  had  a  much  larger  percentage  of 
children  as  only  about  one-third  of  the  population  was  over  the  age  of 
twenty.  There  were  sixty-four  males  to  every  hundred  females  which 
is  a  far  different  sex  ratio  than  that  of  Massachusetts  (ninety-six  males 
per  one  hundred  females).  These  differences  in  age,  sex  distribution  were 
due  to  the  selected  population. 

All  diseases  were  divided  into  acute  and  chronic,  while  defects  were 
given  a  third  classification.  Under  defects  have  been  listed  underweight 
and  malnutrition,  enlarged  tonsils  and  adenoids,  cross  eyes,  impediments 
in  speech,  nervousness  in  children,  and  defective  mentality. 

During  the  first  year  covered  by  the  survey,  337  individuals  were  sick 
with  406  acute  diseases,  a  crude  acute  disease  rate  of  382  per  1000  and  an 
age,  sex  adjusted  rate  of  354  per  1000.  In  the  second  year  672  individuals 
were  sick  with  1015  acute  diseases,  a  crude  acute  attack  rate  of  955  per 
1000  and  an  age,  sex  adjusted  rate  of  855  per  1000.  Three  hundred  and 
three  of  the  total  individuals  had  435  chronic  diseases,  a  crude  chronic 
disease  rate  of  409  per  1000  and  an  age,  sex  adjusted  rate  of  658  per  1000. 

Of  the  eighty  females  over  fifty,  only  nine  were  without  chronic  dis- 
ease; and  of  the  twenty-four  males  over  fifty,  only  four  were  without 
chronic  disease.  Of  the  717  individuals  under  twenty,  272  defects  were 
noted.    The  majority  of  these  were  enlarged  tonsils   (65.8  per  cent). 

The  problem  of  overcrowding  was  approached  only  from  one  angle, — 
that  of  adequate  sleeping  facilities.    There  were  467  bedrooms  available 


176 

for  the  1062  individuals  in  the  survey,  but  in  thirty-three  cases  the  living 
room,  dining  room,  or  kitchen  were  utilized  as  sleeping  rooms,  making  a 
total  of  500  rooms  used  for  sleeping  purposes,  or  about  0.5  of  a  room  for 
each  individual.  The  larger  the  family,  the  more  crowded  the  sleeping  con- 
ditions became.  All  individuals  belonging  to  families  in  which  each  mem- 
ber had  less  than  0.5  of  a  sleeping  room  were  said  to  live  in  overcrowded 
homes.  There  were  50.2  per  cent  of  the  individuals  living  in  such  homes. 

Sanitation  was  a  term  that  included  the  following  factors:  the  light 
and  air  available  in  the  home ;  the  sanitary  or  unsanitary  conditions  exist- 
ing there  or  in  the  immediate  vicinity ;  the  presence  or  absence  of  a  bath- 
room; and  the  habits  of  personal  and  household  cleanliness.  There  were 
52.5  per  cent  of  the  individuals  living  in  unsanitary  conditions. 

The  diet  of  a  family  was  measured  by  the  number  and  ages  of  the 
individuals  and  also  by  the  selection  of  foods  with  attention  to  that  group 
known  as  protective  foods,  which  are  rich  in  vitamins.  There  were  41.1 
per  cent  of  the  individuals  who  had  poor  diet. 

Approximately  one-seventh  (14.9  per  cent)  of  the  individuals  in  the 
Cambridge  survey  lived  in  uncrowded  quarters,  with  good  sanitation,  and 
had  a  satisfactory  diet. 

To  determine  the  relative  value  of  repeated  visits,  the  Cambridge 
morbidity  for  the  two  years  has  been  compared  for  acute  and  chronic 
disease.  The  data  for  the  first  year  was  obtained  at  the  end  of  the  period, 
that  of  the  second  year  by  multiple  visits  during  the  period. 

In  the  first  three  months  of  the  second  year  an  influenza  epidemic 
occurred.  If  we  deduct  the  attack  rates  for  respiratory  diseases  from 
each  year  we  have  crude  rates  of  269  and  363  per  1000  respectively.  This 
shows  that  the  increase  in  respiratory  diseases  in  the  second  year  is 
responsible  for  the  major  part  of  the  differences.  Again,  if  we  limit  sick- 
ness to  bed  illnesses  only  and  deduct  the  respiratory  diseases  the  crude 
rates  for  the  two  years  would  be  183  and  190  per  1000  respectively.  On 
the  other  hand,  the  non-bed  illnesses  for  non-respiratory  acute  illnesses 
gave  crude  rates  of  82  and  173  per  1000.  This  suggests  that  minor  ill- 
nesses were  reported  to  the  surveyor  more  frequently  when  numerous 
calls  were  made,  but  that  the  more  serious  illnesses  were  reported  equally 
well  in  either  case. 

Follow-up  visits  produced  an  increase  of  11  per  cent  in  reports  of 
chronic  diseases  which  had  existed  on  the  first  visit  of  the  surveyor. 
This  was  probably  due  to  lack  of  confidence  and  complacent  acceptance  of 
a  long  continued  condition.  The  confidence  of  the  individual  interviewed 
must  be  won  to  discuss  conditions  such  as  tuberculosis,  cancer,  and  mental 
diseases  which  are  often  concealed.  It  is  frequently  difficult  to  win  the 
necessary  confidence  in  one  visit.  The  persistence  of  the  disease  itself  is 
a  handicap  in  obtaining  information  as  a  condition  becomes  an  accepted 
fact  and  does  not  always  come  to  the  mind  for  that  very  reason. 

Comparisons,  using  the  total  morbidity,  the  respiratory  diseases,  the 
number  of  illnesses,  the  communicable  diseases  of  childhood,  and  the 
chronic  diseases,  have  been  made  between  the  Cambridge  group  and  the 
other  surveyed  populations  to  determine  the  relative  morbidity.  In  the 
first  year  of  the  Cambridge  survey  the  total  crude  morbidity  rate  was 
791  per  1000,  while  in  Winchester1  the  rate  was  396  per  1000,  in  Shel- 
burne-Buckland2  433  per  1000,  and  in  Lawrence3  302  per  1000.  Cambridge 
shows  a  higher  rate  than  the  other  communities. 

In  the  first  year  of  the  Cambridge  survey  there  were  120  cases  of 
acute  respiratory  diseases,  an  attack  rate  of  113  per  1000.  In  the  second 
year  there  were  629  cases,  an  attack  rate  of  592  per  1000.  Much  of  the 
high  rate  of  this  year  was  due  to  the  influenza  epidemic.  While  the  Cam- 
bridge figures  do  not  furnish  the  respiratory  rate  for  a  shorter  period 
than  a  year,  it  is  reasonable  to  assume  that  the  difference  between  the 
rates  of  the  two  years  might  approach  the  respiratory  rate  for  the  epi- 
demic. With  this  assumption  the  respiratory  rate  would  be  approximately 


177 

475  per  1000.  During  the  epidemic  Bigelow  and  Lombard  *  obtained  in 
five  cities  and  towns  in  Massachusetts  a  respiratory  attack  rate  of  264 
per  1000.  This  would  indicate  that  respiratory  disease  was  much  more 
prevalent  among  the  poor  of  Cambridge  than  in  the  general  population. 

The  percentage  of  sick  individuals  with  multiple  diseases  is  shown  in 
Table  II  in  which  a  comparison  is  made  between  Cambridge,  Shelburne- 
Buckland,  and  Winchester.  This  table  indicates  that  there  is  more  mul- 
tiple sickness  in  the  Cambridge  group  than  in  the  other  groups. 


Table  II. — Percentage  of  Sick  Individuals  by  Number  of  Illnesses 

One 

Two 

Three 

Four 

Cambridge,  1927-1928    

62.1 

82.2 
82.0 

25.0 
14.8 
14.8 

9.4 
2.7 

2.8 

3  5 

Shelburne— Buckland   

0  2 

Winchester 

0  1 

The  common  acute  communicable  diseases  of  children  are  apparently 
no  more  prevalent  in  the  Cambridge  group  than  in  Winchester,  Shelburne- 
Buckland,  or  Lawrence  and  there  is  no  indication  from  this  study  that 
the  poor  have  more  communicable  disease  than  the  population  at  large. 
(Table  III) 

Table  III. — Percentage  of  Individuals  Under  Twenty  Who  Had 
Communicable  Diseases  Prior  to  Surveys 


Disease 

Cambridge 
Survey* 

Lawrence 
Survey* 

Shelburne- 
Buckland 
Survey* 

Winchester 
Survey* 

Chicken  pox 

Diphtheria    

Mumps    

31.4 
4.9 

20.1 
9.9 

54.0 

66.1 

22.0 
4.0 

13.0 
6.9 

39.8 

60.8 

42.1 
3.3 
15.0 
13.7 
53.5 
39.4 

43.4 
3.2 

27.2 

Scarlet  fever   

Whooping  cough    . 
Measles 

8.4 
52.4 
59.1 

*  Cambridge  survey  based  on  717  individuals  under  twenty.  Lawrence  survey  based  on  11,352  indi- 
viduals under  twenty.  Shelburne-Buckland  survey  based  on  394  individuals  under  twenty.  Winchester 
survey  based  on  3,365  individuals  under  twenty. 

The  age  specific  rates  for  the  chronic  sick  in  Cambridge  have  been 
compared  with  similar  rates  in  the  1929  and  1930  surveys,  in  the  group 
receiving  public  relief  in  the  three  cities  in  the  1930  survey,  and  in  the 
inmates  of  the  Brockton  City  Infirmary.  The  Cambridge  survey  and  the 
Brockton  City  Infirmary  groups  have  rates  higher  than  in  the  other 
groups.    (Table  IV) 

Table  IV. — Chronic  Sickness 
(Age  Specific  Rates  per  1000) 


Age  Group 
(Years) 

Cambridge 
Survey 

Chronic 

Disease 

Survey 

1929 

Chronic 

Disease 

Survey 

1930 

Public  Relief 

Group  Survey 

1930 

Brockton  City 
Infirmary 

0-19 

20-39  ........ 

40-^9 

50-59 

60-69  

70-79  

80  + 

123 
463 
624 
680 
868 
1,000 
1,000 

17 
56 
117 
207 
355 
538 
680 

174 

248 
368 
540 
692 

362 
577 
643 
696 
637 

800 
888 
838 
944 
667 

178  ' 
Sickness,  with  the  exception  of  chicken  pox,  diphtheria,  mumps,  scarlet 
fever,  whooping  cough,  and  measles,  is  more  prevalent  among  the  poor 
than  the  general  population.  The  figures  indicate  that  the  respiratory 
diseases  are  more  prevalent  among  the  poor,  but  it  is  difficult  to  determine 
whether  chronic  disease  is  the  cause  or  the  result  of  poverty. 

Conclusions 

1.  Major  acute  illnesses  are  reported  equally  well  with  one  visit  at  the 
end  of  the  year  as  with  several  during  the  year. 

2.  Minor  acute  illnesses  are  reported  more  accurately  with  frequent 
visits. 

3.  Chronic  diseases  are  reported  slightly  better  with  frequent  visits. 

4.  The  morbidity  rates  for  common  acute  communicable  diseases  of 
children  are  similar  in  the  poor  as  in  the  general  population. 

5.  Morbidity  among  public  dependents  is  much  greater  than  among 
the  general  population. 

References 

1.  Lombard,  Herbert  L.,  M.D.  A  Sickness  Survey  of  Winchester, 
Mass.  Part  1:  General  Morbidity.  American  Journal  of  Public  Health 
and  the  Nation's  Health,  September,  1928. 

2.  Lombard,  Herbert  L.,  M.D.,  and  Scamman,  Clarence  L.,  M.D. 
A  Morbidity  Survey  of  Shelburne-Buckland.  New  England  Journal  of 
Medicine,  Vol.  198,  No.  12,  pp.  625-629,  May  10,  1928. 

3.  Lawrence  Morbidity  Survey:    In  Preparation. 

4.  Bigelow,  George  H.,  M.D.,  and  Lombard,  Herbert  L.,  M.D.  Res- 
piratory Tract  Infections  in  Massachusetts  in  the  Winter  of  1928-1929. 
New  England  Journal  of  Medicine,  Vol.  201,  No.  10,  pp.  474-478,  Sep- 
tember 5,  1929. 

RED  CROSS  HEALTH  WORK  IN  MASSACHUSETTS 

Harding  L.  White 
Director  of  Membership,  Boston  Metropolitan  Chapter 

The  American  National  Red  Cross  supervises  from  its  Headquarters  at 
Washington  five  health  services.  All  of  them  are  carried  on  in  some  Red 
Cross  Chapters  in  Massachusetts;  no  Chapter  has  them  all. 

The  reason  for  this  apparent  dissimilarity  in  chapter  health  programs 
is  found  in  the  Red  Cross  policy  which  was  restated  in  a  vote  of  the 
National  Executive  Committee,  December  13,  1922,  "a  service  or  activity 
should  meet  a  need  not  covered  by  existing  organizations."  Hence  Public 
Health  Nursing,  which  is,  after  service  to  disabled  veterans  and  disaster 
relief,  the  primary  activity  of  the  Red  Cross  in  many  sections  of  the 
country,  is  carried  on  by  comparatively  few  Massachusetts  Chapters.  In 
many  cases,  also,  Red  Cross  Chapters  undertake  a  project,  particularly 
in  the  field  of  health,  for  a  demonstration  period  only.  When  its  worth  and 
practicality  has  been  shown,  it  is  then  taken  over  and  continued  by  the 
proper  public  authorities. 

The  National  Red  Cross  Health  Services  are:  Public  Health  Nursing, 
Nutrition,  Home  Hygiene  and  Care  of  the  Sick,  First  Aid  and  Life  Sav- 
ing. Other  services,  undertaken  permanently  or  for  a  short  time  to  meet 
a  local  need,  are  conducted  by  the  Chapters  involved  and  are  not  in- 
cluded in  a  national  program. 

Of  the  73  Red  Cross  Chapters  in  Massachusetts,  18  carry  on  Public 
Health  Nursing.  In  a  typical  year  39  nurses  made  67,149  nursing  visits 
and  inspected  22,544  school  children.  Nutrition  work  has  been  so  well 
stimulated  by  the  State  Public  Health  Department  that  only  six  chapters 
have  found  it  necessary  to  include  it  in  their  program.  Home  Hygiene  and 
Care  of  the  Sick,  popularly  called  Home  Nursing,  is  exclusively  a  Red 
Cross  activity.  It  is  found  in  27  chapters  of  the  State  and  in  one  year 
5,200  students  were  given  instruction  and  3,217  received  their  certificates. 


179 

The  same  number  of  Chapters  (27)  have  offered  teaching  in  First  Aid. 
During  the  past  year  3,867  persons  were  trained.  This  represents  only 
those  who  completed  their  courses,  passed  the  tests,  and  received  their 
certificates.  Many  more  took  a  part  of  the  instructions  or  attended 
demonstrations. 

Training  in  Life  Saving  proves  to  be  the  service  for  which  there  is 
the  greatest  demand.  It  is  carried  on  by  46  Massachusetts  Chapters.  Dur- 
ing the  past  year  there  were  enrolled  3,581  new  Life  Savers,  making  a 
total  enrollment  in  the  State  of  25,352.  Twenty-five  Chapters,  or  branches 
of  Chapters,  carry  on  other  health  work  such  as  dental  clinics,  supplying 
milk  for  school  lunches,  and  other  needed  services  which  local  organiza- 
tions have  not  yet  undertaken. 

Of  the  50,000  nurses  enrolled  in  the  American  Red  Cross  Nursing 
Reserve,  there  is  now  a  total  of  2,330  in  Massachusetts.  This  reserve  not 
only  provides  nurses  for  Red  Cross  public  health  service  in  connection 
with  local  Chapters  and  instructors  in  Home  Hygiene  and  Care  of  the  Sick, 
but  is  also  on  call  for  an  epidemic  or  a  disaster  as  in  the  influenza  which 
followed  the  War,  or  in  the  Mississippi  Flood  of  four  years  ago.  By  Con- 
gressional enactment,  it  is  the  official  reserve  of  the  Nursing  Corps  of 
the  Army  and  Navy.  The  nurses  are  enrolled  through  a  series  of  com- 
mittees, local,  state  and  national. 

The  Boston  Metropolitan  Chapter  has  three  chapter-wide  health  ser- 
vices: Home  Nursing,  First  Aid,  and  Life  Saving.  The  Home  Nursing 
course  not  only  teaches  the  planning  of  the  healthful  home  and  the  pre- 
vention of  the  spreading  of  disease,  as  well  as  how  to  deal  with  common 
ailments  and  emergencies,  care  of  the  bed  patients  and  the  handling  of 
babies  and  small  children,  but  also  attempts  to  stimulate  an  interest  in 
promotion  of  community  health.  These  courses  are  offered  throughout 
the  Boston  Metropolitan  territory  for  adults  and  children  and  are  held 
either  at  the  Chapter  classroom  or  in  schoolrooms,  in  colleges,  in  indus- 
trial plants,  in  settlement  house,  church,  club  or  scout  groups,  or  wherever 
opportunity  offers.  The  First  Aid  course,  which  teaches  practical  pro- 
cedure in  all  cases  of  accident  before  a  doctor  comes,  is  offered  in  the 
same  places  and  in  police  and  fire  stations.  For  the  past  three  years  the 
accent  in  the  first  aid  work  of  the  Chapter  has  been  upon  the  training 
of  policemen  and  firemen.  During  this  time  nine  hundred  and  fifty-four 
members  of  the  police  and  fire  departments  have  been  trained.  Three 
hundred  and  sixty-five  of  these  were  in  Boston  proper  and  the  remainder 
were  in  the  following  branches  of  the  Boston  Metropolitan  Chapter: 
Arlington  60,  Braintree  12,  Brookline  72,  Chelsea  155,  Belmont  32,  Ded- 
ham  20,  Everett  42,  Norwood  32,  Revere  67,  Watertown  60,  Woburn  37. 

The  Life  Saving  course  teaches  the  approach  to  a  drowning  person, 
breaks  and  carries,  and  the  prone  pressure  method  of  resuscitation.  In 
winter,  classes  are  held  in  Greater  Boston  pools  and  in  summer  they  are 
offered  at  beaches  in  and  around  Boston.  The  only  other  health  activities 
in  the  territory  of  the  Boston  Chapter  are  dental  clinics  carried  on  as 
local  projects  by  three  of  its  branches,  and  a  psychiatric  social  worker 
in  one  other.  The  steady  increase  in  the  amount  of  health  work  of  the 
Boston  Chapter  during  the  past  ten  years  has  been  caused  by  the  increas- 
ing public  interest  in  the  services  offered. 

At  the  present  time  the  Boston  Chapter  officials  see  no  limit  to  the 
opportunity  offered  for  further  training  in  the  present  three  lines:  Life 
Saving,  First  Aid  and  Home  Nursing. 


180 

PEDIATRIC  EDUCATION 

REPORT  OF  THE  SUBCOMMITTEE  ON  MEDICAL  EDUCATION 

Borden  S.  Veeder,  Chairman 

White  House  Conference  on  Child  Health  and  Protection 

Section  on  Medical  Service 

Committee  on  Medical  Care  for  Children 

Pediatrics  can  no  longer  be  denned  simply  as  "diseases  of  children," 
neither  can  it  any  longer  be  relegated  to  a  minor  place  in  medical  educa- 
tion and  practice. 

Realizing  this,  the  Committee  has  made  a  study,  by  means  of  question- 
naires, of  pediatric  practice  of  physicians  active  in  this  field,  the  position 
pediatrics  holds  on  medical  school  programs  and  the  demand  and  supply 
for  graduate  instruction  in  pediatrics  today. 

First  on  the  questionnaire  to  physicians  was  the  inquiry  as  to  the 
adequacy,  in  their  opinion,  of  the  pediatric  courses  in  their  respective 
medical  schools.  Forty-four  per  cent  of  the  pediatric  specialists  and 
those  general  practitioners  especially  interested  in  pediatrics,  felt  that 
"in  the  light  of  their  present  experience,"  their  course  was  "mediocre 
or  unsatisfactory."  About  thirty  per  cent  of  the  general  practitioners 
replying  to  the  questionnaire  considered  their  course  "mediocre  or  poor, 
in  one  respect  or  another." 

Practice  of  preventive  pediatrics,  including  routine  health  examina- 
tions, vaccination,  T.  A.  T.,  the  relation  of  physicians  to  the  Public  Health 
campaign,  and  frequency  of  graduate  study,  was  also  covered  by  the 
questionnaire.  The  tabulated  report  and  following  discussion  are  well 
worth  careful  reading  by  all  interested  in  preventive  medicine  and  public 
health  activities. 

Undergraduate  and  graduate  teaching  in  pediatrics  available  in  the 
United  States  is  taken  up  in  some  detail.  A  condensed  outline  of  a  pedi- 
atric course  for  medical  schools  with  recommendations  for  minimum 
teaching  requirements  is  added. 

Another  useful  item  in  this  report  is  a  summary  of  "Short  Courses" 
in  pediatrics  offered  by  medical  schools  all  over  the  country. 


News  Notes 


Mothers'  Classes 

Mothers'  Classes  are  planned  to  teach,  through  group  instruction,  the 
Health  Principles  of  Family  and  Community  Life.  They  may  supplement 
or  reinforce  home  instruction. 

In  group  instruction  the  mothers  are  away  from  home  cares  and  re- 
sponsibilities for  the  time  being,  which  leaves  them  in  a  more  receptive 
state  of  mind.  This  means  of  instruction  affords  an  opportunity  for  social 
contact,  with  change  of  ideas  and  standards  of  living  as  well  as  for 
receiving  definite  instruction  in  health  education. 

The  number  of  lessons  may  vary,  preferably  from  eight  to  twelve,  held 
weekly.  The  location  should  be  as  accessible  as  possible  to  all  members 
of  the  class. 

It  is  desirable,  whenever  possible,  to  have  two  attractive,  light,  and  airy 
rooms,  one  being  a  kitchen,  or  having  cooking  facilities,  which  enables 
the  mothers  to  prepare  and  serve  refreshments  that  are  planned  in  rela- 
tion to  the  lesson  of  the  day. 

Many  teaching  points  may  be  stressed  with  this  activity.  This  should 
be  informal,  so  that  the  mothers  will  feel  constantly  that  they  are  con- 
tributing, which  helps  to  instill  a  feeling  that  the  class  is  theirs.  The 
refreshments  are  dainty  and  attractively  served  by  the  mothers  at  the  end 
of  the  class. 


181 

The  objectives  of  Mothers'  Classes  are  many: 
The  establishment  of  good  health  habits. 
Care  of  the  home  and  family. 
Medical  and  dental  supervision. 

Budgeting  family  income,  with  special  emphasis  on  confinement. 
Baby's  layette. 
Postpartum  care. 
Registration  may  be  in  charge  of  a  member  of  the  class,  who  is  also 
responsible  for  introducing  new  members  to  the  class. 

Following  the  registration  of  all  members,  one  half  hour  is  spent  in 
a  pre-activity  period,  which  is  an  activity  with  the  members  of  the  class 
before  the  lesson  plan  of  the  day. 

Pre-activities  are  planned  in  relation  to  the  lesson.  For  example,  the 
making  of  custard,  cocoa  and  cereal,  pattern  cutting,  abdominal  binder, 
brassiere,  baby's  layette,  maternity  dress  and  the  making  of  the  booklet 
to  hold  illustrative  material  received  at  the  end  of  each  lesson. 

One  half  hour  should  be  devoted  to  the  lesson  following  the  pre-activity. 
Each  lesson  must  be  well  prepared,  and  with  the  idea  in  mind  of  meeting 
the  needs  of  the  class. 

Suggestions  for  Lesson  Topics  are: 
Prenatal  care. 
The  home  and  family. 

Food  for  the  expectant  mother,  in  relation  to  the  family. 
If  the  class  is  a  "Cradle  Class,"  i.  e.,  mothers  of  preschool  children,  the 
lesson  should  be  planned  in  relation  to  the  needs  of  the  preschool  child. 

The  use  of  posters  and  exhibits  in  a  Mothers'  Class  is  valuable.  The 
posters  may  be  original  or  from  educational  or  commercial  organizations. 
When  posters  and  exhibits  are  used,  they  should  relate  to  the  lesson  plan 
of  the  day  and  carry  only  one  thought.  Care  should  be  taken,  in  using 
materials  for  exhibits  and  posters,  that  they  be  clean,  attractive,  simple, 
few  in  number,  and  arranged  to  clearly  and  immediately  convey  the 
educational  point. 

In  conducting  Mothers'  Classes  the  nurse  will  find  it  profitable  as  well 
as  interesting  to  have  the  responses  of  the  members  of  the  classes  re- 
corded, throughout  the  entire  period.  These  may  be  used  later  as  teaching 
points. 

To  secure  regular  attendance,  certificates  may  be  offered  and  gradua- 
tion exercises  held. 

American  Society  for  Control  of  Cancer — Educational  Material 
We  are  in  receipt  of  a  sample  set  of  educational  material  from  the 
American  Society  for  the  Control  of  Cancer.  This  material  is  available 
to  the  laity  as  well  as  to  the  medical  profession  in  single  copies  or  in 
quantities,  free  of  charge.  Posters  and  statistical  charts  are  also  issued 
without  cost  and  films  are  loaned,  gratis,  to  responsible  groups.  The 
address  of  the  association  is  25  West  43rd  Street,  New  York  City,  N.  Y. 

International  Hospital  Association 
At  the  close  of  the  Second  International  Hospital  Congress  which  met 
in  Vienna  from  June  8th  to  14th,  the  representatives  of  the  forty-one 
countries  participating  in  the  Congress  voted  unanimously  to  organize 
an  International  Hospital  Association. 

The  purpose  of  the  Association  is  to  bring  about  an  international 
exchange  of  opinion  and  international  cooperation  in  all  problems  and 
in  all  fields  of  hospital  work  and  in  all  relationships,  economic,  sociologic 
and  hygienic. 


182 


Book  Notes 


The  Child  From  One  to  Six — His  Care  and  Training.  Publication 
No.  300,  U.  S.  Department  of  Labor,  Children's  Bureau,  1931.  150 
pages.  Price  $.10.  For  sale  by  Superintendent  of  Documents,  Wash- 
ington, D.  C. 

This  pamphlet  for  the  small  sum  of  ten  cents  makes  available  for 
intelligent  parents  comprehensive  information  on  the  care  of  the  pre- 
school child.  It  is  an  authoritative  work  written  interestingly  but  in 
simple  language.  All  phases  of  the  "runabout's"  life  are  covered  from 
his  surroundings  to  his  emotional  development.  Especially  valuable  is 
the  chapter  on  preserving  health  and  preventing  disease. 

The   Principles  and   Practice   of   Hygiene — Dean   Franklin   Smiley, 
Adrian  Gordon  Gould  and  Elizabeth  Melby.    Published  by  Macmillan 
Co.  1930.    415  pages. 
This  textbook  on  hygiene  for  nurses  is  attractive  in  its  make-up;  both 

print  and  illustrations  are  excellent.    The  material  is  well  balanced  and 

presented  in  an  interesting  manner.    It  includes  a  valuable  section  on 

hygiene  and  health  habit  formation. 


183 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  April,  May,  and  June  1931,  samples  were  col- 
lected in  265  cities  and  towns. 

There  were  2,149  samples  of  milk  examined,  of  which  450  were  below 
standard;  from  39  samples  the  cream  had  been  in  part  removed,  and 
11  samples  contained  added  water.  There  were  77  samples  of  Grade  A. 
milk  examined,  66  samples  of  which  were  above  the  legal  standard  of 
4.00%  fat,  and  11  samples  were  below  the  legal  standard. 

There  were  313  samples  of  food  examined,  of  which  63  were  adulter- 
ated. These  consisted  of  6  samples  sold  as  butter  which  proved  to  be  oleo- 
margarine; 3  samples  of  eggs,  all  of  which  were  sold  as  fresh  eggs  but 
were  not  fresh;  16  samples  of  hamburg,  all  of  which  contained  a  com- 
pound of  sulphur  dioxide  not  properly  labeled;  5  samples  of  sausage,  1 
sample  of  which  contained  starch  in  excess  of  2  per  cent,  and  4  samples 
contained  a  compound  of  sulphur  dioxide  not  properly  labeled;  1  sample 
of  liver,  and  1  sample  of  roasting  pork,  both  of  which  were  decomposed; 
1  sample  of  milk  shake  which  was  made  with  skimmed  milk;  21  samples 
of  clams  which  contained  added  water;  1  sample  of  maple  sugar  adulter- 
ated with  cane  sugar  other  than  maple;  7  samples  of  maple  syrup  which 
contained  cane  sugar;  and  1  sample  of  cream  which  was  not  labeled  in 
accordance  with  the  law. 

There  were  217  samples  of  drugs  examined,  of  which  69  were  adulter- 
ated. These  consisted  of  44  samples  of  spirit  of  nitrous  ether,  all  of 
which  were  deficient  in  the  active  ingredient;  17  samples  of  ether  for 
anaesthesia,  all  of  which  contained  aldehyde;  and  8  samples  of  argyrol 
solution  not  corresponding  to  the  professed  standard  under  which  it  was 
sold. 

The  police  departments  submitted  1,538  samples  of  liquor  for  exam- 
ination, 1,509  of  which  were  above  0.5%  in  alcohol.  The  police  depart- 
ments also  submitted  24  samples  of  narcotics,  etc.,  for  examination,  7 
of  which  were  morphine,  2  opium,  2  samples  of  food  which  were  tested 
for  poisons  with  negative  results;  1  sample  of  pills  which  Was  found 
to  consist  of  a  Chinese  herb  remedy,  containing  no  narcotics;  1  sample 
of  a  liquid  which  was  found  to  contain  alcohol,  sugar  and  glycerine; 
1  sample  of  "Pix-Up"  which  was  examined  and  found  to  conform  to 
the  composition  stated  on  the  label;  1  sample  consisted  of  a  dilute  so- 
lution of  ammonia  containing  aluminium  phosphate,  and  a  brownish 
colored  waxy  substance;  1  sample,  consisting  of  a  sample  of  liquid 
coffee  which  was  tested  for  poisons  with  negative  results;  one  sample 
was  a  small  quantity  of  a  white  substance  which  was  found  to  consist 
chiefly  of  calcium  phosphate;  one  sample  of  milk  which  was  found  to 
contain  strychnine;  and  6  of  these  samples  were  submitted  by  the  Dis- 
trict Attorney  of  Middlesex  County  through  the  Wilmington  Police  De- 
partment, which  consisted  of  3  samples  of  vomitus  and  3  samples  of 
milk,  all  of  which  were  tested  for  poisons  with  negative  results.  A 
sample  submitted  by  Dr.  Wheeler,  Department  pf  Public  Health,  con- 
sisted of  a  number  of  colored  pieces  of  candy  which  were  tested  for 
presence  of  poison  with  negative  results.  Two  of  the  pieces  showed 
the  presence  of  bacteria. 

There  were  878  bacteriological  examinations  made  of  milk. 

There  were  39  bacteriological  examinations  made  of  soft  shell  clams, 
15  samples  in  the  shell,  5  of  which  were  unpolluted,  and  10  were  pol- 
luted; and  24  samples  shucked,  10  of  which  were  unpolluted,  and  14 
were  polluted.  There  were  8  bacteriological  examinations  made  of 
hard  shell  clams,  in  the  shell,  all  of  which  were  unpolluted.  There 
were  2  bacteriological  examinations  made  of  razor  clams  in  shell, 
which  were  unpolluted.  There  was  one  bacteriological  examination 
made  of  shell  washing  which  was  polluted. 

There  were  141  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  99  cities  and  towns  visited  for  the  inspection  of  pas- 
teurizing plants,  and  256  plants  were  inspected. 


184 

There  were  69  convictions  for  violations  of  the  law,  $1,400  in  fines 
being  imposed. 

H.  P.  Hood  and  Sons  and  Spero  Christopher  of  Cambridge;  Joseph 
Fortin  of  Middleboro;  Angelo  Garello  and  Francis  Noel  of  North 
Adams;  Raymond  Gascon  of  East  Brookfield;  Charles  H.  Menard  and 
George  Norman  of  Westport;  Manoog  Mihranian  and  Nemer  Jowdy  of 
Methuen;  Frank  Ghiloni  of  Marlboro;  Nicholas  Poulous  of  Stoughton; 
Walter  Kopinos  of  West  Springfield;  Anthony  Tsouprakakis  of  Cam- 
bridge; Sarkis  Yagoobian,  Christos  Saklas,  Andreson  &  Patterson,  In- 
corporated, Mardiros  Demirjian,  Edward  J.  Higgins,  and  William  Pa- 
tronas,  all  of  Worcester;  Timothy  J.  Cronin  of  Milford;  Thomas  Banas 
and  Anthony  Duda  of  Ware;  Arthur  Benoit  and  Thomas  McCarthy  of 
Winchendon;  Massasoit  Lunch  of  Holyoke;  and  Joseph  L.  Walker  of 
Barnstable,  were  all  convicted  for  violations  of  the  milk  laws.  Charles 
H.  Menard  and  George  Norman  of  Westport;  Nicholas  Poulous  of 
Stoughton;  and  Anthony  Duda  of  Ware,  all  appealed  their  cases. 

Adelbert  M.  Peck  of  Swansea;  Samuel  Bayley  of  Ipswich;  Paul 
Babel  of  Norwood;  Eugene  Barthel  of  Gardner;  Robert  Kravitz  of  New 
Bedford;  Mary  Armata  and  John  Dabosz  of  Holyoke;  Alex  Hassapes 
of  Marlboro;  George  Corey,  2  cases,  and  George  Yameen  of  Lawrence; 
New  England  Provision  Company  and  Carl  Foster  of  Boston;  Loring 
Tripp  of  North  Rochester;  Myron  W.  Johnson  of  Athol;  Alex  Gold- 
stein of  Worcester;  and  Simon  Kronick  of  North  Adams,  were  all  con- 
victed for  violations  of  the  food  laws. 

Christos  Douros  of  Roxbury;  Abraham  Miller  of  New  Bedford; 
George  F.  Cobb  of  Falmouth;  and  James  Pappas  of  Palmer,  were  all 
convicted  for  false  advertising. 

Henry  Frodema  of  Springfield;  Samuel  Kidder  &  Company  of  Charles- 
town;  John  Corsiglia  of  Greenfield;  Finnish  Drug  Company,  Incorpo- 
rated of  Fitchburg;  and  Louis  0.  Tavelli  of  Williamstown,  were  all 
convicted  for  violations  of  the  drug  laws. 

Ashland  Farm  Milk  Company.  Incorporated,  of  Holbrook;  Whiting 
Milk  Companies  of  Charlestown ;  Nemer  Jowdy  of  Methuen ;  and  James , 
J.  Gilgun  of  Maiden,  were  all  convicted  for  violations  of  the  pasteuri- 
zation law.    Ashland  Farm  Milk  Company,  Incorporated  of  Holbrook 
appealed  their  case. 

Elm  Spring  Farm,  Incorporated,  of  Waltham;  and  Whiting  Milk 
Companies  of  Charlestown,  were  convicted  for  violations  of  the  Grade 
A  Milk  Law.  Elm  Spring  Farm,  Incorporated,  of  Waltham  appealed 
their  case. 

Antone  Aguiar,  Harry  Helfenbein,  and  Armand  Roy,  all  of  Fall 
River ;  Morris  Friedman,  2  cases,  of  Waltham ;  and  Abraham  Rosen- 
field  of  New  Bedford,  were  all  convicted  for  violations  of  the  mattress 
law. 

Castolo  &  Moura,  and  Everybody's  Fruit  and  Vegetable  Market,  In- 
corporated, of  New  Bedford;  and  Israel  Kaplan  of  Lynn,  were  all  con- 
victed for  violations  of  the  cold  storage  law. 

Edwin  W.  Sears  of  Charlemont  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  origi- 
nal packages  from  manufacturers,  wholesalers,  or  producers: 

One  sample  of  cream  which  was  not  labeled  in  accordance  with  the 
law  was  obtained  from  Chatham  Cafe  of  Chatham. 

One  sample  of  milk  shake  which  was  made  with  skimmed  milk  was 
obtained  from  C.  W.  Leavitt  of  Dedham. 

One  sample  of  maple  sugar  adulterated  with  cane  sugar  other  than 
maple  was  obtained  from  Nicolas  Wonlas  of  Southbridge. 

Maple  Syrup  which  contained  cane  sugar  was  obtained  as  follows: 
1  sample  each,  from  James  Pappas  of  Palmer,  Cobb's  Lunch  and  New 
York  Sandwich  Shop,  Incorporated,  of  Falmouth;  Economy  Grocery 
Company,  Rood  &  Woodbury  Division,  and  City  Lunch,  Incorporated, 
both  of  Springfield;  and  Blue  Moon  Lunch  of  Worcester. 


185 

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

1  sample  each,  from  Alex  Goldstein  of  Worcester;  The  Great  At- 
lantic and  Pacific  Tea  Company  of  Quincy;  Moro's  Market  of  Norfolk 
Downs;  Mary  Armata  of  Holyoke;  Alex  Hassapes  of  Marlboro;  U 
Save  Market  of  Lawrence;  Suher's  Market,  Samuel  Tillman,  Economy 
Grocery,  and  Auburn  Market,  all  of  Springfield;  Harry  Lerner  of 
Brookline;  Simon  Kronick  of  North  Adams;  Economy  Grocery  Com- 
pany of  Waltham;  Radio  Markets,  Incorporated,  of  Newburyport;  and 
Abraham  Hodas  of  Greenfield. 

Sausage  which  contained  a  compound  of  sulphur  dioxide  not  prop- 
erly labeled  was  obtained  as  follows: 

1  sample  each,  from  Eugene  Barthel  of  Gardner;  and  Brockton  Pub- 
lic Market  of  Brockton. 

One  sample  of  sausage  which  contained  starch  in  excess  of  2  per 
cent  was  obtained  from  M.  W.  Johnson  of  Athol. 

One  sample  of  roasting  pork  which  was  decomposed  was  obtained 
from  Nathan  Strauss,  Incorporated,  operating  under  the  name  of 
Wonder  Market,  Springfield. 

One  sample  of  liver  which  was  decomposed  was  obtained  from  Na- 
than Strauss,  Incorporated,  operating  under  the  name  of  Growers 
Outlet,  Springfield. 

Clams  which  contained  added  water  were  obtained  as  follows:  5 
samples,  from  I.  W.  Stavis  of  Chelsea ;  2  samples  each,  from  E.  D.  Nut- 
ting of  Newburyport,  and  Harold  Mclntyre  of  Rowley;  and  1  sample 
each,  from  Richard  Hussey,  Harry  Brockelbank,  John  Maguire,  and 
Merrimac  Shellfish  Company,  all  of  Newburyport;  Kneeland  Brothers 
of  Rowley;  Chaney  Randall  of  Revere;  and  Interstate  Shellfish  Com- 
pany of  Hull. 

There  were  ten  confiscations,  consisting  of  6  pounds  of  decomposed 
chickens;  100  pounds  of  decomposed  turkeys;  1090  pounds  of  decom- 
posed and  emaciated  poultry;  35  pounds  of  decomposed  raccoons;  23 
pounds  of  decomposed  beef;  5  pounds  of  decomposed  pork;  15  pounds 
of  decomposed  pork  loins;  7  pounds  of  decomposed  stew  meat;  8 
pounds  of  decomposed  beef  sausages;  27  pounds  of  decomposed  Ham- 
burg steak;  and  850  pounds  of  decomposed  scup. 

The  licensed  cold  storage  warehouse  reported  the  following  amounts 
of  food  placed  in  storage  during  March  1931: — 2,042,370  dozens  of 
case  eggs;  963,893  pounds  of  broken  out  eggs;  373,505  pounds  of  but- 
ter; 1,091,455  pounds  of  poultry;  4,553,752^  pounds  of  fresh  meat 
and  fresh  meat  products;  and  1,691,608  pounds  of  fresh  food  fish. 

There  was  on  hand  April  1,  1931: — 2,172,870  dozens  of  case  eggs; 
1,471, 511Y2  pounds  of  broken  out  eggs;  1,347,794  pounds  of  butter; 
5,191,029  pounds  of  poultry;  18,865,746  pounds  of  fresh  meat  and 
fresh  meat  products;  and  7,271,714  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  April,  1931: — 3,673,560  dozens  of  case 
eggs;  891,635  pounds  of  broken  out  eggs;  504,717  pounds  of  butter; 
683,973  pounds  of  poultry;  4,115,780  pounds  of  fresh  meat  and  fresh 
meat  products;  and  2,628,269  pounds  of  fresh  food  fish. 

There  was  on  hand  May  1,  1931: —  5,551,770  dozens  of  case  eggs; 
1,862,704  pounds  of  broken  out  eggs;  1,049,797  pounds  of  butter; 
3,798,041  pounds  of  poultry;  17,255,6331/4  pounds  of  fresh  meat  and 
fresh  meat  products;  and  7,523,575  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following 
amounts  of  food  placed  in  storage  during  May,  1931: — 3,203,730  doz- 
ens of  case  eggs;  849,760  pounds  of  broken  out  eggs;  1,326,640  pounds 
of  butter;  791,990  pounds  of  poultry';  3,452,473  pounds  of  fresh  meat 
and  fresh  meat  products;  and  5,081,165  pounds  of  fresh  food  fish. 

There  was  on  hand  June  1,  1931: — 8,551,170  dozens  of  case  eggs; 
2,166,999  pounds  of  broken  out  eggs;  1,855,997  pounds  of  butter; 
3,071,6591/2  pounds  of  poultry;  lejllS.SSl1^  pounds  of  fresh  meat  and 
fresh  meat  products;  and  31,764,706%  pounds  of  fresh  food  fish. 


186 
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    .  Under  direction  of  Commissioner. 

Division  of  Sanitary  Engineering  .     Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Division  of  Communicable  Diseases     Director, 

Gaylord  W.  Anderson,  M.D. 


Division  of  Water  and  Sewage  Lab- 
oratories  . 
Division  of  Biologic  Laboratories  . 

Division  of  Food  and  Drugs  . 

Division  of  Child  Hygiene 
Division  of  Tuberculosis 
Division  of  Adult  Hygiene    . 


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,  Alton  S.  Pope,  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. 

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  Pittsfield. 


Publication  of  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
13,500-     10-'31.     Order  3714. 


•TATE. 


►ton 


COMMONHEALTH 


Volume  18 

No.  4 


OCT.- NOV.- DEC. 
1931 


White  House  Conference 


This    number    brings    to    you    papers    read    at    the    Institutes    of    the 

Massachusetts     Committee     for     the     White     House     Conference     on 

Child  Health  and  Protection 


MASSACHUSETTS 
DEPARTMENT   OF  PUBLIC  HEALTH 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State- 
Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

Message  from  the  Governor           .......  189 

Foreword     ...........  190 

White  House  Conference  on  Child  Health  and  Protection,  by  H.  E. 

Barnard           .........  191 

White  House  Conference  on  Child  Health  and  Protection,  1930-1931, 

by  Mary  R.  Lakeman,   M.D 192 

What  Can  We  Expect  from  the  White  House  Conference?  by  Haven 

Emerson,  M.D.         ........  193 

Section  I — Medical  Service — Richard  M.  Smith,  M.D.,  Chairman       .  196 
Section  II — Public  Health  Service  and  Administration — Curtis  M. 

Hilliard,  Chairman           .......  196 

Child  Health — Some  Public  Health  Aspects,  by  Murray  P.  Hor- 

wood,  Ph.D .  .198 

The  Findings  of  the  Committee  on  Public  Health  Organization, 

by  Charles  F.  Wilinsky,  M.D 205 

Milk,  by  Frank  E.  Mott                              208 

Milk  Production — Regulations  Essential  and  Non-Essential,  by 

J.  H.  Frandsen 214 

Section  III — Education  and  Training — Mary  McSkimmon,  Chairman  217 

The  Home  and  the  Child,  by  Louisa  P.  Skilton  ....  217 

Health  of  the  School  Child,  by  Ernest  Stephens                              .  219 
Health  of  the  School  Child,  by  Margaret  C.  Ells                            .224 

Recreation  and  Leisure  Time,  by  Zenos  E.  Scott       .          .          .  226 

Youth  Outside  Home  and  School,  by  Eva  Whiting  White  .          .  227 

Section  IV — The  Handicapped — Alfred  F.  Whitman,  Chairman         .  228 

Organizations  for  the  Handicapped,  by  Richard  K.  Conant         .  230 

Some  Highlights  on  Child  Dependency,  by  Cheney  C.  Jones      .  231 

The  Physically  Handicapped  Child,  by  Gordon  Berry,  M.D.       .  236 

Mentally  Handicapped,  by  Samuel  W.  Hartwell,  M.D.       .          .  240 
Book  Notes: 

Health  Protection  for  the  Preschool  Child      ....  242 
Permanent  Play  Materials  for  Young  Children                               .  243 
Report   of   Division   of   Food   and   Drugs,   July,    August,    and    Sep- 
tember, 1931   ...                    244 

Index           ...........  247 


MESSAGE  FROM  HIS  EXCELLENCY 

JOSEPH  B.  ELY 

GOVERNOR  OF  THE  COMMONWEALTH 

We  know  much  in  regard  to  the  health  and  protection  of 
our  children  which  is  not  generally  utilized  for  their  health 
and  protection.  A  national  committee  on  this  subject  called 
by  the  President  studied  the  matter  intensively  for  over  a 
year  and  has  reported.  Last  spring  I  appointed  a  committee 
for  Massachusetts,  the  purpose  of  which  is  to  bring  this  in- 
formation to  every  community  and  home  in  this  State  that 
our  children  may  benefit.  It  is  particularly  pertinent  at  this 
time  since  the  scars  of  economic  stringency  may  well  be  more 
permanent  on  our  children  than  on  anything  else  in  our  civi- 
lization. 

I  trust  that  this  number  of  The  Commonhealth  will  be 
carefully  studied  by  parents,  teachers  and  the  whole  list  of 
those  interested  directly  or  indirectly  in  the  health  and  wel- 
fare of  our  children,  to  the  end  that  such  resources  as  we 
have  may  be  more  fully  utilized  and  that  an  informed  public 
opinion  will  be  built  up,  from  which  may  develop  such  other 
resources  as  are  not  yet  available. 


FOREWORD 

His  Excellency,  Governor  Ely,  outlines  his  reasons  for  the  formation 
of  a  Committee  on  Child  Health  and  Protection  and  the  very  imperative 
importance  of  this  matter  at  this  time.  I  can  only  add  that  if  the  Com- 
mittee can  create  widespread  informed  public  opinion  in  regard  to  child 
health  and  protection  it  will  have  succeeded;  if  it  cannot  create  such  in- 
formed public  opinion  it  will  have  failed,  since,  as  has  been  said,  ideas 
are  the  most  permanent  thing  in  man's  civilization. 

But  the  dissemination  of  ideas  is  such  a  clumsy  hit  or  miss  proposi- 
tion, in  which  you  have  no  way  of  judging  results.  Some  will  misunder- 
stand; most  will  not  be  interested.  In  the  end  you  will  have  spent  money 
and  time  and  energy  on  a  vain  thing  and  have  added  talk  to  a  world  al- 
ready overburdened  with  verbiage.  Thus  reacts  the  man  after  a  bad 
breakfast ! 

Surely  it  would  be  easier  to  have  a  wise  despot  order  that  all  the  wis- 
dom of  the  White  House  Conference  be  put  at  once  to  work.  Tomorrow 
the  diet  of  all  undernourished  children  would  then  be  supplemented  but 
not  revolutionized ;  only  safe  milk  would  be  consumed  by  all  our  children ; 
some  constructive,  leisurely  play  by  himself  would  be  assured  to  all  pre- 
school children;  every  woman  would  put  herself  under  competent  medical 
supervision  early  in  each  pregnancy;  all  needed  laws  for  the  protection 
of  our  children  would  be  passed ;  special  classes  for  the  handicapped  would 
be  freely  available;  and  all  the  rest  of  the  accumulated  wisdom  would  be 
put  to  work;  that  is,  if  we  lived  under  a  benevolent  despot. 

But  we  don't!  We  live  under  a  government  of,  by  and  for  the  people. 
That  means  endless  talks,  meetings,  conferences,  conversations  and  other 
methods  of  exchanging  ideas  so  that  out  of  it  all  certain  dominating  de- 
sires may  appear.  It  is  a  futile  form  of  government  if  you  like,  but  under 
it  if  enough  people  get  their  teeth  into  an  idea  and  keep  them  there  long 
enough  they  will  get  what  they  want  as  surely  as  night  follows  day. 

This  then  is  the  objective  of  the  Massachusetts  Committee  of  the  White 
House  Conference  on  Child  Health  and  Protection :  to  place  the  many  in- 
formed speakers  on  the  various  sections  of  the  Conference  before  all  the 
groups  that  we  can  interest  in  all  the  cities  and  towns  of  the  State  before 
next  June,  so  that  an  intelligent  comprehension  of  adequate  standards  of 
health  and  protection  may  be  developed  and  wholesome  dissatisfaction 
with  lower  standards  may  be  widespread ;  all  of  which  will  give  the  great- 
est possible  assurance  that  our  children,  present  and  to  come,  will  not 
lack  in  this  regard.  • 

May  this  issue  of  The  Commonhealth  also  contribute  to  this  end! 


191 

WHITE  HOUSE  CONFERENCE  ON  CHILD  HEALTH  AND 

PROTECTION 

By  H.  E.  Barnard 

Director,  Central  Administration  Office 

The  White  House  Conference  on  Child  Health  and  Protection  brought 
together  the  available  knowledge  on  what  is  happening  to  the  children  in 
this  country.  The  experts  who  made  up  the  Conference  made  their  ob- 
servations everywhere  children  are  to  be  found.  When  their  reports  and 
findings  are  finally  published  we  will  have  a  complete  picture  of  American 
childhood.  The  volumes  are  rapidly  appearing  from  the  press.  There  will 
be  in  all  about  forty,  with  some  twenty  pamphlets,  making  when  finished 
a  comprehensive  library  of  child  life. 

Due  to  the  nation-wide  stimulus  of  the  White  House  Conference  an 
active  follow-up  in  all  parts  of  the  country  has  resulted.  By  the  end  of 
this  year  sixteen  states,  Indiana,  Georgia,  Utah,  New  Jersey,  New  Hamp- 
shire, Florida,  Mississippi,  Maine,  Oklahoma,  Louisiana,  Michigan,  Massa- 
chusetts, Virginia,  Idaho,  South  Carolina  and  Montana  will  have  held  con- 
tinuation conferences. 

Local  conferences  have  followed  state  conferences  in  many  places.  The 
city  of  Chicago  held  a  regional  conference  in  October.  Ninety  organiza- 
tions of  Chicago  sponsored  this  conference,  and  national  and  local  leaders 
from  nearly  every  branch  of  child  welfare  took  part  in  the  program. 

These  Conferences  are  bringing  together  groups  that  haven't  before 
found  a  common  interest,  but  which  see  in  the  interpretation  of  the  Chil- 
dren's Charter  an  opportunity  for  everyone  to  make  a  finer  world  for 
children  to  grow  up  in. 

The  Children's  Charter,  its  nineteen  points  the  crystallized  hopes  of  the 
nation  for  its  children,  is  being  used  by  communities  as  a  yardstick  by 
which  they  may  determine  how  nearly  local  conditions  approximate  what 
the  Conference  experts  deem  essential  to  the  well-being  of  children.  Every 
day  the  Conference  office  in  Washington  receives  letters  similar  to  this 
one  from  Louisiana:  "Our  Superintendent  of  Schools  has  announced  that 
the  objective  for  the  year  in  the  public  schools  of  New  Orleans  will  be  the 
Children's  Charter."  Or  this  from  one  of  the  Home  Demonstration  Agents 
in  Massachusetts :  "We  would  like  to  secure  one  hundred  sets  of  the  White 
House  Conference  leaflets  prepared  by  Marion  Faegre.  We  are  eager  to 
use  them  in  our  child  guidance  study  group." 

The  National  Congress  of  Parents  and  Teachers  has  adopted  the  Char- 
ter as  the  basis  of  its  year's  program.  Many  other  national  organizations 
are  cooperating  actively  with  the  Conference  to  make  effective  the  points 
of  the  Charter.  Among  these,  to  mention  just  a  few,  are  The  American 
Legion,  Child  Welfare  Division;  American  Child  Health  Association, 
American  Library  Association,  Child  Welfare  League  of  America,  Ameri- 
can Dental  Association,  American  Association  of  University  Women, 
Kiwanis,  National  Grange,  National  Education  Association  and  National 
Council  of  Parent  Education. 

Some  organizations  and  communities  have  set  themselves  to  the  real- 
ization of  definite  points  of  the  Charter.  The  town  of  Radburn,  New 
Jersey,  selected  points  four,  five  and  six  as  a  goal  toward  which  to  pro- 
gress in  its  child  health  work. 

From  coast  to  coast  the  White  House  Conference  has  fired  the  imagina- 
tion of  pur  people.  Though  the  Conference  is  only  one  year  behind  us 
many  communities  have  already  laid  strong  foundations,  made  concrete 
beginnings  of  this  structure  which  will  uphold  the  future  of  our  children. 


192 

THE  WHITE  HOUSE  CONFERENCE  ON  CHILD  HEALTH  AND 
PROTECTION— 1930-1931 

By  Mary  R.  Lakeman,  M.D., 
Executive  Secretary,  Massachusetts  Committee 

The  White  House  Conference  on  Child  Health  and  Protection  of  last 
November  was  the  third  conference  of  experts  in  the  various  problems  of 
child  welfare  to  be  called  by  a  President  of  the  United  States.  Some  of  us 
remember  the  occasion  of  the  first  conference  in  1909  to  which  President 
Roosevelt  invited  some  200  men  and  women,  each  an  authority  in  some 
phase  of  the  care  of  dependent  children ;  that  is,  of  children  who  for  some 
reason  could  not  be  cared  for  by  their  parents  or  in  their  own  homes. 

Several  important  principles  were  laid  down  by  that  Conference,  notably 
the  principle  that  poverty  alone  should  not  be  the  cause  for  removing  a 
child  from  its  own  home.  As  a  direct  result  of  this  first  conference,  the 
Children's  Bureau  was  established  in  1912  within  the  Department  of 
Labor.   Miss  Julia  Lathrop  was  made  its  chief. 

Ten  years  later  at  the  close  of  the  World  War,  and  toward  the  end  of 
Children's  Year,  a  similar  conference  was  called  by  President  Wilson. 
This  time  the  interests  were  broader,  child  labor  and  some  educational 
problems  falling  within  the  scope  of  the  conference.  Consideration  was 
also  given  to  maternal  care  and  infant  mortality. 

One  of  the  conspicuous  results  of  this  conference  was  the  passage  of 
the  Sheppard-Towner  Act,  which  was  designed  to  reduce  the  loss  of  life  in 
early  infancy  and  among  mothers  at  childbirth. 

In  preparation  for  the  Conference  of  1930,  a  planning  committee  of  27 
men  and  women  was  appointed  by  President  Hoover.  Dr.  Ray  Lyman 
Wilbur,  Secretary  of  the  Interior,  was  its  chairman. 

This  Committee,  enlarging  itself  as  it  went  about  its  task,  was  busy 
for  sixteen  months  before  the  Conference  was  called,  studying  through- 
out the  country  conditions  relating  to  the  well-being  of  children.  Presi- 
dent Hoover  said  of  this  Committee:  "Their  task  has  been  magnificently 
performed,  and  today  they  will  place  before  you  such  a  wealth  of  material 
as  was  never  before  brought  together." 

When  the  Conference  was  convened,  it  brought  together  more  than 
2,000  individuals,  each  one  of  whom  was  actively  engaged  in  some  form  of 
work  for  the  betterment  of  the  condition  of  children  in  this  country. 

The  Conference  was  divided  into  four  sections:  I,  Medical  Service;  II, 
Public  Health  Service  and  Administration;  III,  Education  and  Training; 
IV,  The  Handicapped  Child.  Each  of  these  sections  was  further  sub- 
divided into  committees  and  subcommittees  almost  without  number. 

The  Medical  Section  found  its  task  so  enormous  that  its  members  asked 
for  more  time  in  which  to  complete  their  studies ;  hence,  this  section  met 
in  February  of  1931. 

At  the  close  of  these  Conferences,  the  governor  of  each  state  was  urged 
to  devise  some  means  by  which  the  findings  of  the  Conference  might  be 
carried  back  to  the  people  of  his  state.  The  response  of  Massachusetts 
was  the  appointment  by  His  Excellency,  Governor  Ely,  of  a  committee  of 
which  he  made  Dr.  George  H.  Bigelow,  Commissioner  of  Public  Health, 
chairman.  The  other  members  of  the  committee  are:  Vice -Chairmen: 
Miss  Mary  Barr,  Mrs.  Leslie  B.  Cutler,  Mrs.  Carl  Dreyfus,  Mrs.  George 
Hoague,  Dr.  Patrick  Kelleher,  Mrs.  Nellie  Millea,  Rev.  George  P.  O'Conor 
and  Mrs.  Arthur  G.  Rotch;  Secretary:  Mr.  Frank  Kiernan;  Treasurer: 
Mr.  Roy  M.  Cushman;  Chairman,  Section  I:  Dr.  Richard  M.  Smith; 
Chairman,  Section  II:  Professor  C.  M.  Hilliard;  Chairman,  Section  III: 
Miss  Mary  McSkimmon;  Chairman,  Section  IV:  Mr.  Alfred  F.  Whitman; 
and  the  Executive  Secretary. 

The  graph  on  page  193  shows  the  make-up  of  the  working  plan  of  the 
Massachusetts  Committee. 


193 

In  October,  two  Institutes  were  arranged,  each  of  two  days'  duration. 
One  was  held  in  Boston,  October  6  and  7 ;  the  other  in  Springfield,  October 
9  and  10.  The  actual  attendance  was  approximately  400  in  Boston  and 
200  in  Springfield.  The  number  reached  at  different  times  was  undoubt- 
edly much  larger,  as  the  audiences  changed  greatly  according  to  the  sub- 
ject under  consideration. 

The  Committee  has  been  fortunate  in  securing  the  services  of  a  large 
number  of  competent  speakers,  who  have  volunteered  to  present  to  inter- 
ested groups  the  findings  of  any  section  or  a  subject  falling  within  the 
scope  of  one  of  the  four  sections.  It  was  deemed  unwise  to  undertake  to 
cover  the  entire  Conference  in  a  single  session.  A  good  many  organiza- 
tions, however,  are  planning  a  series  of  four  or  more  meetings.  There 
is  no  expense  to  a  group  asking  for  a  speaker,  except  that  of  travel. 


MASSACHUSETTS  COMMITTEE 
WHITE  HOUSE  CONFERENCE  ON  CHILD  HEALTH  AND 

PROTECTION 

His  Excellency,  Joseph  B.  Ely 

Governor  of  the  Commonwealth 

Honorary  Chairman 


SECTION  i 
MEDICAL  SERVICE 

OtBICHMDMSMITHMD 


■B- 

PRENATAL  AND 
MATERNAL  CAM 


SECTION  E 

PUBLIC  HEALTH 
SERVICE   TUJD 
ADMINISTRATION 
CMUPJISMHIUMD 


A 

G80WTH  AND 
OEVtLOPMEKT 


•c- 

MEDICAL  CASE 


tV 

COMMUNICABLE 
DISEASE 
CONTROL 


•A 

PUBLIC  HEALTH 
OtCANIIATIOM. 


•c- 

MILK 

PRODUCTION 
AND  CONTROL 


SECTION  m 
EDUCATION  AND 

TRAINING 
CfrMAlYM'SKIMMON 


■EV 

THE  IHEAMT 
ANt  PRESCHOOL 

CHILD 
CH'ABHiAllfllOT 


D- 

VOCATIONAL 
GUIDANCE  HUD 
CHILD  LABOR. 

UMLEMHUBW 


F- 

SPECIAL 

CLASSES 

IH-timUIR  LORD 


•c- 

THE  SCHOOL 
CHILD 

CltFREIRlKAttMII 

to. 


A 

THE  FAMILY 

AND  PAREUT 

EDUCATION 

OHttS.0»H0A«ll 


•Ev 

RECREATION  b 
PHYSICAL 
EDUCATION 

tfrURlSCHlAJH 


<3 

YOUTH 
OUTSIDE  OF 

HOME  AND 

SCHOOL 

IN'AJLSTOIiEMili 


SECTION  H 
THE  HANDICAPPED 
CH-  ALFRED  F-WHITAUM 


PHYSICALLY 
AND  MENTALLY 
HANDICAPPED 


C-2 

SOCIALLY 
HANDICAPPED 
DELINQUENCY 


A 

STATE"*-  LOCAL 
OKiANIIATlONS 

FOR  THE 
HANDICAPPED 


CI 

SOCIALLY 

HANDICAPPED- 

DEPENDENCY  «* 

NEGLECT 


MASSACHUSETTS  COMMITTEE 
ROOM305 -I5ASHBURT0N  PL.  BOSTON 

CH'OEO.H.BIGELOW  M.D. 


INSTITUTE  BOSTON  OCTOBER.  fc^7 


SPEAKERS 


INSTITUTE  SPP-INOriELD  OCTOBER  9-H» 


WHAT  CAN  WE  EXPECT  FROM  THE  WHITE  HOUSE 
CONFERENCE? 

By  Haven  Emerson,  M.D. 

Columbia  University,  New  York  City 

The  White  House  Conference  has  put  the  parents  of  the  United  States 
on  trial.  If  they  do  not  care  enough  for  their  children  to  use  the  wisdom 
that  has  now  become  public  property,  no  national  ballyhoo  will  save  the 
child. 


194 

The  individual  inertia  created  by  faith  in  organization,  in  public  serv- 
ice, in  official  provision  for  health  is  in  no  respect  more  devastating  than 
in  the  relation  of  parent  to  child. 

To  quote  a  recent  British  author  on  Democracy,  "When  the  present 
devices  of  philanthropy  shall  have  had  their  day  and  their  futility  shall 
have  been  demonstrated,  some  great  teacher  will  re-discover  the  old  truth 
that  salvation  lies  in  a  right  condition  of  mind." 

The  parental  mind  will  have  to  go  through  the  agony  of  abandoning  the 
pleasant  pastime  of  rationalizing  its  emotions,  of  exalting  its  family  tra- 
ditions, of  accepting  its  race  superstitions,  and  can  not  escape  the  change 
from  sentimentalism  to  science  which  our  day  demands. 

That  is  not  to  say  that  emotions  are  taboo,  or  traditions  unworthy,  if 
they  really  work,  or  superstitions  untrustworthy  if  their  origins  are  in 
the  eternal  truths  of  the  past. 

Biology  has  made  the  ultimate  challenge.  And  now,  from  a  gleaming, 
almost  dazzling  white  forum,  it  challenges  parents  to  disregard  at  their 
peril  the  lessons  it  offers  for  that  most  intriguing  because  most  compli- 
cated and  promising  of  all  animals,  our  own  offspring. 

If,  as  some  believe,  the  beginnings  of  improvement  are  to  be  found  in 
humility,  acknowledgment  of  error,  readiness  for  betterment,  then  we 
must  first  see  a  willingness  among  parents  to  abandon  their  present 
self-satisfaction  with  their  children. 

It  is  not  enough  to  repeat  the  formula  of  infant  health  that  growth  is 
the  child's  most  important  job,  nor  to  admit  that  for  the  school  child 
there  must  be  at  least  proper  vision,  good  hearing,  and  a  growing  ability 
to  think.  We  have  come  a  long  way  from  our  grandparents'  days  when 
the  birth  rate  was  30,  when  half  of  all  the  children  born  alive  died  before 
they  reached  their  fifth  birthday,  when  diphtheria  took  away  as  many 
children  in  a  year  as  tuberculosis  now  takes  among  all  ages  of  the  popu- 
lation, when  a  third  of  all  deaths  were  in  children  under  two. 

We  have  even  more  recently  cleared  our  streets  and  schools  of  the 
humpbacked,  the  crooked  legged,  the  neglected  tuberculous  and  rachitic. 
We  think  more  in  terms  of  handicaps,  breakdowns  and  wasted  energy  in 
attaining  mature  well-being  than  by  death  rates  and  disease, incidence. 
All  these  are  assurances  of  progress  but  they  leave  us  unsatisfied  and 
rightly  so  as  our  standard  is  forced  upward  by  the  scarcity  of  childhood. 

Remember  that  so  long  as  records  have  been  kept  there  has  never  been 
a  time  when  among  120,000,000  people  the  children  were  so  small  a 
proportion. 

As  we  tend  to  encumber  the  earth  more  persistently  in  old  age  and 
develop  a  preponderance  of  grandparents,  there  are  fewer  children  to 
dignify  and  justify  our  existence.  With  the  fall  of  birth  rates  in  some 
New  England  states  to  lower  levels  than  that  of  France,  the  lessened 
losses  of  infant  life  have  filled  the  upper  decades  with  actual  or  potential 
parents. 

Life  is  no  longer  a  dreadful  mystery  dominated  by  alternating  fears 
and  hopes,  but  a  journey  of  exploration  along  paths  charted  or  at  least 
lighted  by  the  discoverers  who  have  gone  before. 

There  are  some  eminent  colleagues  in  England  who  have  warned  us 
that  modern  curiosity  and  overanxiety  resulting  from  propaganda  and 
confusing  publicity  have  created  a  fear  complex  about  health  and  that  it 
were  better  if  we  returned  to  our  ancient  ignorance  and  stolid  resigna- 
tion. With  this  attitude  the  White  House  Conference  declared  its  uncom- 
promising disagreement  and  to  all  intents  and  purposes  proclaimed  in  its 
loudest  though  microphonic  voice  that  the  only  fear  worthy  of  an  Ameri- 
can parent  was  fear  of  ignorance,  uncertainty  as  to  their  understanding 
of  the  factors  bearing  upon  the  best  and  most  enduring  health  of  their 
children. 

Just  before  the  beginnings  of  the  public  health  movement  which  dates 
here  and  abroad  at  about  the  middle  of  the  last  century,  it  was  said  in 


195 

your  very  city  here  by  an  optimistic  and  tolerant  man  that  "It  would  be 
hard  to  find  a  civilized  people  who  are  more  timid,  more  cowed  in  spirit, 
more  illiberal  than  we."  Can  we  give  evidence  that  this  is  an  unfair 
description  of  us  today?  And  yet,  do  we  not  lack  courage  when  we  see 
the  burial  procession  of  mothers,  dying  unnecessarily  in  childbirth,  and 
this  followed  by  another  of  infants  at  least  half  of  whom  were  sacrificed 
to  the  timidity  of  those  who  did  not  dare  to  demand  the  application  of 
knowledge  to  save  lives. 

We  know  so  much  more  than  we  use.  Again  a  wise  crack  of  the  know- 
it-alls.  But  why?  The  answer  takes  us  back  to  the  cause  of  the  challenge 
which  I  say  has  put  parents  on  trial.  We  have  moved  from  a  traditional, 
through  a  material  or  physical,  to  a  biological  attitude  towards  life  and 
learning  which  affects  our  whole  social  equilibrium  and  demands  our 
attention.  *| 

What  specifically  are  parents  expected  to  do  and  to  know  so  that  the 
challenge  of  the  White  House  Conference  may  be  well  and  promptly  met? 

Others  with  suitable  qualifications  will  deal  in  this  issue  with  the  les- 
sons in  education  and  training  and  with  our  duties  and  privileges  towards 
the  handicapped  child.  It  is  of  medical  service  and  public  health  service 
and  administration  I  would  speak. 

(a)  We  may  expect  that  parents  will  demand  and  obtain  at  their  own 
expense  from  their  family  physician  progressive  education  in  the  ele- 
ments of  healthy  growth  and  development,  based  on  periodic  medical 
examination  of  their  children  and  the  manner  of  their  lives.  The  vari- 
ables of  inheritance,  environment,  economic,  social  and  religious  status, 
and  of  the  personality  of  each  child  will  be  considered  by  the  physician 
in  transforming  his  knowledge  of  human  physiology  and  anatomy  into 
the  conduct  of  family  life,  the  child's  most  valuable  background. 

(b)  Each  husband  will  be  expected  to  demand  for  his  wife  during  her 
expectant  nine  months,  at  his  expense,  if  possible,  otherwise  through  some 
publicly  supported  medical  and  nursing  station,  a  guidance  in  the  best 
way  of  life  to  insure  a  living, child  and  a  surviving  mother,  capable  of  and 
determined  to  nurse  it. 

This  practice  of  preventive  education  of  the  individual  mother  based 
upon  precise  and  trustworthy  medical  tests  and  observations,  is  capable 
when  universally  demanded  and  provided,  of  revolutionizing  not  only  our 
discreditable  maternal  care  of  today  but  our  attitude  towards  syphilis 
and  gonorrhea  and  to  the  social  obligations  of  the  community  to  the  work- 
ing woman  who  also  bears  children. 

(c)  Both  parents  will  be  expected  to  grow  with  the  child  in  tolerance, 
gentleness  and  mutual  respect  so  that  the  sensitive  and  unformed  per- 
sonality and  emotions  of  the  child  shall  not  be  wounded  by  fear,  deceit  or 
conflict,  as  the  child  will  be  guarded  by  medical  skill  against  the  damages 
of  infection,  and  by  all  its  elders  against  physical  accident  in  play  or  work. 

These  in  their  full  implications  are  in  the  field  of  personal  contribu- 
tions to  the  child.  There  remain  those  actions  and  attitudes  and  knowl- 
edges which  determine  the  public  contribution  to  child  health. 

What  shall  we  expect  here  from  the  White  House  Conference? 

First,  that  parents  will  learn  that  their  children  have  a  right  to  be  safe- 
guarded by  the  health  officers  of  nation,  state  and  home  town  by  the  use 
of  tax  money  and  the  authority  of  the  law. 

It  is  expected  that  every  community  will  have  the  benefit  not  only  of 
official  but  of  some  form  of  volunteer  health  association  which  can  be 
trusted  as  the  conscience  of  the  people  in  this  field. 

It  is  expected  that  parents  of  children  will  see  that  in  appropriations 
and  in  functions  the  public  health  services  meet  at  least  the  minimum 
standards  proposed  by  the  American  Public  Health  Association. 

To  accomplish  this  the  best  way  is  to  carry  out  a  survey  of  the  f  acili- 


196 

ties  and  performance  in  public  health  in  each  political  unit  of  each  state. 
This  does  not  imply  a  muckraking  raid  but  a  journey  of  self -education  in 
the  possibilities  of  communal  action  in  the  interest  of  individual  health. 

Briefly,  the  parents  of  the  United  States  of  America  are  challenged,  to 
engage  teachers  of  health  as  their  medical  advisers  and  not  only  treaters 
of  disease;  to  make  certain  that  their  local  government  employs  a  full- 
time  qualified  health  officer;  to  learn  the  practical  uses  and  results  of 
effective  health  service  at  public  expense;  to  act  in  the  light  of  science. 

The  facts  are  at  your  disposal.  Compulsion  will  not  put  them  to  work. 
The  impulse  to  get  results  must  be  shifted  from  promoters  to  parents. 

SECTION  I 
MEDICAL  SERVICE 

Richard  M.  Smith,  M.  D.,  Chairman 

Papers  on  the  subjects  covered  by  Section  I  have  been  published  in  the 
New  England  Journal  of  Medicine  as  follows: 

Prenatal  and  Maternal  Care.  Robert  L.  DeNormandie.  Vol.  205,  No. 

19  (Nov.  5,  1931)  p.  895. 
Maternal  Mortality.    What  Must  Be  Done  About  It.    John  Rock. 

Vol.  205,  No.  19  (Nov.  5,  1931)  p.  899. 
The  Findings  of  the  Committee  on  Growth  and  Development  of  the 

White  House  Conference  on  Child  Health  and  Protection.    Harold 

C.  Stuart.  Vol.  205,  No.  21  (Nov.  19,  1931)  p.  1004. 
Review  of  Findings  of  Committee  on  Medical  Care  of  the  White 

House   Conference   on   Child   Health  and   Protection.    Robert   B. 

Osgood.  Vol  205,  No.  26  (Dec.  24,  1931)  p.  1241. 

SECTION  II 
PUBLIC  HEALTH  SERVICE  AND  ADMINISTRATION 

Curtis  M.  Hilliard,  Chairman 

The  section  on  Public  Health  Service  and  Administration  has  to  do  with 
the  organization  and  functions  of  agencies,  both  official  and  non-official, 
that  definitely  promote  health  and  well-being  and  prevent  unnecessary 
sickness  and  death  amongst  children. 

For  the  most*  part,  the  matters  considered  in  this  section  redound  to 
the  benefit  of  people  of  all  age  groups  and  not  to  children  only.  Com- 
munity sanitation,  clean,  safe  milk,  and  tuberculosis  prevention  work  are 
of  general  importance,  and  if  neglected  in  an  hypothetical  childless  city, 
would  quickly  lead  to  health  wreckage  in  the  adult  population. 

On  the  other  hand,  the  prevention  of  milk-borne  tuberculosis  of  cow 
origin,  which  is  transmissible  to  children  only,  diphtheria  immunization 
programs,  and  the  staffing  of  health  departments  with  nurses  doing  infant 
and  child  hygiene  work  are  obviously  of  specific  value  to  the  young. 

This  section  would  emphasize,  therefore,  the  organization  and  services 
that  will  be  of  principal  benefit  to  children,  but  cannot  entirely  divorce  the 
discussion  from  the  more  general  matters. 

Organization  is  basic.  Without  personnel,  properly  trained  for  the 
special  fields  of  public  health  work,  and  devoted  to  their  work,  welded 
together  under  an  executive  head,  we  cannot  hope  for  efficiency  in  health 
work.  We  would  not  expect  farmers  to  operate  complicated  textile  machin- 
ery, or  bank  clerks  to  make  good  farmers,  yet  there  has,  curiously  enough, 
been  the  impression  that  a  taxicab  driver  may  serve  satisfactorily  as  a 
health  officer  or  a  carpenter  may  be  competent  to  serve  on  milk  inspec- 
tion. 

Official  health  work  in  the  United  States,  like  other  governmental  organ- 


197 
ization,  is  decentralized.    The  federal  work  is  somewhat  diffuse,  being 
scattered  through  different  departments,  but  the  U.   S.   Public  Health 
Service  is  the  most  important  unit. 

Massachusetts  has  a  highly  organized  and  efficient  Public  Health  De- 
partment with  eight  distinct  divisions,  including  Divisions  of  Hygiene, 
Tuberculosis,  Sanitation,  and  Communicable  Diseases.  The  cities  and 
towns  in  the  state  are  required  to  provide  boards  of  health;  what  the 
composition  and  work  may  be  is  largely  up  to  each  community.  Our  towns 
and  small  rural  communities  are  often  woefully  lacking  in  anything  that 
resembles  adequate  personnel  and  health  work.  Issuing  permits  to  gar- 
bage collectors  and  milk  dealers,  and  tacking  cards  on  the  doors  of  homes 
where  there  are  cases  of  chickenpox  or  measles,  constitute  the  chief,  if 
not  the  only,  activities. 

Citizens  demand,  and  willingly  pay  for,  fire  protection  and  police  protec- 
tion; we  still  have  fence  viewers  and  inspectors  of  slaughter,  showing  the 
sound  sense  of  our  ancestors,  but  also  the  inertia  of  government  of  today. 
But  of  health  and  life,  our  own  and  our  children's,  we  are  careless,  not 
applying  the  most  remarkable  and  beneficent  discoveries  of  all  ages  that 
save  life  and  extend  the  life  span. 

The  first  and  most  important  recommendation  is  then  a  full-time, 
properly  trained,  health  personnel.  Where  a  community  does  not  have  a 
full-time  job,  or  money  enough  to  pay  for  this  work,  it  may  combine  with 
nearby  communities  to  employ  a  health  officer,  milk  and  sanitary  inspec- 
tor, community  nurse,  or  whatsoever  trained  persons  may  be  necessary 
to  give  at  least  minimum  adequate  health  service.  Recognition  is  given 
to  the  extremely  valuable  services  of  private  agencies  working  in  the 
public  health  field.  They  have  often  pioneered  in  such  fields  as  community 
nursing  and  infant  welfare.  They  have,  and  always  will  have,  a  distinct 
contribution  to  make  to  health  work.  It  is  urged  that  the  work  of  such 
organizations  be  closely  and  understanding^  allied  to  that  of  official 
health  bodies  for  mutual  aid  to  achieve  optimum  results. 

A  second  report  of  this  section  deals  with  communicable  disease  con- 
trol. Most  of  the  epidemic  diseases  occur  chiefly  in  childhood  and  are 
most  fatal  in  the  early  years  of  life.  The  public  holds  too  lightly  the 
consequences  of  those  two  ubiquitous  diseases,  measles  and  whooping 
cough.  Familiarity  ever  breeds  contempt.  These  two  diseases  today  are 
the  most  frequent  cause  of  death  in  children  under  five  years  old  from 
infectious  agents.  It  is  supremely  important  for  parents  to  realize  this, 
and  to  protect  little  children  from  these  diseases,  or  to  procure  medical 
advice  if  infection  occurs.  Scarlet  fever  and  diphtheria  are  duly  respected 
as  they  should  be,  though  the  former  disease  causes  less  than  one  third 
the  fatalities  of  whooping  cough. 

Every  board  of  health  should  adopt  and  enforce  regulations  which  con- 
form to  the  latest  knowledge  regarding  the  quarantine  and  isolation  of 
persons  sick  with  communicable  disease,  and  those  exposed  to  disease.  In 
Massachusetts  a  set  of  minimum  requirements  have  been  drawn  up  by  a 
committee  of  experts  and  should  serve  as  a  guide  to  every  community  in 
the  state. 

There  are  two  diseases  that  could  be  rendered  obsolete  by  the  applica- 
tion of  present  day  knowledge.  One  of  these,  smallpox,  needs  no  discus- 
sion, as  the  experience  of  135  years  bears  its  own  testimonial.  Where  vac- 
cination has  been  continuously  and  conscientiously  practiced,  this  loath- 
some scourge  has  disappeared,  where  neglected  it  still  attacks  and  maims, 
or  kills  its  victims.  The  compulsory  vaccination  law  for  school  children 
in  this  state  should  be  upheld  and  enforced. 

The  other  disease  has  become  controllable  only  within  the  last  dozen 
years.  What  has  been  accomplished  with  smallpox  may  now  be  done  with 
diphtheria.  Let  us  pray,  since  diphtheria  is  fatal  chiefly  in  childhood,  that 
the  same  shocking  delay  and  neglect  shown  by  people  during  the  last  cen- 
tury with  regard  to  smallpox,  will  not  prevail  with  this  disease.  The  mir- 


198 

acle  of  a  weapon  put  in  our  hands  with  which  to  allay  the  terror  and 
tragedy  of  this  highly  fatal  disease!  Any  parent  who  fails  to  have  his 
child  protected  is  negligent  of  a  duty;  and  any  community  not  providing 
the  facilities  for  diphtheria  immunization  would  seem  to  be  criminally 
negligent.  Children  should  be  protected  as  early  in  life  as  possible;  im- 
munity probably  lasts  for  life. 

Tuberculosis,  year  in  and  year  out,  remains  man's  greatest  foe.  We 
have  no  single  way  of  combating  the  "white  plague"  and  yet  by  attacks 
upon  it  from  various  angles,  it  has  yielded  steadily  until  now  it  causes 
scarcely  one-third  the  ratio  of  deaths  to  population  that  it  caused  a  half 
century  ago.  The  contest  against  tuberculosis  has  been  pressed  back  earlier 
and  earlier  in  life  until  now  it  is  realized  that  sound  health  building  in 
childhood,  and  avoidance  of  infection  early  in  life,  are  amongst  the  most 
essential  preventive  measures.  The  early  discovery  of  tuberculosis,  or 
better,  the  discovery  of  predisposition  for  this  disease,  so  that  early  treat- 
ment and  resistance  can  be  built  up,  are  most  important  factors. 

The  third  and  last  sub-division  of  this  section  deals  with  milk,  unques- 
tionably our  most  universally  used  and  most  valuable  food,  especially  in 
relation  to  child  nutrition.  Milk  is  also,  potentially,  man's  most  danger- 
ous food  from  the  standpoint  of  the  spread  of  disease.  From  the  cow  may 
come  tuberculosis,  undulant  fever,  or  septic  sore  throat,  while  man, 
through  handling,  may  seed  milk  with  scarlet  fever,  diphtheria,  and  ty- 
phoid germs.  Besides  this,  milk  on  account  of  its  origin,  handling  arid 
fluid  condition  may  pick  up  more  microbes  than  any  other  food.  We  do 
not  need  to  argue  the  desirability  of  producing  milk,  only  from  healthy 
cattle.  Barnyard  manure  or  other  dirt  in  milk  does  not  appeal  to  any  one. 
All  will  agree,  then,  that  the  cleanest  milk  that  it  is  reasonable  to  demand 
is  milk  produced  from  healthy  cows,  especially  cows  free  from  tubercu- 
losis. The  health  specialist  is  not  satisfied  with  this  alone,  but  realizes 
that  most,  if  not  all  milk,  to  be  safe,  must  be  heated.  The  panacea  against 
milk-borne  disease  is  pasteurization;  a  scientific  commercial  heating  of 
milk,  under  rigid  control  and  supervision,  to  a  temperature  and  for  a 
time  that  certainly  kills  every  disease  microbe  that  can  lurk  in  milk,  but 
which  does  not  impair  its  food  value.  The  committee,  then,  recommends 
milk  produced  from  tuberculosis-free  cows  in  clean  dairies,  clean  hand- 
ling and  pasteurization,  all  of  this  checked  by  proper  milk  inspection. 

These  are  but  a  few  of  the  most  salient  of  the  findings  and  recom- 
mendations of  that  great  body  of  experts  that  worked  on  these  problems 
of  Health  Service  and  Administration  at  the  request  of  President  Hoover. 
If  the  communities  of  Massachusetts  and  the  people  of  the  State  would 
but  follow  the  recommendations,  what  a  lot  of  unnecessary  suffering  would 
be  prevented!  How  many  lives  would  be  saved!  How  much  happier  and 
healthier  would  be  our  children !  The  challenge  is  in  the  knowledge  of 
how  to  achieve  these  results. 

CHILD  HEALTH— SOME  PUBLIC  HEALTH  ASPECTS 

By  Murray  P.  Horwood,  Ph.D. 

Department  of  Biology  and  Public  Health 
Massachusetts  Institute  of  Technology 

Disraeli  once  said  that  "Public  Health  is  the  foundation  upon  which 
rests  the  happiness  of  the  people  and  welfare  of  the  state.  Reform  di- 
rected toward  the  advancement  of  the  public  health  must  ever  take  pre- 
cedence over  all  others."  This  point  of  view  was  never  appreciated  more 
fully  than  it  is  today.  Although  it  is  essential  for  the  federal  and  state 
governments  to  be  interested  in  the  health  of  pigs,  cows,  horses,  sheep  and 
other  domestic  animals,  and  in  the  diseases  of  wheat,  corn,  cotton  and 
other  crops,  because  of  their  economic  importance,  it  is  likewise  neces- 
sary for  governmental  agencies  to  exhibit  at  least  an  equivalent  degree 
of  interest  in  the  health  of  the  people,  and  more  particularly,  in  the  health 


199 

of  the  mothers,  infants  and  young  children.  Not  so  many  years  ago,  it 
was  impossible  to  obtain  any  printed  literature  from  the  federal  govern- 
ment on  prenatal  care,  or  on  the  care  of  infants  and  children,  even  though 
numerous  pamphlets  were  available  for  free  distribution  on  the  care  of 
animals,  and  the  solution  of  other  problems  on  the  farm.  Happily  that 
day  is  now  past,  for  among  the  most  popular  bulletins  published  by  the 
U.  S.  Government  today,  are  those  excellent  pamphlets  prepared  by  the 
Children's  Bureau  entitled  (1)  Prenatal  Care;  (2)  Infant  Care;  (3)  Child 
Management.  The  demand  for  these  bulletins  is  remarkably  widespread; 
their  quality  is  of  a  very  high  order;  and  their  availability  is  proof  of 
the  current  interest  which  the  Federal  Government  exhibits  in  its  great- 
est source  of  wealth — the  health  of  its  mothers  and  children. 

Life  on  the  earth  is  a  continuous  phenomenon.  The  child  of  today  is 
the  adult  of  tomorrow.  To  him  will  be  entrusted  the  responsibility  for 
carrying  on  intelligently  and  wisely.  The  adult  of  today,  therefore,  has 
an  enduring  and  fundamental  responsibility  to  the  child  of  his  own  gen- 
eration. This  is  particularly  true,  since  the  dependent  period  in  the  life 
of  the  individual  is  so  prolonged.  The  animal,  after  a  short  period  of 
maternal  supervision  and  training  is  compelled  to  shift  for  itself,  and 
to  obtain  worldly  wisdom  in  the  school  of  experience  alone.  The  child, 
however,  must  be  carefully  nursed  and  guided  through  the  delicate,  un- 
certain days  of  early  infancy  and  childhood,  until  its  physical  roots  have 
been  planted  deeply  and  firmly.  After  that,  when  the  pressure  of  con- 
tinuing its  mere  physical  existence  is  somewhat  diminished,  there  is  the 
great  urge  to  become  familiar  with  the  experiences  of  the  past, — the  great 
social  heritage,  which  is  man's,  and  which  makes  it  possible  for  him  to 
maintain  and  extend  the  civilization  that  he  enjoys.  Part  of  that  social 
heritage  is  a  knowledge  concerning  the  control  of  the  environment,  the 
nature  of  disease,  its  causes,  the  modes  of  prevention,  and  the  organiza- 
tion of  daily  life  along  hygienic  lines,  so  essential  for  good  health  and  sur- 
vival. The  problem  of  child  health  and  protection  requires  therefore, 
years  of  effort  and  supervision,  and  since  the  hope  of  the  future  of  man 
is  intimately  linked  up  with  the  childhood  of  today,  it  is  essential  that  the 
interest  which  has  been  stimulated  in  this  aspect  of  human  welfare,  should 
be  a  continuous  and  ever-increasing  process. 

The  recent  White  House  Conference  on  Child  Health  and  Protection 
testifies  to  the  fact  that  the  Federal  Government  has  an  abiding  interest 
in  the  citizens  of  tomorrow,  for  it  represented  the  third  White  House 
Conference  on  Child  Health,  and  it  brought  to  Washington  about  3,000 
men  and  women  who  are  leaders  in  the  medical,  public  health,  educational 
and  social  aspects  of  child  welfare  work.  The  Conference,  which  was  held 
from  November  19-22,  1930,  was  called  together  by  President  Hoover 
whose  interest  in  child  health  and  welfare  work  has  been  of  long  stand- 
ing. Prior  to  the  Conference,  sixteen  months  had  been  devoted  to  prepara- 
tory study  and  research,  and  to  the  assembling  of  a  vast  amount  of  data 
on  all  phases  of  the  child  health  and  welfare  problem.  About  1,200  expert 
workers  were  engaged  in  the  task. 

It  is  not  generally  appreciated  perhaps,  that  this  was  the  third  White 
House  Conference  on  Child  Health.  The  first  was  convened  in  1909,  at 
the  suggestion  of  President  Roosevelt,  and  concerned  itself  very  largely 
with  the  dependent  child.  As  a  result  of  this  Conference,  the  Children's 
Bureau  was  established  and  placed  under  the  U.  S.  Department  of  Labor. 
The  work  of  this  Bureau  has  already  had  tremendous  beneficent  effect, 
and  its  value  in  the  country  at  large  is  appreciated  by  a  large  and  in- 
formed portion  of  the  population. 

The  second  White  House  Conference  on  Child  Health  was  called  by 
President  Wilson  in  1919.  This  Conference  interested  itself  in  (1)  The 
economic  and  social  basis  for  child  welfare  standards;  (2)  Child  labor; 
(3)  Health  of  children  and  mothers;  (4)  Children  in  need  of  special  care; 
and  (5)  Standardization  of  child  welfare  laws. 


200 

As  a  Result  of  this  Conference,  the  Sheppard-Towner  Act  for  the  pro- 
tection of  maternity  and  infancy  was  enacted,  and  many  states  received 
the  necessary  stimulus  and  support  for  the  conduct  of  effective  prenatal, 
obstetrical  and  infant  welfare  work. 

The  third  White  House  Conference  which  was  called  by  President 
Hoover,  and  organized  in  1929,  had  as  its  purpose,  "To  study  the  present 
status  of  the  health  and  well-being  of  the  children  of  the  United  States 
and  its  possessions ;  to  report  what  is  being  done ;  and  to  recommend  what 
ought  to  be  done  and  how  to  do  it."  The  purpose  of  the  Conference  was 
not  to  engage  in  research  primarily,  but  to  assemble  all  of  the  available 
significant  information  pertaining  to  child  health  and  welfare,  to  organize 
it  properly,  and  to  agree  on  the  minimum  requirements  essential  for  a 
modern  program  in  child  health  and  welfare  work.  Accordingly,  the  Con- 
ference was  divided  into  four  parts,  one  of  which  dealt  with  medical 
service,  another  with  public  health  and  administration,  another  with  edu- 
cation and  training,  and  the  fourth  with  the  handicapped  child.  In  many 
respects  this  Conference  was  the  broadest  of  all,  for  it  included  in  its  dis- 
cussions, not  only  the  children  in  special  need  of  protection  and  those  who 
are  dependent,  but  likewise  all  children,  and  the  social  and  environmental 
factors  that  influence  modern  childhood. 

The  purpose  of  the  Conference  was  summarized  in  an  interesting  and 
striking  way  by  President  Hoover  in  his  opening  address  at  the  Confer- 
ence. He  said,  "Our  country  has  a  vast  majority  of  competent  mothers. 
I  am  not  so  sure  of  the  competent  fathers.  But  what  we  are  concerned 
with  here  are  things  that  are  beyond  her  power.  She  cannot  count  the 
bacteria  in  the  milk;  she  cannot  detect  the  typhoid  which  comes  through 
the  faucet,  or  the  mumps  that  pass  round  the  playground.  She  cannot 
individually  control  the  instruction  of  our  schools  or  the  setting  up  of 
community-wide  remedy  for  the  deficient  and  handicapped  child.  But  she 
can  insist  upon  officials  who  hold  up  standards  of  protection  and  service 
to  her  children, — and  one  of  your  jobs  is  to  define  these  standards  and  tell 
her  what  they  are.  She  can  be  trusted  to  put  public  officials  to  the  acid 
test  of  the  infant  mortality  and  service  to  children  in  the  town, — when 
you  get  some  standard  for  her  to  go  by." 

In  spite  of  the  manifold  remarkable  achievements  of  the  twentieth  cen- 
tury already,  the  accomplishments  in  the  field  of  child  health  during  the 
first  30  years  of  the  present  century,  will  doubtless  represent  one  of  the 
most  significant  contributions  of  the  century.  Infant  mortality  rates  have 
fallen  from  150  or  more  infant  deaths  per  1,000  live  births  at  the  begin- 
ning of  the  century  to  70  or  less  at  the  present  time.  Tuberculosis  mortal- 
ity has  been  cut  over  75  per  cent  during  the  same  period ;  diphtheria  and 
typhoid  mortality  has  been  greatly  diminished,  and  the  significance  of 
diarrhea  and  enteritis  under  two  as  a  cause  of  death  has  been  lessened 
enormously.  Much  of  this  achievement  is  due  to  the  purification  of  water 
supplies,  the  construction  of  sewers,  the  improvement  and  pasteurization 
of  milk  supplies,  the  more  satisfactory  protection  of  food  supplies,  and 
the  marked  improvement  in  our  knowledge  concerning  the  proper  hygiene 
of  infancy  and  childhood. 

It  isn't  any  wonder  therefore,  that  the  average  expectancy  of  life  at 
birth  has  been  greatly  increased.  This  increase,  however,  has  occurred 
almost  entirely  as  a  result  of  the  marked  saving  in  human  life  which  has 
been  effected  in  infancy  and  childhood.  The  chief  accomplishment  in  the 
public  health  movement  during  the  past  30  years,  has  been  in  the  preven- 
tion of  infant  and  child  mortality.  For  example,  the  average  expectancy 
of  life  at  birth  in  Massachusetts  in  1850  was  39  years.  In  1925,  it  was 
59  years.  Thus  the  gain  in  average  life  expectancy  at  birth  during  the 
period  under  consideration  was  20  years.  At  age  10,  however,  the  gain 
in  the  average  expectancy  of  life  was  only  8  years.  At  age  20,  it  was  6 
years ;  and  at  age  40,  it  was  only  1  year.  In  fact,  at  age  60,  there  was  an 
actual  diminution  in  the  average  expectancy  of  life  of  one  year. 


201 

In  spite  of  the  remarkable  accomplishments  in  the  field  of  infant  and 
child  health  work,  much  still  remains  to  be  done.  Infant  death  rates  are 
still  unnecessarily  high,  and  premature  deaths  and  preventable  diseases 
occur  among  our  child  population  with  a  frequency  altogether  too  high. 
The  infant  mortality  rate  in  Boston  in  1930  was  70.2;  in  Detroit,  64.8; 
in  Philadelphia,  64.0;  in  New  York,  57.3;  in  New  Haven.  46.9;  in  Port- 
land, Oregon,  40.4;  and  in  San  Francisco,  40.0.  It  is  obvious  that  infant 
death  rates  vary  in  the  United  States  even  today,  and  while  by  compari- 
son with  1900,  our  present  rates  must  be  considered  low,  they  are  prob- 
ably twice  as  high  as  they  ought  to  be.  Who  knows  when  the  prevention  of 
premature  infant  or. child  mortality  may  save  a  genius  for  the  race, — a 
Shakespeare,  a  Pasteur,  a  Newton,  a  Faraday,  an  Edison  or  a  Lincoln, — 
for  as  Secretary  Wilbur  said,  "It  is  one  of  the  great  marvels  of  human 
experience  that  such  outstanding  human  achievements  should  come  from 
seven  pounds  of  cells  and  fluids  encased  in  the  helpless  frame  of  a  baby." 

In  Massachusetts  alone  in  1930,  there  were  4,440  infant  deaths,  with 
an  infant  death  rate  of  60.3.  Of  this  number,  25.3  per  cent  died  on  the 
first  day  of  life;  2,047  or  46.1  per  cent  died  during  the  first  week  of  life; 
and  2,  594  or  58.4  per  cent  died  during  the  first  month  of  life.  Of  all 
the  infant  deaths  in  Massachusetts  in  1930,  72.0  per  cent  occurred  dur- 
ing the  first  three  months  of  life  and  84.8  per  cent,  during  the  first  six 
months  of  life.  The  very  early  infant  deaths  are  due  to  prematurity, 
congenital  debility,  malformations,  or  injuries  received  at  birth.  This  evi- 
dence makes  it  appear,  that  the  greatest  hope  in  the  further  reduction  of 
infant  mortality  lies  in  having  better  and  more  complete  prenatal  super- 
vision, as  well  as  expert,  obstetrical  service  at  the  time  of  delivery.  The 
gastric,  intestinal  and  respiratory  deaths  among  infants,  which,  at  one 
time,  were  so  numerous,  have  been  greatly  diminished.  Gastric  and  in- 
testinal diseases  caused  394  infant  deaths  in  Massachusetts  in  1930,  or 
8.9  per  cent  of  the  total  number  of  infant  deaths,  while  respiratory  dis- 
eases caused  633  infant  deaths  in  Massachusetts  during  the  same  year. 

Another  method  of  appraising  the  magnitude  of  the  child  health  prob- 
lem in  the  United  States  today  consists  in  reviewing  the  following  data, 
obtained  from  the  White  House  Conference.  There  are  approximately 
45,000,000  children  in  the  United  States  today.  Of  this  number  35,000,000 
are  reasonably  normal.  There  are  however,  6,000,000  children  who  are 
improperly  nourished;  1,000,000  who  have  defective  speech;  1,000,000 
who  have  weak  or  damaged  hearts;  675,000  who  present  behavior  prob- 
lems; 450,000  who  are  mentally  retarded;  382,000  who  are  tuberculous; 
3,000,000  who  have  impaired  hearing;  18,000  who  are  totally  deaf;  300,- 
000  who  are  totally  crippled;  50,000  who  are  partially  blind;  14,000  who 
are  wholly  blind;  200,000  who  are  delinquent;  and  500,000  children  who 
are  dependent.  The  mere  citation  of  these  reliable  statistics  gives  one 
some  idea  of  the  magnitude  of  the  child  health  and  welfare  problems, 
with  which  the  country  as  a  whole  must  wrestle,  even  today. 

The  Conference,  however,  brought  out  additional  evidence  which  points 
to  the  need  of  increasing  community  efforts  for  the  further  control  of 
preventable  diseases  and  deaths  among  infants  and  children.  For  example, 
there  are  at  least  10,000,000  deficients  in  the  United  States  today,  more 
than  80  per  cent  of  whom  are  not  receiving  the  necessary  attention,  though 
our  knowledge  and  experience  show  that  these  deficiencies  can  be  pre- 
vented and  remedied  to  a  high  degree.  Furthermore,  the  Conference  re- 
ported that  about  95  per  cent  of  the  children  in  the  United  States  suffer 
from  dental  caries,  and  that  over  3,000,000  cases  of  communicable  disease 
are  reported  annually.  The  latter  are  responsible  for  15  per  cent  of  all 
the  deaths.  In  addition,  they  bring  about  many  permanent  disabilities 
like  blindness,  damaged  hearts  and  kidneys,  and  a  greater  susceptibility 
to  other  infections  which  may  handicap  the  child  throughout  life.  The 
Conference  also  reported  that  50-75  per  cent  of  the  crippled  children  in 
the  United  States,  owe  their  condition  to  poliomyelitis  and  tuberculosis, 
both  of  which  are  theoretically  preventable  diseases. 


202 

One  of  the  factors  most  intimately  linked  up  with  the  problem  of  child 
health  and  welfare,  is  the  question  of  preventable  maternal  mortality.  It 
is  an  interesting  commentary  that  in  spite  of  the  excellent  progress  that 
has  been  made  against  infant  and  child  mortality  during  the  past  30  years 
very  little  has  been  done  to  diminish  the  maternal  mortality  rate.  And 
yet  the  welfare,  supervision  and  guidance  of  the  child,  as  well  as  the 
unity  of  the  home  and  the  maintenance  of  family  life,  is  linked  up  most 
intimately  with  the  prevention  of  these  unnecessary  deaths.  In  New 
York,  for  example,  which  is  one  of  the  great  medical  centers  of  the  world, 
and  which  has  had  excellent  public  health  administration  in  the  past,  the 
maternal  mortality  rate  from  1898  to  1930  has  remained  stationary;  and 
in  1930,  the  maternal  death  rate  was  equal  to  5.43  per  1,000  live  births. 
This  is  true  in  spite  of  the  fact  that  the  death  rate  from  puerperal  septi- 
cemia has  come  down  during  the  same  period  from  2.0  to  0.92  per  1,000 
live  births. 

It  is  estimated  that  40  per  cent  of  the  maternal  deaths  are  due  to  in- 
fections; approximately  25  per  cent  to  toxemias  and  8  to  10  per  cent  to 
hemorrhages  which  are  at  least  controllable,  if  not  absolutely  preventable. 
Thus,  at  least  75  per  cent  of  the  maternal  deaths  are  theoretically  pre- 
ventable. The  White  House  Conference  reported  that  "if  our  present  day 
obstetrical  knowledge  could  be  universally  and  skillfully  applied,  several 
thousands  of  maternal  lives,  and  tens  of  thousands  of  fetal  and  infant 
lives  could  be  saved  annually,  and  much  suffering  and  injury  avoided.  It 
is  unlikely  that  the  maternal  and  early  infant  mortality  in  this  country 
will  be  above  reproach,  until  certain  minimum  and  fairly  uniform  re- 
quirements are  met,  before  a  license  is  granted  for  the  practice  of  ob- 
stetrics." The  Conference  concluded  that  adequate  care  for  maternity 
cases  in  the  home  and  hospital  with  segregated  maternity  services  should 
be  available  in  every  urban  and  rural  community  and  that  adequate  med- 
ical education  is  fundamental  to  any  program  for  maternal  care. 

Still  another  problem  that  requires  increasing  attention,  and  which  must 
be  considered  simultaneously  with  the  problem  of  maternal  mortality,  is 
the  high  stillbirth  rate  found  generally  throughout  the  country,  even  in 
the  leading  medical  centers.  For  example,  the  stillbirth  rate  as  recently 
as  1928  was  4  per  100  live  births.  In  other  words,  for  every  100  babies 
born  alive,  4  are  stillborn.  Parents  who  have  had  the  experience  of  an 
expectant  birth  will  appreciate  how  long  the  period  of  gestation  is  in 
daily  living  as  well  as  the  patience,  anxiety,  discomfort  and  danger  this 
experience  usually  entails.  In  such  cases,  the  crushing  effect  of  frustra- 
tion must  take  an  enormous  toll  in  nervous  strength  and  physical  vitality, 
while  the  problem  of  mental  adjustment  must  be  very  real.  Through 
proper  and  adequate  prenatal  supervision  and  through  the  use  of  experi- 
ence, careful  obstetrical  service  at  the  time  of  delivery,  considerable  pro- 
gress should  be  made  in  further  diminishing  the  present  stillbirth  rate. 

It  is  generally  recognized  that  the  preschool  group  is  the  most  neglected 
age  group  in  the  present  public  health  program  and  yet  it  represents  the 
age  period  when  the  most  effective  preventive  work  can  be  performed.  It 
is  in  this  period  that  such  defects  as  defective  teeth,  enlarged  or  diseased 
tonsils  and  adenoids,  defective  breathing,  defective  vision,  nervous  de- 
fects, malnutrition  and  undernourishment,  and  incipient  tuberculosis 
should  be  detected  and  corrected.  There  is  very  little  value  in  seeing  the 
same  children  in  a  dental  clinic  year  after  year  with  dental  caries,  if 
nothing  has  been  done  in  the  meantime  to  educate  the  child  or  its  parents 
concerning  the  important  relationship  between  an  adequate  and  well-bal- 
anced diet  and  sound  dental  health.  If  effective  public  health  work  were 
practiced  among  the  preschool  child  population,  which  included  physical 
examinations,  preventive  inoculations  against  diphtheria  and  smallpox, 
health  education  and  the  correction  of  all  remediable  defects,  it  would  be 
possible  to  eliminate  much  of  the  medical,  nursing  and  dental  work  per- 
formed In  our  schools  today,  Such,  however,  should  be  the  aim  of  every 


203 

forward-looking  program  whose  object  is  to  protect  and  promote  child 
health. 

Diphtheria  and  smallpox  are  two  diseases  that  can  be  eliminated  alto- 
gether by  preventive  inoculations,  but  it  is  important  that  such  immun- 
ization should  be  practiced  early  in  childhood.  Statistics  from  Michigan 
show  that  the  fatality  rate  for  diphtheria  during  the  first  year  of  life  is 
61  per  cent;  during  the  second  year,  34.7  per  cent;  and  during  the  third 
year,  21.4  per  cent.  It  has  also  been  demonstrated  that  most  of  the  deaths 
from  diphtheria  occur  during  the  preschool  period.  During  1927,  for 
example,  57  per  cent  of  all  the  diphtheria  deaths  occurred  among  children 
under  5.  It  is  obvious  therefore,  that  the  time  to  practice  diphtheria 
immunization  is  during  the  preschool  period.  If  the  immunizations  are 
deferred  until  school  life,  a  large  portion  of  the  value  to  be  derived  from 
such  a  campaign  is  sacrificed. 

That  success  does  attend  a  well-organized  campaign  of  diphtheria 
immunization  even  in  very  large  cities  is  indicated  by  the  experiences  of 
New  York  and  Philadelphia.  It  has  been  demonstrated  that  a  community 
can  be  protected  against  an  epidemic  of  diphtheria  if  35  per  cent  of  the 
children  under  5  are  immunized.  In  1929,  New  York  City  immunized 
211,985  children  against  diphtheria,  and  169,466  in  1930.  Of  the  381,451 
children  who  were  immunized  during  these  two  years,  33.5  per  cent  were 
under  2  years,  43.0  per  cent  were  between  2  and  6  years,  and  23.5  per 
cent  were  over  6  years. 

The  story  in  Philadelphia  is  essentially  similar.  In  1930,  the  local  health 
department  estimated  that  40  per  cent  of  all  the  children  under  5  had 
been  immunized  against  diphtheria;  80-85  per  cent  of  all  the  children 
between  5  and  9 ;  and  60-65  per  cent  of  all  the  children  between  10 
and  14.  The  experiences  of  New  York  and  Philadelphia,  as  well  as 
many  other  cities  that  might  be  included,  testify  to  the  fact  that  diph- 
theria can  be  brought  under  control  today.  The  diphtheria  mortality 
in  New  York  in  1930  was  2.86  per  100,000  population,  and  in  Philadelphia 
for  the  same  year,  only  2.46.  These  rates  compare  with  those  of  125  per 
100,000  or  more  that  used  to  prevail  annually  in  our  large  cities,  prior  to 
the  introduction  of  antitoxin,  toxin-antitoxin  and  the  other  effective 
means  for  combating  diphtheria. 

It  is  to  be  regretted  that  during  the  ten  years  period,  from  1919-1928, 
there  were  reported  in  the  United  States  553,559  cases  of  smallpox,  when 
it  is  recognized  that  successful  vaccination  would  have  prevented  every 
single  case.  In  the  early  part  of  the  nineteenth  century,  20  per  cent  of  all 
children  died  of  smallpox  before  they  reached  the  age  of  10  and  one  third 
of  all  the  deaths  occurring  among  children  from  all  causes  were  due  to 
smallpox.  In  view  of  these  data  it  is  obvious  that  there  is  still  need  for 
preaching  early  vaccination  against  smallpox  and  to  provide  the  necessary 
facilities  in  each  community  to  protect  child  life  against  this  scourge. 

In  view  of  the  great  opportunities  that  still  exist  for  eliminating  pre- 
ventable disease  and  death  among  children  and  for  promoting  child  health, 
it  is  well  to  inquire  what  are  the  essential  administrative  requirements 
for  attaining  these  ends.  The  chief  recommendation  of  the  White  House 
Conference  on  this  subject  was  that  every  community  should  have  full- 
time,  trained  public  health  personnel  of  pleasing  personality  and  endowed 
with  the  ability  to  handle  subordinates  effectively  as  well  as  a  spirit  of 
cooperation  so  essential  for  the  successful  conduct  of  public  health  work. 
In  addition,  the  health  department  must  be  provided  with  a  budget  ade- 
quate to  meet  the  public  health  needs  of  the  community  effectively.  Given 
such  an  organization,  with  the  financial  support  suggested,  there  is  little 
need  for  enumerating  the  other  recommendations  for  effective  health  ad- 
ministration, for  a  trained  health  officer  would  be  familiar  with  the  de- 
tailed requirements  for  the  successful  conduct  of  his  department. 

Curiously  enough,  any  administrative  set-up  which  falls  short  of  the 
recommendation  made  by  the  White  House  Conference,  must  prove  to  be 


204 

essentially  ineffective  and  expensive.  It  is  absurd  to  attempt  to  carry  on 
any  business,  especially  one  that  requires  professional  training  and  sci- 
entific skill,  without  a  director  employed  on  a  full-time  basis,  who  is  quali- 
fied both  by  training  and  experience.  Such  a  makeshift  would  not  be 
tolerated  in  business  or  industry.  It  should  not  be  permitted  in  the  out- 
standing municipal  activity,  which  exerts  such  a  direct  influence  on  the 
lives  and  well-being  of  the  people  in  the  community.  The  famous  words 
of  Dr.  Hermann  M.  Biggs  must  always  be  remembered.  "Within  certain 
limits,  a  community  can  determine  its  own  death  rate." 

Here  in  Massachusetts,  there  have  been  innumerable  illustrations  of 
the  wisdom  of  full-time,  trained  personnel  in  the  administration  of  pub- 
lic health  activities.  Outstanding  in  this  connection  is  the  State  Depart- 
ment of  Public  Health,  which  has  followed  this  plan  with  marked  success 
for  over  half  a  century,  and  is  regarded  today  as  the  best  State  Depart- 
ment of  Public  Health  in  the  country.  Where  the  local  community  repre- 
sents a  population  unit  of  sufficient  magniture,  it  should  unquestionably 
provide  for  a  health  department  of  its  own,  with  the  type  of  personnel  al- 
ready described.  Where  the  community  is  too  small  or  too  poor  to  pro- 
vide for  the  effective  administration  of  its  public  health  activities,  then 
the  best  solution  lies  in  the  formation  of  a  cooperative  health  unit,  con- 
sisting of  a  number  of  small  towns  or  rural  areas,  each  contributing  its 
share  to  the  proper  financing  of  the  project,  in  order  that  full-time,  trained 
health  personnel  may  be  available.  The  experience  of  the  Wellesley  Co- 
operative Health  Unit  testifies  to  the  wisdom  and  practicality  of  the  plan. 
The  recent  organization  of  the  Southern  Berkshire  and  Nashoba  Health 
Units,  partly  financed  by  the  Commonwealth  Fund,  and  staffed  with  un- 
usually fine  and  capable  personnel,  is  additional  evidence  of  the  best  avail- 
able solution  of  the  problem  of  public  health  administration  in  small 
towns  and  rural  areas.  There  are  so  many  small  towns  in  Massachusetts 
at  present  without  adequate,  local  provision  for  proper  public  health  ad- 
ministration, that  the  idea  of  cooperative  health  units  should  spread, 
until  each  town  and  rural  district  will  be  provided  for  in  this  way. 

In  every  community  there  is  not  only  an  official  health  agency,  but  like- 
wise one  or  more  voluntary  health  agencies.  Among  the  latter  are  the 
Visiting  Nurse  Association,  the  local  tuberculosis  association  and  possibly 
the  Red  Cross  and  other  welfare  agencies.  Usually  the  voluntary  health 
organizations  are  conducted  efficiently  and  are  supervised  by  personnel  of 
excellent  training  and  ability.  They  often  serve  as  a  stimulus  to  the 
official  health  agency  in  order  that  better  and  more  progressive  health 
work  may  be  performed.  In  addition,  they  often  supplement  what  the 
official  health  agency  is  doing.  Sometimes,  because  of  their  greater  flexi- 
bility from  an  administrative  standpoint,  they  are  able  to  conduct  demon- 
strations of  new  but  reliable  public  health  projects.  The  voluntary  health 
agency  is  therefore  a  valuable  element  in  the  public  health  machinery  of 
any  community.  In  order  to  be  most  effective,  however,  it  is  essential  that 
the  relationship  between  the  official  and  voluntary  health  agencies  should 
be  friendly  and  cooperative.  Every  effort  should  be  made  in  every  com- 
munity to  attain  this  desirable  end. 

Other  recommendations  of  an  administrative  nature  made  by  the 
White  House  Conference  require  the  prompt  reporting  of  disease,  the 
timely  analysis  of  all  vital  statistics  and  the  proper  isolation  of  cases 
and  contacts,  so  essential  for  the  effective  control  of  disease.  There 
should  also  be  an  adequate  epidemiological  investigation  of  all  cases 
of  disease  reported  to  the  health  department  and  suitable  facilities  for 
the  proper  hospitalization  of  such  cases.  The  health  department  should 
also  be  equipped  with  suitable  diagnostic  laboratory  facilities  as  an 
aid  in  the  prompt  and  early  detection  of  disease,  and  in  the  supervision 
of  the  local  water  and  milk  supplies.  Adequate  provision  must  also  be 
made  for  the  proper  control  of  carriers  and  for  the  establishment  of  an 
expert,  consultant,  clinical  diagnostic  service.    The  community  should 


205 

also  provide  all  of  the  reliable  biological  products  now  available  either 
for  treatment,  prevention  or  diagnosis,  and  should  conduct  campaigns 
for  the  immunization  of  the  population  against  diphtheria,  smallpox 
and  typhoid  fever. 

In  addition,  there  should  be  an  adequate  public  health  nursing  staff, 
organized  on  a  generalized  basis,  and  provided  with  adequate  super- 
vision which  would  carry  on  an  effective  program  of  health  education 
in  the  home  and  aid  in  other  ways  in  the  conduct  of  the  local  public 
health  program.  There  should  also  be  an  effective  campaign  of  popular, 
health  education  and  a  well  organized  program  of  health  education  in 
the  schools.  Every  effort  should  also  be  made  to  stimulate  the  interest 
and  cooperation  of  the  local  physicians  and  dentists.  At  the  same  time, 
the  public  should  be  educated  to  go  to  their  accredited  practitioners 
for  preventive  treatment  in  all  branches  of  medicine  and  dentistry. 
Finally,  the  Conference  recommended  that  there  should  be  adequate 
supervision  over  all  water  supplies,  milk  supplies,  food  supplies  and  sew- 
age disposal,  and  that  the  health  department  should  encourage  as  far 
as  possible,  the  improvement  of  housing  and  working  conditions,  the 
extension  of  playground  and  recreational  facilities  and  the  maintenance 
of  a  wage  scale  conducive  to  healthy  living. 

The  protection  of  child  health  makes  an  emotional  appeal  to  the 
citizenry  of  every  community  which  should  not  be  overlooked.  The 
child,  so  helpless  by  itself,  has  the  potentiality  of  greatness,  and  it  is 
one  of  the  glories  of  the  American  commonwealth,  that  its  people  have 
always  been  desirous  of  providing  the  necessary  opportunities  and 
the  protection  so  essential  to  the  proper  development  of  its  great- 
est asset, — its  children.  With  the  welfare  of  the  child  population  as  the 
basis  for  its  appeal,  most  communities  should  be  able  to  provide  the 
public  health  machinery  so  essential  for  the  attainment  of  this  end. 
President  Hoover,  however,  epitomized  this  whole  philosophy  in  words 
that  are  likely  to  be  remembered  for  a  long  time,  and  it  is  only  fitting 
therefore  to  quote  his  words  in  conclusion. 

"We  approach  all  problems  of  childhood  with  affection.  Theirs  is  the 
province  of  joy  and  good  humor.  They  are  the  most  wholesome  part  of 
the  race,  the  sweetest,  for  they  are  fresher  from  the  hands  of  God. 
Whimsical,  ingenious,  mischievous,  we  live  a  life  of  apprehension  as 
to  what  their  opinion  may  be  of  us.  A  life  of  defense  against  their 
terrifying  energy;  we  put  them  to  bed  with  a  sense  of  relief  and  a 
lingering  of  devotion.  We  envy  them  the  freshness  of  adventure  and 
discovery  of  life.   We  mourn  over  the  disappointments  they  will  meet. 

"If  we  could  have  but  one  generation  of  properly  born,  trained,  edu- 
cated and  healthy  children,  a  thousand  other  problems  of  government 
would  vanish." 

THE    FINDINGS    OF    THE    COMMITTEE    ON    PUBLIC    HEALTH 

ORGANIZATION  OF  THE  WHITE  HOUSE  CONFERENCE 

ON  CHILD  HEALTH  AND  PROTECTION 

By  Charles  F.  Wilinsky,  M.D. 

Deputy  Commissioner  of  Public  Health,  City  of  Boston 

Director  of  the  Beth  Israel  Hospital,  Boston 

The  Committee  on  Public  Health  Organization  of  the  White  House 
Conference  on  Child  Health  and  Protection  not  only  presented  a  pic- 
ture of  the  efforts  of  the  official  health  agencies  but  the  activities  of 
the  private  groups  as  well,  and  the  conclusions  and  recommendations 
had  for  their  objective  the  advocacy  of  such  changes  or  adjustments  as 
would  best  result  in  the  type  of  organization  which  could  apply  to  the 
maximum  advantage  of  existing  knowledge  for  the  promotion  and  pro- 
tection of  the  health  of  our  children.   This  study  included  a  picture  of 


206 
the  organization  and  responsibilities  of  the  federal  government,  the 
state,  the  city,  as  well  as  rural  communities.  It  considered  thoroughly 
the  relationship  of  the  agencies  supported  by  taxation  and  those  by  pri- 
vate grant  or  contribution.  It  also  went  into  the  question  of  necessary 
training  of  public  health  personnel  as  well  as  the  responsibilities  of 
the  medical  and  dental  professions. 

Federal  Health  Organization 

It  was  pointed  out  that  while  the  bulk  of  the  public  health  activities 
carried  on  by  the  government  is  conducted  by  the  United  States  Public 
Health  Service  under  the  Treasury  Department,  that  there  were  addi- 
tional health  services  in  the  Departments  of  Agriculture,  Commerce, 
Labor,  Interior  and  Department  of  State,  and  it  was  recommended  that 
there  be  a  development  of  closer  inter-relationship  between  these  vari- 
ous departments  and  particular  emphasis  was  placed  upon  the  obliga- 
tion of  the  Federal  Government  to  assist  through  state  departments  of 
health  the  states  themselves,  the  cities  and  rural  communities  and 
wherever  such  assistance  is  needed  for  the  maintenance  of  adequate 
health  protection. 

State  Health  Organization 

In  the  studying  of  state  health  organization  throughout  the  country, 
it  was  agreed  that  it  was  impossible  to  set  up  any  system  that  would 
apply  universally  to  all  of  the  states  because  of  the  difference  in  local 
conditions  and  customs,  but  it  was  stressed  that  it  was  important  to 
bear  in  mind  that  it  was  not  only  desirable  but  necessary  to  secure 
such  public  health  organization  as  would  insure  every  individual  in  the 
state — be  it  rural,  town  or  city — the  benefit  of  such  knowledge  and 
service  as  would  result  in  the  protection  of  health.  It  was  recognized 
that  the  ultimate  responsibility  and  conduct  of  public  health  service 
was  a  definite  function  of  government  and  that  the  state  government 
was  responsible  for  the  health  protection  of  the  entire  state.  This 
statement  is  made  with  a  definite  realization  of  the  very  important  part 
which  should  be  played  by  the  general  practitioner  of  medicine  in  carry- 
ing out  public  health  measures  for  the  prevention  of  disease  among  his 
patients  and  the  dissemination  of  health  knowledge,  and  public  health 
officers  should  work  shoulder  to  shoulder  with  the  medical  profession 
for  the  attainment  of  maximum  results. 

In  giving  consideration  to  the  entire  national  structure  of  public 
health  organization,  there  is  revealed  the  need  of  adequately  trained 
personnel  and  money  for  the  maintenance  of  necessary  programs.  This 
brings  up  for  consideration  the  great  need  for  inter-relationship  be- 
tween state  and  federal  health  service  because  of  the  administrative 
and  financial  responsibilities  involved.  Wherever  state  or  county  health 
service  is  adequately  functioning,  the  responsibility  for  this  particular 
community  may  rest  lightly  upon  the  shoulders  of  the  federal  and  city 
health  departments  but  wherever  and  whenever  the  inverse  is  true  and 
communities  are  unable  to  support  financially  adequate  health  services,  it 
is  reasonable  to  presume  that  it  becomes  the  obligation  of  the  state 
for  its  own  protection  to  aid  that  particular  community.  Likewise,  when 
the  state  is  unable  to  maintain  sufficient  health  service,  it  would  then  be 
he  responsibility  of  the  federal  government  to  render  assistance  for  the 
maintenance  of  at  least  minimum  standards. 

City  Health  Departments 

A  very  intensive  study  -was  made  of  municipal  health  departments 
resulting  in  the  following  conclusions:  That  there  was  a  need  for  full- 
time  local  health  organization  composed  of  well-trained  personnel,  and 
a  need  of  adequate  financial  support;  that  there  should  be  better  co- 
ordination between  official  and  voluntary  agencies.  Attention  is  called 
to  the  value  and   importance  of  health   councils.    The   Boston    Health 


207 
League  is  cited  as  an  example,  the  council  strongly  supporting  the  local 
health  department  and  at  the  same  time  developing  better  inter-rela- 
tionship between  health  agencies.  It  was  the  judgment  of  the  com- 
mittee that  some  activities  now  included  in  the  program  of  health  de- 
partments might  in  a  marked  measure  be  carried  on  by  the  general 
practitioner  of  medicine  where,  particularly  in  the  field  of  child  health, 
the  family  physician  should  become  the  practitioner  of  preventive  as 
well  as  curative  medicine.  Everything  should  be  done  to  develop  co- 
operation between  health  departments  and  medical  societies,  result- 
ing in  the  creation  of  machinery  either  within  local  health  organiza- 
tions or  in  centers  of  medical  education  which  will  reach  a  great  mass 
of  medical  practitioners. 

Rural  Health  Organizations 

It  was  pointed  out  that  Massachusetts  established  in  1797  a  system 
of  local  boards  of  health  and  was  a  pioneer  state  in  this  field.  Study 
of  the  rural  health  organization  revealed  a  great  need  for  the  pooling 
of  rural  health  interests  by  the  creation  of  county  health  departments 
which  would  promote  adequately  a  health  service  for  a  sufficient  unit 
of  the  population  to  make  such  an  objective  possible.  There  is  a  great 
need  in  this  field  for  support  by  either  the  federal  government  or  pri- 
vate foundations  for  the  extension  of  this  work  in  rural  communities 
now  unable  to  support  adequate  public  health  work  because  of  lack  of 
funds.* 

Relation  of  Official  and  Non-Official  Agencies  in  Public  Health 

Organization 

Something  has  already  been  said  about  the  parts  played  by  unofficial 
agencies.  Approximately  $30,000,000  is  expended  by  private  agencies 
for  public  health  in  the  United  States  annually.  This  makes  for  a  very 
significant  part  of  public  health  service,  and  everything  possible  should 
be  done  to  coordinate  the  activities  of  the  official  and  unofficial  groups, 
thereby  avoiding  duplication  and  waste.  It  is  important,  however,  to 
stress  the  fact  that  such  leadership  must  rest  within  the  official  health 
departments  and  that  no  program  should  be  fostered  without  at  least  an 
effort  to  obtain  approval  of  local  health  officers. 

Instruction  and  Training 

The  inadequate  existence  of  institutions  organized  for  the  purpose  of 
training  public  health  workers  is  glaringly  revealed.  If  we  are  to  have 
a  sufficient  army  of  public  health  workers,  medical  schools  and  addi- 
tional schools  of  public  health,  sufficiently  equipped  and  endowed,  must 
provide  background  for  this  training. 

*  Editor's  Note : 

In  response  to  this  need,  the  Commonwealth  Fund  of  ,New  York 
City  is  now  aiding  the  State  Department  of  Public  Health  in  the 
promulgation  of  a  rural  health  program  in  Massachusetts.  This 
program  centers  around  the  organization  of  two  District  Health 
Units  composed  of  fourteen  and  fifteen  towns  respectively.  None 
of  these  communities  by  itself  has  a  population  of  over  6,000.  In 
each  area,  a  group  of  adequately  trained,  full-time  workers  is  re- 
sponsible for  carrying  out  a  properly  balanced  public  health  pro- 
gram. 

Barnstable  County,  Massachusetts,  already  has  a  full-time  health 
officer.  In  other  parts  of  the  State,  however,  it  seems  that  the 
district  instead  of  the  county  is  the  more  feasible  basis  for  the 
institution  of  well-balanced,  full-time  health  service.  The  two 
District  Health  Units  already  organized  should  serve  as  demon- 
stration models  not  only  for  other  parts  of  Massachusetts  but  also 
for  the  other  New  England  states. 


208 
Administration  of  Child  Health 

It  has  been  rather  fittingly  said  that  we  are  living  in  the  "Century  of 
the  Child."  A  real  contribution  in  life-saving  has  been  made  in  this 
age  group.  The  infant  mortality  rate  has  been  cut  in  two  in  the  last 
30  years,  resulting  in  an  enormous  amount  of  life-saving  and  doing 
much  toward  the  increase  of  the  span  of  life  because  of  a  reduction  in 
hazards  among  the  very  young.  There  is  still  much  to  be  done  which  is 
so  dependent  upon  the  development  of  adequately  paid  and  sufficiently 
trained  personnel  held  responsible  for  the  development  of  adequate 
programs.  Again  it  must  be  emphasized  that  the  physician  and  dentist 
can  do  much  in  the  field  of  disease  prevention  among  children  and 
every  effort  should  be  made  by  intelligent  health  officers  to  obtain  their 
cooperation  and  assistance.  Increasing  impetus  for  the  promotion  of 
health  and  prevention  of  disease  among  our  children  so  strongly  cham- 
pioned and  sponsored  by  President  Hoover  and  resulting  in  the  organ- 
ization, the  deliberations  and  the  recommendations  of  the  White  House 
Conference  on  Child  Health  and  Protection  will  assume  greater  mo- 
mentum because  of  the  intelligent  realization  by  sympathetic  health 
workers  that  the  recommendations  are  reasonable  and  sound  and  passed 
on  by  them  to  the  citizenry  of  our  country. 

MILK 

By  Frank  E.  Mott 
Director,  Bureau  of  Milk  Inspection,  City  of  Boston 

Milk  is  the  food  with  which  you  first  became  acquainted  in  your  life 
and  without  it  you  would  have  lived  only  a  very  short  time.  If  a  length 
of  time  of  acquaintance  means  much  we  should  know  a  lot  about  milk. 
We  do  know  considerable  but  milk  touches  closely  the  mystery  of  life  and 
apparently  it  is  not  to  be  given  to  man  to  know  too  much  about  that  and 
so  it  appears  that  our  knowledge  of  milk,  considerable  as  it  is,  is  only  the 
simpler  part  of  all  that  might  be  known  about  this  food  for  such  complex 
constitution. 

When  you  use  milk  it  is  for  its  food  value  only.  Although  milk  contains 
about  87 ^  per  cent  water  you  do  not  use  it  for  its  water  content.  Filth 
can  be  added  to  milk;  bacteria  with  pathogenic  possibilities  can  be  in 
milk,  and  you,  as  a  consumer,  cannot  tell  that  such  milk  is  not  fit  for  your 
use.  You  need  help  and  so  in  recognition  of  these  facts,  and  also  that  milk 
is  so  easily  adulterated,  your  legislature  has  passed  an  elaborate  system 
of  laws  establishing  the  standards  of  food  values  and  prohibiting  adulter- 
ation of  milk.  Such  laws  can  be  enforced  one  hundred  per  cent  and  as  a 
result  we  have  better  milk  without  restricting  the  quantity  of  milk  avail- 
able. 

No  matter  how  rich  a  milk  may  be,  no  matter  how  well  adapted  as  a 
food  for  the  use  of  children  milk  may  be,  it  would  appear  to  be  unthink- 
able that  milk  potentially  unsafe  for  the  use  of  children  would  be  fed  to 
them  and  yet  that  is  precisely  what  is  being  done  in  some  communities 
and  thereby  a  real  public  health  problem  is  created.  It  is  about  this  phase 
of  the  milk  problem  that  I  shall  talk  today. 

In  America,  milk  appears  to  be  a  necessity  for  babies  and  children. 
That  is  the  reason  why  in  a  conference  where  the  subject  is  Child  Health 
a  discussion  of  milk  is  quite  sure  to  be  of  importance. 

So  far  as  we  know  babies  must  have  milk  in  some  form  or  they  die. 
There  appears  to  be  no  substitute  for  milk  which  will  sustain  the  life  of 
an  infant.  So  far  as  we  can  see  this  may  be  expected  to  be  so  in  the 
future.  If  milk  is  not  available  for  the  baby  in  the  form  of  mother's  milk 
then  milk  must  be  obtained  from  some  other  source.  Of  all  sources  avail- 
able no  source  other  than  the  cow  appears  likely  to  be  of  importance. 


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After  an  American  baby  is  weaned  the  child  then  appears  to  have  some 
chance  of  surviving  if  cow's  milk  is  not  available,  but  not  a  good  chance. 
Only  by  means  of  a  plentiful  supply  of  good  milk  after  being  weaned  does 
the  American  child  appear  to  have  the  best  chance  of  a  healthy  childhood. 
Then  we  depend  upon  cow's  milk.  Now  unfortunately,  it  appears  to  be 
true  that  mothers  are  increasingly  less  likely  to  be  able  to  nurse  their 
own  infants  so  it  seems  probable  that  in  the  future  a  good  safe  cow's  milk 
must  be  available  to  a  greater  extent  for  the  use  of  infants. 

So  far  as  food  values  are  concerned  milk  is  the  most  nearly  complete  of 
all  foods.  No  other  single  food  can  compare  with  it.  So  far  as  supply  is 
concerned,  in  the  United  States  at  least,  plenty  of  milk  is  available  every- 
where. 

Why,  then,  are  health  officers  so  concerned  about  the  milk  supply,  par- 
ticularly with  respect  to  milk  available  for  the  use  of  children?  It  is  be- 
cause a  good  food  for  human  beings  is  sure  to  be  a  good  food  for  other 
forms  of  life  and  milk  is  perhaps  the  best  example  of  the  truth  of  that 
general  statement. 

Such  organisms  as  those  which  cause  typhoid  fever,  scarlet  fever,  diph- 
theria, septic  sore  throat,  undulant  fever,  tuberculosis,  diarrhea  and 
gastro-enteritis  will,  if  they  happen  to  get  into  the  milk,  find  in  it  a 
medium  perfectly  adapted  for  their  growth  and  they  thrive,  wax  strong 
in  numbers,  produce  their  toxins,  and  if  such  milk  is  consumed  by  anyone, 
that  person  probably  will  develop  that  particular  disease  of  which  the 
infecting  organism  is  the  causative  agent,  and  the  chance  of  developing 
the  disease  will  depend  firstly,  upon  the  size  of  the  dose,  and  secondly, 
upon  the  resistivity  of  the  individual.  With  children  the  dosage  is  bound 
to  be  large  and  the  resistivity  is  bound  to  be  relatively  small  and  the  child 
in  such  circumstances  has  but  little  chance  to  survive  such  an  infection. 

How  may  such  infections  get  into  milk?  Firstly,  some  may  be  in  the 
milk  as  it  is  drawn  from  the  cow,  for  the  cow  may  not  be  healthy  and  if 
diseased  the  organism  causing  the  disease  is  quite  sure  to  be  in  the  milk. 
Secondly,  the  infection  may  get  into  the  milk  because  some  person  who 
handled  the  milk,  either  the  milker  or  some  other  person,  has  the  disease 
and  the  bodily  discharges  of  diseased  persons  are  likely  to  be  infected. 

I  would  now  like  to  present  for  your  consideration  a  legal  definition 
of  milk: 

"Milk  is  the  lacteal  secretion  obtained  by  the  complete  milking  of  one 
or  more  healthy  cows  properly  fed  and  kept,  and  excluding  such  milk  as 
may  be  drawn  fifteen  days  before  and  five  days  after  calving."  I  would 
call  your  attention  particularly  to  the  words  "healthy  cows"  and  let  us 
consider  the  subject.  We  know  that  cows  are  likely  to  have  many  diseases 
and  we  know  that  some  of  the  diseases  which  cows  have  may  be  trans- 
ferred to  human  beings  through  their  milk.  If  we  have  a  class  of  healthy 
cows  and  if  we  also,  as  we  do,  have  a  class  of  unhealthy  cows,  then  there 
must  be  a  change  in  cow  life  at  times  from  a  condition  of  health  to  a 
condition  of  disease.  When  does  this  change  take  place?  Is  it  a  change 
that  is  noticeable  as  soon  as  it  takes  place  or  may  there  be  a  considerable 
period  during  which  cows,  apparently  healthy,  are  in  fact  shedders  of 
bacteria  in  their  milk  which  are  capable  of  producing  disease  in  human 
beings?  The  latter  statement  is  the  fact.  Cows  in  many  respects  are  no 
different  from  human  beings  in  that  they  may  and  do  frequently  appear 
to  be  in  good  health  and  yet,  as  a  matter  of  fact,  are  diseased,  and  many 
such  cows  are  constantly  shedding  in  their  milk,  bacteria  which  when 
taken  into  the  human  system  are  capable  of  causing  disease.  Further- 
more, it  is  well  established  by  bitter  experience  that  cows  may  be  appar- 
ently healthy,  that  they  may  be  so  apparently  healthy  that  when  exam- 
ined by  the  most  expert  veterinarian  the  fact  of  the  presence  of  disease 
may  not  be  disclosed  and  yet  such  cows  may  be,  and  are,  shedding  through 
their  milk,  disease  producing  organisms. 

I  am  now  going  to  relate  a  few  actual  occurrences.    A  bacteriological 


210 

examination  of  the  milk  in  the  general  supply  of  a  large  producer  of  certi- 
fied milk  was  found  to  contain  pus  and  streptococci,  indicating  the  pres- 
ence of  one  or  more  diseased  animals  in  the  milking  herd.  There  had  been 
previous  to  this  discovery  the  regular  physical  examination  of  the  entire 
herd  by  the  competent  veterinarian  employed  by  the  producer.  Appar- 
ently all  of  the  animals  were  healthy.  After  the  discovery  by  bacterio- 
logical examination  made  by  the  Health  Department,  samples  of  milk 
were  taken  from  each  individual  cow  and  the  one  cow  was  discovered 
which  was  infected.  This  cow  was  then  examined  by  a  group  of  the  most 
skilled  veterinarians,  including  some  who  were  teaching  veterinary  medi- 
cine at  a  prominent  college.  No  veterinarian  was  able  to  tell  by  physical 
examination  that  this  cow  was  diseased.  The  cow  was  then  autopsied, 
was  found  not  only  to  be  discharging  pus  and  streptococci  because  of  an 
infection  of  the  udder,  but  was  also  found  to  have  a  tuberculous  udder. 
That  cow  was  indicated  to  be  healthy,  by  the  tuberculin  test,  yet  that  cow 
was  discharging  bovine  tubercle  bacilli  as  well  as  pus  and  streptococci  in 
her  milk.  The  supervision  of  the  milk  production  was  as  good  as  existed 
anywhere  at  that  time  which  was  approximately  fifteen  years  ago. 

Another  case  and  this  within  the  present  year.  Bacteriological  exam- 
ination of  the  milk  of  a  certain  producer  of  certified  milk  showed  bacteria 
content  in  increased  numbers  from  day  to  day,  also  indications  of  an  in- 
cipient inflammatory  udder  condition.  Samples  were  taken  from  each  in- 
dividual cow  in  the  producing  herd  and  the  animal  causing  the  condition 
was  isolated.  This  animal  had  been  examined  by  a  skilled  veterinarian 
during  the  previous  week.  He  had  pronounced  the  cow  to  be  one  hundred 
per  cent  healthy.  This  cow  was  then  re-examined  by  a  group  of  skilled 
veterinarians  and  under  physical  examination  no  abnormality  was  found. 
An  autopsy  was  then  made  and  it  was  found  that  the  cow  was  in  the  early 
stages  of  what  would  have  been  a  bad  mastitis  with  the  discharge  of  pus 
and  streptococci  in  the  milk. 

From  these  actual  experiences  it  is  apparent  that  even  with  an  elaborate 
system  of  supervision  there  must  be  a  period  during  which  cows  which 
are  apparently  healthy  are  in  fact  shedders  of  bacteria  which  are  capable 
of  producing  disease  in  human  beings. 

In  an  effort  to  control  and  possibly  eradicate  tuberculosis  in  cows  the 
system  of  tuberculin  testing  and  slaughter  of  reactors  has  been  adopted. 
Whether  or  not  this  system  is  the  best  system,  and  there  are  unquestion- 
ably two  sides  to  this  question,  some  experts  holding  out  with  a  strong  and 
apparently  well  founded  argument  that  this  system  is  bound  to  create  a 
breed  of  very  tender  animals  and  subject  to  tuberculosis,  nevertheless,  it 
is  a  well  known  fact  that  the  method  of  testing  used  is  not  one  hundred 
per  cent  perfect.  Cows  which  have  been  given  the  tuberculin  injection, 
though  they  have  tuberculosis,  will  not  react  positively  to  a  subsequent 
tuberculin  test  for  some  time.  Furthermore,  cows  may  react  negatively 
during  the  period  of  gestation  and  then  react  positively  after  calving. 

Then  also  in  order  to  obtain  animals  which  are  free  from  infectious 
abortion  we  have  under  way  a  program  for  the  elimination  of  cows 
affected  with  this  disease,  and  here,  too,  the  tests  are  not  one  hundred 
per  cent  efficient. 

Furthermore,  a  herd  too  frequently  is  diseased  and  pronounced  free 
from  tubercular  reactors  or  from  infectious  abortion  and  then  by  subse- 
quent test,  after  a  lapse  of  a  few  months,  is  found  to  have  a  high  per- 
centage of  animals  that  have  during  the  period  either  become  infected  or 
have  reached  that  particular  point  where  they  respond  positively  to  the 
tests  when  applied.  It  is  therefore  apparent  that  during  such  periods 
cows  which  are  apparently  healthy  are  in  fact  shedders  of  those  par- 
ticular organisms  which  may  cause  disease  when  their  milk  is  consumed 
by  human  beings. 

Do  not  think  because  cows  have  been  tested  for  tuberculosis  with  a 
negative  result  that  as  a  matter  of  fact  no  cows  with  tuberculosis  are 


211 

present.  As  I  have  already  indicated  the  test  is  not  one  hundred  per  cent 
efficient,  but  even  if  it  were  one  hundred  per  cent  efficient  it  is  quite  pos- 
sible that  cows  may  be  free  from  tuberculosis  today  and  break  down  with 
the  disease  tomorrow.  Three  years  ago  a  certain  herd  producing  certified 
milk  was  tested  and  no  reactors  were  found.  Six  months  later  the  cows 
were  again  tested  and  over  fifty  out  of  a  total  of  one  hundred  and  twenty- 
three  of  the  cows  were  found  to  have  tuberculosis.  This  indicates  how 
rapidly  there  may  be  a  change  from  a  condition  of  apparent  health  to  a 
condition  of  positive  disease.  Concerning  the  ordinary  herd  of  cows, 
within  the  year  a  dealer  applied  for  credit  as  a  distributor  of  milk  pro- 
duced exclusively  from  tuberculin  tested  cows.  On  investigation  it  was 
found  that  two  of  his  herds  had  recently  been  tuberculin  tested.  One 
herd  of  105  cows  had  90  cows  which  reacted  positively;  the  other  herd 
of  60  cows  had  45  cows  with  tuberculosis.  These  herds  were  average 
Massachusetts  herds  not  under  a  system  of  examination  for  the  eradica- 
tion of  tuberculosis.  Furthermore,  it  is  known  beyond  doubt  that  outside 
of  herds  producing  certified  milk  approximately  sixty  per  cent  of  all  the 
cows  have  infectious  abortion  in  some  stage,  and  of  these  sixty  per  cent, 
approximately  twenty  per  cent  of  them  are  actually  shedding  in  the  milk 
the  bacteria  which  are  the  causative  agents  of  the  disease. 

I  have  gone  into  the  subject  of  healthy  cows  at  some  length  in  order 
that  you  may  fully  appreciate  the  significance  of  the  following  statement, 
which  is,  that  practically  all  mixed  milk,  excepting  only  a  small  portion 
of  the  certified  milk,  contains  bacteria  with  disease-producing  possibilities 
which  come  from  the  cow  itself,  either  directly  from  the  udder  or  from 
cow  feces  which  get  into  the  milk.  So  much  for  those  diseases  to  which 
the  human  race  is  subject  and  which  may  be  transferred  through  milk, 
the  causative  organisms  of  which  come  from  the  cow,  and  the  danger 
which  exists  with  respect  to  the  diseases  I  have  mentioned,  is  likely  to  be 
present  also  when  other  cow  diseases  are  active. 

Let  us  now  consider  the  second  way  in  which  milk  may  become  con- 
taminated with  organisms  which  may  cause  disease,  and  that  is  through 
the  agency  of  employees  who,  in  handling  the  milk,  get  into  it  portions 
of  their  various  body  discharges.  Some  of  this  danger  can  be  reduced  by 
careful  supervision  of  the  health  of  employees  but  it  is  doubted  that  com- 
plete elimination  of  this  danger  will  be  possible.  This  is  because  of  the 
fact  that  it  is  oftentimes  true  that  the  particular  periods  when  human 
beings  who  are  diseased  are  shedders  of  the  particular  organisms  which 
is  causing  the  disease,  are  in  the  early  stages  of  the  disease  when  it  has 
not  yet  become  possible  to  diagnose  its  true  character.  Something  also 
may  be  done  by  using  a  mechanical  system  in  milk  production.  Here  also 
it  seems  to  be  impossible  to  completely  eliminate  the  danger.  Further- 
more, for  the  present  at  least,  such  mechanical  methods  of  production  are 
applicable  only  to  milks  which  bring  a  high  price  at  retail.  So  that,  in 
spite  of  all  that  we  know  how  to  do  at  the  present  time  it  appears  that 
the  danger  that  the  milk  may  be  contaminated  by  employees  handling  it 
will  certainly  be  with  us  for  some  time  to  come. 

Fortunately,  it  has  been  found  that  pasteurization,  and  by  that  I  mean 
proper  pasteurization,  destroys  the  life  of  all  those  bacteria  which  so  far 
as  we  know  are  likely  to  cause  disease  if  present  in  milk.  Pasteurization 
makes  milk  safe  so  far  as  is  known  without  altering  materially  the  chem- 
ical composition  of  it.  As  to  the  vitamins  in  milk  the  only  one  known  to 
be  altered  is  Vitamin  C  and  even  that  is  only  partly  destroyed.  This  re- 
duction in  Vitamin  C  potency  is  readily  compensated  for  by  a  plentiful 
supply  of  this  Vitamin  from  other  and  safer  sources. 

Now,  pasteurization  makes  .milk  safe  with  respect  to  bacterial  infec- 
tion but  it  does  not  destroy  the  toxins  or  organic  poisons  which  are  waste 
products  of  bacterial  growth.  If  milk  has  great  numbers  of  bacteria  it 
has,  as  a  matter  of  consequence,  great  amounts  of  bacteria  toxins,  and  if 
such  an  unclean  milk  is  then  pasteurized  such  milk  is  not  a  safe  food,  for 


212 
the  toxins  apparently  survive  pasteurization  and  will  cause  diarrhea  and 
gastro-enteritis,  especially  in  children. 

Anyone  who  proposes  raw  milk  as  a  market  milk  for  general  use  is 
either  ignorant,  misinformed,  or  a  fanatic.  Equally  ignorant,  misin- 
formed, or  fanatic  is  anyone  who  thinks  that  pasteurization  can  make  a 
dirty  milk  entirely  safe. 

A  milk  supply  for  general  use,  and  especially  for  children,  in  order  to 
be  safe  must  be  produced  from  animals  as  healthy  as  possible,  and 
properly  fed  and  kept;  produced  with  the  help  of  clean  employees  using 
suitable  methods;  cooled  below  50°  Fahrenheit  promptly  after  produc- 
tion; pasteurized;  again  cooled  promptly  below  50°  Fahrenheit  and  kept 
at  that  temperature  until  consumed.  Such  a  market  milk  is  clean,  raw 
milk  to  which  has  been  added  the  final  factor  of  safety  afforded  by  proper 
pasteurization.  You  could  not  differentiate  by  means  of  taste  between 
such  a  pasteurized  milk  and  the  raw  milk  from  which  it  was  made. 

In  1927  Bigelow  and  Forsbeck  charted  the  correlation  between  the  in- 
crease in  the  pasteurization  of  the  milk  supply  and  the  decrease  in  deaths 
from  diarrhea  and  gastro-enteritis  in  children  under  two  years  of  age. 
A  similar  chart  made  by  the  Boston  Health  Department  shows  a  similar 
relation.  These  studies  abundantly  prove  that  there  is  an  immediate  fall 
in  infant  mortality  which  follows  the  pasteurization  of  the  milk  supply 
of  a  community.  At  the  present  time  there  is  the  greatest  need  for  the 
extension  of  pasteurization  to  include  the  milk  distributed  for  general 
use  in  small  towns  and  in  rural  communities.  It  is  common  knowledge 
that  milk  which  cannot  find  a  sale  in  cities  where  milk  inspection  exists, 
and  where  pasteurization  prevails,  seeks  and  finds  a  sale  in  small  com- 
munities where  there  is  little  or  no  milk  inspection.  Too  often,  it  comes 
to  my  attention  that  this  is  being  done.  Too  often,  milk  from  a  diseased 
cow  which  cannot  be  shipped  to  Boston  finds  a  lodging  place  in  the  stom- 
ach of  the  children  of  the  producer  of  that  milk. 

I  would  like  to  arrange  for  you  different  kinds  of  milk  in  the  order 
of  their  comparative  safety. 

First  comes  Certified  Milk — Pasteurized.  This  is  certified  milk  to  which 
the  safety  afforded  only  by  proper  pasteurization  has  been  added;  pro- 
duced, bottled,  sealed  and  pasteurized  under  the  supervision  of  a  Medical 
Milk  Commission.  This  special  product  is  the  purest,  cleanest  and  safest 
milk  obtainable  anywhere  at  any  price.  Those  who  want  the  best  will  use 
it.  It  is  especially  indicated  for  the  use  of  children  after  being  weaned 
and  after  being  taken  from  the  milk  prescribed  by  the  physician.  It  all 
comes  from  cows  as  healthy  as  it  is  at  present  possible  to  have  cows.  The 
price  of  this  milk,  about  twenty-seven  cents  a  quart,  is  prohibitive  for 
general  use. 

Next  lower  in  the  order  of  safety  comes  Grade  A  Milk  pasteurized. 
This  is  a  clean,  raw  milk  often  from  cows  tuberculin  tested  and  pro- 
nounced free  from  tuberculosis,  to  which  the  safety  afforded  only  by 
proper  pasteurization  has  been  added.  It  sells  at  a  small  premium  above 
ordinary  market  milk  and  is  worth  the  price  which  is  about  seventeen 
cents  a  quart. 

Next  lower  in  the  order  of  safety  is  Market  Milk  pasteurized  and 
sometimes  called  Grade  B  Milk  pasteurized.  The  raw  pre-pasteurized 
milk  is  as  pure  and  as  clean  as  milk  can  be  produced  on  the  large  scale 
necessary  to  supply  the  needs  of  most  of  our  people  and  to  it  the  final 
factor  of  safety  afforded  by  proper  pasteurization  has  been  added.  At 
the  present  time  in  Boston  about  sixty  per  cent  of  this  grade  of  milk 
comes  from  cows  which  have  been  tuberculin  tested  within  a  year  and 
pronounced  free  from  tuberculosis.  We  expect  that  within  five  years 
ninety  per  cent  of  this  grade  will  be  from  cows  tuberculin  tested  yearly. 
This  pasteurized  milk  is  the  cheapest  safe  food  available  anywhere. 
People  may  use  it  with  the  assurance  that  it  is  safe. 

Next  lower  in  the  order  of  safety  is  Certified  Milk.    This  is  a  raw 


213 

product,  the  cleanest,  purest  raw  milk  that  can  be  made  if  it  is  produced 
under  the  supervision  of  a  competent  medical  milk  commission  which 
actually  functions.  If  it  is  what  it  should  be  Certified  Milk  is  drawn  only 
from  animals  tested  frequently  and  pronounced  free  from  disease.  If  a 
good  pasteurized  milk  is  available  Certified  Milk  should  be  used  only  on 
the  advice  of  a  physician. 

The  lowest  in  the  order  of  safety  is  raw  milk;  a  milk  that  is  natural 
only  for  calves;  uncertain  in  safety;  and  whoever  uses  it  takes  a  chance. 
If  you  value  the  health  of  your  children  view  it  with  the  greatest  sus- 
picion and  use  it  only  on  the  advice  of  a  physician,  and  make  him  select 
the  source. 

Just  a  word  or  two  about  the  milk  of  the  future.  Extensive  researches 
now  in  progress  indicate  that  we  are  on  the  threshold  of  the  door  through 
which  important  discoveries  will  come.  The  results  of  these  researches 
when  applied  to  the  production  of  milk  appear  to  be  able  by  control  of 
the  diet  of  the  cow  to  impart  to  the  cow  an  ability  to  resist  disease  as 
well  as  to  impart  to  the  milk  produced  certain  important  qualities.  Among 
these  qualities  are  important  changes  in  the  mineral  content  so  that  desir- 
able mineral  elements  in  a  form  readily  assimilated  during  digestion  are 
made  available.  Vitamin  content  not  only  can  be  increased  but  also  can 
be  maintained  at  a  high  value  during  the  entire  year.  It  appears  that  the 
milk  of  the  future  is  likely  to  be  far  more  important  as  a  food  for  chil- 
dren than  is  the  milk  of  the  present. 

Finally,  I  wish  to  leave  with  you  a  message  for  all  consumers  of  milk. 
Health  officials  endeavor  to  place  in  your  hands  a  safe  pasteurized  milk 
as  pure  and  clean  as  can  be  produced  for  the  price  paid.  Such  a  milk  is 
the  cheapest,  safe  food  available  anywhere.  Care  for  it  well  by  placing  it 
in  the  coldest  part  of  the  refrigerator  promptly  after  delivery  so  that 
when  used  it  may  still  have  the  good  qualities  it  had  when  delivered  to 
you.  Have  your  children  use  only  pasteurized  milk  of  the  best  grade 
which  you  can  afford  and  use  plenty  of  it.  A  glass  of  such  milk  between 
meals  as  well  as  at  meal  times  will  go  a  long  way  towards  promoting  a 
better  child  health. 

There,  my  friends,  is  a  presentation  of  the  true  facts  about  the  milk 
supply  of  this  Commonwealth.  What  are  you  going  to  do  about  it?  What 
can  you  do  about  it?  The  power  of  a  health  official  to  act  is  limited  by 
the  powers  vested  in  him  by  the  Legislature.  The  Legislature  is  your 
representative.  Your  Legislature  has  vested  in  the  local  boards  of  health 
sufficient  authority  to  require  pasteurization,  but  can  you  rely  on  your 
local  boards  of  health  to  act?  In  some  cases,  particularly  in  the  cities, 
yes.  But  in  the  cities  pasteurized  milk  predominates  now,  due  largely  to 
the  action  of  local  boards  of  health  supported  by  city  public  opinion. 
Recommendaton  No.  1  of  the  Committee  on  Milk-Production  and  Control 
of  the  White  House  Conference  is  "that  pasteurization  be  required  when- 
ever practicable." 

Boston  milk  is  99.4  per  cent  pasteurized  and  the  only  raw  milk  is  milk 
certified  by  the  Medical  Milk  Commission  of  Boston,  Inc.,  and  for  gen- 
eral use  we  recommend  that  even  certified  milk  be  pasteurized.  It  seems 
apparent,  therefore,  that  you  do  not  need  to  be  concerned  about  the  milk 
available  for  children  in  cities.  How  about  the  rural  communities? 
Approximately  fifty  per  cent  of  our  entire  population  resides  in  small 
towns  and  in  rural  communities.  Such  communities  are  served  largely  by 
small  distributors  of  milk  who  are  producers,  one  and  two  cow  producers 
in  a  large  percentage  of  cases,  selling  less  than  twenty  quarts  of  milk  a 
day  to  neighbors.  Under  our  laws  these  producers  do  not  require  a  license 
to  sell  milk  and  the  place  where  produced  and  the  conditions  of  production 
and  the  product  itself  in  such  cases  are  practically  free  from  inspection. 
The  nearer  one  gets  to  the  source  of  production  the  greater  the  sentiment 
for  raw  milk. 

No  local  board  of  health  in  such  communities  could  hope  to  enforce  a 


214 
regulation  requiring  milk  to  be  pasteurized.  The  consumers  in  rural  com- 
munities do  not  know  the  facts  about  the  disease-producing  potentialities 
of  raw  milk.  They  are  dominated  by  the  wishes  of  neighbor  producers 
who  desire  to  sell  milk  raw.  Such  a  regulation  would  be  against  the  force 
of  local  public  opinion.  If  children  who  drink  milk  are  to  receive  the  pro- 
tection afforded  only  by  pasteurized  milk  the  only  alternative  is  com- 
pulsory pasteurzation  as  a  state  law.  What  are  the  prospects  for  such  a 
state  law?  The  weight  of  public  opinion  in  small  towns  and  rural  com- 
munities appears  definitely  to  be  against  such  a  law.  It  is  so  because  the 
consumers  in  such  communities  do  not  know  the  facts.  Cities  are  indif- 
ferent to  such  a  law.  They  would  be  glad  to  have  it  but  they  do  not  need 
it.  Compulsory  pasteurization  for  them  is  already  provided  by  local  board 
of  health  regulation. 

When  a  bill  for  state-wide  compulsory  pasteurization  is  up  for  con- 
sideration there  is  a  swapping  of  votes  between  representatives  of  rural 
communities  who  are  opposed  to  such  a  bill  and  representatives  from 
cities  who  are  indifferent  to  such  a  bill  and  the  bill  is  lost  in  committee. 
But  when  the  representative  from  the  rural  community  hears  from  the 
folks  back  home  he  sits  up  and  takes  prompt  notice.  Educate  the  folks 
back  home,  give  them  the  true  facts  about  the  potential  danger  to  their 
children  if  they  drink  raw  milk — then  a  bill  for  state-wide  compulsory 
pasteurization  of  milk  will  be  successful.  Then  we  shall  see  the  children 
in  rural  communities  and  small  towns  benefit  from  the  decrease  in  the 
death  rate  of  children  which  has  always  followed  as  a  result  of  the  in- 
creased use  of  pasteurized  milk. 

MILK  PRODUCTION— REGULATIONS  ESSENTIAL  AND 
NON-ESSENTIAL 

By  J.  H.  Frandsen 
Massachusetts  State  College 

In  recent  years  since  milk  has  come  to  be  considered  one  of  our  most 
important  foods,  milk  sales  have  greatly  increased  and  nearly  everybody 
has  something  good  to  say  about  milk.  On  the  whole,  this  is  very  splendid, 
but  it  also  brings  added  responsibility  for  there  is  a  growing  tendency 
for  consumers,  women's  clubs  and  public  health  agencies  to  pry  into  all 
questions  pertaining  to  quality  and  healthfulness  of  dairy  products.  We 
see  this  expressed  concretely  in  the  numerous  demands  and  restrictions 
put  upon  dairymen  by  our  city  and  state  health  departments. 

Quite  likely  some  health  officials  with  more  zeal  than  actual  knowledge 
of  the  vital  things  to  incorporate  in  milk  ordinances  have  sponsored  regu- 
lations that  were  of  little  consequence  in  really  safe-guarding  the  milk 
supply  but  which  work  a  real  hardship  on  the  milk  producer. 

Experience  proves  that  in  nearly  all  instances  milk  regulations  have 
been  largely  ignored  unless  they  are  fundamentally  sound  and  backed  by 
an  intelligent  and  understanding  public  that  has  proper  regard  for  them 
and  a  willingness  on  their  part  to  make  proper  economic  adjustment  to 
cover  added  cost  of  milk  production. 

On  the  other  hand,  the  increased  use  of  milk  and  better  understanding 
of  the  cause  and  spread  of  certain  epidemics  make  it  imperative  that 
dairymen  be  alert  and  in  full  sympathy  with  such  measures  as  actually 
improve  quality  and  safety  of  milk.  Enforcement  of  such  regulations 
should  spell  a  better  and  safer  milk — the  kind  of  milk  that  will  not  be  on 
the  defensive  every  time  an  epidemic  breaks  out.  Clean  and  safe  milk 
increases  consumption  and  brings  better  prices  to  producers. 

Every  manufacturer  carefully  watches  the  demands  and  whims  of  his 
consumers — I  believe  that  milk  producers  may  with  profit  watch  the 
changing  public  demand  as  regards  a  cleaner,  better  and  safer  milk.  If 
a  dairyman  fails  to  respond  to  the  essentials  necessary  for  this  quality 
milk — he  soon  finds  himself  without  a  market. 


215 

New  methods  of  transportation  and  refrigeration  make  the  consumer 
less  dependent  than  usual  on  local  supply.  Let  me  illustrate.  I  know  a 
man  in  central  Iowa  who  used  to  sell  his  milk  to  the  local  creamery  at 
Mason  City,  Iowa.  When  last  I  saw  him,  a  little  more  than  a  year  ago,  I 
remember  he  showed  me  a  card  from  the  Board  of  Health  at  Cleveland, 
Ohio,  saying  that  his  dairy  had  been  inspected  and  that  if  he  would  put 
in  better  milk-cooling  facilities  his  milk  would  be  accepted  for  the  city 
of  Cleveland — almost  a  thousand  miles  away.  His  milk,  with  other  milk 
from  that  vicinity,  was,  of  course,  moving  in  modern  tank  cars. 

I  have  little  patience  with  meaningless  regulations,  as  I  have  said  be- 
fore, with  regulations  that  make  for  little  if  any  progress  and  do  work  a 
hardship  on  the  producer,  in  the  form  of  higher  production  costs  which 
are  seldom  absorbed  by  the  consumer. 

Health  department  regulations  often  contain  a  great  number  of  items 
— some  very  important  in  the  production  of  clean  milk  of  low  bacterial 
content,  but  many  that  really  contribute  only  in  a  minor  way  to  the  pro- 
duction of  clean  milk.  As  a  result  of  an  enormous  amount  of  work  study- 
ing most  of  the  regulations  with  which  you  are  familiar,  a  government 
bulletin  says  "Experiments  indicate  that  it  is  possible  for  the  average 
dairyman  on  the  average  farm  without  expensive  barns  and  equipment 
to  produce  milk  practically  free  from  visible  dirt,  which  when  fresh  has 
a  low  bacterial  count.  Only  four  simple  factors  need  be  employed.  They 
are: 

1.  Sterilized  utensils. 

2.  Clean  cows,  clean  udders  and  teats. 

3.  Small  top  milk  pails. 

4.  Holding  milk  at  50°  F.  or  less?" 

The  bulletin  adds,  "The  value  of  these  factors  was  thoroughly  deter- 
mined by  experiments  conducted  in  an  experimental  barn  and  further 
demonstrated  by  their  successful  practical  application  on  several  farms. 

"In  connection  with  the  production  of  milk  of  low  bacterial  content  and 
which  is  practically  free  from  visible  dirt,  it  seems  evident  from  the  re- 
sults that  undue  emphasis  has  been  given  to  factors  and  methods  of  minor 
importance,  while  those  which  directly  affect  the  bacterial  content  have 
not  been  sufficiently  emphasized. 

"It  must  again  be  pointed  out  that  only  one  phase  of  the  production  of 
a  sanitary  milk  has  been  considered  in  this  paper.  No  attempt  has  been 
made  to  study  the  factors  which  are  most  directly  concerned  with  pre- 
venting the  infection  of  milk  by  pathogenic  organisms.  The  factors  affect- 
ing the  health  of  the  cattle  have  not  been  studied,  nor  has  the  influence 
of  general  conditions  of  cleanliness  surrounding  the  production  of  milk 
been  given  consideration." 

I  have  stressed  the  simple  practical  things  that  should  be  practiced  in 
the  production  of  clean  milk  of  low  bacterial  count  that  satisfies  some 
markets.  The  far-seeing  dairyman,  will,  however,  want  to  go  farther — he 
will  want  to  study  newest  facts  regarding  foods,  sanitation  and  trend  of 
public  demands  for  milk.  In  other  words,  he  has  an  eye  to  the  demands 
of  the  future.  He  does  not  wait  to  be  coerced  by  the  consumer  nor  by 
the  state's  inspection  officials.  He  goes  after  the  market  with  a  product 
that  will  stand  the  closest  scrutiny. 

Undoubtedly  many  things  are  charged  to  milk  that  rightfully  belong 
elsewhere.  However,  we  must  admit  that  danger  lurks  in  milk  from 
diseased  cows.  Therefore  we  stand  shoulder  to  shoulder  with  officials  for 
regulations  that  will  stamp  out  diseases  and  give  us  more  milk  from 
disease-free  cows. 

Regarding  the  importance  of  carrying  on  the  tuberculosis  eradication 
work,  Calvin  Coolidge  (then  President)  in  a  message  to  Congress  said : 
"The  furnishing  of  pure  milk  is  of  vital  importance  to  the  health 
of  the  people.    Because  of  its  interstate  character,   it  is  entirely 


216 

proper  that  the  Federal  Government  share  with  the  states  the  cost 
of  protecting  this  great  food  supply.  The  amount  included  in  the 
estimates  should  permit  adequate  prosecution  of  the  work  of  elim- 
inating tuberculous  cattle  from  dairy  herds.  The  results  of  the  work 
already  done  warrant  the  belief  that  we  can  confidently  expect  the 
complete  elimination  of  this  menace  to  health." 

The  gist  of  the  recent  New  England  Marketing  Conference,  if  I  under- 
stood it  correctly,  was  that  New  England  farmers  must  strive  to  develop 
and  hold  the  market  of  the  highest  price  for  the  best  of  perishable  foods, 
such  as  the  finest  fruit  and  the  best  grades  of  fresh,  carefully  inspected 
milk.  The  following  resolution  was  passed  by  the  New  England  Market- 
ing Association  at  its  meeting : 

"We  believe  that,  for  the  protection  of  New  England  dairy  markets, 
early  steps  should  be  taken  to  eliminate  bovine  tuberculosis  from  all  our 
herds.  We  reaffirm  our  confidence  in  the  tuberculin  test  and  urge  that 
New  England  legislatures  provide  adequate  funds  for  the  furtherance  of 
the  work." 

A  Massachusetts  Program 

At  a  bovine  tuberculosis  conference  recently  held,  facts  were  given 
indicating  that  there  is  a  larger  percentage  of  tuberculosis  in  Massa- 
chusetts cattle  than  in  those  of  neighboring  states.  If  this  be  true,  we 
must  not  slow  up  in  our  clean-up  campaign.  I  think  we  are  all  familiar 
with  the  economic  reasons  for  ridding  our  herds  of  this  disease. 

1.  No  very  sick  cow  can  be  a  profitable  cow. 

2.  A  few  diseased  cows   (spreaders,  so-called)   may  infect  the  whole 
herd. 

3.  There  is  also  a  danger  of  human  infection,  particularly  to  farm  chil- 

dren, that  we  cannot  afford  to  overlook. 

Recent  epidemics  emphasize  quite  definitely  the  dangers  of  milk  infec- 
tion from  human  sources.  Trask  has  tabulated  260  milk-borne  epidemics 
and  has  compiled  240  more  reported  by  others.  Of  the  epidemics  tabu- 
lated by  Trask,  the  following  observations  were  made: 

Typhoid  Fever  traceable  to  milk 179 

Scarlet  Fever  traceable  to  milk 51 

Diphtheria  traceable  to  milk 23 

Septic  Sore  Throat  traceable  to  milk 7 

It  is  undoubtedly  true  that  the  tendency  is  to  charge  some  epidemics  to 
milk  that  probably  should  belong  somewhere  else,  yet  the  danger  is  suffic- 
iently great  so  that  every  precaution  should  be  taken  to  exclude  from 
the  handling  of  milk,  men  who  are  known  to  be  typhoid  carriers  or  any 
one  showing  signs  of  having  or  coming  down  with  a  communicable  disease. 
The  water  used  for  rinsing  of  dairy  utensils  must  also  be  free  from 
suspicion. 

Producers  have  little  patience  with  meaningless  regulations  but  they 
should  be  ever  on  the  alert  to  support  legislation  that  will  give  consumers 
of  our  favored  markets  the  necessary  regulations  to  practically  guarantee 
them  a  clean,  safe  and  better  quality  of  milk  than  can  be  found  in  other 
sections. 

New  Englanders  demand  "new  laid"  eggs  and  the  finest  flavored  fruit. 
They  are  already  well  accustomed  to  quality  in  dairy  products,  so,  even 
with  tank  cars  to  hold  down  temperatures,  it  is  hardly  possible  that  or- 
dinary milk  shipped  from  the  Mid-west  will  satisfy  our  high  standard 
demands. 

As  has  been  done  in  some  other  states,  let  Massachusetts  dairymen 
co-operate  with  consumer  groups  in  demanding  safe  milk  standards  and 
additional  safeguards  for  milk,  on  the  theory  that  anything  that  builds 
confidence  and  improves  the  quality  of  milk,  our  best  food,  will  react  to 
the  profit  of  Massachusetts  dairymen. 


217 
Summary 

1.  Clean  cows. 

2.  Clean  and  sterilized  utensils. 

3.  Small  top  milk  pails. 

4.  Quick  cooling  and  storage  of  milk. 

5.  Healthy  cows. 

6.  Clean,  healthy  milkers. 

7.  Clean  milk  house,  cement  floors,  and  cooling  equipment. 

8.  Elimination  as  far  as  possible  of  fly  breeding  places. 

THE  HOME  AND  THE  CHILD 

By  Louisa  P.  Skilton 
Cambridge,  Massachusetts 

Responsibility  for  the  training  and  education  of  the  16,000,000  pre- 
school children  of  the  United  States  has  been  definitely  placed  by  the 
White  House  Conference  upon  the  parents  of  these  children.  This  great 
group  of  children,  urban  and  rural,  representing  an  inheritance  from  all 
nationalities,  all  religions,  all  political,  social  and  economic  strata  has,  in 
the  past,  made  no  great  demands  upon  society;  nor  have  the  parents  of 
these  children  for  them. 

More  recent  realization  of  the  importance  of  early  years  for  physical 
development  has  focussed  attention  upon  the  significance  of  this  same 
period  for  mental  and  social  development.  For  a  small  percentage  of  city 
children,  day  nurseries,  nursery  schools,  and  kindergartens  may  supple- 
ment the  home.  The  young  child,  however,  is  still  found  overwhelmingly 
in  homes.  A  national  program  for  his  training  and  education  can  be 
carried  on  only  through  the  cooperation  of  his  parents.  The  job  at  hand, 
therefore,  is  to  train  the  parent  to  train  the  child.  This  is  no  new  idea.  But 
at  the  present  moment  we  are  embarrassed  with  such  a  wealth  of  material 
from  experts  in  contributing  fields  of  knowledge  that  the  problem  seems 
to  be  how  this  material  may  be  interpreted  to  Mr.  and  Mrs.  Parent  living 
in  your  city — so  that  they  will  make  use  of  it  in  training  the  children  in 
their  homes. 

This  is  .the  acid  test.  If  we  cannot  interpret  this  material  so  that  it 
will  be  of  practical  value  in  the  home,  the  primary  purpose  of  the  White 
House  Conference  is  thwarted.  For  instead  of  enriching  the  lives  of  all 
children,  the  findings  will  remain  committee  reports,  consulted  and  used 
only  by  specialists  and  will  reach  only  the  limited  number  of  children 
with  whom  they  come  in  contact. 

At  the  beginning  of  its  work  the  committee  made  a  study  of  the  care 
children  were  actually  receiving  in  their  homes.  Standards  were  higher 
than  had  been  expected.  From  this  study  of  3500  selected  children  a  com- 
posite picture  of  the  American  four  year  old  was  evolved.  He  sleeps 
eleven  and  a  half  hours,  daily,  he  drinks  one  and  a  half  to  two  and  a  half 
pints  of  milk,  his  diet  is  adequate  (but  not  perfect).  He  is  not  weighed 
regularly.  He  has  even  chances  of  receiving  cod  liver  oil  in  winter.  His 
clothes  are  changed  with  regularity,  suits  daily,  undergarments  twice  a 
week.  He  owns  and  uses  a  tooth  brush.  He  receives  one  to  four  spankings 
a  month! 

From  all  these  details,  the  fact  stands  out  that  the  physical  care  of  the 
child  is  on  a  higher  level  than  his  mental  and  social  development.  For  his 
future  training  the  committee  urges  recognition  of  the  twofold  problem 
of  this  period  and  recommends 

1.  Establishment  of  basic  habits  of  health. 

2.  Establishment  of  desirable  attitudes  and  adjustments  toward  objects 
and  persons. 

The  subcommittee  on  Housing  and  Home  Management  under  the  chair- 
manship of  Martha  Van  Rensellaer  has  already  made  available  in  book 


218 
form,  "The  Home  and  the  Young  Child,"  standards  for  the  type  of  home 
in  which  this  training  may  be  accomplished  with  the  least  amount  of 
effort.  Parents  building,  remodelling,  buying  or  renting  a  home  may  find 
a  thoughtful  analysis  of  housing  standards  with  relation  to  the  life  of 
the  child  as  a  member  of  the  family.  A  hasty  review  reveals  a  house  of 
charm  and  distinction,  located  on  a  large  lot,  on  a  minor  street  of  a 
zoned,  residential  neighborhood.  It  is  accessible  to  churches,  schools,  cul- 
tural and  shopping  centers.  The  grounds  are  graded  and  planted  with 
trees,  shrubs,  and  vines.  There  is  provision  for  play  space.  Waste  dis- 
posal is  prompt  and  complete.  The  house  is  supplied  with  natural  light 
and  sunlight;  it  is  of  sound  durable  material,  resistant  to  fire;  it  is 
insulated  against  dampness,  heat,  cold,  and  sound.  Definite  areas  are 
arranged  for  the  activities  of  the  child.  All  rooms  are  convenient  for 
their  purpose  and  include  a  place  for  the  child  of  the  family. 

Upon  the  abilities,  standards  and  methods  of  the  mother  depends  largely 
the  management  of  this  plant.  No  other  institution  offers  more  real 
material  for  the  education  of  the  child.  Manual  skills  may  be  developed. 
Wholesome  attitudes  toward  work  and  play  may  be  developed.  Vital  also, 
to  sound  family  life,  the  attitude  of  the  child  toward  his  mother  and 
father  may  be  established.  There  is  a  distinct  need  for  a  greater  con- 
sideration of  the  possibilities  for  education  which  the  home  affords  the 
preschool  child.  Such  education  should  be  for  the  home  of  today  and 
tomorrow,  not  yesterday,  and  never  should  the  child  of  any  age  be 
exploited  in  the  home. 

Modern  labor  saving  equipment  suitable  for  the  needs  and  size  of  the 
family  conserve  the  time  and  energy  of  the  mother.  She  should  also  study 
her  methods  of  work  in  order  to  shorten  the  time  involved  and  to  secure 
better  results.  In  other  words,  if  she  cannot  afford  a  vacuum  cleaner 
today,  how  may  she  use  the  corn  broom  she  owns  in  a  quicker  and  more 
healthful  way!  Much  has  already  been  said  of  the  influences  of  good 
design  and  color  in  the  home.  Familiarity  with  the  best  of  pictures,  the 
best  of  books,  and  the  best  of  music  builds  up  the  resistance  of  the  child 
against  the  cheap  and  ordinary.  In  later  life,  trained  interests  may  be 
acquired  but  adults  have  a  natural  fondness  for  the  surroundings  of  child- 
hood. 

Another  factor  of  home  life  which  has  direct  bearing  on  the  -health  and 
happiness  of  the  child  is  income  management.  If  the  income  is  too  small 
or  is  poorly  administered  the  child  not  only  suffers  from  lack  of  adequate 
food,  sunlight,  warmth,  recreation,  or  medical  attention  but  also  from 
the  loss  of  tranquility  and  the  sense  of  security.  Constant  worry  and 
irritation  on  the  part  of  the  parents  are  bound  to  reflect  in  their  dealings 
with  the  child.  Further  study  as  to  the  cost  of  adequate  standards  is 
advised.  Money  measurements  accompanied  by  physical  and  mental  meas- 
urements are  recommended  for  research  problems. 

Clothing  as  it  contributes  to  the  comfort,  health  and  energy  of  the  child 
is  an  interesting  study  in  itself.  The  committee  offered  no  scientifically 
determined  data  as  to  amounts  and  kind  but  outlined  areas  for  research 
such  as 

1.  Relation  of  fiber  to  hygienic  value. 

2.  Relation  of  fabric  and  design  , 

(a)  to  physical  health; 

(b)  to  mental  health. 

3.  Economic  aspects. 

Certainly,  the  preschool  child  living  in  a  home  so  planned,  so  managed, 
and  so  financed  would  find  time,  place  and  materials  to  develop  his  creative 
interests  and  to  know  the  joy  of  accomplishment.  Wise  the  parent  who 
can  stand  by  and  let  him  know  it!  Would  he  not  be  forming  habits  of 
independence?  Perseverance?  Play?  Work?  Ability  to  cooperate?  And 
will  he  not  reflect  the  attitude  of  his  family? 


219 

Outside  the  home,  there  already  exist  three  good  allies  for  the  training 
of  the  preschool  child.  The  committee  finds  that  day  nurseries  of  the  relief 
type  are  improving  in  standards.  It  recognizes  the  nursery  schools  as  an 
educational  attempt  to  meet  modern  conditions  and  feels  that  they  should 
continue  without  standardization.  It  endorses  heartily  the  kindergartens 
now  attended  by  only  25%  of  our  children  and  feels  that  public  funds 
should  be  used  to  increase  facilities  for  this  age  level  before  being  ex- 
pended for  a  lower  age  level. 

At  their  best  these  three  agencies  supplement  the  home  and  are  not 
intended  to  supplant  it.  Parents  still  stand  as  "guardians  of  personality." 
What  is  personality?  The  report  of  the  White  House  Conference  defines 
it  as  "The  individual  with  all  his  emotional  and  intellectual  peculiarities 
trying  to  realize  happiness  and  efficiency  in  the  environment  in  which  he 
lives."  A  morning  paper  (October  6)  commenting  on  the  death  of  Senator 
Dwight  Morrow  said  that  his  success  in  dealing  with  Mexico  depended 
upon  his  courtesy,  patience  and  understanding.  These  same  qualities  used 
by  parents  in  guiding  children  would  be  equally  successful, — the  same 
courtesy  that  they  would  accord  to  strangers,  patience  with  slowness, 
with  changing  interests,  and  understanding  of  his  needs  so  that  the  child 
has  confidence  to  reveal  himself  without  fear  of  ridicule  and  to  be  sure 
of  a  sympathetic  response.  How  may  the  parents  let  the  child  develop  his 
own  life  and  at  the  same  time  "belong"  to  the  family? 

Parents  have  a  big  task.  No  two  children  are  alike  and  the  same  child 
is  not  alike  for  two  consecutive  days.  Parents  need  the  help  of  every 
specialist,  the  teacher,  the  nurse,  the  social  worker,  the  psychologist  or 
the  psychiatrist,  they  need  advice  from  specialized  fields  available  in 
direct,  usable  form.  Parents  alone  are  responsible  for  the  continuity  of 
the  training  and  education  of  their  children.  But  it  requires  the  co- 
operation of  all  working  together  to  attain  the  ideals  of  the  Children's 
Charter : 

"For  every  child  a  home  and  that  love  and  security  which  a  home 
provides." 

"For  every  child  a  dwelling,  safe,  sanitary  and  wholesome — and  a 
home  environment  harmonious  and  enriching." 

HEALTH  OF  THE  SCHOOL  CHILD 

By  Ernest  Stephens 

Deputy  Superintendent  of  Schools 

Lynn,  Massachusetts 

If  we  are  honestly  to  attempt  a  consideration  of  the  health  of  the  school 
child,  certain  fundamental  principles  must  be  prominently  in  our  minds. 
We  are  dealing  with  the  whole  child.  We  are  concerned  with  his  mental, 
his  emotional  and  social  health  as  well  as  his  physical  well-being.  This  is 
not  a  close  corporation  where  we  are  to  determine  what  is  good  for  the 
child,  and  he  must  take  it  or  leave  it.  Unfortunately  in  the  past,  and  to  a 
large  degree  in  the  present,  health  consideration  has  been  of  this  type 
and  the  result  has  been  that  the  child  has  left  it.  There  is  no  reason 
under  the  sun  why  a  child  should  be  interested  in  all  the  things  we  dis- 
cuss with  him  in  the  schools  unless  he  sees  the  reason  for  it,  or  has  in- 
terest in  it.  The  thing  I  am  trying  to  say  is  that  the  child  must  be  an 
active  participant  in  this  partnership. 

We  need  to  know  very  definitely  how  this  child  of  whatever  age  reacts 
to  his  environment,  how  does  he  develop,  how  does  he  learn? 

Kilpatrick  says,  "In  the  field  of  education  we  are  concerned  with 
the  whole  individual.  The  whole  child  is  present  and  active  in  every 
response  and  each  such  response  through  the  learning  it  brings  re- 
makes in  some  measure  for  good  or  ill  every  part  within  the  child  as 
well  as  the  organization  itself  which  constitutes  the  whole.    Every 


220 

situation  met  is  an  opportunity  for  the  better  and  wider  integration 
of  the  self  or  the  disintegration  of  self.  Always  and  everywhere  the 
effect  on  the  child's  self  of  each  thing  done  by  it,  or  to  it,  or  before  it, 
is  the  most  serious  question  that  we  can  confront.  It  is  always  the 
whole  child  which  we  influence  and  for  whom  we  are  responsible. 

"We  wish  then  all  the  child's  experience  to  result  in  more  and 
better  self  direction,  a  self  direction  which  at  one  and  the  same  time 
means  that  his  acts  are  increasingly  his  own,  more  and  more  thought 
through  by  himself,  but  also  that  they  are  decided  more  and  more 
surely  in  the  light  of  a  wider  and  wider  view  of  all  that  is  involved 
in  what  he  does,  including  in  particular  the  effect  on  others. 

"The  unit  element  of  the  curriculum  is  not  fact  or  skill  but  a 
novelly  developing  life  experience.  In  each  such,  the  learner  truly 
lives  in  his  own  personal  capacity,  he  feels  real  and  personal  concern, 
and  in  the  effort  to  control  the  experience  develops  and  pursues  con- 
sciously wrought  purposes.  The  learning  process  is  essentially — 
grappling  with  the  novelly  developing  difficulties  of  the  situation. 
Since  each  such  situation  is  infinitely  connected  with  surrounding 
life,  each  thing  learned  at  once  gets  light  from  the  situation  and  in 
turn  throws  light  upon  it.  Such  learning  connects  any  item  into  an 
infinite  web  of  meaning  connections." 

But  in  addition  to  what  learning  is,  and  how  it  takes  place,  we  need 
to  know  certain  facts  about  the  child  as  accurately  as  science  can  tell  us. 
What  is  the  physical  condition  of  the  child,  are  there  any  defects  against 
which  we  should  guard,  is  there  any  reason  for  special  consideration, 
special  placement  or  adjustment?  To  gain  this  information  there  must 
be  an  enlightened,  intelligent,  adequately  trained  medical  service  operat- 
ing under  the  supervision  of  sympathetic,  determined,  far-seeing  school 
administrators  who  have  a  sound  philosophy  of  their  job,  and  who  are 
willing  to  fight  for  the  realization  in  their  school  systems  of  the  beautiful 
theories  we  so  glibly  talk  about. 

An  adequate  health  service  will  include  the  summer  round-up  of  the 
preschool  child.  In  many  places  in  Massachusetts  we  are  doing  this  very 
effectively.  On  certain  days  which  are  given  proper  publicity  children 
who  are  expecting  to  enter  school  in  the  fall  go  to  the  school  and  are  sup- 
plied with  information  which  definitely  tells  the  parent  what  he  can  do  in 
helping  to  give  his  children  the  best  possible  start.  Those  parents  who 
can  afford  it  are  urged  to  take  their  children  to  the  family  physician, 
those  who  cannot  do  this  are  urged  to  attend  the  clinics.  Remediable 
defects  are  noted  and  parents  are  urged  to  have  them  corrected  before 
school  opens.  Check-up  examinations  are  made  by  the  school  physicians 
in  the  fall  to  aid  in  this  important  matter. 

There  should  be  an  annual  health  examination  for  each  pupil  each  year. 
The  Massachusetts  law  provides  for  this  but  unfortunately  the  law  is 
ignored.  This  should  be  done  by  the  school  physician  who  is  adequately 
trained  for  this  job.  His  training  should  include  public  health.  It  is 
most  unfortunate  that  so  frequently  the  school  physician  is  a  young  doc- 
tor just  out  of  medical  school,  a  Civil  Service  appointee,  who  needs  this 
particular  employment  to  round  out  his  financial  condition.  It  would  help 
so  much  if  the  school  physician  could  be  a  doctor  of  standing  in  the  com- 
munity so  that  his  decisions  would  not  be  so  frequently  questioned  by 
the  members  of  his  own  medical  fraternity.  The  best  service  could  be 
rendered  by  a  physician  serving  full  time  in  the  employ  of  the  school  de- 
partment who  had  the  community  public  health  point  of  view,  and  who 
lived  close  enough  to  the  school  enterprise  to  know  what  it  is  all  about, 
who  did  not  speak  "ex  cathedra"  about  matters  of  which  he  knew  little 
or  nothing,  who  could  enter  sympathetically  with  the  school  game,  inter- 
preting on  the  one  hand  highly  scientific  medical  points  of  view  to  the 
members  of  the  school  organization,  and  on  the  other  hand  who  could 


221 

interpret  to  the  members  of  the  medical  fraternity  the  no  less  intricate 
and  complex  and  highly  specialized  problems  of  the  school. 

This  medical  service  should  also  include  dentists  and  dental  hygienists. 

School  nurses  should  be  better  trained  for  the  specific  task  they  have 
to  do.  The  general  background  should  be  broader.  There  should  be  defin- 
ite training  in  public  health,  special  training  in  how  to  approach  the 
pupils  of  different  age  groups,  techniques  for  aiding  the  teacher,  how  to 
meet  parents  in  the  follow-up  work  through  home  visits.  Personality  and 
good  common  sense  count  for  so  much  in  this  strategic  position. 

The  adequate  health  service  should  include  daily  inspections  for  the 
purpose  of  preventing  and  controlling  communicable  diseases. 

The  White  House  Conference  report  includes  immunization  in  this  serv- 
ice. "This  is  primarily  a  preschool  problem.  The  most  desirable  time  for 
vaccination  against  smallpox  is  before  six  months  of  age,  as  soon  as  the 
infant's  nutritional  status  is  well  established.  Immunization  against 
diphtheria  is  advisable  after  six  months  of  age.  Immunization  against 
both  of  these  diseases  is  the  responsibility  of  the  parent,  but  should  be 
required  by  the  board  of  health  and  school  regulation.  Entrance  to  the 
junior  high  school  is  the  time  for  re  vaccination  against  smallpox.  The 
school  should  promote  immunization  by  education." 

"The  function  of  the  school  medical  service  is  not  to  make  diagnosis 
nor  to  give  treatment,  but  to  assist  the  school  in  its  work  of  education 
and  to  refer  to  parents  and  family  physicians,  children  with  remediable 
defects.  In  this  connection  the  cooperative  help  of  the  school  nurse  and 
the  visiting  teacher  in  influencing  parents  to  have  remedial  work  promptly 
attended  to  is  extremely  important." 

Every  school  department  should  have  one  or  more  psychologists  to 
whom  pupils  who  need  special  study  may  be  referred.  The  White  House 
report  recommends  one  psychologist  for  every  1,000-1,500  elementary 
pupils,  one  to  every  500-600  pupils  in  the  secondary  schools,  preferably 
attached  to  separate  schools  rather  than  to  the  central  office.  These  staff 
officers  should  have  at  least  two  years  of  graduate  training  in  a  school  of 
education. 

The  mental  health  of  pupils  is  of  major  importance.  Segregation  ac- 
cording to  special  needs  and  abilities  is  recommended.  "Pupils  wrongly 
grouped  develop  symptoms  of  maladjustment  which  frequently  exhibit 
themselves  in  day  dreaming,  sulking,  boisterousness,  defiance  and  the  like. 

"An  extra  curricular  social  program  should  furnish  opportunity  for 
learning  habits  of  social  adjustment  through  healthful  outside  activities. 
A  type  of  discipline  should  obtain  that  respects  the  personality  of  the  child 
and  helps  him  to  an  inner  adjustment  to  recognize  his  own  conflicting 
desires  and  to  substitute  socially  valuable  behavior  for  those  of  his  wishes 
which  are  ethically  or  aesthetically  undesirable.  Conditions  which  arouse 
the  emotions,  such  as  nagging,  quarrelling,  fear  and  overexcitement 
should  be  avoided." 

Some  sort  of  a  program  of  education  for  parents  is  imperative  if  a 
worthwhile  health  education  program  is  to  be  attempted  in  the  schools. 
Work  must  be  done  with  the  practicing  physicians  in  any  community  if  a 
solid  wall  of  opposition  is  to  be  avoided.  This  is  perhaps  the  natural 
situation  since  so  many  of  the  M.  D.'s  are  of  an  older  school,  have  not, 
perhaps  could  not,  because  of  their  busy  lives,  keep  up  with  the  trends 
of  the  time.  One  office  call  if  the  physician  has  the  wrong  point  of  view 
or  is  uncooperative  can  do  irreparable  harm  to  a  school  program  of  health 
education. 

Such  a  program  as  is  outlined  in  the  White  House  Conference  report  is 
expensive.  To  carry  it  out  in  its  entirety  will  cost  from  8-10%  of  the 
appropriation.  Actual  costs  range  from  $2.50-$3.00  per  pupil  in  some 
places,  to  from  $5.00-$8.00  in  others.  Massachusetts  in  1929-30  spent 
$1.56  per  pupil. 


222 
The  Curriculum 

The  child,  his  interest,  the  novelly  developing  life  experience,  "prac- 
tice with  satisfaction,"  "let  annoyance  attend  the  wrong,"  marginal  and 
concomitant  learnings,  dynamic  civilization,  integrated  learning,  are  key 
phrases  to  those  engaged  in  curriculum  reconstruction. 

What  does  our  elementary  curriculum  concern  itself  about?  In  a  course 
of  study  just  ready  for  teacher  use  in  one  of  our  Massachusetts  cities,  I 
find  in  the  introduction  a  statement  as  to  what  it  is  all  about. 

"Health  education  is  the  sum  of  experiences  in  the  school  and  elsewhere 
which  favorably  influence  habits,  attitudes,  and  knowledges  related  to  in- 
dividual and  community  health.  It  prepares  the  child  to  meet  everyday 
needs.  Health  is  essential  if  the  child  is  to  enter  whole-heartedly  into  his 
school  work.  One  who  is  able  to  conserve  and  improve  his  health  has  open 
to  him  one  of  the  roads  to  happiness. 

"Health  is  a  feeling  of  well-being.  It  is  the  basis  of  a  balanced  work- 
ing of  physical  and  mental  processes. 

"Health  education  should  present  to  the  pupil  adequate  facts,  positive 
knowledges,  and  right  attitudes  toward  individual  and  community  health. 

"The  health  education  program  should  encourage  the  cooperation  and 
support  of  parents  and  the  general  public." 

This  course  suggests  the  following  Decalog  of  Health: 

1.  Keep  the  body  clean. 

2.  Keep  the  body  erect. 

3.  Eat  the  right  amount  of  wholesome  food. 

4.  Play  and  exercise  properly. 

5.  Get  enough  sleep  and  rest. 

6.  Go  to  the  dentist  twice  a  year. 

7.  Keep  the  school,  the  home,  and  neighborhood  as  healthy  as  possible. 

8.  Avoid  communicable  diseases. 

9.  Keep  a  healthy  mind. 

10.    Know  your  own  physical  limitations  and  live  within  them. 

"Health  education  is  continuous.  It  cannot  be  confined  to  any  restricted 
place  in  the  program.  Health  should  be  taught  as  the  need  arises.  There- 
fore, health  education  is  in  many  cases  incidental.  The  success  of  instruc- 
tion in  health  education  depends  on  what  the  child  does  rather  than  what 
he  says.  Therefore  place  the  emphasis  on  attitudes  and  practices  so  that 
knowledge  will  function." 

The  following  topics  outline  the  scope  of  work  in  Health  Education  in 
these  particular  elementary  schools : 

I.  Growth  VIII.  Sleep  and  Relaxation 

II.  Nutrition  IX.  Healthy  Home  and  Commun- 

III.  Cleanliness  ity 

IV.  Remediable  Physical  Defects  X.  Safety 

V.  Prevention  of  Colds  XI.  Mental  Health 

VI.  Communicable  Diseases  XII.  Preparation  for  Vacation 

VII.  Teeth 

This  same  course  suggests  units  of  work,  bibliographies,  etc.,  which 
are  very  helpful.  This  course  suggests  standards  for  adjustment  of  school 
furniture,  weighing  and  measuring,  conduct  of  milk  lunch,  cleanliness, 
remediable  physical  defects,  sight  tests,  hearing  tests  (whisper  tests  and 
audiometer  tests).  The  suggestions  to  teachers  also  show  procedures  for 
getting  pupils  examined  by  the  school  psychologist,  the  child  guidance 
clinic,  types  of  cases  to  be  handled  by  the  visiting  teacher,  what  the 
custodian  and  janitor  service  may  be  expected  to  contribute  to  health,  the 
work  of  the  lip  reading  teachers,  the  teacher  of  speech  defect,  sight 
saving,  crippled  children,  open  air  classes,  class  for  the  deaf,  and  safety 
education. 

It  must  be  evident  that  here  in  Massachusetts  much  is  being  done  in 


223 

the  elementary  schools  along  lines  of  health  education  suggested  by  the 
White  House  Conference. 

Quoting  from  the  report  "Pupils  leaving  high  school  should  have  knowl- 
edge of  the  structure  and  function  of  the  human  body,  the  biology  of 
reproduction,  knowledge  and  skills  which  will  enable  them  to  co-operate 
in  the  reduction  of  accidents,  knowledge  and  skill  in  first  aid,  knowledge 
of  the  effects  of  tobacco,  alcohol  and  other  narcotics  and  patent  medicines 
on  the  individual  human  organism  and  on  society,  freedom  from  super- 
stition on  subjects  concerning  health  and  disease,  respect  for  the  scientific 
method  as  it  applies  to  health,  and  a  specific  knowledge  of  their  assets  and 
liabilities  in  bodily  equipment." 

Work  in  the  building  of  satisfactory  courses  of  study  in  health  educa- 
tion in  the  secondary  schools  lies  far  behind  that  in  the  elementary 
schools.  In  a  few  spots  scattered  over  the  country  some  real  progress  is 
being  made  and  it  is  hoped  that  results  will  be  much  better  in  the  near 
future.  Undoubtedly  the  chief  reason  for  this  situation  is  the  fact  that 
physical  education  has  been  under  the  domination  of  commercialized 
sports,  and  the  program  of  studies  in  the  junior  and  senior  high  schools 
is  so  cluttered  with  superficial  matter  that  health  education  has  been  kept 
out  of  the  program.  It  has  its  foot  in  the  front  door  and  I  can  promise 
you  results  in  the  very  near  future.    First  things  must  be  first. 

Administrative  Set-Up 

There  is  far  greater  unanimity  of  opinion  as  to  what  the  administrative 
set-up  ought  to  be. 

The  superintendent  of  schools  should  have  on  his  staff  a  director  of 
health.  The  conference  report  suggests  that  he  be  a  "physician  with  edu- 
cational training  and  experience  or  an  educator  with  a  Ph.D.  degree  with 
a  major  in  health  and  other  related  fields."  The  only  comment  I  desire 
to  make  in  this  is  that  the  M.  D.  with  educational  training  and  experience 
almost  can't  be  found  and  if  you  attempt  to  head  up  the  work  by  a  Ph.  D., 
the  medical  men  frequently  just  won't  cooperate. 

The  principal,  elementary  and  secondary,  is  the  responsible  administra- 
tive officer  of  the  school  and  the  health  program  must  be  conducted 
through  him. 

In  the  elementary  schools  under  sympathetic,  well  trained  supervisors, 
the  health  education  program  must  be  in  charge  of  the  classroom  teacher. 

In  the  secondary  schools  there  should  be  either  a  health  counsellor  in 
charge  with  faculty  committees  cooperating  or  a  faculty  committee  can 
take  on  the  responsibilities  of  promoting  a  health  education  program. 

This  counsellor  or  council  should 

(a)  "See  that  health  is  given  its  proper  place  in  the  curriculum. 

(b)  "Study  all  available  data  relating  to  health  in  the  school. 

(c)  "Plan  the  most  effective  use  of  the  school  health  service. 

(d)  "Obtain  the  physician's  and  nurse's  advice  relative  to  health  mat- 

ters in  the  home  or  at  school. 

(e)  "Maintain  adequate  cumulative  records  of  each  pupil's  health  his- 

tory. 

(f )  "On  the  basis  of  information  thus  assembled,  advice  with  reference 

to  modification  of  policies." 

As  soon  as  we  can  devise  through  experimentation  a  satisfactory  senior 
high  school  content  course  in  health  education,  I  believe  it  should  be  made 
a  required  course  for  all  pupils  for  graduation. 

In  democracy's  schools,  with  an  ever-increasing  age  limit,  however  wise 
or  unwise  that  may  be,  we  must  give  more  and  more  attention  to  the 
special  child — the  deaf  and  hard  of  hearing,  the  defective  in  speech,  the 
blind  and  partially  seeing,  the  crippled,  for  children  with  behavior  prob- 
lems, the  nervous,  the  emotionally  unstable  and  the  delinquent,  the  ment- 
ally retarded  and  the  gifted. 


224 

Interest  in  meeting  these  special  problems  has  forced  upon  educators 
the  imperative  need  of  work  in,  guidance,  both  educational  and  vocational, 
that  pupils  in  the  first  place  may  choose  wisely  their  electives  within  the 
school  and  secondly  may  learn  rather  intimately  about  the  opportunities, 
the  pitfalls,  the  hazards  in  the  workaday  world. 

We  are  living  in  a  dynamic  civilization,  marked  just  now  by  a  pro- 
longed depression.  The  task  of  the  school  must  ever  be  so  to  adapt  its 
work  that  boys  and  girls  may  learn  to  live  fuller  and  richer  lives  today 
and  be  ready  to  adjust  to  the  changing  demands  of  tomorrow.  Our  young 
people  will  then  be  trained  to  face  life  unafraid. 

y  THE  HEALTH  OF  THE  SCHOOL  CHILD 

By  Margaret  C.  Ells, 
Principal,  Girls'  Continuation  School,  Springfield 

The  object  of  this  paper  is  to  present  the  aims  of  the  recent  White 
House  Conference  regarding  the  health  of  our  school  children,  which 
means  to  study  and  improve  the  present  status  of  the  health  and  well- 
being  of  the  children  of  the  United  States  and  its  possessions,  to  report 
what  is  being  done ;  to  recommend  what  ought  to  be  done  and  how  to  do  it. 

The  Third  White  House  Conference  called  by  President  Hoover  included 
the  subjects  in  former  conferences  but  was  enlarged  to  take  in  all  chil- 
dren, in  their  total  aspects,  including  social  and  environmental  factors 
that  are  influencing  the  modern  child. 

The  statistics  given  us  show  that  there  are  approximately  1,500,000 
specially  gifted  children  out  of  a  total  of  45,000,000  growing  children  in 
this  country.  Of  this  total  35,000,000  are  reasonably  normal,  the  remain- 
ing 10,000,000  being  deficient  in  one  way  or  another,  though  knowledge 
and  experience  show  that  these  deficiencies  can  be  prevented  and  reme- 
died to  a  high  degree.  It  is  not  within  the  province  of  this  paper  to  go 
into  the  deficiencies  but  more  to  turn  our  minds  to  those  35,000,000  rea- 
sonably normal  children,  radiating  joy  and  mischief  and  hope  and  faith. 
These  are  the  vivid,  romping,  everyday  children,  our  own  and  our  neigh- 
bors, with  all  their  strongly  marked  differences.  In  the  1,500,000  specially 
gifted  children  there  lies  the  future  leadership  of  the  nation  if  we  devote 
ourselves  to  their  guidance.  The  children  less  fortunate  than  they  must 
also  have  their  full  rights — a  cause  which  appeals  to  the  heart  of  every 
man  and  woman.  Causes  of  handicaps  should  be  discovered  and  the  work 
of  schools  extended  to  help  them  develop  to  the  best  of  their  physical, 
moral  and  mental  abilities. 

Some  of  the  most  pertinent  recommendations  affecting  the  health  of 
the  school  child  follow: 

1.  For  every  child  in  this  great  land  of  ours  a  right  to  the  best 
physical,  moral  and  mental  health  of  which  the  individual  is  capable. 

2.  Every  child  is  entitled  to  a  home — this  home  feeling  is  a  birth- 
right and  where  it  is  broken  there  is  always  a  reflection  in  the  atti- 
tude and  health  of  the  child.  Many  children  leave  school  for  this  rea- 
son, no  one  at  home  takes  the  proper  interest  and  the  child  drifts 
into  the  world  of  work  without  a  pilot  to  steer  him  through  the  im- 
pressionistic adolescent  years.  As  a  result,  there  is  so  often  a  break 
in  health — sometimes  physical,  mental  or  moral  and  often  in  all 
phases  of  health. 

3.  For  every  child,  spiritual  and  moral  training  to  help  him  to 
stand  firm  under  the  pressure  of  life.  Without  this  the  child  is  like 
a  shipwrecked  mariner  and  he  follows  every  whim  and  fancy  as  he 
has  no  standards  to  hold  him  up  to  the  higher  and  better  things  of 
life.  Teachers  should  be  ideals  for  childhood,  men  and  women  of  cour- 
age, character  and  sympathy.  The  best  way  to  teach  character  is  by 
good  example,  for  we  are  told  that  what  you  are  speaks  so  loudly  to 
the  child  that  he  cannot  hear  what  you  say. 


225 

4.  For  every  child,  health  protection  from  birth  through  ado- 
lescence, including  periodical  health  examinations  and  where  needed, 
care  by  specialists  and  hospital  treatment;  regular  dental  examina- 
tions and  care  of  teeth;  protective  and  preventive  measures  against 
communicable  diseases;  the  insuring  of  pure  food,  pure  milk,  and 
pure  water.  This  is  a  large  order  and  we  have  only  scratched  the 
surface  in  the  work  that  is  mapped  out  for  the  health  of  the  school 
child.  At  times  we  have  felt  that  we  have  made  more  advances  in  our 
health  work  in  the  last  decade  than  in  almost  any  other  line,  but 
when  we  survey  this  recommendation  by  the  special  committee  of  the 
White  House  Conference,  we  realize  that  we  have  just  begun.  Many 
of  us  can  look  back  to  a  school  nurse  as  a  "rare  specimen"  in  our 
schools,  and  parents  were  a  bit  unwilling  to  have  Johnnie  or  Susie 
sent  to  the  nurse  when  she  made  her  visit  at  school  but  all  this  has 
changed.  A  nurse  is  looked  upon  by  the  majority  of  our  parents  as 
a  most  necessary  and  guiding  friend.  How  often  do  we  hear  the 
school  nurse  quoted  by  our  school  children  and  what  she  says  is  "law 
and  gospel"  in  that  home.  "One  good  community  nurse,"  says  Presi- 
dent Hoover,  "is  worth  a  dozen  policemen."  Who  can  tell  or  who  can 
measure  the  work  of  a  faithful  nurse?  She  knows  no  length  of  day, 
but  flits  to  this  family  and  to  that  like  an  angel  of  mercy,  her  only 
thought  is  SERVICE  TO  HUMANITY.  But  what  we  need  in  order 
to  carry  out  this  program  is  more  and  more  good  nurses.  The  time  is 
not  far  distant  when  teachers  will  be  called  upon  to  be  better  equipped 
in  health  work  to  cooperate  with  the  directions  of  physicians  and 
nurses  in  health  work  for  school  children. 

5.  A  right  to  play,  necessary  for  the  health  of  every  child.  More 
playgrounds,  people  trained  to  carry  on  in  recreational  activities  of 
all  kinds. 

6.  For  every  child,  protection  against  labor  that  stunts  growth, 
either  physical  or  moral.  In  our  guidance  and  placement  work,  the 
question  always  comes  to  us,  "Would  I  send  a  child  of  mine  to  this 
place?  With  what  type  of  people  will  he  come  in  contact?  How  will 
this  environment  affect  his  mental  health?  Will  it  lead  him  to  high- 
minded  thoughts  or  will  it  influence  him  to  dwell  on  the  morbid  and 
vulgar?"  A  great  responsibility  is  at  the  door  of  one  confronted  with 
such  a  task.  This  particular  job  may  make  or  ruin  a  boy  or  a  girl. 
There  is  more  to  guidance  and  placement  than  the  numbers  recorded, 
for  we  must  answer  in  conscience  to  the  youth  committed  to  our  care. 
It  is  this  care  and  watchfulness  that  the  President  of  our  United 
States  is  asking  of  you  and  of  me  in  regard  to  protective  measures  of 
all  kinds  for  the  youth  of  our  land. 

7.  Seek  out  and  open  the  way  for  those  of  superior  capacity.  Hu- 
man life  is  the  supreme  gift  of  all  humans  and  we  must  preserve  it 
at  all  times.  The  wretched  frame  of  a  little  body  may  be  a  Cagsar,  a 
Washington,  a  Shelley  or  a  Roosevelt.  It  is  not  for  us  to  foretell  the 
potentialities  of  human  life. 

8.  It  should  be  our  common  aim  to  prepare  the  American  child 
physically,  mentally  and  morally,  more  fully  to  meet  the  responsibility 
of  tomorrow  than  we  have  been  able  to  meet  today ;  future  men  and 
women  of  ability  to  be  the  self-starters,  operating  under  their  own 
personal  control,  not  people  to  follow  like  a  herd  or  develop  an  emo- 
tional storm  when  confronted  by  difficulties. 

9.  To  each  mother  the  development  of  her  baby  into  a  good  and 
useful  citizen — this  is  the  one  absorbing  and  vital  experience  of  her 
life.  We  stand  in  awe  as  we  watch  this  current  of  human  life  stream 
by.  Life  is  our  only  real  possession  and  in  the  twinkling  of  an  eye 
we  may  lose  it,  so  the  mother  has  a  right  to  know  the  proper  care  and 
treatment  for  her  baby — a  God-given  possession. 

10.  Nursery   schools,    safety   education,    social   hygiene,    schools 


226 

equipped  to  give  proper  ventilation,  proper  lighting  and  spaces  in 
school  buildings  for  health  service.  Also  proper  administrative  pro- 
cedure for  health  work,  rural  and  urban,  budget  provisions  specifi- 
cally for  school  health  work  and  attention  to  the  summer  vacation 
problem.  This  last  recommendation  no  doubt  implies  more  supervi- 
sion of  children  during  the  summer  months  with  varied  activities. 

John  Dewey  has  said,  "What  the  best  and  wisest  parent  wants  for  his 
child,  that  must  the  community  want  for  all  its  children." 

Finally,  mental  health  should  be  given  greater  consideration.  Courses 
of  study  should  be  built  around  the  interests  of  the  youth,  not  the  adult. 

A  definite  effort  should  be  made  to  gain  an  understanding  of  the 
child,  his  interests  and  his  dislikes ;  a  chance  to  consult  a  psychiatrist  and 
a  psychologist  to  be  able  to  give  the  right  kind  of  help  to  the  different 
personalities — the  lonely,  the  queer,  the  stupid,  the  moody,  neurotic,  anti- 
social, etc.  If  teachers  have  the  ability  to  inspire  confidence,  children  will 
talk  out  their  troubles  and  thereby  get  relief.  Ours  not  to  condemn,  but 
to  study  the  individual  and  if  possible  give  him  a  ray  of  hope,  for  "it 
springs  eternal  in  the  human  breast." 

We  can  improve  and  strengthen  the  health  of  the  school  child  only 
when  we  think  of  him  as  a  unit — mind,  soul  and  body — always  trying  to 
show  these  children  that  we  have  faith  and  confidence  in  them,  and  child- 
hood will  not  betray  that  trust.  This  is  the  ideal  that  President  Hoover 
places  before  us,  the  work  he  asks  us  to  carry  on,  to  work  so  that  we  may 
lift  the  children  of  today  to  higher  standards  of  health,  spiritual,  physical, 
mental  and  moral,  so  that  succeeding  generations  will  profit  by  it.  Let  us 
have  faith,  child-like  faith  and  trust,  and  not  give  way  to  discouragements 
and  arguments  of  how  this  work  cannot  be  improved  but  a  confidence  that 
we  will  reach  a  higher  goal,  as  our  own  New  England  Poet  Emily  Dick- 
inson, writes, 

"I  never  saw  a  moor, 
I  never  saw  the  sea, 
Yet  know  I  how  the  heather  looks, 
And  what  a  wave  must  be. 

I  never  talked  with  God 
Nor  visited  in  Heaven, 
Yet  certain  am  I  of  the  spot, 
As  if  a  chart  were  given." 

RECREATION  AND  LEISURE  TIME 

By  Zenos  E.  Scott 
Superintendent  of  Schools,  Springfield,  Mass. 

The  report  of  Committee  "E"  on  Physical  Education  and  Recreation 
of  the  White  House  Conference  is  encouragingly  optimistic  on  the  one 
hand  and  discouragingly  challenging  on  the  other.  There  are  many  ex- 
amples of  noted  achievements;  likewise  there  are  many  facts  presented 
which  show  that  much  is  yet  to  be  accomplished  before  we  may  feel  that 
we  have  measured  up  to  what  is  expected  of  us.  I  shall  attempt  first,  to 
set  forth  some  of  the  salient  features  of  the  committee's  report;  second, 
to  place  my  own  interpretation  on  recreation  and  the  use  of  leisure  time. 

In  studying  the  incidence  of  Recreation  and  Physical  Education  the 
committee  divides  the  subject  into  the  following  headings:  1)  Recreation 
for  the  preschool  age;  2)  Recreation  for  the  school  age  (in  school  and 
out  of  school)  ;  3)  Leadership  training  for  a  program  for  either  the  pre- 
school or  the  school  age  child. 

In  its  findings  under  the  preschool  age  group,  the  committee  showed 
that  the  preschool  age  represented  almost  one-seventh  of  the  nation's 
population;  that  in  general  the  efficiency  of  the  program  for  recreation 


227 

diminished  from  the  eighteen-year-old  group  to  the  young  child  in  the 
home.  Current  judgment  criticizes  this  situation,  and  asks  that  in  our 
program  more  provision  be  made  for  the  preschool  age.  In  this  connec- 
tion there  is  evidence  that  the  parent  needs  to  gain  a  much  better  concep- 
tion of  and  practice  in  recreation  for  the  young  child.  The  effort  is  not 
to  take  the  young  child  away  from  the  home  for  this  aspect  of  his  growth 
but  rather  to  have  an  understanding  in  the  home  of  the  problems  involved 
so  that  the  home  may  have  in  it  facilities  for  leadership  to  the  greatest 
extent. 

The  committee  relies  upon  students  of  civic  problems  to  set  the  stand- 
ards for  playground  space  and  parks,  the  standard  being  one  acre  of 
parks  and  playgrounds  for  each  one  hundred  inhabitants  in  urban  centers. 
This  standard  is  not  attained  in  the  majority  of  American  cities. 

In  the  committee's  findings  on  recreation  for  the  school  age  much 
stress  is  placed  upon  the  necessity  for  a  real  program  of  physical  edu- 
cation as  a  regular  part  of  every  school  curriculum;  competent  and  well- 
trained  teachers  of  physical  education;  adequate  playgrounds,  and  facili- 
ties within  the  school  building  for  play  space ;  a  sound  program  of  physi- 
cal education  and  athletic  activities  based  upon  individual  needs  of  pupils ; 
the  importance  of  physical  education  activities  as  the  means  of  offering 
real  opportunities  for  guidance  in  behavior,  health  habits,  and  right 
habits  of  character  formation.  (One  can  see  the  difficulties  yet  to  be  over- 
come when  he  realizes  that  there  are  approximately  11,000,000  children 
in  rural  schools ;  that  many  of  our  small  towns  and  cities  are  yet  without 
adequate  gymnasiums  and  playgrounds;  that  in  some  of  the  larger  cities, 
the  effort  to  secure  large  playgrounds  and  parks  is  just  being  exerted.) 
The  report  praises  the  cooperative  efforts  put  forth  by  municipal  govern- 
ments and  private  agencies  to  increase  park  and  playground  facilities. 

The  report  shows  how  various  agencies  outside  the  school  are  render- 
ing service  and  cooperating  for  the  great  benefit  of  the  school  age  group. 
In  the  words  of  the  committee,  the  nation  is  indeed  fortunate  to  have  such 
agencies  as  the  Girl  Scouts  of  America;  the  Boy  Scouts  of  America,  the 
Camp  Fire  Girls;  the  Order  of  DeMolay;  Knights  of  Columbus  and 
Catholic  Boys  Brigade;  Young  Men's  Christian  Association;  Young 
Women's  Christian  Association;  Young  Men's  Hebrew  Association; 
Young  Women's  Hebrew  Association;  the  Four-H  Clubs,  and  other 
agencies,  working  for  the  welfare  of  youth.  The  private  agencies  spend 
many  millions  annually,  and  enlist  the  volunteer  efforts  of  thousands  of 
workers  and  leaders.  The  Parks  and  Playground  Association  of  America 
also  renders  very  valuable  service  in  this  phase  of  work  with  the  children 
of  school  and  after-school  age.  It  is  estimated  that  over  14,000,000  chil- 
dren from  eight  to  eighteen  years  of  age  profit  through  the  efforts  of 
these  combined  agencies. 

Under  the  heading,  Leadership  Training,  the  committee  indicates  that 
there  is  much  to  be  accomplished;  that  the  problem  of  providing  whole- 
some and  stimulating  leadership  is  the  most  difficult  one  before  us;  that 
higher  standards  for  recreation  workers  and  physical  training  teachers 
is  of  first  importance  in  this  program  for  better  opportunities  for  the 
youth  of  the  nation. 

YOUTH  OUTSIDE  HOME  AND  SCHOOL 

By  Eva  Whiting  White 

Head  Worker,  Elizabeth  Peabody  House 

Boston,  Massachusetts 

There  are  45,590,341  young  people  under  the  age  of  18!  These  young 
people  are  our  citizens  of  tomorrow  and  those  who  will  be  responsible  for 
the  future  of  the  country.  We,  who  are  older,  are  their  guardians.  It 
is  to  us  that  they  look  for  providing  those  opportunities  in  the  field  of 
recreation  which  will  mean  their  future  efficiency  and  well-being. 


228 

Throughout  the  White  House  Conference,  at  nearly  every  session,  the 
values  of  recreation  and  the  absolute  necessity  of  making  available  every 
opportunity  for  the  free  play  of  children  were  emphasized.  Not  only  is 
it  seen  clearly  today  that  recreation  builds  up  physical  well-being,  but  it 
is  also  accepted  that  recreation  has  much  to  do  with  mental  balance. 
Moreover,  it  is  the  field  of  recreation  that  develops  social  effectiveness. 

The  challenge  of  delinquency  and  the  challenges  of  physical  and  mental 
handicaps  face  us.  It  has  been  asserted  that  40  per  cent  of  the  time  of 
our  youth  is  given  over  to  leisure  pursuits,  in  some  form  or  other.  The 
remaining  60  per  cent  of  time  is  divided  between  the  home  and  the  school. 
In  spite  of  all  that  has  been  done  in  the  recreation  movement  throughout 
the  last  twenty-five  years,  only  a  beginning  has  been  made.  Playgrounds 
do  not  yet  serve  neighborhood  areas  to  the  extent  of  100  per  cent.  Many 
a  playground  is  too  small  to  meet  adequately  the  demands  of  the  child 
population. 

Training  schools  that  are  responsible  for  graduating  leaders  to  guide 
children  are  still  too  far  entrenched  in  physical  education,  as  such,  to  be 
able  to  develop  the  type  of  curricula  which  will  catch  children  on  the  wing. 
More  red-blooded  able,  winning  men  and  women  are  needed  as  leaders. 
Valuable  as  are  playgrounds  and  recreation  centers,  the  natural  tend- 
encies of  children  lean  toward  the  city  street,  or  the  out-of-the-way  lot, 
or  toward  any  chance  bit  of  space  which  gives  them  the  opportunity  to 
do  things  for  themselves.  Therefore,  we  must  think  of  the  playground 
plus.  Great  care  should  be  taken  not  to  standardize  programs  to  too  great 
a  degree. 

In  the  case  of  recreation,  as  in  other  lines  of  thought,  we  turn  to  the 
home,  because  the  playtime  of  children  begins  at  the  mother's  knee.  Par- 
ents are  the  natural  play  leaders  and  the  home  the  natural  center  of  the 
recreative  interests  of  children.  After  all  that  is  said  and  done  as  to 
the  good  and  bad  influences  of  commercial  amusements,  it  is  the  home 
that  must  bear  the  final  responsibility.  Too  few  parents  hold  themselves 
responsible  for  the  environmental  conditions  under  which  their  children 
are  living. 

In  the  light  of  the  great  values  in  recreation,  what  should  be  our  plans 
for  the  future?  First,  more  than  lip  service  must  be  given  to  supporting 
the  development  of  leisure  time  opportunities ;  second,  we  must  be  willing 
to  spend  money,  both  in  the  support  of  public  departments  and  the  sup- 
port of  private  agencies  in  this  field ;  third,  after  twenty-five  years  devoted 
to  the  development  of  the  playground  technique,  it  is  time  for  us  to  take 
account  of  stock  and  to  re-think  the  value  of  the  activities  and  the  methods 
used ;  fourth,  there  is  no  question  but  that  the  average  program  is  meager 
as  compared  with  what  it  can  and  will  be. 

A  well-rounded  program  includes  physical  activities,  opportunities  for 
taking  part  in  drama,  musical  opportunities  and  the  visual  arts,  to  say 
nothing  of  the  field  of  literature.  The  great  civic  and  social  field  of  the 
future  is  the  field  of  leisure  time. 

SECTION  IV 
THE  HANDICAPPED 

Alfred  F.  Whitman,  Chairman 

Many  of  the  interests  of  this  section  were  brought  to  the  attention  of 
the  whole  country  through  the  original  White  House  Conference  of  1909 
which  concerned  itself  largely  with  the  integrity  of  the  home  and  with 
the  problem  of  children  who  had  to  be  removed  from  their  homes  for 
foster  care. 

The  program  of  Mothers'  Aid  which  had  its  genesis  in  the  first  Con- 
ference has  been  so  extensive  and  so  effective  that  in  1930  it  was  found 
that  all  but  three  states  of  the  Union  provided  such  a  service  and  that 


229 

220,000  children  were  living  with  their  own  parents  under  benefits  of 
mothers'  aid  laws  and  appropriations;  children  who  under  the  old  plan 
would,  no  doubt,  be  in  foster  care  either  in  children's  agencies  or  in 
institutions. 

In  addition  to  efforts  to  help  the  dependent  child  in  his  own  home  the 
program  of  child  dependency  enlists  1500  foster  institutions  and  350 
foster  family  agencies.  These  provide  care  for  another  quarter  of  a  mil- 
lion children  away  from  their  own  homes.  Some  of  the  cases  that  lead 
to  the  breakdown  of  family  life  are  sickness,  both  physical  and  mental, 
mental  defect,  accidents,  premature  death,  unemployment,  inadequate 
wages.  The  Conference  says  that  each  of  these  causes  is  subject  to  great 
reduction. 

Similarly  the  delinquency  of  children  may  be  decreased  when  we  come 
to  understand  the  strains  and  cravings  to  which  the  child  is  exposed  and 
when  we  realize  that  all  those  concerned  with  the  child's  delinquent  acts 
have  a  responsibility  to  understand,  to  aid  and  to  educate  instead  of  to 
punish.  It  is  estimated  that  of  all  the  children  of  juvenile  court  age,  that 
is,  from  seven  to  eighteen,  one  of  every  hundred  finds  himself  in  the  care 
of  courts — about  200,000. annually.  Judge  Cabot,  the  chairman  of  the  sub- 
section on  Delinquent  Children  proposed  one  of  the  most  fundamental 
items  in  the  Children's  Charter,  Section  II,  which  reads :  "For  every  child 
understanding  and  the  guarding  of  his  personality  as  his  most  precious 
right." 

The  sub-section  on  the  Physically  and  Mentally  Handicapped  Child  is 
of  sufficient  importance  to  warrant  a  special  White  House  Conference 
devoted  to  this  one  subject,  for  the  Conference  reports  that  there  are 
from  three  to  five  million  children  concerned  in  this  field  alone ;  the  blind, 
the  deaf,  the  hard-of-hearing,  those  suffering  from  tuberculosis,  heart 
disease  and  certain  parasitic  diseases  in  addition  to  a  large  number  of 
crippled  children  and  those  handicapped  through  mental  defect  or 
through  lack  of  sound  mental  hygiene  facilities.  These  should  not  be 
peculiarly  set  aside  from  other  children  for  their  likenesses  to  other  chil- 
dren are  greater  than  their  differences.  The  child  with  the  handicap 
should  be  so  guided  that  his  aptitude  and  abilities  may  be  given  the  full- 
est development  in  order  that  his  life  may  be  both  happy  and  useful. 
Commissioner  Ellis  of  the  State  Department  of  Institutions  and  Agencies, 
Trenton,  New  Jersey,  who  was  chairman  of  the  sub-section  dealing  with 
the  physically  and  mentally  handicapped,  emphasizes  the  need  of  a  central 
state  agency  for  coordinating  the  interests  of  the  handicapped;  the 
more  extensive  organization  of  special  classes,  and  presents  a  Bill  of 
Rights  which  offers  the  fundamental  principles  of  a  complete  plan  for 
the  care  of  the  handicapped.   This  Bill  of  Rights  reads  as  follows: 

The  Handicapped  Child  Has  a  Right 

1.  To  as  vigorous  a  body  as  human  skill  can  give  him. 

2.  To  an  education  so  adapted  to  his  handicap  that  he  can  be  economi- 
cally independent  and  have  the  chance  for  the  fullest  life  of  which 
he  is  capable. 

3.  To  be  brought  up  and  educated  by  those  who  understand  the  nature 
of  the  burden  he  has  to  bear  and  who  consider  it  a  privilege  to  help 
him  bear  it. 

4.  To  grow  up  in  a  world  which  does  not  set  him  apart,  which  looks  at 
him,  not  with  scorn  or  pity  or  ridicule — but  which  welcomes  him, 
exactly  as  it  welcomes  every  child,  which  offers  him  identical  privi- 
leges and  identical  responsibilities. 

5.  To  a  life  on  which  his  handicap  casts  no  shadow,  but  which  is  full 
day  by  day  with  those  things  which  make  it  worth  while,  with  com- 
radeship, love,  work,  play,  laughter,  and  tears — a  life  in  which  these 
things  bring  continually  increasing  growth,  richness,  release  of 
energies,  joy  in  achievement. 


230 
ORGANIZATIONS  FOR  THE  HANDICAPPED 

Richard  K.  Conant 

Commissioner  of  Public  Welfare 

State  Department  of  Public  Welfare 

In  this  period  of  unemployment,  public  and  private  social  service  agen- 
cies in  Massachusetts  must  be  unusually  alert  to  make  sure  that  parents 
are  not  forced  by  poverty  to  give  up  their  children  as  dependent.  The 
White  House  Conference  report  indicates  that  Massachusetts  has  had  for 
a  long  time  a  high  percentage  of  children  under  the  care  of  public  and 
private  child-caring  agencies  and  of  private  institutions.  This  high  per- 
centage of  children  under  care  in  Massachusetts  is  a  result  partly  of  the 
high  standards  of  service  given  by  the  very  large  number  of  placing 
agencies  and  institutions  and  partly  of  the  standards  which  the  courts 
insist  must  be  maintained  in  the  home  if  it  is  not  to  be  broken  up  for 
neglect. 

The  depression  will  not  have  the  effect  of  increasing  the  percentage  of 
children  under  care  if  we  are  able  to  insist  strongly  enough  upon  our 
cardinal  principle  that  the  home  must  not  be  broken  up  for  poverty  alone. 
We  have  always  boasted  that  in  Massachusetts  there  are  enough  organ- 
izations and  enough  resources  so  that  assistance  can  be  supplied  to  suit- 
able parents  in  a  large  enough  amount  to  keep  the  home  and  the  family 
together. 

Our  experience  with  the  new  law  providing  for  the  investigation  of 
adoptions  indicates  that  there  are  more  families  than  we  had  supposed 
who  were  giving  up  children  for  adoption  by  reason  of  poverty  alone. 
These  cases  were  not  coming  to  the  notice  of  the  social  agencies. 

The  White  House  Conference  finds  throughout  the  country  that  there 
has  been  too  great  an  emphasis  in  providing  care  for  children  away  from 
their  own  homes.  It  urges  the  development  of  more  organizations  to  pro- 
vide for  children  at  home  and  to  give  welfare  service  to  the  whole  family. 
The  number  of  family  welfare  agencies  privately  supported  in  Massa- 
chusetts has  not  increased  in  recent  years.  There  has  been  a  great  de- 
velopment on  the  part  of  publicly  supported  welfare  agencies.  Unless, 
however,  these  agencies  can  be  equipped  with  a  sufficient  number  of  visi- 
tors to  provide  adequate  service,  the  large  amounts  of  money  which  they 
are  now  spending  will  not  do  the  work  in  a  satisfactory  manner  and  there 
will  be  many  cases  where  the  families  have  been  broken  up  unnecessarily. 

Other  findings  of  the  White  House  Conference  are: 

1.  The  Federal  Government  should  give  grants  in  aid  to  promote 
the  proper  care  and  protection  of  the  handicapped  child. 

It  probably  will  be  a  long  time  before  this  principle  would  be  adopted 
in  Massachusetts. 

2.  The  State  should  have  a  central  authority  to  see  that  all  such 
children  are  protected  and  given  proper  support,  care  and  education. 
It  should  furnish  leadership,  set  standards,  promote  social  work  pro- 
grams and  maintain  effective  supervision  over  all  institutions  and 
agencies  having  the  care  of  handicapped  children. 

The  Massachusetts  State  Department  of  Public  Welfare  compares  fav- 
orably with  other  state  departments  and  has  exercised  more  influence 
through  its  direct  case  work  than  the  standards  of  the  White  House  Con- 
ference contemplate.  Supervision  over  the  private  child-caring  agencies 
has  not  progressed  as  far  in  Massachusetts  as  it  has  in  Ohio  and  Minne- 
sota, but  the  private  agencies  here  are  undoubtedly  of  a  higher  stand- 
ard. There  is  need  for  more  education  and  publicity  on  the  part  of  the 
State  Department,  but  the  private  agencies  have  developed  social  work 
programs  here  further  than  they  have  in  the  states  which  are  now  placing 
so  much  emphasis  upon  state  welfare  department  leadership. 


231 

3.  Every  state  welfare  department  should  contain  a  division  auth- 
orized and  equipped  to  handle  all  cases  of  an  interstate  character. 

No  state  has  this.  It  should  be  developed  in  Massachusetts  by  legis- 
lation centralizing  this  portion  of  the  work  of  city  and  town  boards. 

4.  Direct  care.  It  is  sound  policy  for  the  state  to  thrust  back  on 
local  units  responsibility  for  every  kind  of  service  for  handicapped 
children  which  the  local  community  is  able  and  competent  to  admin- 
ister. 

In  Massachusetts  direct  care  has  developed  further  than  the  standards 
of  the  White  House  Conference  contemplate  for  states  which  are  now 
developing  new  programs.  The  State  cares  for  6,462  dependent  and  neg- 
lected children;  cities  and  towns  place  1,187  children  themselves  and  use 
the  State  as  an  agent  to  place  661  other  settled  children.  We  have  not  so 
far  felt  that  the  cities  and  towns,  with  the  exception  of  Boston,  were  able 
to  do  as  satisfactory  work  in  placement  as  the  State  does.  It  may  be  desir- 
able to  place  more  emphasis  upon  local  care. 

5.  The  State  is  too  far  removed  to  assume  case-work  responsi- 
bilities within  the  counties.  The  most  promising  form  of  organiza- 
tion for  child  care  and  protection  is  a  county  welfare  board  with 
administrative  authority. 

Fifty-four  Massachusetts  cities  and  towns,  containing  77  per  cent  of 
the  population  of  the  State,  employ  as  agents  or  visitors  for  their  local 
boards  of  public  welfare  over  150  persons  who  are  reasonably  well  trained 
in  social  work.  For  the  other  23  per  cent  of  the  population  of  the  State  in 
the  small  towns,  it  may  be  possible  to  work  out  a  system  by  which  a  social 
worker  is  employed  jointly.  This  social  worker  should  not  be  the  public 
health  nurse. 

6.  Transfer  of  administrative  duties  from  juvenile  courts. 

In  Massachusetts  the  juvenile  court  does  not  determine  dependency  or 
grant  mothers'  aid. 

7.  Joint  financing  of  private  social  agencies  through  community 
chests  is  as  yet  much  more  common  than  community  engineering  pro- 
vided for  through  councils  of  social  agencies. 

Much  more  should  be  done  in  Massachusetts  in  the  development  of  com- 
munity programs  of  child  welfare  through  councils  of  social  agencies. 

8.  Programs  of  child  welfare  can  be  made  effective  only  by  means 
of  sufficient  and  properly  qualified  personnel. 

The  situation  in  Massachusetts  is  reasonably  satisfactory  in  compari- 
son with  other  states,  but  this  need  is  still  the  greatest  of  all  the  needs 
outlined  by  the  Conference  standards.  Committees  on  training  of  social 
workers  and  educational  programs  for  enlisting  the  trained  workers 
should  receive  the  greatest  attention. 

SOME  HIGHLIGHTS  ON  CHILD  DEPENDENCY 

By  Cheney  C.  Jones 
Superintendent,  New  England  Home  for  Little  Wanders. 

One  cannot  properly  discuss  Section  IV  of  the  White  House  Conference 
without  referring  specifically  to  the  Conferences  of  1909  and  1919.  We 
must  remember  that  the  first  White  House  Conference  dealt  with  the  de- 
pendent child  only.  Though  for  our  particular  section  the  ground  had 
been  broken  twenty  years  before,  there  were  certain  definite  recom- 
mendations of  the  Conference  of  1909  that  were  properly  before  us  for 
consideration  in  1930.  Among  these  suggestions  were  noted  the  following : 


232 
"That  greater  provision  be  made  for  the  assistance  of  needy  children 
in  their  own  homes;  that  greater  use  be  made  of  family  care  for  chil- 
dren who  must  be  removed  from  their  own  homes;  that  child-caring 
agencies  be  responsibly  organized  and  be  inspected  by  the  state;  that 
dependent  children  receive  better  medical  care;  that  a  Federal  Chil- 
dren's Bureau  be  established;  that  an  unofficial  national  organization 
for  the  promotion  of  methods  of  child  care  be  established ;  that  preven- 
tion of  child  dependency  is  better  than  cure;  that  the  causes  of  child 
dependency  be  ascertained,  and,  if  possible,  controlled;  that  tubercu- 
losis and  other  diseases  be  checked." 

On  all  these  recommendations  we  were  able  to  note  marked  progress 
over  the  twenty  year  period.  Practically  all  of  the  development  in  the 
field  of  mothers'  assistance  has  come  since  1909.  The  great  growth  in 
relief  as  applied  by  Family  Welfare  Societies  and  public  outdoor  relief 
departments  has  developed  during  that  period.  Definite  growth  in  the  way 
of  state  supervision  of  private  child-caring  agencies  under  improved  laws 
is  evident.  Great  improvement  in  medical  care  has  been  effected  by  both 
public  and  private  child-caring  societies.  Since  1909  the  Federal  Chil- 
dren's Bureau,  recommended  by  the  first  White  House  Conference,  has 
been  established,  and  today  it  is  impossible  to  think  of  running  the  Gov- 
ernment without  it.  An  unofficial  organization,  namely,  the  Child  Welfare 
League  of  America,  has  been  operating  for  over  ten  years  for  the  promo- 
tion of  better  methods  of  child  care  throughout  the  country. 

The  Conference  of  1919  was  broader  in  scope  than  that  of  1909.  In 
addition  to  dependency,  child  labor  and  education,  the  public  protection 
of  the  health  of  mothers  and  children,  and  children  in  need  of  special 
care,  all  came  in  for  study  and  recommendations.  Never  before  1919  had 
there  been  made  available  such  an  amount  of  definite  criteria  on  the  vari- 
ous phases  of  the  care  of  dependency.  The  1919  Conference  through  the 
Children's  Bureau  publications  gave  practical  workers  in  the  field  definite 
guide  books.  It  is  a  very  significant  thing  that  in  the  recent  White  House 
Conference  we  reaffirm  the  conclusions  and  recommendations  of  the  White 
House  Conferences  of  1909  and  1919  in  all  essentials,  and  urge  that 
these  conclusions  and  recommendations  be  kept  continuously  in  mind. 
The  fact  that  these  conclusions  and  recommendations  stood  up  under 
twenty  years'  experience  and  under  vigorous  debate  in  the  Committees 
of  the  present  Conference  is  certainly  assurance  that  we  have  been  on 
sound  ground  all  the  way  through.  In  a  brief  address  of  this  kind,  one 
can  only  speak  of  certain  basic  principles  which  seem  to  have  stood  out 
through  our  study.   Some  of  these  may  be  stated  in  order: 

1.  The  preservation  of  the  child's  own  family  and  home  must  be 
the  first  thought  of  all  child-caring  agencies.  This  idea  did  not  pre- 
vail to  any  extent  previous  to  1909.  Those  of  us  in  charge  of  old 
societies  have  daily  opportunity  to  realize  that  there  was  a  time  when 
children  were  taken  very  casually,  breaking  up  families  without  much 
consideration.  They  kept  inadequate  records  of  these  children's  lives 
and  they  disposed  of  them  with  a  naive  faith  in  the  motives  and  ca- 
pacities of  those  who  took  them.  If  one  were  unconvinced  about  all 
this,  all  he  would  have  to  do  would  be  to  read  Dr.  Henry  W.  Thurs- 
ton's book  on  the  Dependent  Child.  Since  1909  we  find  marked 
growth  of  the  so-called  widow's  pension  idea,  that  is,  mother's  assist- 
ance, practiced  throughout  the  country.  We  find  forty-four  states 
committed  by  law  to  this  practice, — spending  thirty  million  dollars 
per  annum  providing  care  with  their  own  mothers  for  two  hundred 
and  twenty  thousand  children.  In  addition  we  note  family  welfare 
societies  in  the  country  aiding  three  hundred  and  eighty  thousand 
families,  involving  seventy-five  thousand  children.  During  the  pres- 
ent industrial  and  business  emergency,  with  all  its  unemployment, 
we  find  relief  by  both  public  and  private  agencies  reaching  unheard 


233 

of  proportions.  What  would  be  the  rate  of  child  dependency  in  this 
country  in  1931  if  the  old-fashioned  idea  of  taking  children  into 
foster  care  for  reasons  of  poverty  only  prevailed?  In  fact,  in  this 
practice  we  find  there  has  been  more  change  in  the  past  twenty  years 
than  in  the  previous  one  hundred  years.  The  practice,  however,  is 
not  fully  extended  and  the  money  provided  for  relief  is  often  inade- 
quate. In  the  recent  Conference  we  recommended  that  the  child-caring 
agencies  should  further  modify  their  practice  and  extend  it  in  this 
direction.  We  are  to  labor  in  season  and  out  for  a  fuller  recognition 
of  the  child's  own  family  as  the  source  and  center  of  his  most  pro- 
found emotions  and  his  most  treasured  traditions. 

2.  Organization  problems  are  evident  in  the  child-caring  field  and 
need  immediate  and  thorough-going  attention.  Many  child-caring 
agencies  are  in  danger  of  failing  to  meet  the  requirements  of  chil- 
dren of  today  and  tomorrow  because  of  definite  limitations  in  char- 
ters and  gifts  of  the  past.  The  purposes  of  such  agencies  should  be 
stated  in  general  and  flexible  terms.  When  necessary  these  agencies 
should  ask  appropriate  courts  to  reinterpret  bequests  and  endow- 
ments too  much  limited  by  the  dead  hand.  Prospective  writers  of 
wills  should  be  educated  on  this  point.  It  is  entirely  conceivable  that 
some  child-caring  societies  in  this  country  may  within  a  few  years 
become  mothers'  aid  or  even  fathers'  aid  societies. 

There  are  outstanding  varieties  in  state  programs,  in  fact  forty- 
eight  or  more  experiments  are  going  on.  Some  variety  is  doubtless 
inevitable  and  probably  some  is  desirable,  but  it  is  evident  to  the 
Conference  Committee  that  there  is  too  much  variation.  It  seems  a 
correct  practice  for  state  governments  to  function  both  for  direct 
care  and  for  supervision  of  private  child-caring  agencies.  Probably 
there  is  a  real  difference  between  the  large  and  small  states'  situa- 
tions. In  large  areas  where  county  governments  function,  the  county 
welfare  unit  seems  the  most  promising  plan.  The  old  question  of 
what  is  properly  public  and  properly  private  service  is  not  yet  fully 
and  clearly  answered.  It  grows  more  evident  that  private  society  can 
point  the  way  of  good  service  to  only  a  few.  The  public  agency  must 
be  in  a  position  to  apply  approved  principles  to  the  many.  In  this  par- 
ticular section  of  the  Conference  there  was  made  a  significant  study 
attempting  to  get  at  dependency  rates  in  various  states.  Surprising 
variations  appeared.  When  the  data  are  published  and  available  to 
all  of  us,  it  must  have  the  most  thorough-going  study  and  interpre- 
tation. It  points  to  an  outstanding  need  for  organization  and  method 
in  compiling  accurate  and  comparable  statistics  in  our  field.  The 
Child  Welfare  League  of  America  has  made  some  beginnings  in  this 
direction.  It  would  seem  that  the  Children's  Bureau  and  the  League 
can  help  us  tremendously  in  this  field  and  that  local  agencies  must 
cooperate  fully  and  completely. 

3.  One  of  the  most  significant  happenings  in  the  deliberations  in 
the  dependency  field  was  that  the  "versus"  between  foster  home  care 
and  institutional  care  was  wiped  out.  Both  forms  of  care  in  our  re- 
ports are  called  Foster  Care,  and  both  are  fully  recognized  as  legiti- 
mate. In  our  findings  it  appeared  that  there  are  probably  1,500  child- 
caring  institutions  in  the  country  and  350  placing  agencies.  Approxi- 
mately one  quarter  of  a  million  children  are  under  care  by  these  two 
groups,  one-third  of  them  being  in  foster  families.  The  cost  of  this 
care  is  approximately  sixty  million  dollars.  There  is  a  decline  in  the 
number  of  children  in  institutions  in  proportion  to  total  population. 
Recognizing,  therefore,  that  both  institution  and  foster  family  care 
are  legitimate,  the  Conference  places  emphasis  not  on  one  or  the 
other  type  of  care,  but  on  the  principle  that  the  child  in  either  type 
of  agency  should  be  individualized,  and  personalized.  The  depend- 
ent child  should  have  what  other  sections  of  the  Conference  find 


234 

advisable  for  all  the  children  of  all  the  people,— NOTHING  LESS! 
The  first  and  major  question  must  be,  "What  does  the  child  need?" 
and  child-caring  societies  are  to  search  far  and  near  for  resources  to 
help  answer  this  question  and  to  supply  the  need.  We  cannot  neglect 
the  findings  of  all  other  sections  of  this  White  House  Conference. 
We  are  to  use  whatever  sciences  we  find  available.  An  intelligent  and 
social  use  of  law  is  a  protective  force  for  child  welfare,  potential 
with  possibilities  not  yet  realized.  The  social  use  of  medicine  dili- 
gently, intelligently  and  widely  applied  for  the  benefit  of  the  children 
of  America  is  now  a  solemn  obligation  on  the  table  of  every  board 
of  directors  of  every  children's  agency  in  the  country.  More  recently 
we  have  discovered  that  the  child  has  a  mind  and  we  are  calling 
psychology  and  psychiatry  to  our  assistance.  Law  and  medicine  are 
old,  though  ever  renewing  themselves.  Psychology  and  psychiatry,  in 
their  modern  sense,  are  young  and  their  use  for  us  is  more  difficult. 
Nevertheless  they  are  making  great  contributions  and  are  bringing 
us  to  some  realization  as  to  what  it  may  mean  to  have  found  the 
child's  mind.  We  know  today  that  there  are  mental  states  and  con- 
ditions even  in  children  which  are  too  deeply  situated  for  an  environ- 
mental change  to  benefit  unless  we  go  deeper  into  the  mind  of  the 
child  than  the  layman  can  go.  For  such  the  skilled  psychiatrist  be- 
comes necessary.  We  are  now  face  to  face  with  puzzling,  astounding 
questions  as  to  what  we  may  be  doing  to  these  little  comrades  whom 
we  move  about  on  the  checkerboard  of  life.  If  we  are  to  ask  what 
the  child  needs,  we  dare  not  go  without  asking,  "What  is  on  the 
child's  mind?"   The  task  is  not  simple. 

4.  We  find  child  dependency  greatly  affected  by  differences  of 
race,  nationality,  and  by  mass  migration.  During  the  past  twenty 
years  the  negro,  who  is  our  marginal  worker,  has  been  on  the  move. 
Large  numbers  are  found  living  in  cities,  which  before  had  but  few, 
and  the  care  of  dependent  children  of  these  people  is  bulking  large 
in  a  number  of  these  cities.  We  find  more  than  two  and  a  half  million 
Mexican  people  in  our  country  and  their  residence  is  not  confined 
to  two  or  three  of  the  border  states.  In  one  section  of  New  York 
City  we  find  more  than  150,000  Porto  Rican  citizens  and  the  number 
growing  each  day.  Among  the  Indians  we  find  85,000  children  of 
school  age.  All  of  these  groups  present  outstanding  needs  now.  Some 
valuable  reports  will  be  made  available  in  Conference  publications  on 
the  conditions  of  these  children.  They  must  have  special  study  and 
special  skill  must  be  developed  for  meeting  their  needs.  In  these 
reports  we  shall  find  a  new  slant  on  a  task  bulking  much  larger  than 
heretofore  realized. 

5.  The  fact  that  the  child  protective  function  which  relates  so 
closely  to  the  child-caring  function  is  so  inadequately  developed  in  the 
country  as  a  whole  is  a  puzzling  situation.  If  foster  care  is  to  func- 
tion for  the  greatest  good  of  society,  this  child  protective  function 
must  be  socialized,  staffed  with  trained  workers  and  so  extended  as 
to  cover  the  entire  area  of  the  Nation  along  the  lines  so  carefully 
worked  out  by  the  sub-committee  on  this  particular  service. 

6.  Of  the  three  to  five  million  physically  and  mentally  handicapped 
children  in  our  country  today  many  are  bound  to  be  in  the  custody 
of  foster  care  agencies.  It  becomes  us,  therefore,  to  keep  our  agents 
or  workers  well  informed  on  all  new  found  skills  in  diagnosis,  edu- 
cation, training  and  vocational  guidance  of  this  particular  group  of 
children.  It  behooves  the  child-caring  societies  to  play  a  part  in 
bringing  about  adequate  state  and  national  organization  for  the  co- 
ordination of  what  is  now  a  rather  hit  and  miss  service  to  these 
specially  needy  children.  We  must  play  our  part  in  leading  the  com- 
munity mind  to  consider  these  children  as  assets  rather  than  lia- 
bilities. 


235 

7.  Foster  care  agencies  are  already  committed  to  caring  for  some 
of  the  delinquent  children  and  we  are,  therefore,  obligated  to  ground 
ourselves  in  the  fundamental  thinking  and  philosophy  given  us  by  the 
sub-committee  on  the  handicap  of  delinquency.  It  is  interesting  to 
speculate  on  what  would  happen  in  modern  society  if  the  men  and 
women  of  this  troubled  world  would  think  of  delinquency  as  a  handi- 
cap both  publicly  and  personally.  If  we  are  to  undertake  any  service 
for  delinquents,  we  must  either  have  psychological  and  psychiatric 
service  on  our  own  staffs  or  we  must  find  it  available  in  the  com- 
munity. 

8.  The  outstanding  causes  of  child  dependency  are  now  fairly  well 
determined.  They  are  sickness,  mental  disturbance,  accidents,  (14,- 
000  children  per  year  made  dependent  by  accidental  death  of  father) , 
premature  death  from  certain  diseases;  with  mothers:  tuberculosis, 
childbirth,  heart  disease  (organic)  ;  with  fathers:  violence,  tubercu- 
losis, pneumonia,  heart  disease.  Now  let  us  bear  in  mind  that  all  of 
these  causes  of  child  dependency  would  yield  to  the  extended  practice 
of  well  proven  methods  of  prevention.  Another  outstanding  cause  of 
child  dependency  was  at  the  door  and  staring  through  the  windows 
of  every  committee  room  of  the  Conference.  I  refer  to  the  "wolf"  of 
irregular  employment,  and  if  we  add  inadequate  income  for  those 
employed,  and  extend  into  practical  application  the  findings  and 
recommendations  of  this  section  of  the  Conference  on  the  effects  of 
such  unemployment  and  reduced  income  on  child  life  in  our  country 
today,  there  is  dynamite  in  the  Conference  report.  It  is  to  be  hoped 
that  another  White  House  Conference  ten  years  hence  will  see  marked 
advance  in  this  territory.  At  present  we  don't  know  what  adequate 
family  incomes  would  do  to  child  dependency  rates  in  the  states  of 
this  Union. 

What  shall  we  say  about  Massachusetts?  Perhaps  the  best  we  can  do 
in  the  few  moments  at  our  disposal  is  to  ask  ourselves  certain  questions. 

Since  for  the  first  time  in  the  study  made  by  Section  IV  we  have 
schedules  of  dependency  rates  in  thirty-one  states  of  the  Union,  are  we 
making  known  the  Massachusetts  showings  in  comparison  with  other 
states,  and  are  we  interpreting  those  figures  to  ourselves  and  to  the  public 
in  general? 

Are  we  stimulating  local  responsibility  for  child  dependency  in  the 
Commonwealth?  If  the  Director  of  Public  Welfare,  with  this  question  in 
his  mind,  is  seeking  some  changes  in  the  organization  of  his  operations 
throughout  the  State,  is  he  not  entitled  to  the  enthusiastic  backing  of  all 
citizens  ? 

Is  our  work  for  the  physically  handicapped,  crippled,  et  cetera,  suf- 
ficiently coordinated  for  the  State  and  is  it  all-inclusive? 

Have  we  a  practical  definition  of  the  functions  of  public  and  private 
agencies  ? 

Are  there  not  examples  of  a  need  for  reconsideration  of  the  functions 
and  powers,  the  charters  and  constitutions  of  some  private  child-caring 
societies  ? 

Are  there  any  racial  situations  in  our  State  which  need  special  atten- 
tion? 

If  our  treatment  plan  for  mental  defect  seems  sound  and  wise,  should 
we  not  proceed  to  extend  its  facilities  until  adequate  to  handle  the  prob- 
lem in  its  entirety? 

Are  we  thinking  straight  about  institutions  for  children? 

Is  available  relief  with  skilled  social  service  anywhere  near  sufficiently 
adequate  to  make  sure  that  no  child  in  the  Commonwealth  need  be  re- 
moved from  his  own  parents  for  reasons  of  poverty  alone? 

Are  all  of  us  who  are  in  private  agencies  rightly  relating  ourselves  to 
public  service  "which  is  more  definitely  OURS  than  even  our  own  private 


236 

societies?    We  are  citizens  and  taxpayers  first,  and  knocking  seems  out 
of  order.    Intelligent  cooperation  challenges  our  citizenship. 

In  this  field  of  Child  Dependency  there  is  much  more  that  could  be  said. 
The  time  is  not  available.  The  reports  being  published  challenge  us  to  a 
thorough-going  study  and  to  a  translation  into  action,  to  statesmanship 
in  child  health  and  protection,  for  these  White  House  Conferences  stand 
as  a  definite  recognition  that  the  welfare  of  our  children  is  a  proper  con- 
cern for  statesmen.  The  child  who  is  neglected  by  either  citizen  or  states- 
man menaces  the  well-being  and  happiness  of  both.    On  the  other  hand, 

"WHOSO  SAVES  A  CHILD  FROM  THE  FINGERS  OF  EVIL 

SITS  IN  THE  SEAT  WITH  BUILDERS  OF   CITIES  AND 

PROCURERS  OF  PEACE." 

THE  PHYSICALLY  HANDICAPPED  CHILD 

By  Gordon  Berry,  M.D. 

Worcester,  Massachusetts 

Introduction 

In  my  youth  I  was  told  of  two  children  whose  names  were  Jack  and  Jill. 
Some  inner  urge  of  parental  persuasion  suggested  their  going  to  fetch 
a  pail  of  water.  They  were  apparently  healthy,  happy,  normal  children. 
Jack  seems  to  have  been  the  leader.  They  were  industriously  employed 
and  trying  to  render,  to  the  extent  of  their  limited  ability,  a  service  to 
their  community.  The  nature  of  the  accident  is  not  quite  clear.  But  the 
results  were  serious,  for  Jack  fractured  his  skull  and  Jill  had  multiple 
abrasions  and  possibly  internal  injuries.  I  never  learned  what  happened 
then.  Was  the  paper  plaster  enough?  Did  Jack  lose  his  sight  or  his  hear- 
ing; did  Jill  have  to  go  to  the  hospital  and  get  her  cuts  sewed  up,  or  did 
she  have  to  wear  crutches  or  get  pushed  around  in  a  wheel  chair?  I 
imagine  most  of  the  members  of  this  serious  audience  never  worried 
much  about  Jack  and  Jill;  nor  did  I.  But  we  are  solemnly  met  together 
to  do  so  now.  One  state  after  another,  from  Maine  to  California,  is  rally- 
ing to  our  President's  call,  and  all  over  this  broad  land,  our  citizenry  is 
trying  to  decide  what  should  be  and  shall  be  done  for  the  child  who 
stumbles  and  falls. 

My  part  of  the  discussion  deals  with  the  physically  handicapped  child. 
I  am  to  tell  very  briefly  of  blind  Jack  and  crippled  Jill,  of  deaf  brother 
and  hard  of  hearing  sister.  And  you  and  I  are  profoundly  concerned; 
for  some  little  one  in  your  home  or  in  mine  may  fall  down  the  back  stairs 
tomorrow  while  trying  to  fetch  his  pail  of  water.  If  we  wish  a  text  to 
guide  our  discussion,  we  can  find  no  better  than  the  thirteenth  article  in 
our  Children's  Charter  where  we  pledge  "For  every  child  who  is  blind, 
deaf,  crippled,  or  otherwise  physically  handicapped,  and  for  the  child 
who  is  mentally  handicapped,  such  measures  as  will  early  discover  and 
diagnose  his  handicap,  provide  care  and  treatment,  and  so  train  him  that 
he  may  become  an  asset  to  society  rather  than  a  liability."  Let  us  itali- 
cize that  last:  an  asset  rather  than  a  liability.  We  will  return  to  this 
thought  for  it  is  a  rather  startling  idea. 

The  Nature  and  Extent  of  the  Handicap 
I.     The  Blind 

First  let  us  consider  the  visually  handicapped.  Here  we  have  the  totally 
and  the  partially  blind.  They  are  estimated  at  65,000.  These  deserve  and 
receive  universal  sympathy  for  they  seem  so  helpless,  and  each  of  us 
unconsciously  wonders  how  we  would  feel  if  we  could  no  longer  see  blue 
sky  and  green  trees  and  tumbling  waters  and  autumn  foliage. 

What  is  being  done  for  these  blind?  There  are  61  schools  scat- 
tered through  41  states;  but  they  take  care  of  less  than  6,000  children. 


237 

We  of  Massachusetts  look  with  just  pride  on  our  Perkins  Institute.  Here 
the  work  goes  from  kindergarten  up  through  high  school  and  they  are 
now  developing  the  preschool  work.  Here  we  find  opportunities  for  empha- 
sis in  music,  or  manual  training,  or  physical  culture.  Other  agencies 
interest  themselves  in  blind  babies;  our  public  schools  are  instituting 
sight  saving  classes ;  we  have  a  division  for  the  blind  in  our  State  Board 
of  Education  and  a  Field  Worker  (Miss  Ridgeway)  who  investigates  and 
coordinates  the  activities  throughout  our  Commonwealth.  But  fine  as  this 
is,  it  is  only  a  beginning.  There  are  so  many  blind  children  that  are 
receiving  little  or  no  help. 

We  cannot  review  the  many  recommendations  of  the  committee  on  the 
visually  handicapped.   I  will  refer  to  two: 

a.  The  use  of  play  materials  and  the  invention  of  new  ones,  to  take  the 
place  of  visual  stimuli  in  normal  babies. 

b.  A  careful  study  of  the  training  of  blind  babies  to  determine  the  im- 
portance and  applicability  of  nursery  school  training  vs.  a  supervis- 
ing nurse  or  teacher  in  the  home. 

II.  The  Crippled 

"The  crippled  occupy  the  attention  of  more  volunteer  and  professional 
agencies  than  any  other  type  of  child  service."  In  spite  of  this  fact  there 
is  as  yet  little  definite  knowledge  of  the  numerical  extent  of  the  problem. 
It  is  estimated  at  300,000.  I  think  Massachusetts  may  properly  take  pride 
as  one  of  the  most  advanced  states  in  work  for  these  unfortunates.  We 
have  seven  public  or  private  institutions  where  crippled  children  are  cared 
for  apart  from  the  opportunities  in  our  general  hospitals.  And  these  beds 
are  available  for  the  poor  as  well  as  the  wealthy.  But  why  should  we  let 
the  children  reach  this  sad  condition  where  at  the  best  there  must  be 
months  of  suffering  and  years  of  toil?  Listen  to  this  expert  testimony: 
"Infantile  paralysis,  tuberculosis,  rickets,  and  cerebral  palsy  lead  the  list 
in  the  causative  factors"  for  these  crippled  children,  and  "much  of  the 
damage  done  by  these  diseases  can  be  largely,  if  not  wholly,  prevented." 
There  lies  the  tragedy;  and  there  lies  the  hope  of  the  morrow.  Preven- 
tion through  early  diagnosis  and  prompt  care ;  home  cooperation  through 
parental  education;  these  deserve  unceasing  emphasis. 

III.  The  Deaf  and  Hard  of  Hearing 

(a)   The  Deaf 

The  deaf  and  hard  of  hearing  are  the  largest  group  at  present.  The 
"deaf"  may  be  defined  as  those  who  have  lost  their  hearing  before  speech 
has  been  acquired.  They  present  a  difficult  problem,  for  our  whole  edu- 
cational system,  whether  at  home  or  in  the  school,  requires  hearing  and 
speech,  and  these  children  lacking  both,  must  rely  almost  solely  on  sight 
and  touch  for  their  mental  growth.  To  reach  these  children  through  these 
limited  channels  requires  expert  institutional  care.  Your  child  listens  to 
its  mother  all  day  long.  By  two  it  can  talk  and  at  four  years  it  has  an 
extensive  vocabulary.  But  deaf  little  brother  runs  wild  until  six  when 
first  he  can  be  taken  to  a  school  for  the  deaf;  and  that  most  important 
formative  period  in  his  life  has  been  wasted. 

Statistics  tell  me  that  there  are  in  the  United  States  200  residential 
and  day  schools  for  the  deaf.  These  are  handling  18,767  deaf  children.  In 
Massachusetts  we  have  six  schools  listing  a  total  of  642  pupils.  If  any 
of  you  wish  a  thrilling  and  satisfying  experience,  I  would  urge  your  visit- 
ing the  Clarke  School  or  the  Horace  Mann  School  and  seeing  what  normal 
happy  lives  those  little  deaf  tots  are  living.  And  when  you  realize  how 
modern  science  has  surmounted  this  tremendous  handicap  and  will  send 
this  human  wreckage  on  through  high  school,  perhaps  up  into  college,  and 
out  into  happy  useful  lives,  you  will  thank  God  and  take  courage. 

A  few  of  the  committee  recommendations  are  the  following : 


238 

(1)  Schools  for  the  deaf  need  modernizing.  A  detailed  review  of  the 
teaching  force  and  of  the  curriculum  taught  would  point  the  way. 

(2)  A  careful  study  of  the  preschool  deaf  with  a  view  to  their  discov- 
ery and  education  at  three  or  four  years  of  age  instead  of  starting 
at  six  or  later. 

(3)  Researches  in  heredity;  in  lip  reading;  in  speech  training;  in  vo- 
cational accomplishment. 

(b)   The  Hard  of  Hearing 

Work  for  the  hard  of  hearing  is  relatively  recent.  It  began  with  the 
organization  of  scattered  lip  reading  classes  for  adults.  These  joined  in 
groups  or  leagues  and  in  1919  the  American  Federation  of  Organizations 
for  the  Hard  of  Hearing  was  formed.  Its  growth  has  been  phenomenal. 
They  now  number  almost  one  hundred  leagues,  each  with  an  individual 
membership  ranging  from  thirty-five  to  nine  hundred.  How,  you  ask, 
does  this  concern  the  children  ?  It  is  this  Federation  for  the  Hard  of  Hear- 
ing that  fosters  the  plan  to  discover  and  study  partial  deafness  in  child- 
hood, in  the  hope  that  efforts  applied  during  its  incipiency  may  control 
and  even  prevent  deafness. 

1.  Under  their  stimulation  a  group  testing  audiometer  was  devised  by 
the  Bell  Telephone  Laboratories  and  over  a  million  school  children  have 
already  been  tested  with  it.  From  these  data,  it  is  estimated  that  three 
million  of  our  children  have  sufficient  deafness  to  present  an  educational 
and  social  and  economic  problem.  In  many  cases,  none  suspected  the  child 
to  be  deaf,  thought  it  was  inattentive. 

2.  Then  the  Federation  workers  proposed  ear  clinics  (fashioned  some- 
what after  those  in  Rochester)  to  examine  these  deafened  cases  in  the 
hope  that  some  might  be  cured.  And  thus  far  we  are  encouraged  to  hope 
that  many  will  be  saved  their  hearing  by  reason  of  this  early  attack. 

3.  Next  comes  their  educational  treatment.  The  following  national 
figures  are  cheering: 

Number  of  4-A  Audiometers  in  public  use  180 

Cities  offering  lip  reading  instruction  to  hard  of  hearing 

children  in  the  public  schools  63 

Number  of  children  in  these  classes over  4,000 

In  Massachusetts 1,039 

Cities  having  lip  reading  classes  in  evening  public  schools  60 
Colleges  and  universities  offering  courses  for  the  training 

of  teachers  of  hard  of  hearing  children   13 

This  is  but  a  beginning  but  it  is  a  very  encouraging  beginning.  During 
these  lean  financial  years,  all  such  activities  are  sadly  curtailed,  but  I 
hope  and  trust  that  Massachusetts  will  continue  among  the  leaders  in  this 
splendid  work  for  their  deaf  and  hard  of  hearing  children. 

Let  us  note  a  few  of  the  committee's  findings.   They  are : 

(a)  The  early  detection  of  impaired  hearing  and  prompt  expert  care 
with  a  view  to  preventing  deafness. 

(b)  The  universal  and  repeated  use  of  group  testing  audiometers;  and 
an  effort  to  make  them  applicable  to  children  in  the  earliest  grades. 

(c)  The  teaching  of  lip  reading  and  the  use  of  mechanical  hearing  aids 
in  the  education  of  these  children,  throughout  the  United  States. 

IV.     Tuberculosis,  Cardiac  Diseases,  Intestinal  Parasites 

Into  this  same  group  of  physically  handicapped  are  brought  the  tuber- 
culous and  the  cardiac.  We  are  told  there  are  about  a  million  and  a 
quarter  of  the  former  and  a  half  million  of  the  latter.  Gradually  the  doc- 
tors and  the  health  departments  are  winning  out  in  their  never-ceasing 
struggle  against  these  scourges. 

An  interesting  comment  in  the  Tuberculosis  Committee  report  says: 
"There  appears  to  be  a  growing  tendency  to  place  greater  confidence  in 
restricted  activity  and  increased  nutrition  rather  than  the  undue  emphasis 


239 

hitherto  placed  on  air  and  sunlight,  without  in  any  way  detracting  from 
the  value  of  these  factors." 

The  cardiac  group  claims  that  "education  for  prevention  of  infectious 
disease  and  for  proper  convalescent  care,  is  really  the  only  preventive 
measure  known  against  heart  disease." 

The  Remedy 

This  reviews  hastily  the  task  that  is  before  us.  What  is  the  remedy? 
Our  pledge  tells  us.  (1)  Detection.  The  family,  the  rural  community,  the 
city  and  the  county  must  join  in  intelligent  cooperation.  Surveys  must 
be  more  intensively  conducted  and  helpful  information  widely  distributed 
so  that  parents  and  teachers  and  physicians  will  be  on  the  constant  look- 
out and  early  detect  any  advancing  trouble.  (2)  Medical  care.  Facilities 
must  be  established  for  efficient  medical  care.  The  annual  testing  of 
all  public  school  children  and  a  careful  medical  examination  of  all  doubt- 
ful cases  should  be  a  routine  part  of  our  public  school  and  health  service. 
When  any  difficulty  is  discovered  the  parents  should  be  informed  and 
urged  to  institute  corrective  measures.  (3)  Education.  We  must  so  train 
this  handicapped  child  "that  he  may  become  an  asset  to  society  rather 
than  a  liability."  This  means  expert  education  carefully  adapted  to  his  need. 
It  means  training  him  in  a  selected  trade  where  his  physical  impairment 
will  not  prove  an  economic  handicap.  It  means  that  when  private  financial 
resources  are  lacking,  the  community  or  state  will  bear  the  expense.  It 
means  that  when  these  handicapped  have  been  trained  to  become  economi- 
cally useful  citizens  the  community  shall  accept  them  into  wage  earning 
jobs  for  which  they  are  prepared,  as  readily  as  we  do  a  normal  worker. 

Perhaps  Jack  is  crippled.  I  submit  to  you  that  in  most  cases  it  is  our 
fault  and  not  his  that  the  lad  cannot  run  and  jump.  What  can  we  offer  to 
recompense  him?  The  best  of  surgical  care,  the  finest  of  splints  and 
crutches,  and  our  debt  is  not  half  paid.  We  must  give  him  the  mental 
growth  his  normal  brother  will  have  and  we  must  offer  him  the  training 
and  also  the  job  which  will  assure  him  economic  independence  and  the 
soul  satisfaction  of  being  of  use  among  his  kind. 

It  is  not  Mary's  fault  that  she  went  to  school  and  caught  scarlet  fever 
from  the  girl  at  the  next  desk,  resulting  in  the  loss  of  most  of  her  hear- 
ing. Shall  she  grow  up  stunted  in  knowledge  and  warped  in  spirit,  going 
to  school  till  she  is  sixteen  because  the  law  says  she  must,  but  remaining 
in  the  primary  grades  while  her  early  classmates  and  friends  pass  up  out 
of  her  life  and  she  has  to  associate  with  children  six  years  younger  and 
nearly  half  her  size?  Her  days  are  a  tragedy,  the  nights  her  only  solace; 
and  all  beacuse  her  community  does  not  accept  its  recognized  responsibil- 
ity !  The  story  can  so  easily  be  different.  Early  diagnosis  and  care  might 
have  cured,  or  lip  reading  can  be  taught,  and  mechanical  hearing  aids  are 
available  for  both  school  and  individual  work. 

I  have  listed  5,147,000  as  the  estimated  number  of  our  physically  handi- 
capped children.  This  constitutes  a  challenge  to  our  Nation  and  to  our 
Commonwealth  and  calls  for  a  cooperative  and  strong  and  persistent 
attack  from  all  agencies  concerned.  Encouraging  progress  is  being  made. 
The  two  chief  difficulties  at  present  are  lack  of  comprehensive  knowledge 
of  the  problem  and  lack  of  adequate  facilities  to  help.     „ 

Many  of  these  handicapped  will  become  social  and  economic  burdens 
unless  society  realizes  its  responsibility.  The  new  and  intelligent  approach 
is  not  to  think  of  them  as  liabilities  but  potential  assets.  "Therefore,  in 
work  with  the  handicapped,  we  must  develop  a  wholly  constructive  atti- 
tude— an  attitude  permeated  with  effective  optimism."  The  needs  of  these 
children  in  general  are  the  needs  of  all  children.  They  have  aptitudes  and 
abilities;  we  must  furnish  the  expert  help  to  develop  them. 

Conclusion 

How  many  derelicts  and  criminals  might  we  have  been  spared  and  how 
many  leaders  and  geniuses  might  the  world  have  enjoyed  if  we  had  only 


240 

helped  our  Jack  and  Mary  when  they  needed  it  ?  History  does  not  support 
the  old  Grecian  idea  that  our  bodies  must  be  perfect  to  ensure  our  great- 
est usefulness.  Rather  does  it  suggest  that  he  who  surmounts  a  handi- 
cap becomes  thereby  the  greater  benefactor.  Who  among  his  hearers  in 
Athens  could  have  guessed,  that  the  very  stammering  which  made  Demos- 
thenes' speech  such  a  dismal  failure  was  to  be  the  agency  that  would 
whip  into  perfection  one  of  the  greatest  orators  of  all  time.  John  Milton 
saw  yet  more  wondrous  visions  after  he  became  blind.  And  some  of  the 
most  majestic  symphonies  that  were  ever  composed  were  evolved  in  the 
mind  of  Beethoven  while  he  was  stone  deaf. 

Throughout  the  gamut  of  human  experience,  nature  is  constantly  offer- 
ing compensations  if  we  would  but  accept  them.  Helen  Keller  could  never 
have  developed  her  marvelous  sense  of  touch  unless  she  had  been  forced 
to;  and  she  started  with  less  than  you  or  I.  The  quickness  and  sureness 
of  the  perceptive  sight  in  the  deaf  is  past  our  understanding.  Give  these 
handicapped  children  an  equal  chance  and  many  of  them  will  pass  us  in 
life's  race.  Our  pledge  points  the  way.  First  we  must  try  to  keep  Jack 
and  Mary  from  getting  hurt.  But  if  tumble  they  must,  let  us  see  to  it 
that  whatever  the  damage,  they  shall  grow  up  to  be  not  liabilities,  but 
assets. 

A  Bill  of  Rights  for  the  Handicapped  Child 

I  cannot  close  more  fittingly  than  by  reading  you  the  "Bill  of  Rights" 
presented  by  the  Section  on  the  Physically  and  Mentally  Handicapped.  It 
is  so  understanding  and  so  human  a  document. 

If  we  want  civilization  to  march  forward  it  will  march  not  only  on 
the  feet  of  healthy  children,  but  beside  them,  shoulder  to  shoulder,  must 
go  those  others — those  children  we  have  called  "handicapped" — the  lame 
ones,  the  blind,  the  deaf,  and  those  sick  in  body  and  mind.  All  these 
children  are  ready  to  be  enlisted  in  this  moving  army,  ready  to  make 
their  contribution  to  human  progress ;  to  bring  what  they  have  of  intelli- 
gence, of  capacity,  of  spiritual  beauty.  American  civilization  cannot 
ignore  them. 

The  Handicapped  Child  Has  a  Right: 

1.  To  as  vigorous  a  body  as  human  skill  can  give  him. 

2.  To  an  education  so  adapted  to  his  handicap  that  he  can  be  economi- 
cally independent  and  have  the  chance  for  the  fullest  life  of  which 
he  is  capable. 

3.  To  be  brought  up  and  educated  by  those  who  understand  the  nature 
of  the  burden  he  has  to  bear  and  who  consider  it  a  privilege  to  help 
him  bear  it. 

4.  To  grow  up  in  a  world  which  does  not  set  him  apart,  which  looks  at 
him,  not  with  scorn  or  pity  or  ridicule — but  which  welcomes  him, 
exactly  as  it  welcomes  every  child,  which  offers  him  identical  privi- 
leges and  identical  responsibilities. 

5.  To  a  life  on  which  his  handicap  casts  no  shadow,  but  which  is  full 
day  by  day  with  those  things  which  make  it  worth  while,  with  com- 
radeship, love,  work,  play,  laughter  and  tears — a  life  in  which  these 
things  bring  continually  increasing  growth,  richness,  release  of  ener- 
gies, joy  in  achievement. 

MENTALLY  HANDICAPPED 

By  Samuel  W.  Hartwell,  M.D. 

Director,  Child  Guidance  Clinic 

Worcester,  Massachusetts 

Many  of  the  subjects  discussed  in  earlier  White  House  Conferences 
presented  few  new  aspects  as  they  were  considered  in  the  latest  one.  How- 
ever, this  was  not  true  of  the  mentally  handicapped  child.  When  they 
discussed  the  mentally  handicapped  child  in  the  first  conference,  they 


241 

were  thinking  very  largely  of  the  child  who  was  handicapped  intellectu- 
ally. During  the  past  ten  years,  the  vital  subject  of  mental  hygiene  has 
entered  in  the  picture,  and  now  the  subject  of  the  mentally  handicapped 
child  is  considered  by  everyone  not  only  to  mean  intellectually  handi- 
capped, but  the  child  who  is  handicapped  by  the  emotional  life.  The  child 
who  is  made  more  unhappy,  less  useful  to  others,  or  more  disturbing  to 
those  with  whom  he  comes  in  contact  is  also  handicapped  by  his  mental 
life. 

I  propose  in  the  few  moments  given  me  to  discuss  this  very  large  sub- 
ject, to  report  on  the  White  House  recommendations  and  findings  in  this 
very  large  and  important  field;  to  discuss  first  the  intellectually  handi- 
capped and  later  the  emotionally  handicapped  child. 

Massachusetts  can  well  be  proud  of  her  record  and  her  accomplish- 
ments in  dealing  with  the  mentally  handicapped  child.  No  state  gives 
better  care,  and  few  give  as  good  care,  as  does  Massachusetts,  to  the 
children  and  the  adults  who  must  go  through  life  in  a  measure  shut  away 
from  their  fellows  and  from  interests  and  activeness  of  others  because  of 
their  intellectual  handicaps. 

The  White  House  Conference  considered  the  problem  in  three  phases: 
first,  the  registration  of  feeble-minded  and  the  diagnosis  of  the  amount 
of  retardation  in  these  individuals ;  second,  the  training  of  the  individuals 
outside  of  institutions,  their  care  and  supervision  when  not  in  schools  or 
special  classes;  third,  the  care  in  institutions. 

First,  Massachusetts  has  by  far  the  most  complete  registration  of  any 
state  in  the  Union,  the  State  law  providing  for  compulsory  examination 
for  those  three  or  more  years  retarded  having  accomplished  this  during 
the  last  ten  years.  A  complete  knowledge  of  these  facts  is  of  the  greatest 
service  to  any  state  or  community  as  it  tells  not  only  how  large  the  prob- 
lem is,  but  how  serious  it  is,  and  gives  opportunity  for  a  follow-up  infor- 
mation that  provides  as  to  how  successful  various  ways  of  dealing  with 
the  individual  are  and  how  much  burden  this  service  is  to  the  community. 
Second,  the  care  of  the  feeble-minded  individual  outside  of  the  institu- 
tion consists  largely  at  present  of  speech  classes,  provided  for  them  in 
connection  with  the  public  school  system;  a  small  number  are  coached  in 
private  day  schools.  In  some  states,  very  Ittle  provision  is  made  for  any 
supervision  or  training  outside  of  institutions  except  such  as  is  given  by 
the  family.  Again  Massachusetts  can  be  proud  of  its  record  in  this  line, 
but  the  other  states  are  rapidly  becoming  more  interested  in  this  problem. 
They  are  finding  that  feeble-minded  adults  who  have  been  given  some 
sort  of  a  vocational  guidance  or  other  training  are  much  less  likely  to 
become  social  problems.  Third,  training  in  institutions  may  be  considered 
under  the  heading  of  actual  time  spent  in  institutions  and  the  training 
given,  and  training  of  the  individual  who  is  later  entered  into  the  com- 
munity. At  present,  it  was  felt  in  the  Conference  that  community  educa- 
tion and  cooperation  in  this  very  important  social  plan  was  of  greatest 
importance. 

The  Conference  believed  from  what  information  was  available,  approxi- 
mately 2  per  cent  of  the  population  of  the  United  States  fall  in  the  feeble- 
minded group,  and  another  5  per  cent  were  in  those  classified  by  psycholo- 
gists as  borderline.  In  all  the  discussions,  the  seriousness  of  the  problem 
was  very  often  pointed  out.  In  this  particular  field  of  Child  Welfare, 
many  instructive  plans  are  in  operation  and  in  process  of  planning  all 
over  the  United  States.  A  great  deal  of  research  is  being  done  in  the 
various  schools  and  universities.  The  opinion  of  the  Conference  was  that 
most  of  that  work  was  being  done  along  useful  and  constructive  lines. 

The  work  for  those  children  who  are  handicapped  by  their  personalities, 
whose  emotional  situation  and  emotional  lives  are  making  them  "prob- 
lems" is  in  its  infancy.  This  work  is  being  done  largely  by  Child  Guidance 
Clinics,  and  it  is  only  in  the  larger  centers  where  such  services  are  now 
available.    Some  of  these  clinics  are  conducted  under  the  auspices  of 


242 
schools,  a  few  directly  under  juvenile  courts,  a  few  are  privately  endowed, 
the  majority  are  supported  by  public  or  private  contributions. 

The  White  House  Conference  felt  that  the  set-up  for  the  clinic  should 
either  be  what  is  termed  a  "3  or  4  way  clinic."  In  the  3  way  clinic,  there 
is  a  psychological  department  for  mental  tests,  a  social  department  for 
investigating  and  treating  the  environment  of  the  child,  and  a  psychiatric 
clinical  service  for  the  study  of  the  child's  mental  life  in  all  its  phases, 
and  for  the  treatment  of  this  by  interviews  with  the  psychiatrist  where 
this  is  deemed  necessary  and  wise.  The  fourth  service  is  that  of  the  pedia- 
trician, but  since  clinics  looking  after  the  physical  welfare  of  the  child  are 
so  well  developed  everywhere,  it  is  usually  found  that  this  service  can  be 
conveniently  rendered  by  clinics  not  directly  attached  to  the  Child  Guid- 
ance Clinic. 

In  most  places  these  clinics  have  only  been  in  operation  a  few  years. 
The  final  result  of  their  work  cannot  be  measured.  The  Conference  felt 
that  the  thing  they  were  trying  to  do,  however,  was  probably  as  important 
as  any  department  of  child  welfare  now  being  considered.  An  adult,  if  he 
is  to  be  adjusted  well  socially,  must  be  reasonably  well  adjusted  in  his 
personality  and  emotional  life.  These  things  are  conditioned  and  largely 
determined  by  the  experience  of  the  adult  when  he  was  a  child  or  ado- 
lescent. To  study  the  individual  when  his  personality  is  being  made  is 
productive  of  more  understanding,  and  to  attempt  to  change  this  per- 
sonality into  more  normal  lines,  if  unfortunate  ones  are  developing,  is 
more  hopeful  of  success  when  dealing  with  the  child  than  when  dealing 
with  the  adult. 

The  Conference  stressed  the  need  of  more  thorough  training  of  psychia- 
trists, social  workers  and  psychologists  for  this  particular  work.  The 
difficulty  of  attracting  the  right  kind  of  people  into  the  work  and  the 
danger  of  trying  to  conduct  clinics  without  an  adequately  trained  per- 
sonnel was  pointed  out.  Another  thing  that  was  felt  to  be  very  necessary 
before  a  successful  clinic  could  be  established  was  community  education. 
The  public  at  large  must  know  what  the  Child  Guidance  Clinic  is  trying 
to  do,  its  possibilities  and  its  limitations,  if  the  clinic  is  to  do  the  best 
work.  The  Conference  strongly  endorsed  the  dissemination  of  accurate 
information  about  mental  hygiene  as  it  may  be  applied  to  children  or  to 
adults  who  are  dealing  with  the  children.  The  Conference  felt  that  dur- 
ing the  past  ten  years,  there  has  been  a  great  deal  accomplished  both  in 
dealing  with  the  mentally  handicapped  child  and  with  the  establishing  of 
schools,  clinics  and  institutions  for  their  care. 

Massachusetts,  which  is  well  in  the  forefront  of  the  states  in  these 
important  things,  has  not  as  yet  provided  any  institution  where  children 
with  serious  personality  problems  or  pre-psychotic  children  may  be  segre- 
gated for  treatment.  There  is  a  great  need  for  such  a  provision.  The 
schools  for  delinquent  children  are  handicapped  in  their  work  with  the 
more  normal  child,  the  child  whose  environment  is  largely  accounting  for 
his  misbehavior,  by  the  presence  in  the  schools  of  a  few  seriously  ab- 
normal children.  Could  these  children  be  treated  in  separate  institutions, 
more  could  probably  be  done  for  them,  and  certainly  much  more  could  be 
done  for  the  more  normal  group. 

BOOK  NOTES 

Health  Protection  for  the  Preschool  Child.  White  House  Confer- 
ence Report.  Published  by  the  Century  Company,  New  York  City. 
Price  $2.50.   275  pages. 

The  report  covers  the  following  topics :  a  summary  of  preventive  work 
for  children  throughout  the  United  States ;  the  results  of  a  survey  of  pre- 
school children  as  regards  preventive  medical  and  dental  service  in  156 
cities  and  in  the  rural  areas  of  42  states;  statistical  tables;  a  section  on 


243 

administrative  features  of  the  survey  with  a  description  of  methods  and 
forms  used. 

The  report  is  the  latest  answer  to  the  question  "How  well  is  the  health 
of  preschool  children  in  the  United  States  protected?"  146,000  children 
in  the  cities  studied  and  37,000  in  the  rural  areas  were  reached  by  a 
house  to  house  survey. 

Periodic  health  examination  including  medical  and  dental  examination, 
smallpox  vaccination  and  diphtheria  immunization  were  considered  the 
three  practical  procedures  possible  in  every  community.  Correction  of 
defects  is,  we  judge,  understood  to  be  the  natural  sequel  of  the  health 
examination  as,  of  course,  examination  is  of  little  value  if  not  promptly 
followed  by  correction  of  all  the  remediable  defects  found.  The  statement 
is  made  that  the  older  the  child,  the  more  willing  parents  seem,  to  have 
health  examinations  made.  This  is  the  exact  opposite  of  our  experience 
in  Massachusetts  in  our  State  Well  Child  Conferences  where  examination 
on  infants  is  often  requested  but  we  find  it  more  difficult  to  interest  par- 
ents in  the  yearly  examination  of  preschool  children  or  even  in  the  regular 
examination  before  school  entrance. 

As  to  facilities  for  vaccination  in  our  country,  they  were  found  to  be 
ample  but  the  parent's  attitude  "discouraging  and  hard  to  understand" 
and  this  same  attitude  prevailed  in  regard  to  diphtheria  immunization 
(as  to  facilities  for  diphtheria  immunization,  no  statement  was  made). 

Fifty-one  per  cent  of  the  preschool  children  in  the  states  surveyed  and 
thirty-seven  per  cent  in  the  rural  areas  had  had  a  health  examination 
prior  to  their  sixth  birthday;  but  we  must  remember  that  this  examina- 
tion usually  had  been  given  during  the  first  year  of  life  when  there  is 
the  least  number  of  defects  found.  The  figures  for  dental  examinations 
varied  from  forty  per  cent  of  the  children  in  Cleveland  Heights,  Ohio,  to 
one  per  cent  in  Knoxville,  Tennessee,  the  "midway"  city  figure  being  11 
per  cent.  Dental  examinations  are  naturally  limited  to  children  three, 
four  and  five  years  old.  • 

The  survey  had  some  immediate  results  which  were  encouraging.  For 
example,  one  city  that  had  been  surveyed  asked  for  200  extra  forms  "that 
they  might  continue  for  their  own  information"  (would  that  all  our  sur- 
veys had  such  happy  endings)  and  another  city  noted  a  considerable 
increase  in  the  number  of  children  coming  for  vaccination  and  immuniza- 
tion which  showed  that  surveys  and  health  teaching  can  go  hand  in  hand 
if  the  right  people  do  the  surveying. 

Permanent  Play  Materials  for  Young  Children.  Charlotte  G.  Garri- 
son. Published  by  Charles  Scribner's  Sons,  1926.  Price  $1.00.  119 
pages. 

Primarily  a  guide  for  the  "selection,  use  and  care  of  permanent  play 
material  for  nursery  schools,  kindergartens  and  primary  grades,"  this 
little  book  can  be  read  with  profit  by  parents  and  pediatricians  as  well 
as  by  teachers. 

The  text  of  the  book  is  in  a  sentence  in  the  introduction,  "Toys  are  not 
to  amuse."  Toys  are  the  "tools  of  play"  and  play  is  the  child's  very  life. 

As  a  practical  help,  the  bibliographies  and  the  lists  following  addresses 
of  companies  making  good  toys  are  most  useful.  Only  the  five  and  ten 
cent  stores  are  omitted  and  this  purposely,  as  flimsy  toys  and  particu- 
larly poorly  made  tools  are  deplored. 

This  book,  read  with  the  older  "classic"  on  play  by  Joseph  Lee,  will 
give  anyone  dealing  with  children  an  excellent  start  on  education  in  the 
value  of  play  and  play  materials. 

And,  by  the  way,  the  introduction  by  Patty  Hill  will  give  at  once  a 
clear-cut  idea  of  the  fundamental  needs  in  play  material.  This  is  one  of 
the  few  books  where  the  introduction  is  "inscribed  clearly  on  the  tablet, 
that  he  may  run  who  readeth  it" — a  great  help  to  the  busy  mother  or 
teacher. 


244 
REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  July,  August,  and  September  1931,  samples  were 
collected  in  168  cities  and  towns. 

There  were  1,093  samples  of  milk  examined,  of  which  338  were  below 
standard;  from  17  samples  the  cream  had  been  in  part  removed,  and  4 
samples  contained  added  water.  There  were  52  samples  of  Grade  A  milk 
examined,  46  samples  of  which  were  above  the  legal  standard  of  4.00% 
fat,  and  6  samples  were  below  the  legal  standard. 

There  were  168  samples  of  food  examined,  of  which  44  were  adulter- 
ated. These  consisted  of  9  samples  of  maple  syrup  which  contained  cane 
sugar ;  1  sample  of  mayonnaise  made  with  mineral  oil ;  1  sample  of  cheese 
which  contained  zinc;  6  samples  of  clams,  5  samples  of  which  contained 
added  water,  and  1  sample  was  decomposed;  22  samples  of  eggs,  15 
samples  of  which  were  cold  storage  not  marked,  3  samples  were  decom- 
posed, and  4  samples  were  sold  as  fresh  eggs  but  were  not  fresh;  4 
samples  of  hamburg  steak,  all  of  which  contained  a  compound  of  sulphur 
dioxide  not  properly  labeled,  1  sample  of  which  was  also  decomposed;  and 
1  sample  of  soup  stock  which  was  decomposed. 

There  were  80  samples  of  drugs  examined,  of  which  33  were  adulter- 
ated. These  consisted  of  25  samples  of  spirit  of  nitrous  ether,  all  of  which 
were  deficient  in  the  active  ingredient;  5  samples  of  argyrol  not  corre- 
sponding to  the  professed  standard  under  which  they  were  sold ;  2  samples 
of  headache  powders  which  contained  acetanilid  and  were  misbranded; 
and  1  sample  of  magnesium  citrate  which  was  not  up  to  the  U.  S'.  P. 
standard. 

The  police  departments  submitted  1,794  samples  of  liquor  for  examina- 
tion, 1,763  of  which  were  above  0.5%  in  alcohol.  The  police  departments 
also  submitted  25  samples  of  narcotics,  etc.,  for  examination,  7  of  which 
were  morphine,  4  opium,  1  heroin,  1  sample  consisted  of  a  mixture  of 
earth  and  petroleum  oil; 3  samples  of  white  powder  and  2  samples  of 
liquids  were  tested  for  arsenic  with  negative  results;  1  sample  consisted 
of  water  and  petroleum  oil ;  1  sample  of  a  white  powder  contained  a  trace 
of  arsenic;  a  sample  of  yellow  liquid  was  tested  for  narcotics  with  nega- 
tive results;  a  sample  of  pills  was  called  for  by  a  police  officer  before  an 
analysis  could  be  completed;  1  sample,  consisting  of  a  brown  powder  con- 
tained lobelin,  an  alkaloid  of  lobelia;  1  sample  was  found  to  consist  of 
cottonseed  oil ;  and  1  sample  of  cooked  meat  which  was  tested  for  metallic 
poisons  with  negative  results.  Six  samples  were  submitted  by  the  Wor- 
cester Board  of  Health,  4  samples  of  which  were  milk,  and  2  samples  of 
meat,  all  of  which  were  tested  for  poisons  with  negative  results;  and  1 
sample  of  liquid,  submitted  by  Medical  Examiner  Dr.  T.  M.  Gallagher  of 
Newton,  was  tested  for  cyanide  with  negative  results. 

There  were  738  bacteriological  examinations  made  of  milk. 

There  were  30  bacteriological  examinations  made  of  soft  shell  clams, 
14  samples  in  the  shell,  7  of  which  were  unpolluted,  and  7  were  polluted; 
and  16  samples  shucked,  1  of  which  was  unpolluted,  and  15  were  polluted. 
There  were  no  bacteriological  examinations  made  of  hard  shell  clams. 

There  were  80  hearings  held  pertaining  to  violations  of  the  Laws. 

There  were  93  cities  and  towns  visited  for  the  inspection  of  pasteuriz- 
ing plants,  and  380  plants  were  inspected. 

There  were  48  convictions  for  violations  of  the  law,  $730  in  fines  being 
imposed. 

Owen  Clifford  and  Ephraim  Lavoie  of  Ludlow;  Henry  K.  Davis  of 
Charlton  Depot;  Joseph  Due  of  Wilbraham;  Manuel  Flores  and  John 
Lopes  of  Somerset;  H.  P.  Hood  &  Sons,  Incorporated,  of  Lynn;  Peter 
Futek  and  Ef rem  Ivashko  of  West  Springfield ;  Nicholas  Poulos  of  Stough- 
ton;  Mattie  Marceau  of  Vineyard  Haven;  Najeep  Dyer,  Paul  Garas 
and  James  M.  Kelley,  all  of  Hingham;  Phillip  Helfrich  and  Fred  V. 
Hooke  of  Salisbury;  Mary  Jordan  and  George  MacNeil  of  Oak  Bluffs; 
Anna  Masterson  of  Nantasket;  Sebastian  Kusiak  and  Stanley  Pajak  of 


245 
Chicopee  Falls;  and  Alta  Crest  Farms,  Incorporated,  of  Spencer,  were  all 
convicted  for  violations  of  the  milk  laws.    Henry  K.  Davis  of  Charlton 
Depot;  and  Phillip  Helfrich  and  Fred  V.  Hooke  of  Salisbury  appealed 
their  cases. 

Herman  Busanski,  Nathan  Strauss,  Incorporated,  2  cases,  and  Economy 
Grocery  Stores,  Incorporated,  all  of  Springfield;  Henry  G.  Wilson  of 
Spencer;  Fred  M.  Gorman  of  Gloucester;  and  James  M.  Kelley  of  Hing- 
ham,  were  all  convicted  for  violations  of  the  food  law.  Nathan  Strauss, 
Incorporated,  2  cases,  Economy  Grocery  Stores,  Incorporated,  both  of 
Springfield;  and  Henry  G.  Wilson  of  Spencer,  appealed  their  cases. 

Ernest  Helmis  of  Falmouth;  Martel  Druifuss  of  Springfield;  John  H. 
O'Connell,  Clifford  W.  Allen,  and  Modern  Lunch,  Incorporated,  all  of  Nan- 
tucket; Nicolas  Woulas  of  Southbridge;  and  Nicholas  Kougias  of  New 
Bedford  were  all  convicted  for  false  advertising.  Martel  Druifuss  of 
Springfield  appealed  his  case. 

Owen  Clifford  of  Ludlow;  Patrick  Faherty  of  Quincy;  George  Zervas 
of  Ipswich;  and  Alta  Crest  Farms,  Incorporated,  of  Spencer,  were  all 
convicted  for  violations,  of  the  pasteurization  law.  George  Zervas  of 
Ipswich  appealed  his  case. 

McKesson-Eastern  Drug  Company  of  Springfield;  Samuel  Kidder  & 
Company,  Incorporated,  2  cases,  of  Charlestown;  Jacob  Glazer  of  Milton; 
Benjamin  Iris  of  Falmouth;  and  Andrew  H.  March  of  Shelburne,  were 
all  convicted  for  violations  of  the  drug  laws. 

Paul  Levenson  of  Springfield  was  convicted  for  violation  of  the  mattress 
law. 

Clover  Leaf  Dairy,  Incorporated,  of  Haverhill  was  convicted  for  viola- 
tion of  the  Grade  A.  Regulations. 

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: 

Clams  which  contained  added  water  were  obtained  as  follows :  1  sample 
each,  from  Daniel  J.  Hussey,  Harry  Brockelbank,  Samuel  Hicks,  and 
Ernest  W.  Nutting,  all  of  Newburyport;  and  Harold  E.  Mclntyre  of 
Rowley. 

One  sample  of  clams  which  was  decomposed  was  obtained  from  Uptown 
Cafeteria  of  Boston. 

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

1  sample  each,  from  Ellas  Cohn  of  Springfield;  Ganem's  Market  of 
Lawrence;  and  Central  Public  Market  of  Cambridge. 

One  sample  of  hamburg  steak  which  contained  a  compound  of  sulphur 
dioxide  not  properly  labeled  and  was  also  decomposed  was  obtained  from 
Uptown  Cafeteria  of  Boston. 

Maple  Syrup  which  contained  cane  sugar  was  obtained  as  follows: 

1  sample  each,  from  Clifford  W.  Allen  and  Modern  Lunch,  Incorporated, 
of  Nantucket;  James  J.  McCarthy  and  Colonial  Lunch  of  Hingham; 
Maude  W.  Sotes  of  Onset;  Goody  Shoppe  of  New  Bedford;  Fred  Gorman 
of  Gloucester;  and  Thomas  G.  Murray  of  Hull. 

One  sample  of  soup  stock  which  was  decomposed  was  obtained  from 
Uptown  Cafeteria  of  Boston. 

One  sample  of  mayonnaise  which  was  made  with  mineral  oil  was  ob- 
tained from  Mrs.  Agnes  W.  Moore  of  Shawsheen  Village. 

There  were  six  confiscations,  consisting  of  250  pounds  of  decomposed 
fowl;  225  pounds  of  decomposed  beef;  10  pounds  of  decomposed  pork 
loins;  15  pounds  of  decomposed  beef  liver;  6  pounds  of  decomposed  pork 
liver;  and  15  pounds  of  decomposed  sausage  meat. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  June  1931 : — 2,072,160  dozens  of  case 
eggs;  1,938,572  pounds  of  broken  out  eggs;  5,237,904  pounds  of  butter; 
1,241,774  pounds  of  poultry;  3,716,024%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  5,885,725  pounds  of  fresh  food  fish. 


246 

There  was  on  hand  July  1,  1931: — 10,170,420  dozens  of  case  eggs; 
3,347,228  pounds  of  broken  out  eggs;  6,483,200  pounds  of  butter;  2,859,- 
387^/2  pounds  of  poultry;  14,674,739%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  14,831,815  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  July,  1931: — 673,170  dozens  of  case  eggs; 
558,455  pounds  of  broken  out  eggs;  3,764,791  pounds  of  butter;  1,106,855 
pounds  of  poultry;  3,369,519  pounds  of  fresh  meat  and  fresh  meat  pro- 
ducts ;  and  4,191,992  pounds  of  fresh  food  fish. 

There  was  on  hand  August  1,  1931: — 9,902,400  dozens  of  case  eggs; 
3,275,278  pounds  of  broken  out  eggs;  9,352,995  pounds  of  butter;  2,699,- 
391%  pounds  of  poultry;  11,554,033  pounds  of  fresh  meat  and  fresh  meat 
products;  and  17,000,813  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  August,  1931: — 465,720  dozens  of  case 
eggs;  298,920  pounds  of  broken  out  eggs;  1,987,676  pounds  of  butter; 
954,074  pounds  of  poultry;  2,277,104  pounds  of  fresh  meat  and  fresh 
meat  products;  and  6,828,039  pounds  of  fresh  food  fish. 

There  was  on  hand  September  1,  1931: — 9,069,930  dozens  of  case  eggs; 
2,932,773  pounds  of  broken  out  eggs;  424,301  pounds  of  butter;  2,229,- 
268%  pounds  of  poultry;  7,338,124  pounds  of  fresh  meat  and  fresh  meat 
products;  and  21,459,162  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  .     Under  direction  of  Commissioner. 

Division  of  Sanitary  Engineering  .     Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Division  of  Communicable  Diseases    Director, 

Gaylord  W.  Anderson,  M.D. 
Division  of  Water  and  Sewage  Lab- 
oratories  .......     Director  and  Chemist,  H.  W.  Clark 

Division  of  Biologic  Laboratories  .     Director  and  Pathologist, 

Benjamin  White,  Ph.D. 
Division  of  Food  and  Drugs  .  Director  and  Analyst, 

Hermann  C.  Lythgoe,  S.B. 
Division  of  Child  Hygiene  Director,  M.  Luise  Diez,  M.D. 

Division  of  Tuberculosis        .  Director,  Alton  S.  Pope,  M.D. 

Division  of  Adult  Hygiene  Director, 

Herbert  L.  Lombard,  M.D. 

State  District  Health  Officers 

The  Southeastern  District     .         .     Richard     P.     MacKnight,     M.D., 

V  !  ;     New  Bedford. 
The  Metropolitan  District     .         .     Charles  B.  Mack,  M.D.,  Boston. 
The  Northeastern  District  .     Robert  E.  Archibald,  M.D.,  Lynn. 

The  Worcester  County  District  Oscar  A.  Dudley,  M.D.,  Worcester. 

The  Connecticut  Valley  District  Harold  E.   Miner,   M.D.,   Spring- 

field. 
The  Berkshire  District  .         .     Walter  W.  Lee,  M.D.,  No.  Adams. 


INDEX 

PAGE 

Achieving  a  Successful  Wardrobe,  by  Elsie  K.  Chamberlain  .37 

American  Society  for  Control  of  Cancer — Educational  Material    .  .    181 

Anderson,    Gaylord   W.,    M.D.,    Relation    of   Typhoid    Carriers   to   Food 

Supply ....      93 

Antipneumococcic  Serum,  by  Benjamin  White,  Ph.D.   ....    164 

Baldwin,  Esther  V.,  B.S.,  Breakfast  and  Luncheon  17 

Baldwin,  Esther  V.,  B.S.,  and  Lakeman,  Mary  R.,  M.D.,  Successful  Living     39 
Barnard,  H.  E.,  White  House  Conference  on  Child  Health  and  Protection   191 
Beardsley,  Sarah  Morse,  Mental  Fitness    ......        8 

Beckler,  Edith,  S.B.,  Pneumococcus  Type  Determination  .    162 

Belding,  David  L.,  M.D.,  Laboratory  Supervision  of  Milk  .76 

Berry,  Gordon,  M.D.,  The  Physically  Handicapped  Child  .    236 

Bigelow,  George  H.,  M.D.,  Foreword  to  Lobar  Pneumonia  Number  .    131 

Book  Notes: 

Child  from  One  to  Six — His  Care  and  Training   .  .182 

Health  Protection  for  the  Preschool  Child — White   House   Confer- 
ence Report      .........    242 

Home  Guidance  for  Young  Children   .  .  .  .  .    122 

Permanent  Play  Materials  for  Young  Children    ....    243 

Prenatal   Care  .  .  .  .    123 

Principles  and  Practice  of  Hygiene    ......    182 

Year  Book  of  Obstetrics  and  Gynecology    ...  .    123 

Boris,  Anne  A.,  Giblin,  Marie  R.  and  Minsky,  Sadie,  Morbidity  Survey 

Among  Individuals  Receiving  Outdoor  Relief  in  Cambridge        .    174 
Breakfast  and  Luncheon,  by  Esther  V.  Baldwin,  B.S.  17 

Brew,  James  D.,  Future  Policies  in  Sanitary  Milk  Control   .  .80 

Budgets  for  Low  Incomes        .......  56 

Business  Woman,  What  is  a,  by  M.  Luise  Diez,  M.D.    ....        3 

Cambridge,  Morbidity  Survey  Among  Individuals  Receiving  Outdoor  Re- 
lief in,  by  Marie  R.  Giblin,  Anne  A.  Boris  and  Sadie  Minsky     .    174 
Camp  Sanitation,  by  Walter  E.  Merrill      ......      99 

Cancer,  American  Society  for  Control  of — Educational  Material    .  .181 

Care   of  the   Tissues    Supporting   the   Teeth,   by   William   Rice,    D.D.S., 

D.M.D 30 

Chamberlain,  Elsie  K.,  Achieving  a  Successful  Wardrobe    .  .37 

Chapman,  David  A.,   Smoke  Nuisance        .  .  .  .    106 

Child  Dependency,  Some  Highlights  on,  by  Cheney  C.  Jones  .    231 

Child  from  One  to  Six — His  Care  and  Training  .  .  .  .    182 

Child   Health — Some   Public   Health   Aspects,   by   Murray   P.    Horwood, 

Ph.D.  .  . ;    198 

Child  Health  Day,  1931  53 

Clark,  Harry  W.,  Industrial  Waste  Problems  .  .  .72 

Clark,  Harry  W.,  What  is  Pure  Water?    .......  .67 

Committee  on  Public  Health  Organization  of  the  White  House  Confer- 
ence on  Child  Health  and  Protection,  by  Charles  F.  Wilinsky, 

M.D .205 

Community   Health   Organization   in   Massachusetts,   by   W.   F.   Walker, 

Dr.  P.  H 108 

Conant,  Richard  K.,  Organizations  for  the  Handicapped  230 

Cummins,  Loretta  Joy,  M.D.,  Some  Facts  One  Should  Know  About  the 

Skin ...      33 

Diagnosis  of  Lobar  Pneumonia,  by  Frederick  T.  Lord,  M.D.  .134 

Diez,  M.  Luise,  M.D.,  What  is  a  Business  Woman?        ....        3 

Doctors  Talk  on  Nursing  ........      57 

Editorial  Comment: 

Child  Health  Day,  1931 53 

Summer  Round-Up  .  .  .  .53 

Then  and  Now  .........    122 

Tidings  ........  .53 

Education,   Pediatric,  Report  of  the   Subcommittee   on  Medical  Educa- 
tion, bv  Borden  S.  Veeder  .  .  .180 
Ells,  Margaret  C,  The  Health  of  the  School  Child                                         .    224 
Ely,  His  Excellency  Joseph  B.,  Message  on  the  White  House  Conference  189 
Emerson,  Haven,  M.D.,  What  Can  We  Expect  from  the  White   House 

Conference?  .  ....    193 

Epidemiology  of  Pneumonia,  by  M.  J.  Rosenau,  M.D.   .                                  .132 
Findings  of  the  Committee  on  Public  Health  Organization  of  the  White 
House  Conference  on  Child  Health  and  Protection,  by  Charles 
F.  Wilinsky,  M.D 205 


248  PAGE 

Food  and  Drugs,  Report  of  Division  of: 

October,  November  and  December,   1930    .  .  .  .61 

January,  February  and  March,  1931   ...  .  .    124 

April,  May  and  June,  1931  ....  .    183 

July,  August  and  September,   1931    .  .  ...    244 

Food  Establishments,  Sanitation  of,  by  Hermann  C.  Lythgoe  89 

Frandsen,    J.    H.,    Milk    Production — Regulations    Essential    and    Non- 
Essential  .........    214 

Future  Policies  in  Sanitary  Milk  Control,  by  James  D.  Brew  80 

Giblin,   Marie,   Boris,   Anne   A.,   and   Minsky,    Sadie,    Morbidity   Survey 

Among  Individuals  Receiving  Outdoor  Relief  in  Cambridge      .    174 
Gonorrhea  and  Syphilis,  The  Health  Officer  in  the  Control  of,  by  Nels 

A.  Nelson,  M.D.  ......    113 

Good  Posture  as  a  Business  Asset,  by  Marion  Shepard,  M.D.  .      29 

Governor's  Message  on  White  House  Conference        ....    189 

Handicapped,  The,  by  Alfred  F.  Whitman  ...    228 

Handicapped,  Mentally,  by  Samuel  W.  Hartwell,  M.D.  .    240 

Handicapped,  Organizations  for  the,  by  Richard  K.  Conant   .  .    230 

Handicapped  Child,  The  Physically,  by  Gordon  Berry,  M.D.   .  .    236 

Hartwell,  Samuel  W.,  M.D.,  Mentally  Handicapped  .    240 

Health,  Community,  Organization  in  Massachusetts,  by  W.  F.  Walker, 

Dr.  P.  H.  108 

Health  of  the  School  Child,  by  Ernest  Stephens  .....    219 
Health  of  the  School  Child,  by  Margaret  C.  Ells  .224 

Health  Officer  in  the   Control   of  Gonorrhea  and   Syphilis,   by  Nels  A. 

Nelson,   M.D 113 

Health  Protection  for  the  Preschool  Child — White  House  Conference  on 

Child  Health  and  Protection  Report    .  .242 

Health  Service,  Organizing  for  Better  ....      56 

Health  Work,  Red  Cross,  in  Massachusetts,  by  Harding  L.  White   .  .178 

Healthful  Lighting,  by  William  Firth  Wells 105 

Heffron,  Roderick,  M.D.,  The  Massachusetts  Pneumonia  Plan  .    172 

Hilliard,  Curtis  M.,  Public  Health  Service  and  Administration  .196 

Home  and  the  Child,  by  Louisa  P.   Skilton  .217 

Home   Guidance   for  Young   Children        ......    122 

Horwood,  Murray  P.,  Ph.D.,  Child  Health — Some  Public  Health  Aspects.  198 
Housekeepers  of  Industry,  by  Harold  W.  Stevens,  M.D.        ...        3 

Importance  of  Public  Water  Supply,  by  A.  D.  Weston  .  .69 

Industrial  Nursing  ...  .....      57 

Industrial  Waste  Problems,  by  Harry  W.  Clark  ...      72 

Industry,  Housekeepers  of,  by  Harold  W.  Stevens,  M.D.      ...        3 

Infant  Mortality  in  Massachusetts    .  .  .55 

International  Hospital  Association    .  .  .181 

Jones,  Cheney  C,  Some  Highlights  on  Child  Dependency    .  .    231 

Laboratory  Supervision  of  Milk,  by  David  L.  Belding,  M.D.  .76 

Lakeman,  Mary  R.,  M.D.  and  Baldwin,  Esther  V.,  B.S.,  Successful  Living     39 
Lakeman,  Mary  R.,  M.D.,  White  House  Conference  on  Child  Health  and 

Protection,    1930-1931 192 

Latimer,  Jean  V.,  M.A.,  Sleep  for  Health  and  Charm  .  .35 

Leisure,  Use  of,  by  Helen  I.  D.  McGillicuddy  .13 

Leisure  Time,  Recreation  and,  by  Zenos  E.  Scott        ....    226 
Lighting,  Healthful,  by  William  Firth  Wells  .105 

Living,  Successful,  by  Mary  R.  Lakeman,  M.D.,  and  Esther  V.  Baldwin, 

B.S 39 

Lobar  Pneumonia,  Diagnosis  of,  by  Frederick  T.  Lord,  M.D.  .134 

Lobar  Pneumonia,  Prophylaxis  and  Treatment  of,  by  Edwin  A.  Locke, 

M.D ...    141 

Lobar  Pneumonia,  Serum  Therapy  in  Type  I,  by  W.  D.  Sutliff,  M.D.        .    152 
Locke,  Edwin  A.,  M.D.,  The  Prophylaxis  and  Treatment  of  Lobar  Pneu- 
monia      ..........    141 

Lord,  Frederick  T.,  M.D.,  The  Diagnosis  of  Lobar  Pneumonia  .    134 

Luncheon,  Breakfast  and,  by  Esther  V.  Baldwin,   B.S.  .  .17 

Lythgoe,  Hermann  C,  Sanitation  of  Food  Establishments    .  89 

Massachusetts  Pneumonia  Plan,  by  Roderick  Heffron,   M.D.  .    172 

Mental  Fitness,  by  Sarah  Morse  Beardsley        .....        8 

Mentally  Handicapped,  by  Samuel  W.  Hartwell,  M.D.  .    240 

Merrill,  Walter  E.,  Camp  Sanitation  ...      99 

Merrill,  Walter  E.,  Sanitation  of  Wayside  Stands  96 

Message  from  the  Governor  on  the  White  House  Conference  on  Child 

Health  and  Protection      ........    189 


249 

Use  of  Leisure 


McGillicuddy,  Helen  I.  D.,  M.D. 

Milk,  by  Frank  E.  Mott . 

Milk,  Laboratory  Supervision  of,  by  David  L.  Belding,  M.D. 
Milk  Control,  Future  Policies  in  Sanitary,  by  James  D.  Brew 
Milk   Production — Regulations    Essential    and    Non-Essential,    by   J.    H. 
Frandsen  ......... 

Minsky,  Sadie,  Giblin,  Marie  R.,  and  Boris,  Anne  A.,  Morbidity  Survey 

Among  Individuals  Receiving  Outdoor  Relief  in  Cambridge 
Morbidity  Survey  Among  Individuals  Receiving  Outdoor  Relief  in  Cam- 
bridge, by  Marie  R.  Giblin,  Anne  A.  Boris  and  Sadie  Minsky   . 
Mothers'   Classes    .......... 

Mott,  Frank  E.,  Milk 

Nelson,  Nels  A.,  M.D.,  The  Health  Officer  in  the  Control  of  Gonorrhea 
and  Syphilis      ......... 

New   England   Council — Committee   on   Public   Health 
News  Notes: 

American  Society  for  Control  of  Cancer — Educational  Material    . 

Budgets  for  Low  Incomes 

Doctors  Talk  on  Nursing 

Industrial  Nursing 

Infant  Mortality  in  Massachusetts 

International  Hospital  Association 

Mothers'   Classes 

New  England  Council — Committee  on  Public  Health 

Organizing  for  Better  Health  Service      •    . 

Salmon,  Thomas  W.,  Memorial 
Nursing,  Industrial  ...... 

Nursing,  The  Doctors  Talk  On  .... 

Nursing  Care  of  the  Pneumonia  Patient,  by  Walborg  Peterson,  R.N. 
Organization,   Community  Health,  in  Massachusetts,  by  W.  F.  Walker, 

Dr.  P.  H 

Organizations  for  the  Handicapped,  by  Richard  K.  Conant  . 
Organizing  for  Better  Health  Service        ...... 

Pediatric  Education,  Report  of  the  Subcommittee  on  Medical  Education, 
by   Borden   S.    Veeder         ....... 

Permanent  Play  Materials  for  Young  Children,  by  Charlotte  G.  Garrison 
Peterson,  Walborg,  R.N.,  Nursing  Care  of  the  Pneumonia  Patient 
Physically  Fit  Every  Day  in  the  Month,  by  Florence  A.  Somers,  B.S.    . 
Physically  Handicapped  Child,  by  Gordon  Berry,  M.D. 
Pneumococcus  Type  Determination,  by  Edith  Beckler,  S.B. 
Pneumonia,  Epidemiology  of,  by  M.  J.  Rosenau,  M.D.   . 
Pneumonia,  Lobar,  Diagnosis  of,  by  Frederick  T.  Lord,  M.D. 
Pneumonia,  Lobar,  Prophylaxis  and  Treatment  of,  by  Edwin  A.  Locke, 

M.D 

Pneumonia,  Lobar,  Serum  Therapy  in  Type  I,  by  W.  D.  Sutliff,  M.D. 
Pneumonia,  The  Massachusetts  Plan,  by  Roderick  Heffron,  M.D.    . 
Pneumonia  Patient,  Nursing  Care  of,  by  Walborg  Peterson,  R.N.   . 
Porter,  Alma,  Recreation  ...  .... 

Posture,  Good,  as  a  Business  Asset,  by  Marion  Shepard,  M.D. 
Prenatal  Care         .......... 

Principles  and  Practice  of  Hygiene   ....... 

Prophylaxis  and  Treatment  of  Lobar  Pneumonia,  by  Edwin  A.  Locke, 

M.D 

Public  Health  Service  and  Administration,  by  Curtis  M.  Hilliard   . 
Recreation,  by  Alma  Porter    ........ 

Recreation  and  Leisure  Time,  by  Zenos  E.  Scott  .... 

Recreational  Resources  in  Massachusetts,  by  Eva  Whiting  White  . 
Red  Cross  Health  Work  in  Massachusetts,  by  Harding  L.  White  . 
Relation  of  Typhoid  Carriers  to  Food  Supply,  by  Gaylord  W.  Anderson, 

M.D 

Rice,  William,  D.D.S.,  D.M.D.,  Care  of  the  Tissues  Supporting  the  Teeth 

Rosenau,  M.J.,  M.D.,  The  Epidemiology  of  Pneumonia 

Salmon,  Thomas  W.,  Memorial  .  .  .,         . 

Sanitation  of  Food  Establishments,  by  Hermann  C.  Lythgoe 

Sanitation  of  Wayside  Stands,  by  Walter  E.  Merrill    .... 

School  Child,  Health  of  the,  by  Margaret  C.  Ells 

School  Child,  Health  of  the,  by  Ernest  Stephens  .... 

Scott,  Zenos  E.,  Recreation  and  Leisure  Time    ..... 

Serum,   Antipneumococcic,   by   Benjamin   White,   Ph.D. 


PAGE 
13 

208 
76 
80 

214 

174 

174 
180 
208 

113 

60 

181 
56 
57 
57 
55 

181 

180 
60 
56 
59 
57 
57 

168 

108 

230 

56 

180 
243 
168 
6 
236 
162 
132 
134 

141 
152 
172 
168 
8 
29 
123 
182 

141 
196 

10 
226 

15 
178 

93 

30 

132 

59 

89 

96 

224 

219 

226 

164 


250  PAGE 

Serum  Therapy  in  Type  I  Lobar  Pneumonia,  by  W.  D.  Sutliff,  M.D.  .    152 

Shepard,  Marion,  M.D.,  Good  Posture  as  a  Business  Asset   .  .  .29 

Skilton,  Louisa  P.,  The  Home  and  the  Child  .  .217 

Skin,  Some  Facts  One  Should  Know  About  the,  by  Loretta  Joy  Cummins, 

M.D 33 

Sleep  for  Health  and  Charm,  by  Jean  V.  Latimer,  M.A.  .  .35 

Smoke  Nuisance,  by  David  A.  Chapman    .  .106 

Some  Facts  One  Should  Know  About  the  Skin,  by  Loretta  Joy  Cummins, 

M.D 33 

Some  Highlights  on  Child  Dependency,  by  Cheney  C.  Jones  .  .231 

Somers,  Florence  A.,  B.S.,  Physically  Fit  Every  Day  in  the  Month  6 

Stephens,  Ernest,  Health  of  the  School  Child  .  .219 

Stern,  Frances,  A  Workshop  of  Life  .  ..'".'.  .20 

Successful  Living,  by  Mary  R.  Lakeman,  M.D.,  and  Esther  V.  Baldwin, 

B.S 39 

Summer  Round-Up  .  .  ...  .'■'..  .53 

Survey,  Morbidity,  Among  Individuals  Receiving  Outdoor  Relief  in  Cam- 
bridge, by  Marie  R.  Giblin,  Anne  A.  Boris  and  Sadie  Minsky   .    174 
Sutliff,  W.  D.,  M.D.,  Serum  Therapy  in  Type  I  Lobar  Pneumonia  .  .    152 

Syphilis,  The  Health  Officer  in  the  Control  of  Gonorrhea  and,  by  Nels  A. 

Nelson,   M.D.    .  .113 

Teeth,   Care   of  the   Tissues   Supporting  the,   by  William  Rice,   D.D.S., 

D.M.D 30 

Tidings 53 

Typhoid  Carriers,  Relation  of,  to  Food  Supply,  by  Gaylord  W.  Anderson, 

M.D.         ..." 93 

Use  of  Leisure,  by  Helen  I.  D.  McGillicuddy,  M.D 13 

Veeder,  Borden   S.,   Pediatric  Education,  Report  of  the   Subcommittee 

on  Medical  Education  .......    180 

Walker,  W.  F.,  Dr.  P.  H.,  The  Community  Health  Organization  in  Massa- 
chusetts ........    108 

Wardrobe,  Achieving  a  Successful,  by  Elsie  K.  Chamberlain  37 

Water,  What  is  Pure,  by  Harry  W.  Clark  .  .  .  .67 

Water  Supply,  Public,  Importance  of,  by  A.  D.  Weston        .  .  .69 

Wayside  Stands,  Sanitation  of,  by  Walter  E.  Merrill   .  .  .96 

Wells,  William  Firth,  Healthful  Lighting 105 

Weston,  A.  D.,  Importance  of  the  Public  Water  Supply  .69 

What  Can  We  Expect  From  the  White  House  Conference?   by  Haven 

Emerson,   M.D. 193 

What  is  a  Business  Woman?,  by  M.  Luise  Diez,  M.D.   ....        3 

What  is  Pure  Water?,  by  Harry  W.  Clark  .  .67 

White,  Benjamin,  Ph.D.,  Antipneumococcic  Serum        ....    164 

White,  Eva  Whiting,  Recreational  Resources  in  Massachusetts  .15 

White,  Eva  Whiting,  Youth  Outside  Home  and  School  .    227 

White,  Harding  L.,  Red  Cross  Health  Work  in  Massachusetts  .178 

White  House  Conference  on  Child  Health  and  Protection  (Special  Issue 

— see  page  188) 
White   House   Conference   on   Child   Health   and   Protection,   by   H.    E. 

Barnard  ..........    191 

White  House   Conference   on   Child   Health  and  Protection,   1930-1931, 

by  Mary  R.   Lakeman,  M.D.  .192 

White  House   Conference  on  Child  Health  and  Protection,  A  Message 

from  the  Governor  on  the  .  .189 

White    House    Conference    on    Child   Health   and    Protection — Pediatric 
Education — Report   of  the    Subcommittee    on   Medical   Educa- 
tion, by  Borden  S.  Veeder  .......    180 

White   House   Conference  on   Child  Health  and   Protection — What   Can 

We  Expect  from  the,  by  Haven  Emerson,  M.D.  .    193 

Whitman,  Alfred  F.,  The  Handicapped      ...  .  .    228 

Wilinsky,  Charles  F.,  M.D.,  Findings  of  the  Committee  on  Public  Health 
Organization  of  the  White  House  Conference  on  Child  Health 
and  Protection  ........    205 

Workshop  of  Life,  by  Frances  Stern  .  .  .  .  .  .20 

Year  Book  of  Obstetrics  and  Gynecology   ......    123 

Youth  Outside  Home  and  School,  by  Eva  Whiting  White  .    227 

Publication  op  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
5500.     l-'32.     Order   4300. 


WIELIlluRTWfca^«^ 


is  /   ~r        i    s 


ffATE  HO 


THE 
COMMONHEALTH 


Volume  19 
No.  1 


JAN.- FEB.- MAR.- 
1932 


Dental  Hygiene 


MASSACHUSETTS  : 
DEPARTMENT   OF  PUBLIC  HEALTH 


fAIEUIIMi   ;  ■»*  i  t 
FEB  16  1188 

THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  of 
Public  Health  ,  , 

Sent  Free  #&  an?/  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

Trends  in  the  Development  of  the  Dental  Program  of  the  Massachusetts 

Department  of  Public  Health,  by  George  H.  Bigelow,  M.D.  .  .       3 

Dental  Hygiene  as  Part  of  the  Well   Child  Conference,  by  Eleanor   G. 

McCarthy,   B.S.,   D.H 4 

Providing  Dental  Care  to  Maternity  Cases,  by  George  H.  Wandel,  D.D.S.       9 
Food  at  Low  Cost  for  Teeth,  by  Mary  Spalding,  B.S.,  M.A.   .  .  .10 

The  Importance  of  the  Baby  Teeth,  by  R.  C.  Willett,  D.M.D.   .  .12 

Prevention  of  Malocclusion,  by  Frank  A.  Delabarre,  A.B.,  D.D.S.,  M.D.   .     13 
Directions  for  Brushing  the  Teeth  Properly   .  .  .  .  .  .15 

Vincent's  Infection,  by  Francis  H.  Daley,  D.M.D.   .  .  .  .15 

Pyorrhea,  by  E.  Melville  Quinby,  M.R.C.S.,  L.R.C.P.,  D.M.D.   .  .  .17 

Dentistry  Must  Embark  on  Research,  by  Leroy  M.  S.  Miner,  D.M.D.,  M.D.     20 
Cancer  of  the  Mouth  —  How  to  Recognize  and  Prevent  it,  by  Charles  M. 

Proctor,    D.M.D 21 

Proposed  Dental  Program  for  the  Southern  Berkshire  Health  District,  by 

Frederick  S.  Leeder,  M.D.,  D.P.H 23 

Notes  from  the  White  House  Conference,  by  Eleanor  G.  McCarthy,  B.S., 

D.H 25 

The  Junior  League  Dental  Clinic,  by  Mrs.  Roswell  G.  Mace   .  .  .29 

A  Prenatal  and  Preschool  Dental  Program  from  a  Public  Health  Nursing 

Point  of  View,  by  Eva  A.  Waldron,  R.N 30 

Preschool  and  Prenatal  Dental  Clinic,  by  J.  Hal  T.  Maloney,  D.D.S.  .  31 

The  Preschool  Chijd  'at  the  Town  Dental  Clinic,  by  Helen  M.  Heffernan, 

R.N.  :    /."  :   ,  :•;>•■  J.     '      .  '[  '!'.  A  ':.•.■,    .  .  .  .32 

A  Red  Cross  Traveling  Dental  "Clinic,  by  "Nancy  A.  Trow       .  .  .34 

Building  Sound  Teeth,  by  May  E.  Foley 35 

The  Dental  Hygienist  in  the  Schools,  by  Osirene  E.  Rowell,  D.H.   .  36 

The  Teaching  of  .Oral  Hygiene  to  ^Newsboys,  by  Harry  Goldinger,  D.M.D.  .     38 
Institutional  Dentistry,  h,y  ^Rmahii'el  Kline,, D.M.B.-  . ;;  ..  .  .  .39 

Pits  and  Fissures  .  .  .  .  ...  .  .  .  .43 

Editorial  Comment         .  .  .  .  .  .  .  .  .  .44 

Mother's    Day 45 

Book  Notes: 

Body  Mechanics:    Education  and   Practice        .  .  .  .  .45 

Psychology  and  Psychiatry  in  Pediatrics:   The  Problem   .  .  .46 

Institute  for  Child  Guidance  Studies — Selected  Reprints   .  .  .46 

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


1931 


48 


TRENDS  IN  THE  DEVELOPMENT  OF  THE  DENTAL  PROGRAM 
OF  THE  MASSACHUSETTS  DEPARTMENT  OF  PUBLIC  HEALTH 

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

Massachusetts  was  the  first  State  to  include  dental  hygiene  in  its 
public  health  program.  Since  the  beginning  of  the  program  the  De- 
permanent  has  been  quick  to  change  its  policy  as  developments  in  the 
field  of  dental  thought  indicated  that  changes  were  needed. 

The  program  is  thirteen  years  old.  In  tracing  trends  in  the  develop- 
ment of  the  work  there  appear  to  be  five  rather  distinct  periods.  Study 
of  the  current  thought*  in  each  period  and  the  corresponding  changes 
in  the  Department's  dental  program  reveals  growth  in  several  direc- 
tions. 

1919-1922 

In  1919,  leaders  in  the  dental  profession,  feeling  that  mouth  health  is 
esseritial  to  general  health  and  that  children  should  visit  the  dentist 
regularly  and  clean  their  teeth  at  least  three  times  a  day,  volunteered  to 
organize  a  state-wide  program  for  the  Department 

Educational  material  was  prepared  and  consulting  service  offered. 
There  was  such  a  demand  for  this  service  that  it  was  soon  made  a 
permanent  part  of  the  Department's  child  hygiene  program.  The  main 
objective  of  the  program  during  this  period  was  to  stir  the  public  to 
some  realization  of  the  extent  of  dental  disease  among  children. 

1922-1926 

Health  officials  throughout  the  State  became  interested  in  this  new 
phase  of  child  health  work  and  soon  the  following  thoughts  appeared : 

//  children  are  too  poor  to  visit  the  dentist,  the  community  should  take 
care  of  them  through  dental  clinics.  The  neivly  created  dental  hygienist 
can  be  used  to  assist  at  the  dental  clinic,  give  prophylactic  treatment  to 
children  in  school  and  teach  them  hoiv  to  care  for  their  teeth. 

As  a  result  of  this  thinking  the  Department  helped  to  organize  dental 
clinics  for  needy  children  of  all  ages  throughout  the  State  and  offered 
advisory  service  to  dental  hygienists  employed  to  do  work  in  the  schools. 

1926-1928 

During  these  years  two  facts  commanding  attention  were,  (1)  that 
good  nutrition  is  a  fundamental  factor  in  the  prevention  of  dental  disease; 
(2)  that  practically  all  permanent  molars  erupt  ivith  defective  enamel. 
If  these  defects  could  be  filled  shortly  after  eruption  large  cavities,  tooth- 
aches, abscesses  and  extractions  would  be  prevented. 

As  a  result  of  (1),  the  Department  began  to  consider  ways  and 
means  of  developing  the  nutritional  side  of  the  State  and  the  local 
dental  programs;  as  a  result  of  (2),  a  definite  clinic  policy  of  opening 
dental  clinics  to  prenatal  and  preschool  cases  and  of  concentrating 
school  dental  clinic  work  on  the  lower  grades  (to  care  for  newly  erupted 
molars)  was  issued  by  the  Department. 

By  1928  the  majority  of  the  clinics  in  the  State  had  adopted  this  new 
policy.  New  educational  material  was  written  including  this  new 
knowledge.  The  "dental  certificate"  plan  used  with  success  in  Miss- 
issippi was  launched  in  Massachusetts  to  interest  the  "family  dentist 
child"  in  regular  dental  care  (heretofore  everyone  had  concentrated 
on  the  needy  child  only). 

1928-1931 

The  White  House  Conference  held  in  1930,  has  crystallized  much 
of  the  material  on  the  prevention  of  dental  disease  that  has  been  ac- 
cumulating for  several  years. 


*  Shown    in    italics 


4 
Typical    examples    of    current   thought    during    this    period    are    as 
follows. 

Good  development  of  the  teeth  and  resistance  to  dental  disease  may  be 
a  matter  of  general  nutrition. 

"Modern  research  has  produced  substantial  evidence  that  dental  caries 
depends  upon  a  general  metabolic  disturbance  based  on  faulty  nutrition." 
(White  House  Conference) 

The  first  step  in  preventive  dentistry  must  be  taken  by  the  medical 
profession. 

In  public  health  work  the  program  of  the  school  dentist  and  school  den- 
tal hygienist  must  be  supplemented  by  the  work  of  the  public  health  nurse 
who  has  contact  with  mothers,  infants  and  preschool  children. 
In  reviewing  the  Department's  present  program  we  find — 

That  the  number  of  school  dentists  and  school  dental  hygienists  now 
employed  by  communities  is  so  large  that  they  have  formed  a  separate 
organization. 

That  the  number  of  children  receiving  dental  certificates  from  clinics 
and  family  dentists  has  increased  from  25,000  in  1928  to  130,000  in  1931 
(the  largest  number  reported  by  any  State  in  the  country). 

That  the  number  of  dental  clinics  has  increased  until  we  have 
reached  second  place  in  the  country  (Pennsylvania  177,  Massachusetts 
158).* 

That  the  dental  certificate  plan  has  grown  from  a  yearly  campaign 
as  part  of  May  Day — Child  Health  Day  to  an  integral  part  of  the  yearly 
school  health  program. 

That  there  is  an  increased  awareness  of  the  relation  of  good  nutri- 
tion to  second  teeth  on  the  part  of  the  medical  and  dental  professions, 
health  officers,  public  health  nurses,  school  dental  workers  and  parents. 
That  dental  nutrition  is  emphasized  in  all  the  Department's  educa- 
tional material  and  in  lectures  given  to  professional  and  lay  groups. 

That  the  field  is  no  longer  dominated  by  the  school  child;  a  state- 
wide preschool  dental  program  is  in  the  making. 

That  the  importance  of  deciduous  teeth  as  well  as  newly  erupted  per- 
manent teeth  is  being  emphasized. 

That  communities  are  beginning  to  include  dentists  or  dental  hygien- 
ists on  their  Well  Child  Conferences  and  Summer  Round-Ups. 

That  preschool  children  are  eligible  to  school  dental  clinics  in  a 
number  of  towns. 

So  brief  a  review  hardly  justifies  a  discussion  of  future  develop- 
ments but  it  is  probably  safe  to  predict  that  in  the  dental  program  of 
the  future  the  work  of  dentists  and  dental  hygienists  will  be  closely 
correlated  with  the  work  of  health  officers  and  public  health  nurses, 
for  the  entire  responsibility  for  sound  teeth  in  mouths  free  from  dental 
disease  no  longer  rests  with  the  dental  profession  alone. 

DENTAL  HYGIENE  AS  PART  OF  THE  WELL  CHILD  CONFERENCE 

Eleanor  G.  McCarthy,  B.S.,  D.H., 

Consultant  in  Dental  Hygiene, 

Massachusetts  Department  of  Public  Health 

We  all  agree  that  dental  service  for  the  child  includes  more  than 
filling  the  four  six-year  molars  and  extracting  deciduous  molars  decay- 
ed beyond  repair.  Yet  that  is  all  that  most  of  our  dental  clinics  caring 
for  the  first  three  grades,  can  accomplish. 

It  has  been  murmured,  and  with  increasing  crescendo  in  recent  years, 
that  we  "must  reach  the  preschool  child."  In  1925  we  began  to  see 
that  it  was  absurd  to  allow  children  of  all  ages  to  enter  the  dental 
clinic  when  most  of  the  decay  in  the  permanent  molars  spreads  from 


"Study  of  Dental  Clinics  in   the  United   States,   1930."   American   Dental   Association 


5 

developmental  defects  in  the  enamel  and  can  be  checked  if  the  teeth 
are  treated  soon  after  eruption.  A  lively  campaign  for  the  early  treat- 
ment of  the  famous  "six-year  molar"  was  launched  and  in  two  years' 
time  the  majority  of  the  clinics  in  the  State  were  concentrating  on 
the  first  three  grades.  As  a  result,  the  permanent  molars  were  filled 
rather  than  extracted  and  more  children  received  care,  for  obviously, 
the  smaller  the  fillings  the  less  time  required  to  care  for  each  child. 

As  Dr.  E.  F.  Mackey  of  Arlington  pointed  out  recently,*  if  a  child 
first  comes  to  the  clinic  at  five,  six  or  seven  years  of  age  with  all  eight 
deciduous  molars  decayed  beyond  repair  and  needing  extraction,  it 
does  relatively  little  good  to  care  for  the  four  permanent  molars  that 
are  erupting.  They  will  drift  forward,  and  while  it  is  splendid  to  save 
six  year  molars,  per  se,  very  little  has  been  accomplished  from  the 
point  of  view  of  good  occlusion  and  a  "smooth-working  dental  machine" 
for  the  child  later  on.  Approximately  one-half  of  the  patients  in  the 
Arlington  clinic  enter  in  the  preschool  years.**  In  this  way,  deciduous 
molars  have  been  saved  and  the  number  of  extractions  in  the  lower 
grades  reduced  to  a  minimum.  Because  of  this  plan  the  total  number 
of  operations  done  at  the  clinic  steadily  increases  each  year. 

The  school  dental  clinic  (like  the  family  dentist)  can  give  much 
better  care  to  children  if  they  can  be  seen  first  at  three  years  rather 
than  at  six  years. 

What  are  the  various  ways  in  which  this  most  needed  change  in 
community  dental  programs  can  be  brought  about? 

We  assume  that  the  school  dental  clinician  realizes  the  importance 
of  the  preschool  patient  and  will  plan  time  for  him  if  he  can  be  reached 
and  brought  to  the  clinic.  At  this  point  the  dental  program  merges 
with  the  community  preschool  program  and  the  community  public 
health  nursing  program.  The  school  dentist  and  school  dental  hygien- 
ist  have  no  way  of  developing  this  phase  of  the  work  alone  for  they 
have  no  contact  with  the  home.  Community  nurses — in  some  cases  the 
public  health  nurse  carrying  on  a  generalized  program  including  pre- 
school children,  in  other  cases  the  visiting  nurse  or  board  of  health 
nurse— can  watch  for  children  three  and  four  years  of  age  when  mak- 
ing home  visits.  Looking  at  baby  teeth  and  urging  an  early  trip  to  the 
dentist  even  though  the  children's  teeth  look  perfectly  all  right,  or 
when  they  show  just  the  tiniest  spots  of  decay,  is  a  routine  part  of  the 
public  health  nurse's  preschool  visit. 

If  the  nurse  knows  that  the  clinic  dentist  is  anxious  to  start  his 
patients  long  before  they  get  to  school,  she  can  make  arrangements 
for  little  children  in  poor  families  to  go  to  the  clinic.  If  the  clinic 
staff  feels  that  "they  are  too  busy  to  care  for  preschool  children,"  the 
interested  nurse  may  be  able  to  find  some  other  way  of  getting  the 
children  cared  for.  In  Springfield  and  Worcester,  for  instance,  the 
Junior  League  has  established  dental  clinics  for  preschool  children  to 
fill  the  demand  created  by  the  visiting  nurses. 

There  is  one  difficulty  with  the  referring  of  preschool  children  to 
the  clinic  by  the  nurses.  It  is  the  same  difficulty  that  we  have  in  the 
school  program  where  there  is  no  dental  examination.  The  nurse  has 
had  very  little,  if  any,  training  in  diagnosing  mouth  conditions  and  she 
is  apt  to  choose  children  with  the  worst  looking  mouths  for  clinic  care. 
In  the  case  of  the  school  child,  it  means  that  the  cases  of  defective 
enamel  and  beginning  caries  that  can  be  detected  only  by  a  trained 
eye  and  an  explorer  go  by  unnoticed.  In  the  case  of  the  preschool 
child,  all  too  often  the  four  or  five-year-old  with  cavities  so  large  they 
are  impossible  to' fill  is  brought  to  the  clinic  rather  than  the  little  child 


*  At  the  mid-winter  meeting  of  the  Massachusetts  Association  of  School  Dental  Workers 
**  Many   other    communities    are   working    on    this    plan.     The    returns    from    the    school    dental 
hygiene    questionnaire    which    included    the    question,    "Are    preschool    children    treated    at    the 
clinic?"     showed  that  17  communities  are  caring  for  preschool  children  at  their  regular  school 
clinic  and  that  10  communities  are  conducting  special  clinics  for  preschool  children. 


6 
whose  teeth  "seem  to  be  all  right."  To  help  the  nurses  in  their  home 
follow-up,  to  relieve  them  of  diagnosis,  which  is  not  a  part  of  their 
program  and  to  relieve  the  school  physician  of  the  responsibility  of 
trying  to  see  the  tiny  defects  without  the  proper  instruments,  the  Depart- 
ment has  made  it  a  definite  State  Policy  that  every  community  plan  to 
have  "a  dentist  or  dental  hygienist  supplement  the  examination  of  the 
school  physician." 

In  the  same  way,  in  thinking  of  the  preschool  child,  as  soon  as  possi- 
ble, each  community  should  plan  to  have  a  dental  examination  at  any 
gathering  of  preschool  children,  to  help  the  physician  and  nurse  to 
know  just  which  children  present  the  best  opportunity  for  preventive 
dental  care. 

At  this  point,  again  the  community  dental  program  must  wait  for 
the  development  of  the  whole  child  health  program  of  which  it  is  only 
a  part.  In  other  words,  if  there  is  no  gathering  of  preschool  children 
there  can  hardly  be  a  dental  examination.  In  that  case  the  dental 
workers,  if  there  are  any,  should  help  in  any  way  they  can  to  establish 
a  well  child  conference  for  preschool  children  if  physicians  and  nurses 
in  that  community  feel  that  such  a  conference  is  needed.  The  well 
child  conference  of  today  was  the  baby  clinic  of  yesterday.  Child 
health  workers  are  no  longer  interested  in  the  small  babies  only,  but 
are  anxious  to  continue  their  education  program  of  supervision  of 
these  babies  until  they  are  ready  to  go  to  school  and  receive  the  protec- 
tion of  the  school  health  service.  In  communities  which  have  just 
established  a  summer  round-up  conference,  this  conference  should 
grow  downward  into  a  real  well  child  conference,  and  a  dental  exam- 
ination, as  well  as  a  physical  examination,  should  be  given  to  the 
children. 

The  largest  group  of  defects  found  at  these  summer  round-up  con- 
ferences is  defects  of  the  teeth.  However,  it  is  usually  too  late  to 
correct  these  defects.  A  summer  round-up  dental  examination  may 
result  in  finding  some  teeth  that  can  still  be  filled,  now  and  then  an 
early  erupted  permanent  molar,  a  few  or  many  (depending  on  the  nutri- 
tional condition  of  the  group)  abscessed  teeth  that  can  be  removed 
before  the  opening  of  school.  This  is  better  than  nothing,  just  as  our 
first  school  dental  clinics  although  they  struggled  with  the  worst  mouths 
through  all  the  grades  were,  oh,  so  much  better  than  nothing!  The 
clinic  gave  relief  from  pain  and  prevented  systemic  infection,  yes,  but 
gave  very  little  service  that  could  be  called  preventive  dental  care. 
The  same  is  true  with  the  preschool  child — have  a  dentist  or  dental 
hygienist  at  the  summer  round-up  conference  by  all  means,  but  extend 
the  conference  to  the  younger  children  as  soon  as  possible  so  that  the 
dental  examiner  can  find  the  beginning  of  trouble  and  refer  the  child 
either  to  his  own  dentist  or  to  the  community  dental  clinic. 

To  emphasize  the  difference  between  the  well  child  conference  for 
all  preschool  children  and  the  summer  round-up  conference  for  only 
those  about  to  enter  school  in  terms  of  the  possibility  for  prevention, 
let  me  cite  the  mouth  conditions  found  in  two  communities  where  the 
Department  demonstrated  a  well  child  conference  and  a  summer  round- 
up conference. 

Well  Child  Summer  Round-up 

Conference  Conference 

Percentage  of  children  examined  with        56%  1% 

apparently  no  caries 
Percentage  of  children  examined  with        31%  48% 

slight  caries   (several  small 

cavities  that  could  be  filled) 
Percentage  of  children  examined  with         10%  51% 

extensive  caries  (most  of  the 

decayed  teeth  beyond  repair) 


7 

The  well  child  conference  reaches  children  between  the  ages  of  two 
and  four  before  decay  has  begun  or  before  it  has  destroyed  the  teeth 
to  the  extent  that  they  are  beyond  repair.  It  is,  therefore,  the  logical 
starting  point  for  a  community  dental  service  that  is  really  preventive. 

If  a  large  town  or  city  has  organized  a  monthly  well  child  conference, 
arrangements  should  be  made  for  a  dental  examination  at  least  once 
or  twice  a  year. 

The  following  list  of  illustrative  material  used  at  the  Department 
demonstration  conferences  may  help  nurses  in  preparing  for  conference 
work,  or  dentists  and  dental  hygienists  who  are  starting  this  work 
for  the  first  time. 

X-ray  pictures  showing  teeth  developing  in  the  jaws. 
Two  charts,  10c  each. 
U.  S.  Government  Printing  Office, 
Washington,  D.  C. 

"Prevent  Facial  Deformities"   (booklet). 

Sample  may  be  obtained  from  the  Department  of  Health, 
Jackson,  Mississippi. 

Three  diagrams  showing  the  inside  of  a  six-year  molar  and  the 
way  decay  progresses  from  fissure  defects  in  the  enamel. 

Dr.  C.  F.  Bodecker, 

Columbia  University, 

630  West  165th  Street, 

New  York,  New  York 

Booklet  showing  children  with  good  and  bad  teeth  and  their  diet 
history. 

Miss  Ruth  White, 

Forsyth  Dental  Infirmary, 

Boston,  Massachusetts 

Price  —  20c 

Plaster  models — 

Normal  development  at  age  of  3  yrs. 
Normal  development  at  age  of  5  yrs. 

Results  of  neglect  of  baby  teeth 
(showing  malocclusion  at  age  of  9  yrs.) 

(Can  be  secured  from  a  local  dentist) 

Material  to  be  Given  to  Mothers 

1.  Diet  sheets  (series  of  five,  from  the  prospective  mother  to  the 
adolescent  child)* 

2.  Dental  leaflets: — 

Eating  for  Teeth 

Caring  for  Teeth 

First  Teeth 

Your  Teeth 

Teaching  the  Child  to  Brush  his  Teeth* 

3.  Forsyth  Dental  Infirmary  has  good  nutritional  material  that  can 
be  purchased  at  low  cost. 

4.  The  New  England  Dairy  and  Food  Council  has  a  new  series  of 
leaflets  telling  the  effect  of  vitamins  on  teeth. 


*  Available   from   Massachusetts   Department   of   Public   Health. 


A  sample  of  the  record  form  for  preschool  dental  examination  on 
well  child  conferences,  drawn  up  by  the  Dental  Advisory  Committee, 
will  be  sent  to  anyone  who  is  interested  in  starting  this  part  of  a  well 
child  conference  or  in  improving  an  already  established  one.  (Address, 
Massachusetts  Department  of  Public  Health,  State  House,  Boston, 
Massachusetts). 

The  dental  examiner  chosen  for  this  work  should  be  interested  in 
the  detection  of  incipient  dental  caries  and  habits  that  may  result  in 
malocclusion.  He  should  be  equally  interested  in  explaining  to  the 
mothers  what  these  conditions  mean.  If  the  examination  is  made 
without  any  attempt  to  use  the  conditions  found  as  teaching  points  in 
educating  the  mothers,  it  loses  most  of  its  real  value. 

I  will  list  some  of  the  topics  that  come  up  for  discussion  at  a  typical 
well  child  conference  to  suggest  what  a  splendid  opportunity  it  offers 
for  teaching  preventive  dentistry: 

Why  small  cavities  should  be  filled  as  soon  as  they  are  found. 

How  decay  progresses  from  fissures  in  the  enamel. 

How  the  pulp  dies  and  an  abscess  forms  if  decay  is  not  stopped. 

Why  some  children's  teeth  decay  and  become  abscessed  more  quick- 
ly than  others  (low  resistance  due  to  poor  nutrition). 

Why  baby  teeth  should  be  filled  as  carefully  as  second  teeth. 

Why  children  should  visit  the  dentist  regularly  as  soon  as  the 
first  teeth  have  all  erupted. 

What  kind  of  a  toothbrush  to  buy  for  a  small  child. 

How  to  teach  a  small  child  to  brush  his  teeth. 

How  to  keep  a  toothbrush  clean. 

Effect  of  certain  habits  on  the  growth  of  the  jaw. 

How  teeth  are  nourished. 

What  foods  build  the  teeth  and  increase  their  resistance  against 
dental  decay. 

Why  abscessed  baby  teeth   are   a  menace  to  the   child's  general 
health. 

A  dental  examination  on  the  well  child  conference  serves  in  the 
following  ways : — 

1.  It  is  a  means  of  discovering  preschool  patients  for  the  commu- 
nity dental  clinic. 

2.  It  is  a  means  of  finding  mouth  conditions  that  parents  know 
nothing  of,  and  of  interesting  them  in  taking  their  children  to 
the  family  dentist. 

3.  It  is  a  means  of  giving  the  nurse  definite  information  as  to 
which  families  need  follow-up  on  the  correction  of  dental 
defects. 

4.  It  is  a  way  of  finding  out  which  families  need  help  on  the 
planning  of  their  diet  (using  condition  of  mouths  as  a  symptom 


9 

of  disturbed  mineral  metabolism  and,  in  most  cases,  a  faulty 
diet). 
5.  If  the  nurse  is  able  to  spend  some  time  with  the  dentist  who  is 
examining,  it  is  a  means  of  teaching  her  some  of  the  common 
symptoms  of  dental  disease,  thus  making  her  equipped  to  do 
preschool  work  in  the  home. 

1  make  a  plea,  therefore,  to — 

Health  officers  and  leaders  of  organizations  interested  in  pre- 
school children  to  plan  for  dental  examinations  as  well  as  physical 
examinations  at  all  well  child  conferences. 

School  dentists  and  school  dental  hygienists  to  stand  in  read- 
iness to  find  some  way  of  admitting  preschool  children  found  at 
these  well  child  conferences  to  the  school  clinic. 

Family  dentists  to  welcome  these  little  children  sent  from  the 
well  child  conference,  give  them  what  care  they  can  and  encourage 
the  mothers  to  continue  bringing  them  in  for  regular  examination. 

All  dentists  and  dental  hygienists  to  stimulate  interest  in  having 
a  dental  examination  at  all  well  child  conferences  and  to  serve 
in  this  capacity  if  given  the  opportunity. 

The  Department  will  be  glad  to  help  individual  communities  plan 
the  best  way  to  develop  this  phase  of  well  child  conference  work. 

PROVIDING  DENTAL  CARE  TO  MATERNITY  CASES* 

George  H.  Wandel,  D.  D.  S. 

Supervisor,  Bureau  of  Dental  Health  Education 

American  Dental  Association. 

The  problem  of  providing  dental  care  to  maternity  cases  is  one  which 
has  been  most  neglected  in  dental  practice.  We  have  our  various  den- 
tal specialties  along  with  the  general  practice  of  dentistry,  but  none  of 
them  really  touches  the  problem  to  any  great  degree.  There  are  a 
number  of  reasons  for  this.  First  of  all,  there  is  a  failure  on  the  part 
of  the  medical  and  dental  profession  to  cooperate.  The  responsibility 
on  this  score  probably  rests  more  heavily  upon  the  shoulders  of  the 
physician  than  upon  the  dentist.  The  physician  is  much  more  apt  to 
come  in  contact  with  the  expectant  mother  than  is  the  dentist,  but  in  a 
large  majority  of  cases,  with  the  possible  exception  of  the  obstetrician,, 
physicians  are  not  instructing  the  pregnant  woman  to  obtain  early 
and  thorough  dental  attention. 

Neither  are  they  giving  women  careful  instruction  in  the  matter  of 
personal  hygiene  of  the  mouth.  On  the  other  hand,  the  dentist,  in 
many  instances,  is  not  giving  the  type  of  care  and  instruction  to  the 
pregnant  woman  that  should  be  given  to  her.  These  discrepancies  are 
largely  due  to  a  failure  of  the  two  professions  to  get  together  on  this 
problem  and  work  out  a  suitable  program  of  instruction  in  oral  hygiene 
for  the  expectant  mother. 

Next,  there  is  the  problem  of  general  lack  of  endeavor  on  the  part  of 
the  public  to  obtain  dental  attention.  It  has  been  variously  estimated 
that  only  between  20  and  25  per  cent  of  the  total  population  obtain 
dental  attention  to  any  degree.  When  it  is  realized  that  this  involves 
all  classes,  and  that  the  pregnant  woman  figures  only  in  this  percent- 
age, it  is  easy  to  see  another  reason  for  this  lack  of  dental  care.  The 
public  is  not  educated  to  the  point  where  it  is  generally  recognized  that 
dental  care  is  an  essential  to  physical  well-being.  In  this  connection, 
there  is  the  widely  prevalent  idea  that  it  is  not  safe  to  give  dental  at- 
tention to  a  pregnant  woman.    This  foolish  idea  exists  not  only  in  the 


*  Presented  through  the  courtesy  of  the  White  House  Conference  on  Child  Health  and  Protection 


10 

minds  of  many  of  the  laity,  but  in  the  minds  of  many  physicians  and 
dentists  as  well.  It  should  be  immediately  dispelled.  Obstetricians 
advise  us  that  there  is  much  greater  danger  to  the  mother  and  fetus 
in  failing  to  provide  dental  attention  than  there  is  in  giving  it. 

We  are  also  advised  that  most  dental  operations  may  be  performed 
with  safety,  that  it  is  better  to  perform  extractions  with  local  or  con- 
duction anesthesia  than  with  prolonged  anesthesia,  and  that  it  is  better 
not  to  submit  the  expectant  mother  to  long  and  fatiguing  sittings. 

Still  another  and  very  important  problem  is  the  great  lack  of  dental 
service  either  of  the  consultant  or  operative  nature  in  hospitals,  clinics, 
and  various  other  health  centers.  Every  effort  should  be  made  to  cor- 
rect this  deficiency.  Too  often  is  dentistry  left  out  of  the  picture  in 
the  organization  of  community  and  state  health  programs,  not  intention- 
ally, but  frequently  because  of  failure  to  think  of  it  and  to  provide  the 
necessary  finances.  In  this  field  there  is  a  wonderful  opportunity  for 
training  a  larger  and  larger  number  of  dentists  in  the  knowledge  of  the 
dental  problems  of  pregnancy.  Such  a  tie-up  would  greatly  improve  the 
service  rendered  by  the  above-mentioned  organizations,  would  improve 
the  knowledge  of  the  dental  and  medical  profession,  and  above  all, 
greatly  benefit  the  thousands  of  expectant  mothers  throughout  the 
country. 

While  there  is  not  a  great  amount  of  printed  information  on  the  sub- 
ject of  the  part  played  by  various  foci  of  infection,  especially  those  of 
an  oral  nature,  there  exists  quite  a  general  impression  that  foci  of 
infection  do  play  a  role  in  many  cases.  Certainly  there  is  enough  evi- 
dence at  hand,  both  clinical  and  otherwise,  to  substantiate  the  claim  that 
all  foci  of  infection  may  be  looked  upon  as  possible  contributing  fac- 
tors in  maternal  morbidity.  Being  one  of  the  most  frequently  present, 
dental  foci  of  infection  are  receiving  more  and  more  consideration. 
Abscessed  teeth,  pieces  of  roots,  teeth  with  the  pulp  removed,  teeth  with 
large  restorations,  and  so-called  pyorrhea  are  all  conditions  that  come 
under  the  shadow  of  suspicion  at  this  time. 

On  the  strength  of  availabe  information,  my  committee  has  seen  fit 
to  recommend  that  dentists  and  physicians  pay  strict  heed  to  the  ne- 
cessity for  preventing  and  eliminating  foci  of  infections  in  the  mouths 
of  expectant  mothers.  Realizing  the  influences  exerted  by  such  condi- 
tions upon  the  health  of  the  average  individual  of  either  sex,  it  is  not 
difficult  to  understand  the  need  for  such  attention  in  the  case  of  the 
expectant  mother.  Much  good  may  be  accomplished  through  the  opera- 
tive arrest  and  correction  of  these  dental  conditions  which  appear  to  be 
exerting  a  negative  influence  upon  the  mother  and  child ;  yet  the  great- 
est good  is  going  to  be  accomplished  through  their  prevention. 

It  is  recognized  that  those  dental  conditions  which  may  contribute 
to  an  upset  in  the  well-being  of  the  mother  and  the  child  are  largely 
preventable  if  taken  in  time.  We  do  not  mean  to  say  that  we  have 
found  the  right  remedies  for  the  complete  prevention  of  dental  caries 
and  pyorrhea,  but  we  do  have  the  means  at  hand,  through  early  and 
regular  dental  attention,  through  proper  regulation  of  the  diet,  and 
through  strict  personal  adherence  to  the  accepted  rules  of  oral  hygiene 
to  prevent  the  extensive  cavities  of  dental  caries  and  gum  irritations 
which  may  eventually  result  in  foci  of  infection. 

FOOD  AT  LOW  COST  FOR  TEETH 

Mary  Spalding,  B.S.,  M.A. 

Consultant  in  Nutrition 

Massachusetts  Department  of  Public  Health 

This  year  the  nutritionists  have  been  asked  not  only  about  foods 
which  will  help  nourish  but  also  about  foods  which  will  nourish  at  the 
least  cost.     No  doubt  dentists  are  being  asked  for  this  same  informa- 


11 

tion  in  regard  to  teeth,  so,  it  might  be  of  interest  to  them  to  know 
what  nutritionists  are  suggesting. 

Boyd,  Drain,  Nelson,  Bunting,  Hadley,  Jay,  Hard  and  Hanke  are  all 
advocating  a  quart  of  milk  for  tooth  building  on  account  of  its  calcium 
and  phosphorus  balance  and  Vitamin  A  content.  Sherman  and  Hawley 
proved  that  children  utilized  the  calcium  of  milk  to  better  advantage 
than  the  calcium  of  vegetables.  Milk,  then,  seems  necessary,  so  we 
are  recommending  that  families  use  the  cheapest,  safe  milk  in  the 
community,  either  the  fresh  milk  or  the  tall  cans  of  evaporated  milk 
which  contain  the  equivalent  of  one  quart  and  may  be  bought  at  sale 
prices.  We  are  advising  the  use  of  one  pint  to  one  quart  with  even 
the  very  low  cost  diet  for  both  children  and  adults,  especially  for  the 
pregnant  and  nursing  mothers. 

As  a  base-forming  diet  favors  the  retention  of  calcium  and  phos- 
phorus, we  are  encouraging  the  use  of  the  cheaper  types  of  vegetables 
and  fruits  which  have  fortunately  been  most  plentiful  this  year, 
especially  spinach,  cabbage,  string  beans  and  kale. 

The  next  question  is  the  cheapest  way  to  get  the  one-half  pint  to 
one  pint  of  orange  juice  which  the  dentists  have  found  keeps  the  pulp, 
the  periodontal  and  the  gingival  tissue  in  healthy  condition.  The 
fruit  growers  tell  us  that  the  small  sized  oranges  give  the  most  juice 
for  the  money.  Florida  fruit  growers  say  that  sizes  216,  250  and  288 
to  a  box  are  most  plentiful  this  year  and  so  the  cheapest.  California 
fruit  growers  tell  us  the  same  about  sizes  200,  216  and  252  to  a  box. 

If  juice  from  these  inexpensive  oranges  proves  too  expensive  for 
the  family  pocketbook,  we  are  advising  an  equal  amount  of  the  canned 
tomatoes  put  through  the  colander.  To  furnish  enough  Vitamin  C  on 
the  low  cost  diet,  we  are  also  suggesting  chopped,  raw  spinach  for 
sandwich  fillings  in  the  children's  lunch  boxes,  and  attractive  ways  for 
making  raw  cabbage  salads  in  the  home.  If  the  Massachusetts  child 
has  the  apple  as  his  only  fruit,  we  are  teaching  him  to  eat  the  skin,  as 
most  of  the  Vitamin  C  in  the  apple  lies  just  below  it. 

The  Mellanbys  found  the  children  in  Great  Britain  to  be  very  defi- 
cient in  Vitamin  D  and  only  produced  healthy  body  tissue  when  this 
vitamin  was  added.  Great  retardation  of  caries  was  shown  in  groups 
of  children  receiving  cod  liver  oil  and  Vitamin  D.  As  the  egg  yolk  is 
one  of  our  best  sources  of  Vitamin  D,  the  American  dentists  and  nutri- 
tionists are  suggesting  one  egg  a  day,  but  unfortunately  this  is  apt  to 
be  expensive  sometimes,  especially  in  the  winter.  Sunshine  in  Mass- 
achusetts in  the  winter  months  is  not  sufficient  to  ward  off  rickets. 
Therefore,  we  are  urging  expectant  mothers  and  small  children  even 
on  the  city  budget  to  use  cod  liver  oil  for  its  Vitamin  D  as  well  as  its 
Vitamin  A  content. 

Lucy  Gillett  who  has  been  feeding  families  on  low  cost  diets  for 
many  years  in  New  York  City  suggests  we  may  well  revive  the  old  slogan, 
"Food  will  save  the  war!"  We  hope  that  the  use  of  inexpensive  foods 
containing  phosphorus,  calcium,  vitamins  A,  C,  and  D  will  help  save 
the  teeth  during  this  period. 

References : 

The  Role  of  the  Diet  in  the  Cause,  Prevention  and  Cure  of  Dental 
Diseases — Milton  Theo.  Hanke.  Journal  of  Nutrition,  Vol.  Ill, 
No.  4,  January  1931,  p.  446. 

Calcium  and  Phosphorus  Metabolism  in  Childhood.  Journal  of  Biolog- 
ical Chemistry,  Vol.  53,   (1922)  p.  375. 

The  Influence  of  Diet  on  Caries  in  Children's  Teeth.  By  the  Com- 
mittee on  Dental  Disease.  Medical  Research  Council.  London — 
1931. 


12 
THE  IMPORTANCE  OF  THE  BABY  TEETH 

R.    C.   WlLLETT,   D.   M.    D. 

Peoria,  Illinois 

Under  normal  conditions  of  life  an  infant's  weight  should  double 
from  birth  to  six  months,  and  by  the  end  of  the  first  year  should  have 
increased  200  per  cent.  During  the  second  year  there  should  be  further 
increase  of  30  per  cent  in  weight.  In  no  other  period  is  the  growth 
so  rapid,  and  it  is  during  these  first  two  years  of  life  that  the  baby 
teeth  erupt. 

The  technical  name  for  these  teeth  is  "deciduous,"  its  Latin  origin 
implying  that  they  are  shed  at  a  certain  time,  usually  in  the  order  in 
which  they  erupt,  and  they  are  replacd  in  the  same  order  by  the  per- 
manent teeth. 

Individual  normal  characteristics  govern  the  time  of  eruption  of  the 
baby  teeth.  They  may  erupt  early  or  late.  An  early  age  for  the  appear- 
ance of  the  lower  central  incisor  teeth  would  be  the  age  of  four  months, 
and  a  late  age  would  be  from  the  eighth  to  tenth  month.  Once  the  baby 
teeth  have  started  to  erupt,  there  should  be  no  long  period  between 
their  consecutive  eruptions  by  twos  and  fours  until  the  process  of  first 
dentition  is  complete.  At  the  age  of  two  and  a  half  years,  if  not  earlier, 
the  well  nourished  child  should  stand  equipped  with  a  full  set  of  twenty 
cutters  and  grinders. 

At  birth  the  infant's  face  and  neck  are  small  in  comparison  with 
that  part  of  the  head  that  incases  the  brain  because  the  brain  is  at 
that  time  one  fifth  of  its  destined  weight.  Growth  of  the  face  and 
neck  begins  with  the  eruption  of  the  teeth,  and  it  is  through  their 
proper  functioning  that  growth  of  other  parts  of  the  head  is  influenced, 
certain  dimensions  of  the  head,  under  normal  conditions,  attaining 
adult  proportions  by  the  time  the  child  reaches  its  seventh  year. 

Too  much  emphasis  cannot  be  placed  upon  the  fact  that  it  is  during 
the  period  of  eruption  of  the  baby  teeth  and  in  early  childhood  that  an 
enduring  foundation  of  future  mental  and  physical  health  should  be 
established,  and  that  the  care  of  the  first  teeth — the  baby  teeth — is 
an  important  factor  of  the  work.    WHY? 

1.  Because  the  use  of  sound  baby  teeth  guarantees  a  better  prepara- 
tion, and  therefore  a  better  assimilation  of  food  for  nutrition.  The 
child,  in  proportion  to  its  weight,  must  eat  and  assimilate  about  three 
times  as  much  food  as  an  adult. 

2.  Because,  through  the  use  of  baby  teeth,  the  muscles  of  mastication 
are  developed  evenly,  and  the  normal  growth  of  the  jaws,  and  all  as- 
sociated parts  of  the  head,  is  directly  promoted. 

3.  Because  this  stimulated  growth  of  the  jaws,  through  use  Of  the 
baby  teeth,  is  favorably  reflected  in  the  size  of  important  air  passages 
leading  from  the  nose  and  throat,  and  these  passages  serve  directly  or 
indirectly  in  the  proper  aeration  of  the  blood. 

4.  Because,  if  the  baby  teeth  are  in  full  and  unimpaired  use,  the  per- 
manent teeth  will  erupt  in  more  regular  and  correct  position. 

5.  Because  unimpaired  baby  teeth  are  a  mental  and  physical  comfort 
to  the  child  and  promote  his  happiness  and  general  good  disposition. 

Recent  advances  made  in  medical  and  dental  science  prove  beyond 
any  doubt  that  there  is  a  close  relation  of  systemic  disease  common  to 
childhood  and  decay  of  the  deciduous  (baby)  teeth.  The  maintenance 
of  the  healthful  condition  of  a  child's  mouth  should  always  be  a  matter 
of  first  consideration. 

Advanced  medical  thought  acknowledges  the  fact  that  "it  is  impossi- 
ble to  practice  modern   scientific  medicine   without  the   cooperation   of 


13 

the  dentist.  In  many  cases  the  dental  treatment  is  of  more  importance 
than  the  medical."1 

In  the  cases  of  even  very  young  children,  recoveries  from  systemic 
conditions,  especially  from  those  having  to  do  with  the  circulatory  and 
nervous  systems,  frequently  follow  the  clearing  up  of  dental  infections 
that  are  the  direct  result  of  early  decay  of  the  baby  teeth.  The  only 
difference  to  be  observed  in  a  child's  reaction  to  dental  focal  infection 
from  that  of  an  adult's  is  that  the  child  is  more  susceptible  to  resultant 
generalized  infection,  and  suffers  more  acutely,  although  his  recovery 
is  more  rapid  after  the  cause  has  been  removed. 

The  onset  of  decay  of  the  deciduous  teeth  may  occur  with  the  erup- 
tion of  the  lower  central  incisors,  but  more  frequently  decay  first  occurs 
in  the  deciduous  molars. 

Two  courses  of  action  are  imperative — a  search  for  the  cause  of  the 
decay,  and  its  correction — but  in  this  search  for  the  cause,  no  time 
should  be  lost  in  the  repair  of  the  structural  defects  already  evident 
in  the  tooth  substance,  and  this  work  should  be  done  with  no  restriction 
as  to  thoroughness  of  operative  procedures. 

PREVENTION   OF   MALOCCLUSION 

Frank  A.  Delabarre,  A.B.,  D.D.S.,  M.D. 

Boston,  Massachusetts 

That  specialty  of  dentistry  called  "Orthodontia,"  which  literally 
means  "Straight  Teeth,"  aims  to  rearrange  crooked  teeth  in  a  more 
harmonious  and  symmetrical  curve  for  the  purpose  of  better  function, 
better  health  and  improved  facial  appearance. 

The  logical  solution  of  any  preventive  effort  naturally  lies  in  finding 
and  eliminating  the  causes  and  contributing  factors.  It  is  not  to  be 
supposed  that  all  of  these  have  been  discovered  yet,  because  it  is  an 
intricate  problem  of  biology,  concerned  with  inheritance,  growth  and 
development  and  the  vital  capacity  of  the  individual  to  attain  full 
adult  stature  according  to  nature's  plan. 

Prevention  is  impossible  today  because  of  insufficient  knowledge  of 
what  we  suspect  are  the  major  causes  of  "Malocclusion,"  so-called. 
But  it  is  possible  to  prevent  many  of  the  severe  complications  that 
characterize  the  older  cases,  by  removing  known  factors  and  starting 
correction  early.  Even  the  baby  teeth  are  frequently  badly  arranged  in 
much  the  same  manner,  but  not  to  the  same  degree,  and  the  tendency  is 
to  become  progressively  worse  with  time. 

The  facts  derived  from  a  study  of  heredity  are  obviously  of  no  value 
in  a  preventive  sense  but  its  influence  must  be  recognized  in  diagnosis 
and  treatment. 

The  fundamental  causes  of  malocclusion  are  to  be  found  in  the  items 
that  violate  the  laws  and  conditions  that  govern  general  growth  and 
development  and  one  of  the  most  important  is  diet  and  the  functions 
of  digestion,  distribution  and  assimilation. 

Diet  control  offers  the  most  universal  and  effective  means  of  preven- 
tion of  malocclusion  because,  if  correctly  applied  early  in  life,  it  will 
be  the  best  means  of  insuring  to  the  child  the  highest  possible  degree  of 
physical  fitness,  consistent  with  the  limitations  imposed  by  its  inherit- 
ance or  other  handicaps.  Since  the  crowns  of  the  baby  teeth  are  being 
formed  before  birth  it  follows  that  the  expectant  mother  should  have 
careful  supervision  to  be  sure  that  the  food  elements  essential  to  tooth 
and  bone  building  are  supplied  to  the  child  through  her.  This  should 
be  continued  through  the  period  of  lactation  also,  and  carried  on  for 
the  child  after  weaning  in  order  to  furnish  the  immense  amount  of 
material  required  in  building  the  new  tissues. 


aWm.  Lentz,  M.D. — "The  Teeth  in  Relation  to  Disease,"  Journal  of  the  A.  D.  A.,   December, 
1931. 


14 

The  Department  of  Agriculture  has  just  issued  a  new  bulletin  on 
"Food  for  Children."  To  sum  it  up,  the  essential  elements  are  proteins, 
water  and  minerals.  Proteins  are  among  the  most  important  construc- 
tion materials  for  all  body  tissues  and  fluids.  They  are  furnished  by 
milk,  cheese,  eggs  and  meat.  Water  is  indispensable,  of  course,  since 
two  thirds  of  the  body  weight  is  water.  The  most  important  minerals 
are  calcium,  phosphorus  and  iron,  the  first  two  in  building  bones  and 
teeth  and  the  later  for  the  red  blood  cells.  Milk,  fruits,  vegetables  and 
meats  supply  the  phosphorus  and  calcium,  while  iron  is  to  be  found  in 
egg  yolk,  green  vegetables,  dried  fruits,  whole  grain  cereals  and  lean 
meat.  Liver,  kidney,  apricots  and  lean  meat  are  also  valuable  in  the 
formation  of  red  blood  cells.  These  elements  will  provide  material  for 
increased  body  growth  but  the  child  needs  also  fats,  sugar  and  starches 
to  supply  the  energy  demanded  by  all  the  activities  of  the  many  vital 
functioning  organs  each  day  of  his  life. 

If  the  child  is  fortunate  enough  to  have  a  good  background  of  heredity 
and  intelligent  diet  control  the  chance  of  having  crooked  teeth  is  very 
much  lessened. 

Among  the  contributing  factors  of  frequent  occurrence  that  help  to 
make  the  jaws  and  teeth  irregular  is  a  group  of  faulty  functional  habits. 

The  growth,  development  and  health  of  the  body  as  a  whole  is  depend- 
ent upon  the  balance  of  all  of  the  many  functions.  If  the  function  of 
digestion  is  impaired  the  value  of  a  good  diet  is  partly  lost;  if  there 
are  leaky  valves  in  the  heart  the  whole  body  suffers. 

The  balance  of  the  various  functions  performed  by  the  teeth,  bones 
and  muscles  of  the  head  and  face  in  chewing,  swallowing,  speaking, 
breathing  and  in  facial  expression  can  be  upset  by  such  faulty  habits 
as  breathing  through  the  mouth  or  unnatural  sucking  habits.  These 
may  appear  very  early  in  life  and  the  longer  they  persist  the  harder  it 
is  to  correct  them.  Mouth  breathing  may  follow  a  common  cold  or  it 
may  be  the  result  of  obstruction  of  the  air  passages  by  adenoids.  Any 
physical  defect  such  as  that  should  be  remedied  as  early  as  possible. 
If  not  attended  to  there  may  develop  what  is  known  as  the  typical 
"adenoid  face"  with  parted  lips,  undeveloped  nose  and  jaws,  drawn 
features,  vacant  expression  and  lack-luster  eyes.  The  "balance"  is 
upset;  regular  teeth  are  rarely  found  in  such  a  child. 

Breathing,  speaking  and  muscle  exercises  are  essential  in  all  pro- 
nounced cases  to  get  rid  of  the  bad  habits  and  restore  the  normal 
balance  of  function. 

All  of  the  twenty  baby  teeth  of  infancy  serve  well  the  needs  of  the 
child  up  to  the  age  of  six  at  which  time  they  begin  to  be  lost  naturally 
and  replaced  in  pairs  by  larger  permanent  ones.  At  this  age  also  four 
big  sixth  year  molars  appear  behind  the  baby  set.  By  the  age  of  twelve 
all  the  baby  teeth  have  been  pushed  out  by  their  successors  and  at 
eighteen  the  child  has  become  a  man  with  thirty-two  teeth. 

Unless  there  is  the  full  number  of  healthy  teeth  in  the  mouth  at  each 
successive  periods  of  development  according  to  the  age,  a  good  arrange- 
ment of  them  cannot  be  expected  because  they  depend  upon  each  other 
for  mutual  support  and  are  so  formed  that  they  will  close  properly  only 
if  they  strike  against  their  mates  in  the  opposite  jaw.  If  they  drift  out 
of  position  the  whole  set  becomes  irregular. 

So  it  is  essential  that  the  teeth  be  kept  healthy  and  free  from  decay. 
This  is  just  as  necessary  for  the  baby  teeth  as  for  the  adult  teeth  other- 
wise the  mutual  support  is  lost,  function  interfered  with,  and  development 
cannot  follow  its  usual  course.  This  amounts  to  a  real  tragedy.  Decay  of 
the  teeth  and  their  early  loss  is  the  most  common  of  all  human  ills. 

Figures  from  the  survey  of  the  White  House  Conference  on  Child  Health 
and  Protection  emphasize  this  handicap. 

It  is  not  uncommon  to  find  an  average  of  eight  cavities  and  two  abscess- 
es even  among  preschool  age  children.    Dentistry  is  seeking  the  cause 


15 

of  decay,  hopes  that  diet  may  prevent  it  and  is  in  a  position  today  to 
control  it  through  recent  added  knowledge  from  scientific  research. 

But  their  efforts  cannot  be  successful  without  cooperation  from  the 
public.  It  cannot  be  accomplished  by  the  old  "hit  or  miss"  methods  of 
care  of  the  mouth. 

There  are  two  absolutely  essential  requirements  for  effective  control, 
the  responsibility  for  which  must  be  assumed  by  the  public:  (1)  the 
child's  first  visit  to  the  dentist  should  be  not  later  than  the  age  of  two  and 
a  half ;  afterward,  not  less  than  four  times  a  year  during  childhood.  Den- 
tal care  is  most  necessary  in  the  early  life  of  the  child  because  it  is  found 
that  many  teeth  come  through  the  gum  with  defects  in  formation  (due 
to  faulty  diet  perhaps)  which  invite  decay;  (2)  frequent  and  periodic 
visits  because  the  progress  of  decay,  once  started  in  these 'weak  spots, 
is  rapid  and  insidious.  Toothache  is  a  symptom  of  advanced  decay  and 
a  reproach  to  the  parent  or  dentist. 

In  addition  to  these  two  responsibilities  of  the  public  must  be  added 
that  of  effective  home  care  of  the  mouth  and  attention  to  all  the  many 
items  that  will  help  the  growing  child  to  be  healthy  and  happy;  such  as, 
rest,  play,  work,  sleep  and  exercise. 

It  is  possible  for  you  to  save  your  child  from  the  handicaps  and  con- 
sequences you  have  undergone  because  of  the  lack  of  this  type  of  service. 

Crooked  teeth  are  to  be  avoided  if  possible  because  of  their  bad  influ- 
ence on  appearance  and  bodily  health  through  lowered  function. 

If  in  spite  of  all  the  care  as  outlined  above  there  is  some  doubt  in  your 
mind  or  the  dentist's  that  your  child's  teeth  may  not  be  even  and  regular, 
remember  that  the  early  signs  are  small  but  important  and  have  an 
examination  made  by  a  specialist. 

Any  orthodontist  will  tell  you  that  there  is  a  decided  advantage  in  keep- 
ing such  cases  under  observation  during  the  early  years  to  note  the  pro- 
gress of  growth  and  development  and  be  prepared  to  start  correction  at 
the  most  favorable  time  to  avoid  the  gross  complications  and  malform- 
ations that  are  accentuated  with  the  added  years. 

DIRECTIONS  FOR  BRUSHING  THE  TEETH  PROPERLY 

There  are  various  accepted  ways  of  brushing  the  teeth.  The  following 
is  one  of  the  simplest: 

Brush  the  outside  of  the  teeth  first,  with  mouth  slightly  open.  Start 
with  the  upper  back  teeth  on  the  left  side.  Put  the  brush  well  up  on  the 
gums  and  brush  downward  with  short  sweeping  strokes. 

Do  this  several  times,  using  the  wrist,  not  the  arm.  Do  the  same 
on  the  front  and  right  side. 

Brush  the  lower  teeth  upward,  using  the  same  sweeping  strokes, 
starting  at  the  left  and  going  to  the  right. 

Brush  inside  of  teeth  in  same  way,  putting  brush  well  up  on  the  gums. 

Open  the  mouth  wide.  Brush  the  chewing  surfaces  in  and  out,  using 
the  whole  arm — the  upper  teeth  first,  then  the  lower  teeth. 

VINCENT'S  INFECTION 

Francis  H.  Daley,  D.M.D. 

Assistant  Professor,  Department  Dental  Pathology 
Tufts  College  Dental  School 

Vincent's  Infection  or  "trench  mouth"  as  it  is  generally  known  to  the 
public  has  received  wide  attention  during  the  past  few  years.  The  disease 
was  known  to  the  dental  profession  more  than  twenty  years  before  the 
World  War,  but  it  was  not  until  that  time  that  large  numbers  of  cases  oc- 
curred. The  general  causes  for  its  widespread  occurrence  then  are  evident. 
General  and  oral  sanitation  in  trench  warfare  is  necessarily  limited;  this 
fact  coupled  with  nervous  and  physical  depression  provided  ideal  condi- 
tions for  an  endemic  outbreak  of  the  disease. 


!6 

Vincent's  Infection  is  a  disease  which  may  be  contracted  by  individuals 
of  all  ages.  Unlike  many  other  diseases  one  attack  does  not  seem  to 
endow  the  patient  with  immunity  to  further  attacks.  In  other  words,  a 
patient  may  be  entirely  cleared  of  the  infection  and  at  a  later  time  be- 
come reinfected.  Oftentimes  patients  who  have  had  the  disease  will  dis- 
play some  loss  of  the  soft  protective  tissues  of  the  mouth.  This  loss, 
even  though  it  is  slight,  will  expose  the  teeth  to  some  extent  and  will 
predispose  the  patient  to  subsequent  attack  by  any  disease-producing 
organisms  which  may  find  their  way  into  the  area.  Therefore,  it  is 
evident  that  if  we  can  prevent  the  lesions  of  Vincent's  Infection  from  de- 
veloping we  may  often  prevent  further  and  more  serious  types  of  infection. 

Most  cases  of  Vincent's  Infection  occur  in  patients  having  lowered 
vital  powers,  general  as  well  as  oral.  Most  cases,  upon  careful  examina- 
tion, will  show  tartar,  irritating  fillings,  or  bridgework  which  presses 
upon  the  delicate  mucous  membranes  causing  an  upset  in  its  blood  cir- 
culation. This,  of  course,  is  bad,  because  when  the  blood  supply  is  af- 
fected they  will  not  receive  the  proper  nutritive  materials  and  their  re- 
sistance will  be  lowered. 

In  Vincent's  Infection  the  gums  bleed  very  profusely  at  the  slightest 
touch.  They  are  reddened  and  inflamed  and  usually  tender.  There  may 
be  a  gnawing  sensation  which  is  decidedly  uncomfortable.  The  teeth 
sometimes  have  a  peculiar  "achy"  feeling;  this  sensation  is  really  caused 
by  the  infection  of  the  gums.  Many  cases  show  a  whitish  or  grayish 
membrane  on  the  gums.  The  odor  of  the  breath  is  significant;  it  is  a  very 
foul  odor  and  the  patient  is  usually  conscious  of  a  bad  taste  in  the  mouth, 
particularly  in  the  morning.  Most  patients  with  the  disease  feel  "all  in" 
and  exhibit  slight  rises  in  temperature. 

In  making  a  diagnosis  of  the  disease  we  consider  all  of  the  above 
symptoms  but  we  also  insist  that  a  "smear"  be  taken  from  the  suspected 
areas.  The  smear  represents  material  gathered  from  the  pockets  about 
the  teeth.  This  material  is  spread  on  a  thin  glass  slide  and  stained  for 
a  microscopic  diagnosis.  This  is  the  only  way  in  which  we  can  accurately 
determine  the  type  of  bacteria  connected  with  the  lesions.  In  Vincent's 
Infection  we  always  find  two  forms  of  bacteria,  and  large  numbers  of 
these,  coupled  with  the  distressing  symptoms  in  the  mouth  itself,  con- 
firm our  diagnosis.  Oftentimes  every  case  of  "bleeding  gums"  is  called 
Vincent's  Infection.  This  probably  accounts  for  the  fact  that  so  many 
practitioners  and  patients  believe  that  the  disease  is  on  the  increase.  From 
our  observation  of  approximately  five  thousand  cases,  we  believe  that  the 
condition  is  definitely  on  the  decrease. 

The  individual  suffering  from  Vincent's  Infection  must  understand 
that  his  only  chance  for  quick  and  complete  recovery  lies  in  absolute  co- 
operation with  his  dentist.  Regular  visits  are  necessary  and  faithful  at- 
tention must  be  given  to  all  the  measures  which  the  dentist  prescribes. 
Regulation  of  living  habits  is  essential;  proper  movement  of  the  bowels, 
attention  to  diet,  and  other  general  health  principles  are  important  factors 
in  clearing  up  the  condition.  Fresh  vegetables,  fruits,  and  mineral  and 
vitamin-containing  foods  are  necessary.  Certain  cases  are  of  obscure 
origin  and  oftentimes  a  thorough  physical  examination  will  aid  in  disclos- 
ing some  elusive  resistance-lowering  factor.  It  is  evident,  therefore,  that 
the  dentist  must  be  aided  by  the  patient.  All  the  dentist  can  do  is  clear 
up  all  possible  local  factors  and  prescribe  necessary  treatment;  it  is  en- 
tirely up  to  the  patient  to  complete  the  treatment  by  following  the  neces- 
sary general  hygienic  and  dietary  measures. 

Proper  care  of  the  mouth  by  the  patient  and  regular  dental  examina- 
tion will  do  much  to  prevent  the  occurrence  of  the  disease.  It  must  be 
borne  in  mind  that  Vincent's  Infection  can  be  transmitted  by  personal 
contact.  Therefore,  if  you  are  unfortunate  enough  to  become  infected, 
use  all  precautions  to  prevent  infection  of  members  of  your  household  and 
your  associates.     If  you  have  never  had  the  disease,  take  the  ordinary 


17 
steps  toward  prevention  by  contact.    See  your  dentist  every  six  months  for 
examination  and  removal  of  irritating  factors  and  be  regular  in  dietary 
and  general  hygienic  habits.     These  measures  represent  the  best  and 
least  expensive  form  of  oral  health  insurance. 

PYORRHEA 

E.  Melville  Quinby,  M.R.C.S.,  L.R.C.P.,  D.M.D. 

Boston,  Massachusetts. 

There  are  certain  terms  used  in  common  parlance  with  reference  to 
definite  conditions  of  disease  which  are  abiding  and  in  spite  of  efforts  to 
dispossess  them  in  the  minds  of  the  public,  they  still  hold  the  fort !  One 
of  such  terms  is  an  "ulcerated  tooth";  another  is  "dead  tooth";  still  an- 
other is  "Pyorrhea,"  generally  known  as  Pyorrhea  Alveolaris. 

Diseases  of  the  supporting  tissues  of  the  teeth,  such  as  "loose  teeth," 
"shaking  teeth,"  "hemorrhage  of  the  gums,"  are  described  in  ancient 
writings.1  The  first  time  that  the  term  "Pyorrhea"  was  mentioned  in 
this  country  was  in  a  paper  read  by  Dr.  F.  H.  Rehwinkel  in  Chicago,  1877, 
entitled  "Pyorrhea  Alveolaris,"  though  this  name  had  been  used  frequent- 
ly by  European  writers  prior  to  this  date.1 

Since  that  time  oceans  of  literature  have  appeared  on  the  subject,  and 
endless  hypotheses  in  etiology  have  been  submitted  and  numberless  treat- 
ments devised,  in  order  to  solve  the  problem — with  the  result  that  the 
said  problem,  like  other  dental  puzzles,  is  still  shrouded  in  mystery,  at 
least  so  far  as  most  people  are  concerned !  And  yet  as  many  teeth  are  lost 
through  Pyorrhea  as  through  caries  or  decay;  and  the  danger  of  systemic 
infection  through  absorption  of  toxins  from  "pus  pockets"  demands  as 
much  attention  on  the  part  of  members  of  the  Healing  Art  as  does  caries 
of  teeth,  with  death  of  the  pulp  and  ensuing  "abscess."  Probably  the  need 
for  such  attention  is  greater  because  the  diseased  tissue  is  so  extensive 
in  area. 

Space  will  not  permit  of  an  exhaustive  analysis  of  etiology,  pathology 
and  treatment  of  Pyorrhea  Alveolaris,  and  I  propose  to  deal  with  the 
matter  from  the  clinical  aspects  of  a  typical  case  of  "Pyorrhea" ;  and  give 
a  few  suggestions  for  treatment. 

At  what  age  does  this  disease  first  manifest  itself?  Most  people  con- 
sider Pyorrhea  to  be  a  disease  of  middle  or  late  life !  As  a  matter  of  fact 
many  children  from  ten  to  twelve  years  of  age  exhibit  symptoms  such  as 
redness,  swelling  and  congestion,  generally  or  locally,  of  the  gums.  Many 
also  present  definite  mobility  of  certain  teeth,  especially  the  front,  at 
an  early  age.  Thus  gingivitis  and  alveolar  disintegration  which  later 
in  life  result  in  loss  of  the  teeth,  should  be  looked  for,  and  carefully  chart- 
ed in  the  examination  of  all  mouths,  from  the  age  of  ten  onward !  Many 
patients  between  the  ages  of  twenty -five  and  forty-five  have  complained  to 
the  dentist  that  the  gums  feel  sore,  and  that  a  tooth  or  teeth  have  become 
loose.  And  in  many  such  mouths  there  is  evidence  of  skillful  mechanical 
restoration  in  decayed  teeth ! 

There  is  no  doubt  that  many  such  cases  of  Pyorrhea  could  have  been 
avoided,  if  there  had  been  from  the  earliest  visits  to  the  dental  office  a 
fifty-fifty  examination  of  the  teeth  and  the  supporting  tissues — the  gums, 
the  tooth  sockets  and  the  pericemental  membrane.  In  the  latter  examina- 
tion, of  course,  X-ray  films  are  required.  (But  nowadays  everyone  ought 
to  have  a  radiographic  survey  once  annually.) 

A  Typical  Experience 

A  woman  fifty  to  sixty  years  of  age  calls  to  obtain  advice  about  the 
loosening  of  two  lower  front  teeth.  A  cursory  inspection  of  the  mouth 
reveals  the  fact  that  the  sole  remaining  molar  (right  lower)  has  tipped 
forward,  owing  to  loss  of  one  first  molar  and  the  two  bicuspids.    The  re- 

VMerritt 


18 

suit  of  "tipping"  has  been  abnormal  stress  between  that  tooth  and  the 
upper  one  in  mastication.  As  a  result,  the  said  molar  has  lost  50  per  cent 
of  gum  and  tooth-socket  support.  Having  pointed  out  these  facts  to  the 
patient,  she  suggests  that  you  "look  over"  the  mouth  generally.  Further 
casual  inspection  reveals  several  "leaky  fillings";  spaces  where  teeth  have 
been  removed  and  not  replaced  artificially ;  teeth  bordering  the  spaces  tip- 
ped and  movable;  a  fixed  bridge  with  one  anchorage  instead  of  two;  films 
and  tartar  in  large  quantities,  covering  most  of  the  teeth  and  gums ! 

There  are  thousands  of  such  cases  all  over  the  country  and  the  object 
of  this  paper  is  to  suggest  a  few  hints  for  prevention  and  alleviation  of 
the  same. 

The  plan  adopted  by  the  writer  is: 

1.  A  talk  with  the  patient  on  general  principles. 

2.  Diagnosis  of  conditions. 

3.  Outline  of  treatment. 

General  Principles,  (a)  The  patient  should  be  instructed  that  attention 
to  teeth  alone  is  not  sufficient  to  ensure  function  in  the  dental  apparatus, 
the  supporting  tissues  must  have  equal  consideration,  viz.,  teeth  and  gums ; 
(b)  The  service  to  be  rendered  is  a  health  service,  because  mouth  condi- 
tions are  interdependent  with  bodily  health;  (c)  That  there  is  no  secret 
or  mysterious  cure  for  Pyorrhea,  that  the  only  real  cure  is  prevention,  but 
that  if  the  proper  precautions  were  taken  in  the  earliest  stages  of  develop- 
ment of  the  dental  machine,  there  would  be  far  less  incidence  of  this 
disease. 

The  steps  for  diagnosis  are: 

(a)  Complete  radiograms  for  1.  Caries — decay. 

2.  Apical  condition — end  of  root. 

3.  Pus  pockets. 

(b)  Transillumination  tests   (to  show  congested  areas  in  gum  tis- 

sues) . 

(c)  Vitality  tests  (to  ascertain  life  of  pulps  (or  nerves)  ). 

(d)  Study  models  (for  occlusion  of  teeth,  contacts  interproximal  or 

to  ascertain  how  the  parts  fit). 

(e)  Mobility  of  teeth — three  stages — 1.  Movable 

2.  Loose 

3.  "Wobbly." 

(f)  Clinical  study — 1.  By  vision 

2.  By  finger 

3.  By  explorers  for  depth  of  pockets,  and  tar- 

tar. 

(g)  1.  History  of  present  complaint 

2.  Family  history 
Personal  history 

3.  Physical  examination 

a  Tonsils 

b  Sinuses 

c  Kidneys 

d  Heart 

e  Blood  pressure 

count 

chemistry 
f  Alimentary  canal 
g  Pelvic  organs 

The  reason  for  all  this  extensive  survey  is  that  in  many  cases  there 
is  some  systemic  condition  present — if  unsuspected — which  militates 
against  a  successful  plan  of  campaign. 

In  every  case  almost  without  exception  a  successful  issue  can  be 
brought  about  only  by  attention  to  at  least 


19 

Three  Factors 

The  said  three  are  indivisible,  if  a  definite  result  is  to  be  obtained. 
They  are  (1)  Nutrition;  (2)  Arrangement  of  teeth:  (3)  Cleaning  of 
teeth  and  stimulation  of  circulation  by  massage. 

1.  Nutrition.  Under  this  heading  is  included  every  condition  of  a 
biological  nature — the  right  elements  in  food  supply  and  the  right  as- 
similation of  same,  for  example;  and  any  systemic  factor  which  inter- 
feres with  the  nutritional  element  must  be  treated  before  success  in 
dealing  with  the  disease  of  the  supporting  tissues  of  the  teeth  can  obtain. 
In  other  words,  the  powers  of  resistance  to  periodontal  disease  must  be 
established  on  a  firm  basis. 

2.  Arrangement  of  Teeth.  Alignment  of  the  parts  or  occlusion  must 
be  fostered  from  the  earliest  period  of  development  of  the  dental  machine, 
by  supplying  the  right  elements  of  growth  and  by  giving  proper  exercise 
to  the  muscles  of  the  jaws.  As  a  result  of  want  of  attention  to  these 
early  principles  about  90  per  cent  of  dental  machines  are  out  of  gear  in 
malocclusion. 

3.  A  definite  system  or  technique  for  systematic  removal  from  teeth 
and  gums  of  all  deposits  of  food  stuff,  intermingled  with  a  mucinous 
element  of  the  saliva,  and  containing  myriads  of  bacteria,  dead  epithelium, 
lime  salts,  etc.,  must  be  established.  Furthermore  this  attention  must 
be  constant  and  allowed  no  "letting  up"  on  the  part  of  the  patient  for 
even  one  day  or  part  of  a  day! 

Every  person  should  see  the  dentist  at  least  four  times  annually  and 
is  strongly  advised  to  ask  the  dentist  to  demonstrate  the  right  use  of  the 
right  kind  of  mouth  cleanser  in  the  mouth  of  the  patient.  The  patient 
also  should  demonstrate  the  technique  used  by  himself  or  herself  to  the 
satisfaction  of  the  dentist. 

There  are  at  least  US  surfaces  to  be  cleaned  in  a  full  set  of  teeth  and 
to  slur  over  the  importance  of  a  clean  mouth — teeth,  gums  and  tongue — 
is  to  do  the  cause  of  dental  health  service  a  grave  injustice. 

The  moral  to  be  deduced  from  this  short  article  may  be  indicated  in  a 
slogan : 

Balanced  Diet 

Clean  Mouths  ; 

Better  Dental  Machines  for  all 

Summary 

1.  Pyorrhea  is  not  to  be  considered  as  one  of  the  plagues —  a  mark 
of  Providential  displeasure,  for  which  there  is  no  redress! 

2.  On  the  contrary — this  disease  has  a  definite  beginning,  with  symp- 
toms obvious  to  those  who  are  looking  for  them. 

3.  Early  recognition  of  symptoms  is  a  sine  qua  non  in  prevention  or 
cure. 

4.  Attention  to  the  three  factors  in  every  case  of 

Nutrition 

Alignment  of  teeth 
Cleaning  of  teeth,  gums  and  tongue 
are  absolutely  necessary  for  a  satisfactory  treatment. 

5.  Dependence  on  the  use  of  widely  advertised  medicaments,  pastes, 
powders,  lotions,  etc.,  except  as  adjuncts  to  the  systemic  and  local  treat- 
ments indicated,  is  to  be  deprecated,  most  strongly! 

6.  There  is  no  attempt  made  to  sterilize  a  mouth,  i.e.,  killing  off  the  bac- 
terial content  of  a  normal  mouth;  but  every  means  possible  should  be 
taken  to  neutralize  the  toxins  from  the  fermentation  and  decomposition 
of  food  stuffs,  from  three  "squares"  a  day! 

7.  Pyorrhea  is  not  an  incurable  or  a  non  preventable  disease;  and  the 
sooner  the  eighty  mjljion  people  of  jthe  United  States  of  America,  unac- 


20 

quainted  with  oral  hygiene  are  educated  on  these  points,  so  much  the 
better  for  the  health  of  future  generations! 

8.  No  mouth  can  be  100  per  cent  efficient  or  healthy  unless  the  function 
of  the  dental  machine  is  unimpaired.  In  other  words,  when  teeth  are 
removed,  the  spaces  must  be  scientifically  filled  so  that  all  the  tooth  units 
get  a  balanced  stress  in  mastication. 

9.  In  the  last  analysis — treatment  should  emphasize  health  measures, 
even  though  infection  may  be  the  most  obviously  exciting  cause  of  symp- 
toms. Thefe  measures  reduced  to  the  lowest  common  denominator  are 
universal  attention  to  diet  and  universal  attention  to  cleanliness — but  the 
attention  must  be  thorough  and  universal. 

DENTISTRY  MUST  EMBARK  ON  RESEARCH 

Leroy  M.  S.  Miner,  D.M.D.,  M.D. 
Dean,  Harvard  Dental  School 

Only  within  the  last  few  years  has  it  been  realized  how  large  a  part 
dentistry  plays  in  the  health  of  the  individual.  For  generations,  dental 
ailments  of  all  types  existed  and  were  treated  by  the  best  means  available 
at  those  times,  but  the  failure  to  realize  that  inadequacy  or  neglect  of 
dental  care  can  wreck  good  general  health  has  brought  much  suffering 
both  physical  and  economic.  Today,  more  than  ever,  the  dental  and 
medical  professions,  and  even  the  general  public,  are  appreciating  the 
fact  that  the  mouth  is  really  the  masticatory  organ  of  the  body  and  that 
its  health  must  exert  a  profound  influence  upon  the  state  of  health  of 
even  remote  parts  of  the  body.  Dentistry  thus  becomes  an  important  cog 
in  the  machinery  of  public  health  service. 

If  dental  caries  affected  only  the  teeth,  causing  their  eventual  break- 
down, we  should  not  be  anywhere  near  as  disturbed  about  it  as  we  are, 
even  though  we  should  regret  immeasurably  the  loss  of  chewing  function, 
to  say  nothing  of  facial  beauty  and  appearance,  accompanying  wide- 
spread decay.  Rather  it  is  the  sequelae  of  caries,  which  lead  us  to  view 
with  alarm  its  almost  universal  prevalence.  We  all  know  that  caries 
neglected  usually  leads  to  pulp  involvements  which  in  turn,  often  result 
in  virulent  abscesses.  Then  when  we  get  into  the  field  of  focal  infection 
we  are  face  to  face  with  a  factor  of  disease  whose  myriad  manifestations 
often  bewilder  the  earnest  surgeon,  physician  or  dentist  seeking  its  solu- 
tion. Organic  impairments,  including  the  various  forms  of  heart  trouble, 
affections  of  the  liver  or  kidneys;  mild  or  severe  arthritic  conditions; 
symptoms  seeming  to  indicate  definite  respiratory  disease;  even  psychia- 
tric ailments  such  as  melancholia,  manic-depressive  psychoses,  and  epi- 
lepsy :  all  these  have  seemed  to  respond  to  the  removal  of  foci  of  infection. 
And  when  it  is  remembered  that  probably  the  greatest  portion  of  focal 
infection  originates  in  the  mouth,  dentistry  becomes  of  tremendous  health 
importance,  and  the  work  of  the  dentist  becomes  significant  and  vital  to 
the  health  of  every  individual. 

Caries,  of  course,  is  not  the  only  oral  condition  to  initiate  pathological 
sequences  leading  to  focal  infection.  Pyorrhea  also  may  be  the  primary 
cause  of  infection,  but  with  this  differentiation  of  idea  we  need  not  be 
concerned.  The  chief  point  of  interest  lies  in  the  fact,  upon  which  author- 
ities generally  agree,  that  practically  all  the  children  in  the  country  are 
affected  by  caries  and  that  well  more  than  half  of  the  adults'  have  pyor- 
rhea. Out  of  120  millions  of  people  in  the  United  States,  probably  90  per 
cent  are  or  have  been  afflicted  with  dental  ills,  which  may  have  produced 
more  or  less  serious  ailments  in  other  parts  of  the  body.  There  are  about 
70,000  dentists  in  the  United  States,  as  compared  with  about  160,000 
physicians.  How  can  the  dentists  cope  with  this  enormous  problem,  tak- 
ing caries  alone?    It  can't  be  done! 

The  only  way  in  which  the  dental  profession  can  face  a  task  of  this 


21 

magnitude  is  to  develop  to  a  greater  extent  than  ever  before  measures  that 
will  prevent  disease.  Since  cure  can  never  resolve  the  problem,  preventive 
dentistry  alone  will  show  us  the  way  out,  and  owing  to  the  intimate  re- 
lation between  health  in  the  mouth  and  health  in  the  body  as  a  whole,  pre- 
ventive dentistry  promises  soon  to  become  one  of  the  most  important 
parts  of  preventive  medicine.  And  when  we  realize  how  little  we  really 
know  about  prevention  in  dentistry,  the  enormous  need  for  dental  re- 
search on  a  comprehensive  scale  becomes  obvious. 

This,  of  course,  is  a  task  for  the  dental  schools  to  undertake,  and  finan- 
cial means  must  be  provided  for  them  to  do  so  within  a  short  time,  if  the 
dental  profession  shall  be  enabled  to  contribute  its  share  to  the  preven- 
tion of  disease  and  the  well-being  of  humanity.  Much  progress  has  been 
made  in  dental  education  within  the  last  few  years  to  carry  dentistry  from 
the  mechanical  to  the  biological  point  of  view,  but  any  extended  progress 
in  the  near  or  even  remote  future  depends  solely  upon  research.  And  by 
research  is  meant  thorough-going  scientific  research  that  is  well  coordinat- 
ed to  related  medical  and  public  health  fields.  Only  by  this  means  are 
we  to  approximate  a  realization  of  the  goal  we  see  so  clearly  and  toward 
which  we  are  striving  so  earnestly. 

CANCER  OF  THE  MOUTH 
HOW  TO  RECOGNIZE  AND  PREVENT  IT 

Charles  M.  Proctor,  D.  M.  D. 
Professor  of  Oral  Surgery,  Tufts  Dental  School 

Cancer  of  the  mouth  is  more  common  than  most  people  are  led  to  be- 
lieve. About  5  per  cent  of  all  cancers  occur  within  the  oral  cavity.  This 
year  more  than  5,000  individuals  in  the  United  States  will  die  as  the  re- 
sult of  cancer  of  the  mouth,  which  means  that  there  are  from  15,000  to 
20,000  individuals  affected  with  precancerous  lesions  of  the  mouth  in 
some  form  or  another  which,  if  seen  and  recognized  today,  could  be  so 
treated  that  the  toll  of  5,000  lives  of  next  year,  and  the  two  succeeding 
years  could  practically  be  wiped  out. 

Cancer  of  the  mouth  and  jaws  when  recognized  as  such  is  almost  always 
fatal.  Why?  Because  if  cancer  in  or  about  the  mouth  is  of  more  than 
three  months  duration  it  is  usually  past  the  operative  stage.  It  is  most 
essential,  then,  for  those  afflicted  to  find  it  out  in  the  very  earliest  stage, 
at  which  time  there  is  no  pain  or  only  a  slight  irritation.  Only  when  pain 
and  ulceration  are  evident  is  it  too  late.  Therefore,  the  frequent  visit  to 
the  dentist  or  dental  clinic  may  save  your  life. 

Need  of  Precaution 

Remember  that  the  dentist  is  the  one  professionally  responsible  for  the 
oral  health  of  the  community.  He  is,  in  fact,  a  health  officer  in  regard 
to  the  oral  conditions.  On  you  and  him  alone  devolves  the  responsibility 
for  the  early  recognition  of  this  disease.  The  dental  clinics  of  the  city, 
conducted  at  the  Boston  Dispensary  Medical  Center,  Tufts  College  Dental 
School,  Harvard  Dental  School,  Forsyth  Dental  Infirmary  and  the  Rox- 
bury  Hospital,  together  with  a  live  group  of  individual  dentists  practic- 
ing throughout  Greater  Boston,  are  all  anxious  to  help  you.  If  you  are 
in  doubt  about  any  condition  of  your  mouth,  go  to  them  at  once. 

The  principal  cause  of  cancer  in  the  mouth,  as  in  other  parts  of  the  body, 
is  due  chiefly  to  irritation.  The  potential  factors  of  irritation,  dirty 
mouths  and  excessive  use  of  tobacco,  either  separately  or  in  combination, 
are  ideal  for  the  beginning  of  cancer  of  the  mouth.  It  is  very  common 
among  men ;  it  is  rarely  seen  in  women.  The  reasons  are  obvious.  There 
are  ten  women  to  one  man  who  visit  the  dentist  for  the  regular  care  of 
their  mouths.  There  are  ten  men  to  one  woman  who  use  tobacco  exten- 
sively.   Therefore,  we  are  compelled  to  conclude  that  with  the  regular  care 


22 

which  the  average  woman  gives  to  her  mouth  hygiene,  90  per  cent  are 
saved  from  this  terrible  disease.  Whereas  90  per  cent  of  men  afflicted 
with  cancer  of  the  mouth  could  have  prevented  it  had  they  taken  ordinary 
precaution  of  regular  systematic  dental  care. 

.     Caused  by  Many  Direct  Irritations 

The  direct  irritations  which  may  cause  cancer  of  the  mouth  are  the 
presence  of  broken  down  teeth  and  roots,  roughened  fillings,  uneven  sur- 
faces of  crowns,  bridges,  or  plates,  and  consistent  biting  of  tongue  or 
cheeks,  use  of  pipes,  especially  the  clay  or  corncob  variety.  The  heat  from 
the  bowl  of  the  pipe  follows  the  stem  and  becomes  a  constant  irritating 
factor  in  cancer  of  the  lip.  This  type  of  cancer  is  not  as  commonly  seen 
as  in  previous  years  when  there  were  only  cheap  pipes  in  vogue. 

Pyorrhea  may  be  another  factor  causing  cancer  of  the  mouth.  Irrita- 
tion from  pus  pockets  extending  into  surrounding  gum  tissue,  may  in 
time,  if  not  properly  treated,  result  in  a  breaking  down  of  tissue  into  a 
cancerous  lesion. 

What  To  Look  For 

Any  sore  in  the  mouth  that  does  not  heal  readily  should  be  viewed 
with  suspicion. 

Any  wart-like  growth,  even  though  it  is  not  tender  to  touch,  upon  the 
tongue,  cheek  or  lips  may  be  precancerous  in  character. 

Any  tissue  which  has  become  overgrown  about  a  crown  or  filling  which 
is  situated  between  two  or  more  teeth,  especially  if  it  bleeds  freely,  should 
receive  immediate  attention. 

Any  inflammation  of  the  gums  should  be  given  the  closest  examination 
by  the  dentist.  Even  tissues  about  pyorrhetic  teeth  have  been  known  to 
become  cancerous. 

Any  milk-white  area  appearing  upon  the  inside  of  the  cheek  or  tongue 
is  probably  what  is  known  as  leukoplakia,  which  is  recognized  as  a  pre- 
cancerous lesion. 

Any  irritation  of  the  tongue  and  cheek  due  to  rubbing  against  broken 
sharp  pieces  of  roots  or  against  artificial  crowns  or  false  teeth,  may  re- 
sult in  cancer. 

Any  combination  of  an  unclean  mouth  and  irritation  of  tissues  makes 
an  ideal  beginning  for  cancer  of  the  mouth;  therefore,  visit  your  dentist 
or  clinic  at  least  every  six  months  to  have  your  teeth  cleaned  and  mouth 
examined. 

Early  recognition  with  surgical  removal  is  the  only  cure  for  cancer. 
If  a  precancerous  lesion  is  evident  the  operation  may  be  done  painlessly 
under  local  anaesthesia  with  every  comfort  to  the  patient  and  surgeon. 

The  only  hope  for  control  of  this  disease  depends  entirely  upon  the 
patient  and  the  dentist — the  patient  to  be  faithful  in  his  regular  attend- 
ance upon  the  dentist;  the  dentist,  trained  to  recognize  the  early  symp- 
toms, refers  the  case  to  the  surgeon  for  treatment. 
Remember — 

That  three  months  of  cancer  of  the  mouth  is  usually  fatal. 

That  rough  edges  of  teeth,  roots  and  artificial  appliances  in  the  mouth 
cause  cancer.    Have  all  these  perfectly  smooth  to  the  tongue  and  cheeks. 

That  unhygienic  conditions  are  potential  factors  in  mouth  cancer; 
therefore,  visit  a  dentist  regularly  and  often. 

That  an  individual  with  cancer  of  the  mouth  is  a  great  liability  upon  the 
community.  So,  again  I  repeat,  that  a  frequent  examination  may  save 
your  life  and  prevent  much  unhappiness  to  those  dependent  upon  you. 

That  all  this  is  theoretically  simple,  but  its  application  difficult.  It  can 
be  done,  however,  if  you  will  do  your  part. 

That  finally  I  have  never  known  or  heard  of  a  case  of  cancer  in  a  really 
clean  mouth. 


23 

PROPOSED  DENTAL  PROGRAM  FOR  THE  SOUTHERN 
BERKSHIRE  HEALTH  DISTRICT 

Frederick  S.  Leeder,  M.D.,  D.P.H. 

Medical  Director,  Southern  Berkshire  Health  Unit 

The  Southern  Berkshire  Health  Unit  is  now  developing  a  compre- 
hensive dental  program  for  the  sixteen  communities  in  that  district. 
It  is  planned  to  incorporate  this  dental  program  into  the  already  exist- 
ing list  of  public  health  services  rendered  by  the  health  unit. 

Too  often  in  the  past,  dental  programs  have  been  restricted  in  use- 
fulness or  have  even  failed  entirely  because  of  being  too  loosely  in- 
tegrated with  already  existing  public  health  services.  Dental  service  is 
just  as  vital  a  part  of  public  health  work  as  is  milk  inspection,  tuber- 
culosis clinics,  or  any  of  the  other  activities  directed  toward  the  safe- 
guarding of  life  and  health. 

In  the  light  of  recent  advances  in  the  fields  of  nutrition,  dentistry, 
and  medicine,  the  time  has  come  when  a  program  of  simply  "pulling 
and  plugging"  must  be  discarded  in  favor  of  a  more  constructive  pro- 
gram, having  for  its  goal  the  prevention  as  well  as  the  early  treatment 
of  dental  defects. 

An  analysis  of  past  dental  programs  in  different  sections  of  the  country 
shows  that  a  rather  alarming  number  of  such  programs  have  fallen  short 
of  their  original  goal.  Some  have  died  a  natural  death  brought  on  by 
inherent  weaknesses  of  organization.  Still  others,  although  continuing 
to  flourish  year  after  year,  accomplish  no  lasting  results  because  of  pay- 
ing insufficient  attention  to  the  educational  opportunities  at  hand.  Pro- 
bably the  biggest  single  factor  leading  to  the  failure  of  a  dental  program 
is  the  failure  to  lay  a  proper  foundation  preceding  the  inauguration  of 
the  actual  demonstration. 

The  problem  facing  the  Southern  Berkshire  Health  District  is  to  assure 
efficient  and  lasting  dental  service  to  the  sixteen  towns  in  the  area.  The 
first  step  toward  the  accomplishment  of  this  objective  is  the  institution  .of 
a  sound  educational  program  for  the  local  dentists,  physicians,  and  public 
health  nurses.     This  educational  program  aims 

1.  To  put  the  very  latest  information  on  nutrition  as  it  affects  teeth 
into  the  hands  of  these  professional  workers,  and 

2.  To  insure  having  each  of  these  groups  pass  this  information  along 
to  the  general  public. 

This  part  of  the  program  has  already  been  started  and  consists  of 
talks  to  the  various  professional  groups  by  recognized  speakers  and  of 
distributing  to  these  professional  groups  the  latest  information  in  pam- 
phlet or  typewritten  form. 

After  several  months  of  intensive  educational  work,  a  full-time  "dental 
health  worker"  is  to  be  taken  on  to  the  staff  of  the  health  unit.  The 
term  "dental  health  worker"  rather  than  "dental  hygienist"  is  used  since 
this  person  is  to  do  more  than  the  usual  program  of  examining  and  clean- 
ing school  children's  teeth.  Her  function  will  be  to  make  dental  inspec- 
tions in  the  schools;  to  prepare  classroom  records  for  the  nurses'  follow- 
up;  to  help  plan  preventive  and  reparative  service  for  their  towns;  to 
talk  with  mothers  at  well  child  conferences ;  to  encourage  prenatal  dental 
hygiene  with  particular  emphasis  on  dietary  problems;  and  finally,  to 
act  as  dental  consultant  to  the  public  health  nurses  of  the  area. 

After  the  dental  health  worker  has  completed  her  study  of  the  individ- 
ual towns,  the  next  step  will  be  the  presentation  of  these  findings  to  the 
local  health  committees  concerned.  With  these  committees,  plans  will  be 
formulated  whereby  each  particular  town  may  obtain  the  service  it  needs. 
Obviously,  the  details  of  this  service  will  vary  among  the  sixteen  towns 
in  this  health  district. 


24 

In  spite  of  local  differences,  however,  three  fundamentals  will  be  in- 
corporated into  each  piece  of  local  service : 

1.  It  will  be  the  policy  to  give  service  to  as  many  children  of  three  and 
four  years  of  age  as  possible  and,  during  the  first  year  of  the  pro- 
gram, to  take  no  patient  (except  for  emergency  work)  over  seven 
years  of  age.  In  succeeding  years,  this  policy  will  be  extended  to 
include  follow-up  of  old  patients  so  that  at  the  end  of  six  years  all 
of  the  elementary  school  children  should  be  under  routine  dental 
care. 

2.  The  clinic  work  must  be  as  nearly  self-supporting  as  possible. 

3.  The  local  programs  must  be  handled  by  local  committees  with  the 
dental  health  worker  and  the  staff  of  the  health  unit  in  the  position 
of  consultants. 

The  factors  which  will  vary  in  the  dental  programs  of  the  several  com- 
munities are  the  presence  or  absence  of  a  local  dentist,  the  availability  of 
a  dentist  in  a  nearby  town,  the  general  economic  level,  and  the  attitude 
of  the  local  dentists  doing  children's  work. 

With  the  aid  of  the  Commonwealth  Fund  of  New  York  City,  the  South- 
ern Berkshire  Health  Unit  is  going  to  purchase  a  portable  dental  equip- 
ment, secure  the  services  of  a  clinic  dentist,  and  help  the  several  local 
committees  to  organize  their  respective  programs.  As  previously  stated, 
the  Unit  will  also  pay  the  salary  and  travel  expenses  of  a  full-time  dental 
health  worker. 

Each  local  committee  is  to  be  responsible  for  paying  for  the  clinic  den- 
tist's time,  for  such  assistance  as  he  may  need  other  than  that  of  the  den- 
tal health  worker,  and  for  all  necessary  clinical  supplies.  Each  local  com- 
mittee will  also  be  responsible  for  the  keeping  of  clinic  records. 

The  high  quality  and  progressive  spirit  of  the  dentists  residing  in  the 
Southern  Berkshire  District  promise  invaluable  advice  and  support  in 
connection  with  the  organization  of  the  local  programs. 

In  previous  dental  programs  it  has  been  found  that  a  charge  of  fifty 
ce"nts  per  operation — whether  cleaning,  filling  or  extracting — will  render 
a  clinic  self-supporting  providing  the  dentist  is  at  least  a  moderately  rapid 
operator  and  funds  are  available  to  pay  for  the  needy  children.  It  is 
important  that  the  people  of  each  community  realize  that  their  dental 
clinic  must  be  self-supporting.  For  the  communities  where  a  clinic  is 
held,  the  clinic  dentist  will  send  a  special  notification  slip  to  the  parents 
who  feel  that  they  cannot  go  to  a  private  dentist,  informing  them  of  the 
approximate  cost  of  having  the  necessary  operations  done  at  the  clinic. 
It  will  be  the  parents'  duty  to  see  that  the  child  arrives  at  the  clinic  with 
the  necessary  money,  and  that  as  soon  as  the  work  is  completed  the  child 
pays  the  member  of  the  local  committee  present  for  that  purpose.  This 
is  not  only  good  training  for  the  child  but  excellent  mental  hygiene  for 
all  concerned.  In  those  cases  where  the  parents  are  unable  to  pay  for  the 
work,  it  may  be  possible  to  arrange  to  have  some  local  organization  pay 
the  bill.  In  such  a  case,  the  child  himself  should  be  given  the  money  so 
that  he  may  "pay  as  he  goes"  just  as  do  his  playmates  who  happen  to 
come  from  more  fortunate  homes. 

A  survey  of  the  sixteen  towns  in  the  health  district  showed  definite 
local  interest  in  the  possibilities  of  a  dental  program.  The  survey  also 
gave  some  clue  as  to  the  kind  and  amount  of  service  which  each  of  the 
towns  would  require.  All  sixteen  of  the  towns  are  interested  in  the  ser- 
vices of  a  dental  health  worker.  Seven  of  the  towns  will  require  no  fur- 
ther dental  service  than  the  health  worker,  these  towns  making  arrange- 
ments for  their  clinical  work  with  local  or  nearby  dentists.  Two  of  these 
towns,  however,  may  wish  to  borrow  the  health  unit's  clinical  equipment 
for  the  use  of  their  local  dentists.  Nine  of  the  towns  will  require  the 
services  of  the  traveling  clinic. 

There  is  no  question  as  to  local  interest  in,  and  need  for,  an  active  den- 


25 

tal  program  in  the  Southern  Berkshire  District.  All  that  remains  is 
for  the  health  unit  to  organize  the  work  and  insure  its  becoming  perman- 
ent. This  can  only  be  accomplished  by  intensive  education  of  professional 
as  well  as  lay  groups,  by  the  organization  of  active  local  committees,  and 
by  establishing  intimate  working  relationships  between  all  interested 
parties. 

In  this  program  particular  stress  must  be  put  on  the  local  public  health 
nurses.  These  nurses,  through  virtue  of  their  position  in  the  public  eye 
and  their  access  to  the  homes  and  schools,  must  be  ready  to  take  every 
opportunity  to  spread  the  gospel  of  the  value  of  proper  diets  in  insuring 
sound  teeth,  which  in  turn  are  important  factors  toward  good  health.  To 
accomplish  this  it  is  fundamentally  important,  as  has  already  been  point- 
ed out,  that  the  proposed  dental  program  be  an  integral  part  of  the  work  of 
the  Southern  Berkshire  Health  Unit. 

The  State  Department  of  Public  Health  also  has  a  part  to  play  in  this 
program,  the  part  of  advisor  and  counselor. 

NOTES  FROM  THE  WHITE  HOUSE  CONFERENCE 

Eleanor  G.  Mc  Carthy,  B.S.,  D.H., 

Consultant  in  Dental  Hygiene, 

Massachusetts  Department  of  Public  Health 

Dr.  Leroy  M.  S.  Miner  tells  us  that  Dr.  Guy  Milberry  is  in  charge  of 
assembling  a  book  on  the  material  relating  to  dentistry  which  was  re- 
ported at  the  White  House  Conference.  As  this  book  may  not  be  ready 
for  circulation  for  several  months,  we  are  including  some  notes  taken  from 
the  report  of  the  Committee  on  Growth  and  Development  (confidential 
copy)  and  the  United  States  Daily  report  of  the  Committee  on  Medical 
Service,  Section  on  Dentistry  and  Oral  Hygiene. 

Committee  on  Growth  and  Development 

"The  different  angles  of  approach  in  studying  the  factors  influencing 
teeth  are  perhaps  the  cause  of  apparent  confusion  in  the  evidence  present- 
ed by  various  investigators.  The  profound  influence  which  the  vitamins 
are  known  to  have  on  the  assimilation  and  utilization  of  available  material 
is  not  yet  completely  worked  out.  The  basis  of  the  peculiarities  of 
various  species  of  experimental  animals  is  only  beginning  to  be  appreciated 
as  comparisons  are  made.  Until  these  considerations  are  fully  understood, 
the  nutritional  factors  involved  in  the  formation  of  sound  teeth  cannot  be 
completely  evaluated.  However,  it  can  be  said  without  qualification  that 
nutrition  is  the  most  vital  of  all  the  influences  deserving  consideration." 

"We  look  forward  confidently  to  the  time  when  it  shall  be  proved  by 
the  clinical  application  to  children  that  prenatal  and  postnatal  control  of 
diet  and  all  the  functions  involved  in  nutrition  and  assimilation,  will 
produce  the  immunity  to  caries  that  is  occasionally  seen  today. 

"The  dental  profession  has  long  been  urging  early  attention  to  the  teeth 
of  the  young  child  and  the  establishment  of  regular  visits  to  the  dentist 
as  soon  as  the  teeth  appear. 

"Early  caries  may  thus  be  controlled  and  infections  necessitating  the  ex- 
traction of  teeth  be  avoided.  From  a  preventive  point  of  view  this  is 
to  be  highly  commended. 

"Impending  deformities  may  be  recognized  and  early  steps  taken  to  pre- 
vent or  control  them.  Untreated  deformities  of  the  jaws  deprive  the  child 
of  an  efficient  masticating  machine.  Early  orthodontic  treatment,  based 
upon  recognition  of  the  various  principles  underlying  growth  and  develop- 
ment of  the  teeth,  jaws,  and  face,  will  more  rapidly  bring  about  the  good 
occlusion  which  the  child  needs  throughout  his  growing  period  and  im- 
prove his  chances  of  becoming  a  normal,  healthy  person." 


26 
Section  on  Dentistry  and  Oral  Hygiene 

I.  Existing  Conditions 

Dental  Caries 

"Surveys  indicate  that  the  incidence  of  dental  caries  among  children  is 
about  95%." 

"There  were  almost  no  figures  given  as  to  racial  differences." 

Dento-Facial  Deformities 

"Probably  85%  of  the  children  suffer  major  or  minor  defects  of  oc- 
clusion of  the  teeth." 

The  major  deformities  appear  to  be  of  nutritional  origin. 

"Percentage  of  structural  defects  nearly,  if  not  quite,  equals  the  per- 
centage of  caries.  It  seems  reasonable  to  believe  that  normal  teeth  are 
not  as  subject  to  caries  as  are  defective  teeth." 

"We  believe  that  the  arrest  in  the  development  of  the  bones  that  carry 
the  teeth  is  due  to  dietary  deficiency  and  that  this  is  the  most  important 
causative  factor  of  the  irregularities  of  the  teeth.  These  deformities  are 
symptoms  of  other  skeletal  defects  which  in  no  instance  can  be  traced  to 
causes  of  a  purely  dental  origin." 

"Caries  and  subsequent  premature  loss  of  teeth  is  the  most  frequent 
and  pernicious  contributory  factor  in  dento-facial  deformities,  resulting 
in  gross  assymetry  even  in  those  cases  where  inherent  forces  of  growth 
and  development  are  adequate." 

Mouth  Infections 

Diseases  such  as  nephritis,  pyelitis  and  endocarditis  may  be  traceable 
to  infected  jaws  or  teeth  and  conversely,  hypoplasia  and  other  deformities 
of  the  teeth  may  be  traceable  to  measles,  whooping  cough  or  scarlet  fever. 
They  may  be  due  to  nutritional  disturbances  as  an  indirect  result.  The 
Committee  feels  that  more  investigation  is  needed  on  this  subject. 

II.  What  Is  Being  Done 

Therapeutic  Procedures 
(Technical -dental  service  or  mechano-therapy) 

(a)  Cleaning  teeth. 

(b)  Filling  the  cavities  in  decayed  teeth. 

(c)  Extracting  teeth   (prematurely  or  at  appropriate  time). 
Extracting  the  temporary  teeth  prematurely  may  wreck  the  permanent 

arches  as  well  as  impair  the  chewing  apparatus  during  the  period  when 
such  teeth  should  function  normally. 

The  retention  of  the  temporary  teeth  beyond  the  time  when  they  should 
exfoliate  normally  may  also  result  in  deformed  arches  when  the  succeeding 
permanent  teeth  finally  erupt. 

"The  Committee  expresses  its  approval  of  the  art  and  skill  established 
by  the  dental  profession  of  America  as  remedial  measures  after  the 
ravages  of  dental  disease  have  brought  about  the  loss  of  these  useful 
organs,  the  teeth". 

(d)  Orthodontic  treatment 

"Orthodontic  procedure  is  undergoing  a  state  Of  transition  in  the 
educational  field  with  some  disagreement  as  to  appropriate  age  of  treat- 
ment." 

"Functional  activity,  such  as  muscle  exercises  of  the  jaws  and  teeth, 
properly  controlled,  as  a  means  of  correcting  incipient  dento-facial  de- 
formities or  bad  habits,  is  prescribed  by  some  practitioners  with  success." 

Educational  Procedures 
(a)  Dental  Teaching — 

Mouth  hygiene  drills — actual  brushing  of  teeth. 


27 

"Nutritional  instruction — which  has  for  its  purpose  the  formation 
of  habits  in  establishing  a  proper  dietary  regime  that  will  insure  good 
health  and  sound  teeth." 

"In  the  field  of  mouth  hygiene  and  prophylaxis  there  is  every  rea- 
son why  the  teachings  and  practice  of  the  dental  profession  should  be  con- 
tinued if  for  no  other  reason  than  that  of  personal  hygiene." 

"The  status  of  the  dental  hygienist  is  at  present  unsettled  and  the 
requirements  for  her  training  cannot  be  established  until  her  future 
function  is  clearly  defined." 

(b)   Three  stages  of  growth  and  development. 

1.  Maternal  and  prenatal  period. 

We  have  scientific  evidence  that  without  a  proper  supply  of  calcium 
and  phosphorus,  sound  teeth  cannot  form. 

"It  has  been  demonstrated  that  three  of  the  known  vitamins  have  a 
direct  influence  on  tooth  formation,  namely,  Vitamins  A,  C  and  D." 

2.  Infant  and  preschool  period. 

This  period  is  sadly  neglected. 

"All  the  crowns  of  the  permanent  teeth  are  developing  in  the  jaws 
and  their  usefulness  throughout  life  is  dependent  entirely  on  the  nutri- 
tion the  child  receives  during  this  period.  Fifty-two  teeth  are  in  various 
stages  of  development  in  the  human  jaws  at  this  time." 

3.  School  Age. 

"The  school  child  presents  special  problems — social,  environmental, 
psychic — in  addition  to  the  nutritional  problem,  with  resultant  influence 
on  his  dentition." 

"The  nutritional  phase  of  these  educational  procedures  in  school 
and  college  life  is  illustrated  today  by  extremes ....  all  of  which  are  little 
understood  by  the  public." 

Miscellaneous 

"The  experimental  laboratories.  .  .  have  shown  that  defects  in  the  de- 
velopment of  the  teeth  and  jaws  can  be  produced,  arrested  or  prevented 
to  a  large  extent  by  regulation  of  the  diet." 

"Modern  research  has  provided  substantial  evidence  that  dental  caries 
depends  upon  a  general  metabolic  disturbance  based  on  faulty  nutrition." 

"...  from  mid-term  in  foetal  life  until  late  infancy  the  teeth  are  de- 
pendent exclusively  on  nutrition,  during  which  time  the  children  are 
under  the  supervision  of  the  family  physician,  or  the  obstetrician  and 
the  pediatrician  and  it  becomes  their  problem  to  advise  the  mother  in 
matters  of  tooth  development.  The  dentist  as  a  rule  has  no  direct  con- 
tact with  the  child  during  this  time  and  rarely  sees  the  mother." 

From  the  age  of  two  years  on  the  child  occasionally  or  regularly  comes 
under  the  supervision  of  the  dentist.  The  need  for  nutritional  attention 
and  study  still  continues  and  some  dentists  are  preparing  to  meet  it. 

"Both  the  public  and  the  professions  are  under-informed  on  matters  re- 
lating to  certain  phases  of  mineral  metabolism  affecting  the  teeth." 

"Medical  and  dental  schools,  schools  of  graduate  instruction,  schools 
for  nurses,  hygienists  and  nutritionists  do  not  teach  it  (mineral  metabol- 
ism and  effect  on  teeth)  adequately". 

The  scientific  and  practical  phases  of  the  problem  are  not  well  correlated 
at  the  present  time. 

A  survey  showed  that  there  was  very  little  information  "regarding 
either  policy  or  procedure  (at  the  dental  schools  in  the  country)  about 
their  activities  in  dentistry  for  children  and  in  nutritional  instruction 
leading  to  the  prevention  of  diseases  and  promotion  of  health." 

A  survey  of  82  medical  schools  in  the  country  showed  that  only  14 
were  "giving  any  time  or  attention  to  dental  relationships." 


28 

"A  survey  of  14  leading  dental  publications  for  1930  showed  281 
articles  dealing  with  various  phases  of  this  problem  of  the  prevention 
of  dental  disorders." 

The  Dental  Associations  have  endeavored  to  carry  on  the  problem  of 
advanced  instruction  to  dentists.  "The  character  of  the  instruction 
given  by  them  is  determined  largely  by  the  executive  officers  or  pro- 
gram committees  who  change  annually,  so  that  rarely  does  a  consecu- 
tive or  continuous  policy  exist  in  them." 

"A  change  of  diet  in  adult  life  is  not  a  panacea  for  the  correction 
of  dental  caries  or  oral  infections."  Home  and  professional  care  of  the 
mouth  is  still  needed  although  caries  has  been  arrested. 

Nutrition — "Circulation  has  been  demonstrated  and  it  has  assumed  a 
special  significance  as  the  medium  through  which  calcium  and  phos- 
phorus are  brought  to  the  tooth  or  taken  away  from  it." 

III.  What  Ought  To  Be  Done 

Adequate  and  Complete  Records 

The  dental  case  record  constitutes  the  base  line  of  our  study.  From 
this  we  develop  our  standards  of  measurements  and  draw  up  appraisal 
forms  which  will  afford  information,  advising  us  of  the  progress  of  our 
patients. 

Periodic  Examination 

Without  which  we  know  little  of  the  need  for  prevention. 

"If  the  condition  of  the  teeth  is  a  symptom  of  a  defective  mineral 
metabolism  then  we  should  take  cognizance  of  these  symptoms  and  insti- 
tute preventive  measures  that  will  forestall  the  dental  calamities  and 
their  sequelae  in  later  life." 

Miscellaneous 

These  educational  institutions  (dental  schools)  should  change  their 
viewpoint  on  dentistry  from  interest  in  the  treatment  of  disease  to  a 
philosophy  of  the  promotion  of  health. 

"Medical  and  dental  schools  should  extend  their  courses  in  physi- 
ology, biological  chemistry  and  pediatrics  to  emphasize  the  funda- 
mental role  of  minerals  and  vitamins  in  the  problems  of  dental  health." 

"Advice  and  consultation  on  the  maintenance  of  dental  health  is  ah 
increasing  and  important  function  of  dentistry." 

"There  is  a  great  need  and  a  great  opportunity  for  extending  the 
frontiers  of  knowledge  through  further  development  of  research  which 
should  be  well  supported  with  sufficient  funds  for  a  continuous  pro- 
gram." 

"The  solution  of  the  dental  problem is  not  entirely  the  re- 
sponsibility of  the  dentist  and  the  medical  profession.  It  is  a  social,  a 
community  problem " 

Professional  efforts  and  whole-hearted  public  support  must  be  com- 
bined if  there  is  to  be  a  definite  progress  toward  the  elimination  of 
dental  disease. 

"Examination  of  dental  conditions  should  be  conducted  and  recorded 
according  to  a  carefully  standardized  method  in  order  that  data  col- 
lected by  various  workers  in  different  localities  may  be  correlated.  A 
careful  study  should  be  made  to  determine  the  effectiveness  of  present 
methods  of  dental  care  in  the  control  and  prevention  of  caries." 

"We  should  continue to  extend  dental  care  and  hygiene,  begin- 
ning in  early  infancy  with  the  close  cooperation  of  the  pediatrician." 

"Systematic  periodic  dental  examinations  and  treatment  should  be 
instituted  to  prevent  the  development  of  infections  due  to  advanced 
caries  and  to  avoid  unnecessary  extractions." 

"Dental  disorders  constitute  one  of  the  earliest  signs  of  an  inferior 


29 

physical  condition.  Their  importance  should  be  recognized  by  the 
medical  as  well  as  the  dental  profession." 

"Obstetricians  and  physicians  are  urged  to  direct  their  efforts 
through  prenatal  and  pediatric  care  toward  the  protection  of  well  de- 
veloped jaws  and  sound  teeth  which  are  formed  in  foetal  life  and 
infancy." 

"We  believe  that  the  prime  object  of  dentistry  is  a  healthy  mouth  in 
a  healthy  body." 

THE  JUNIOR  LEAGUE  DENTAL  CLINIC 

Mrs.  Roswell  G.  Mace,  Chairman 
Springfield,  Massachusetts 

In  1928,  the  Out-Patient  Department  of  the  Springfield  Hospital, 
which  the  Junior  League  of  Springfield  had  established  and  maintained 
for  three  years  as  its  major  project,  was  taken  over  by  the  Community 
Chest.  On  the  advice  of  the  local  dental  society,  and  with  their  help 
and  that  of  the  State  Consultant  in  Dental  Hygiene,  the  League  then  estab- 
lished at  the  Hospital*  in  November  1928,  a  preschool  dental  clinic. 
The  clinic,  at  the  start,  was  open  two  half  days  a  week,  with  a  dentist 
and  an  assistant  in  charge.  Contact  was  made  with  the  various  social 
agencies,  and  notices  of  the  opening  of  the  clinic  were  sent  to  the 
papers.  Due  to  the  great  need  of  dental  care  for  children  of  school  age, 
the  work  the  first  year  was  not  limited  to  preschool  cases,  but  even 
though  no  child  was  refused  treatment,  over  26  per  cent  of  the  cases 
were  of  preschool  age.  Because  of  its  location  in  the  Out-Patient  De- 
partment, adult  cases  were  sent  to  the  clinic,  and  in  March  of  1929 
another  half  day  was  added  to  take  care  of  this  class  of  patient. 

In  March,  1930,  it  seemed  advisable  to  move  the  clinic  to  its  present 
location  at  110  State  Street  in  the  same  building  with  the  Junior  League 
Salvage  Shop  and  Club  Room.  At  the  Hospital  the  need  for  dental  work 
for  prenatal  patients  had  been  most  apparent.  Consequently,  one  half 
day  was  given  to  these  patients,  while  the  other  two  half  days  were 
devoted  to  preschool  patients  only,  eliminating  school  children  and 
adults.  In  September  of  that  year  the  prenatal  work  had  assumed  such 
proportions  that  it  was  necessary  to  add  another  half  day.  Because  of 
the  difficulty  in  getting  the  prenatal  patients  to  the  clinic  early  in 
pregnancy,  it  was  found  that  it  was  in  many  cases  not  possible  to  fin- 
ish the  necessary  work  before  confinement.  Therefore,  early  last  sum- 
mer the  policy  of  extending  the  service  to  this  class  of  patient  for  three 
months  after  confinement  was  started  as  an  experiment.  It  is,  of  course, 
the  hope  of  the  League  that  after  the  clinic  has  been  in  operation  suf- 
ficiently long,  the  education  of  the  prenatal  cases  will  have  progressed 
to  such  a  point  that  they  will  come  to  the  clinic  early  enough  so  that 
the  work  after  confinement  will  not  be  necessary. 

During  the  last  twelve  months  the  clinic  took  care  of  125  prenatal 
patients.  Seven  of  these  came  in  from  the  first  to  third  month,  twenty- 
nine  from  the  third  to  fifth,  twenty-one  from  the  fifth  to  seventh,  fifty- 
eight  from  the  seventh  to  ninth,  and  ten  were  given  postnatal  care.  Of 
the  preschool  cases,  which  numbered  242,  105  were  between  the  ages 
of  two  and  four  and  137  between  four  and  six. 

The  majority  of  the  cases  are  referred  by  the  Visiting  Nurse  Associ- 
ation, the  Wesson  Maternity  Clinic,  the  Buckingham  Home  for  Children, 
the  William  Street  Home  for  Friendless  Women  and  the  West  Spring- 
field Neighborhood  House.  The  appointments  are  made  by  these 
agencies  directly  through  the  assistant  at  the  clinic,  during  clinic 
hours,  which  are  Monday  and  Tuesday  mornings  for  preschool  children, 
and  Monday  afternoon  and  Thursday  morning  for  prenatal  cases.  A  fee 
of  ten  cents  a  visit  is  charged  to  those  who  can  pay  it. 

Beyond  a  few  posters  in  the  clinic  rooms  and  suggestions  to  the 
patient  by  the  dentist  and  his  assistant,  the  League  has  not  gone  into 


30 

nutritional  education,  but  this  is  a  phase  of  the  work  which  the  League 
hopes  to  continue,  perhaps  by  having  a  volunteer  instructor.  Tooth- 
brushes, with  instruction  for  the  proper  use  of  them,  are  given  the 
patients  who  have  none. 

The  cost  of  the  clinic  for  the  last  year  was  $3,134.00,  and  the  total 
number  of  operations  was  1,710,  which  was  an  increase  of  528  over  the 
preceding  year. 

The  League  feels  that  a  project  which  demands  such  widespread  in- 
terest and  fills  such  an  evident  need  in  the  community  has  been,  and 
is,  worthy  of  its  support. 

A  PRENATAL  AND  PRESCHOOL  DENTAL  PROGRAM 

FROM  A 

PUBLIC  HEALTH  NURSING  POINT  OF  VIEW 

Eva  A.  Waldron,  R.  N. 

Director 

Springfield  Nursing  and  Public  Health  Association 

If  the  saying  "A  little  bug  will  get  you  some  day"  is  true,  it  may  seem 
useless  to  stress  factors  which  institute  good  habits  of  hygiene,  behavior 
and  diet;  on  the  other  hand,  the  desire  to  live  is  paramount  in  all.  For 
years,  physicians  and  dentists  have  proven  that  disease  may  come  from 
neglected  teeth,  that  is  to  say,  poorly  nourished  teeth  as  well  as  teeth 
lacking  in  external  care. 

As  a  part  of  the  Maternity  and  Child  Health  program  of  the  Springfield 
Nursing  and  Public  Health  Association,  the  basic  needs  for  good  teeth 
are  introduced  as  early  as  possible  during  the  contact  with  the  "pre- 
schools."  In  the  case  of  "prenatals,"  the  detail  depends  somewhat  upon 
the  duration  of  the  pregnancy. 

Springfield  is  fortunate  in  having  a  prenatal  and  preschool  dental 
clinic  to  which  patients,  who  cannot  afford  their  own  dentist,  may  be 
referred  for  care.  The  prenatal  dental  program  has  been  more  satisfac- 
torily accepted  than  that  of  the  preschool,  perhaps  for  the  reason  that 
rearrangement  of  household  routine,  particularly  of  the  primipara,  lends 
itself  more  easily  to  this  feature.  Transportation  and  placement  of 
children  which  cannot  always  be  planned  ahead  is  a  problem  of  the 
multipara  and  causes  many  broken  appointments. 

Illustrative  pamphlets,  such  as  those  issued  by  the  Department  of 
Public  Health,  are  used  extensively  when  emphasizing  the  material  nec- 
essary to  build  strong  teeth  and  bones,  and  also  when  demonstrating  ex- 
ternal care.  If  eating  for  teeth  happens  to  be  a  new  idea  considerable 
repetition  may  follow  before  the  patient  becomes  prophylaxis-minded  and 
preventive  dentistry  is  actually  accepted.  Much  is  gained  by  stressing 
the  improvement  in  personal  appearance. 

The  six  essentials  for  balanced  nutrition,  outlined  as  follows,  are  stress- 
ed and  elaborated  upon  as  conditions  indicate: 

1  quart  milk 

1  citrous  fruit 

1  vegetable  (raw) 

1  vegetable  (cooked) 

1  whole  grain  cereal  or  whole  wheat  bread 

1  egg 

At  the  child  health  clinics  the  first  approach  to  the  subject  of  dental 
care  is  usually  brought  about  through  the  physical  examination,  when 
specific  recommendations  are  given  by  the  medical  director.  Then,  too,  the 
nurse  attempts  to  prepare  the  child  for  the  situation  he  will  meet  at  the 
clinic  somewhat  in  the  following  elementary  manner:  A  ride,  probably 
in  the  trolley  car,  eventually  arriving  at  the  dentist's  who  is  especially 


31 

fond  of  children — perhaps  there  will  be  an  opportunity  to  wait  in  a  room 
where  there  is  a  piano,  just  the  right  size  for  him,  upon  which  he  can 
play — a  chair  with  arms  also  the  right  size — books,  blocks,  and  possibly 
someone  there  who  will  tell  him  the  story  of  Peter  Rabbit  who  ate  vegeta- 
bles from  the  garden  which  gave  him  strong  teeth.  The  doctor,  of  course, 
will  look  in  his  mouth  and  perhaps  find  and  treat  a  tooth  that,  if  left  un- 
cared  for,  might  hurt  very  badly  the  next  time  he  bit  an  apple.  Here 
again  the  improvement  in  personal  appearance  as  well  as  physical  health 
is  pointed  out.  Having  made  one  contact  resulting  in  pleasant  experiences 
the  child  returns  for  follow-up  without  much  urging.  By  the  time  the 
"preschool"  arrives  at  the  dental  clinic  the  mother  is  informed  about  the 
diet  to  build  teeth,  the  need  of  daily  prophylaxis,  and  why  this  program 
must  be  begun  early  to  protect  deciduous  teeth. 

Education  of  a  varied  nature  is  dispensed  by  the  nurses,  deficiency 
cases,  or  children  with  capricious  appetites,  or  other  food  habits,  are 
referred  to  the  nutritionist.  Having  only  one  to  serve  the  entire  district, 
much  of  this  work  is  advisory  to  groups  by  appointment;  that  is  to  say, 
the  nutritionist  visits  each  clinic  on  schedule  and  the  clients  may  return 
by  appointment  for  this  consultation,  unless,  for  expediency,  a  home  visit 
is  indicated.  Occasionally  a  child  guidance  worker  is  asked  to  help  correct 
some  personality  difficulty  which  is  retarding  a  dental  contact.  Sometimes 
the  two  together  are  necessary  in  case  of  thumb  sucking,  too  prolonged  use 
of  the  bottle,  improper  mastication  of  food  or  malformations  arising 
from  other  causes. 

For  the  year  1931  the  following  figures  show  the  number  of  patients 
receiving  care  at  the  clinic.  "Prenatals"  are  shown  according  to  the 
month  they  were  admitted,  and  the  "preschools"  by  age  groups. 

lst-3rd        3rd-5th        5th-7th        7th-9th        Postpartum        Total 
7  29  21  58  10  125 

Preschool 

2 — 4  yrs.  4 — 6  yrs.  Total 

105  137  242 

The  recent  report  published  by  the  White  House  Conference  Committee 
shows  that  in  Springfield  only  6  per  cent  of  the  children  of  three  years 
of  age  have  had  dental  attention  and  the  majority  of  these  are  in  the 
higher  economic  groups.  There  is  as  yet  no  yard  stick  by  which  results 
can  be  measured  nor  the  extent  to  which  this  clinic  should  serve  the  com- 
munity. During  the  past  two  years  pressure  of  nursing  work  has  greatly 
reduced  the  amount  of  child  health  follow-up  done  by  this  Association. 
However,  it  is  fully  appreciated  that  greater  concentration  on  this  phase 
of  the  work  would  be  well  compensated  and  has  been  clearly  indicated.  It 
has  been  said,  and  rightly  so,  that  health  and  dental  examinations  more 
intimately  reflect  the  educational  and  promotional  activity  of  organized 
health  services  and  the  preventive  attitude  of  the  medical  profession. 

The  important  thing  is  not  to  underestimate  the  relationship  between 
the  teeth  and  the  individual's  health.  It  is  easy  to  become  involved  in  a 
vicious  cycle  of  poor  teeth,  improper  mastication,  faulty  digestion,  auto- 
intoxication, and  consequently  inability  to  carry  on  normal  activity;  on 
the  contrary  dental  prophylaxis  and  adequate  nutrition  provide  good 
teeth,  good  nutrition,  and  positive  health,  the  ultimate  aim  of  Public 
Health  Nursing. 

PRESCHOOL  AND  PRENATAL  DENTAL  CLINIC 

J.  Hal  T.  Maloney,  D.  D.  S. 
Springfield,  Massachusetts. 

The  temperaments  of  preschool  and  prenatal  cases  differ  greatly 
from  those  of  school  age  and  the  ordinary  adult  case. 


32 

The  preschool  child  ordinarily  has  not  had  enough  outside  associa- 
tion to  have  any  fear  of  the  dentist.  In  saying  this  probably  80  per 
cent  of  the  total  is  true.  The  remaining  20  per  cent  are  physically  able 
and  mentally  stubborn  enough  to  put  up  a  battle.  Two  ways  are  open 
to  the  operator  to  overcome  these  handicaps.  Coaxing  and  flattery  is 
invariably  used,  and,  if  unsuccessful,  firmness  may  be  resorted  to. 

Extractions  are  not  attempted  the  first  visit  unless  it  is  absolutely 
necessary.  First  impressions  are  lasting  with  many.  This  is  particu- 
larly true  with  smaller  children.  Following  this  method  the  child  will 
gradually  realize  that  he  is  not  coming  to  the  dentist  to  be  hurt. 

If  there  is  a  chance,  however,  that  pain  may  result  from  operating, 
the  child  is  always  warned  beforehand  that  it  may  hurt  a  little  bit. 
Telling  the  child  that  it  won't  hurt  a  bit  and  then  causing  pain  causes 
that  child  to  lose  confidence  in  the  operator,  because  he  has  been  told 
a  lie. 

Appointments  are  made  at  thirty-minute  intervals  in  order  that 
patients  may  be  kept  waiting  as  short  a  time  as  possible. 

Appointments  are  also  made  every  thirty  minutes  for  prenatal  pa- 
tients, to  lessen  any  broodiness  or  nervousness  that  might  be  caused 
by  long  waiting. 

Cavity  preparation  in  deciduous  teeth  is  generally  circular  and  under- 
cut. Zinc  cement  is  used  in  anteriors,  copper  cement  and  amalgam  in 
posteriors.  Silver  nitrate  is  used  over  hard  decay  in  posteriors.  All 
abscessed  teeth  are  extracted,  usually  with  ethyl  chloride  either  locally 
or  generally. 

In  cases  where  the  teeth  are  badly  spaced  and  subject  to  decay  an 
attempt  is  made  to  find  out  from  the  parent  if  the  child  has  enough 
calcifying  factor,  vitamin  D,  incorporated  in  its  diet.  If  not,  orange 
juice,  cod  liver  oil,  and  foods  that  need  much  mastication,  to  give  exer- 
cise to  the  jaws,  expand  the  dental  arch,  and  prepare  room  for  perman- 
ent teeth,  are  advised. 

Prenatal  cases  are  usually  referred  by  the  visiting  nurse's  associa- 
tion, and  also  have  to  be  handled  very  judiciously  their  first  visit.  The 
majority  of  these  cases  labor  under  the  false  impression  that  dental 
work  should  not  be  done,  particularly  during  pregnancy. 

Soft,  bleeding  gums  are  usually  treated  with  10  per  cent  chromic 
acid  and  20  per  cent  argyrol  with  very  gratifying  results.  Novocaine 
is  used  for  extractions,  general  anaesthesia  having  a  tendency  to  pro- 
duce premature  labor.  At  the  third  and  seventh  month  particular  care 
must  be  taken  that  the  patient  be  not  unduly  upset. 

Expectant  mothers  are  also  advised  as  to  diet,  and  circulars  procured 
from  the  State  House  are  given  to  them.  Very  few  realize  that  their 
diet  will  have  any  bearing  on  the  teeth  of  their  child.  Dr.  Percy  R. 
Howe  says  "A  diet  which  produces  bones  of  poor  quality  invariably 
shows  its  effect  on  the  teeth." 

All  patients  are  treated  with  the  same  respect  and  courteousness  that 
they  would  be  shown  in  a  private  office. 

THE  PRESCHOOL  CHILD  AT  THE  TOWN  DENTAL  CLINIC 

Helen  M.  Heffernan,  R.  N. 
,    Board  of  Health  Nurse,  Arlington,  Massachusetts 

Town  dental  clinics  were  started  to  care  for  the  school  child.  Years 
of  experience  have  proven  that  in  many  cases  children  even  in  first  and 
second  grades  have  waited  until  too  late  for  this  care. 

The  Arlington  Clinic,  realizing  this,  started  taking  preschool  chil- 
dren in  1926;  only  two  such  children  came,  but  these  showed  the  great 
need  of  dental  care  as  early  as  three  years. 

As  board  of  health  nurse,  supervising  homes  with  contagious  dis- 


33 

eases  present,  I  have  the  opportunity  to  talk  to  parents  of  early  dental 
care.  The  Preschool  Clinic  for  Medical  Examination  recommends  such 
care,  but  very  small  results  are  obtained  this  way.  The  parents  seem 
to  understand  better  and  act  more  quickly  when  the  matter  is  presented 
at  home. 

Our  first  active  year  of  preschool  attendance  at  the  clinic  was  1927. 
During  the  year  we  had  nineteen  children,  all  over  three  years  old,  ten 
of  whom  had  all  necessary  work  completed.  The  figures  are  small,  but 
the  results  far-reaching. 

Preschool  attendance  has  grown  slowly  for  two  important  reasons, 
the  first  being  lack  of  time.  The  operating  time  is  three  hours  a  morn- 
ing and  there  are  nine  schools  to  be  accommodated,  which  means  every 
morning  must  be  divided.  This  allows  us  room  for  only  two  preschool 
appointments  at  the  most.  The  second  reason  is  the  difficulty  a  mother 
has  in  leaving  home  with  other  infants  for  which  to  care.  Very  few 
appointments  are  broken;  the  parents  bring  the  babies  even  when 
stormy. 

The  demand  for  clinic  treatment  grows  steadily.  Children  may  come 
between  the  ages  of  one  to  seven  and  continue  through  the  sixth  grade. 
In  1930,  we  ruled  that  no  child  could  attend  the  clinic  unless  entered 
before  he  leaves  the  second  grade.  This  ruling  has  done  more  to  stimu- 
late parents  into  action  than  anything.  However,  there  are  many  par- 
ents who  appreciate  the  advantage  and  understand  the  necessity  for 
early  care.  There  are  also  the  parents  who  bring  their  children  first 
because  of  toothache  and  continue  from  a  knowledge  of  benefits  derived. 

The  work  required  by  these  babies  covers  the  whole  field  of  clinic 
operations.  A  correct  picture  of  this  was  obtained  by  taking  from  the 
record  of  each  preschool  child  who  attended  the  clinic  between  Sep- 
tember 1930  and  June  1931  the  age,  extractions,  treatments,  fillings, 
polishings,  total  operations  and  dismissals.  The  ages  ran  from  two  to 
five,  sixty-four  of  the  ninety-four  were  three  and  four,  the  remainder 
two  and  five.  There  was  a  total  of  forty-seven  extractions,  eleven  of 
which  were  from  two  three-year-olds;  one  lost  eight  teeth,  all  were 
abscessed.  By  treatments  we  mean  Silver  Nitrate  used  under  Amalgam 
for  sterilization,  these  totalled  two  hundred  and  seventy-six.  There 
was  a  total  of  four  hundred  and  eighty-two  Amalgam  or  Black  Copper 
Cement  fillings.  Forty-five  had  their  teeth  polished,  making  a  total  of 
eight  hundred  and  fifty  operations.  Only  fourteen  of  the  ninety-four 
babies  were  not  dismissed,  some  were  dismissed  three  times  during  the 
period,  making  our  number  of  preschool  dismissals  ninety.  One  four 
year  old  girl,  who  started  at  two,  was  dismissed  twice,  making  her 
sixth  dismissal. 

Much  could  be  said  about  the  difficulty  of  working  on  children  so 
young.  We  feel  justified  in  saying  they  are  more  easily  managed  than 
older  children.  Nine  and  ten  year  old  children  go  to  the  dentist  con- 
vinced of  discomfort  from  hearsay,  whereas  the  babies  give  the  dentist 
the  benefit  of  the  doubt  and  cry  only  when  hurt.  Their  mouths  are  small 
and  they  tire  quickly,  but  it  is  not  an  unusual  thing  for  a  child  to  have 
three  small  Amalgam  fillings  at  a  sitting. 

We  had  one  hundred  and  twenty-three  during  1931  at  our  regular 
clinic  sessions,  with  ninety-seven  dismissals — more  than  six  times  as 
many  as  four  years  ago.   Two  of  this  number  were  fifteen  months  old. 

It  is  only  by  constant  pressure  on  the  parents  of  these  infants  that 
we  get  them;  but  it  is  worth  the  energy  we  give.  Parents  need  educa- 
tion and  are  appreciative  when  the  results  prove  its  value.  Later  gener- 
ations will  understand  without  being  shown,  we  hope. 

Is  there  anything  as  beautiful  as  a  healthy  happy  child?  We  often 
see  the  child  change  to  this  during  its  visits  to  the  clinic.  Who  wouldn't 
have  the  will  to  work? 


34 

A  RED  CROSS  TRAVELING  DENTAL  CLINIC 

Nancy  A.  Trow 

Executive  Secretary 

Hampshire  County  Chapter,  American  Red  Cross 

Following  the  close  of  the  war,  the  American  Red  Cross  adopted  a 
public  health  program  which  gave  the  Chapters  an  opportunity  for  real 
service  in  rural  communities.  The  Hampshire  County  Red  Cross  had, 
during  the  trying  days  of  1917,  1918,  and  1919,  so  well  organized  fifteen 
towns  in  the  Chapter  territory  that  when  the  Armistice  was  signed  this 
group  felt  a  real  desire  to  "carry  on." 

There  were  many  disabled  men  to  be  cared  for  and  in  solving  their 
family  problems  the  great  need  of  dental  service  was  forcibly  brought 
home.  Many  of  our  towns  were  twenty  and  thirty  miles  from  a  city 
dentist.  Even  though  some  of  the  families  had  the  necessary  fee  and 
the  transportation  to  bring  the  children  to  a  dentist,  parents  and  grand- 
parents all  worked  on  the  theory  that  they  had  never  spent  money  on 
their  teeth,  they  had  lived  to  a  ripe  old  age,  so  why  bother  with  the 
children.  They  waited  until  the  toothache  was  unbearable  and  then  the 
tooth  was  extracted. 

In  1921  a  member  of  the  Red  Cross  Executive  Board  saw  the  oppor- 
tunity for  solving  this  problem  and  proposed  that  a  traveling  dental 
clinic  for  schools  be  sponsored  by  the  Chapter  to  meet  the  needs  of  the 
small  towns.  A  survey  was  made  which  proved  its  feasibility  and  by 
September  a  Dental  Clinic  Committee  had  been  organized,  portable 
equipment  purchased,  and  a  dentist  engaged  for  two  days  a  week.  We 
then  offered  to  any  town  in  the  county,  without  a  resident  dentist,  the 
services  of  our  dentist.  The  superintendents  of  schools,  school  com- 
mittees, and  nurses  welcomed  this  chance  for  children  to  receive  the 
care  so  much  needed.  A  charge  of  fifty  cents  for  each  operation  was 
made  as  we  felt  this  fee  was  not  prohibitive  for  any  family  receiving 
the  benefits  of  the  clinic.  The  Red  Cross  assumed  all  expenses  and 
carried  the  deficit. 

Our  first  problem  was  to  educate  the  parents,  impressing  them  par- 
ticularly with  the  need  for  the  care  of  teeth  even  for  children  in  the 
lower  grades.  It  has  taken  time  and  patience  to  win  their  confidence 
and  to  convince  them  that  our  chief  interest  is  the  better  health  and 
improved  appearance  of  their  children. 

As  a  result  of  our  efforts  the  clinic  has  gradually  grown  to  a  full- 
time  service.  During  the  fiscal  year  just  closed,  our  dentist  examined 
in  thirteen  towns  1,746  school  children  and  found  1,533  with  dental 
defects.  Nine  hundred  and  ninety-eight  children  attended  the  clinic 
involving  3,385  operations.  We  are  particularly  fortunate  in  our 
present  dentist  for  he  is  as  anxious  as  the  Red  Cross  to  make  the  clinic 
a  success,  and  urges  the  parents  and  committees  to  attend  the  clinic, 
to  learn  more  about  the  program. 

This  year  we  will  serve  fourteen  towns  out  of  a  possible  fifteen.  It 
is  no  longer  necessary  to  seek  the  interest  of  the  committees:  they 
register  their  application  for  the  clinic  with  the  opening  of  the  school 
year  just  as  they  request  the  use  of  the  Red  Cross  audiometer. 

While  for  nine  years  the  major  part  of  the  expense  of  the  clinic  was 
borne  by  the  Chapter,  today  it  is  practically  a  self-supporting  project. 
Formerly  many  of  the  children  needed  dental  care  so  badly  that,  at  the 
request  of  the  nurse  or  teacher,  free  work  was  granted;  but  today  we 
find  that  the  work  is  sufficiently  appreciated  for  the  family  budget  to 
be  planned  with  an  allowance  for  dentistry.  The  Granges,  Women's 
Clubs,  and  church  groups  are  in  many  places  carrying  the  supply  bills 
as  well  as  certain  charitable  cases.    While  some  towns  appropriate 


35 

funds  at  their  town  meetings,  we  still  feel  it  is  better  to  have  the  co- 
operation and  support  of  the  organizations  mentioned. 

Today  so  much  emphasis  is  being  placed  on  the  subject  of  oral 
hygiene  that  we  find  our  cities  and  larger  towns  equipped  to  care  for 
the  children  in  the  public  schools  but  because  of  the  expense  these 
clinics  are  prohibitive  for  smaller  communities.  Therefore  the  Red 
Cross  has  a  real  opportunity  to  provide  this  service  at  a  price  within 
the  reach  of  every  family.  Certainly  there  is  no  better  way  of  serv- 
ing the  small  towns  and  thus  winning  appreciation  for  this  large 
national  organization. 

The  Hampshire  County  Chapter  largely  owes  the  success  of  this 
clinic  to  the  State  Department.  They  have  constantly  guided  and  ad- 
vised through  their  Consultant  in  Oral  Hygiene,  giving  us  the  benefit 
of  their  years  of  experience  in  public  health  work. 

BUILDING  SOUND  TEETH 

(Part  of  the  State  Extension  Service  Program) 

May  E.  Foley 

Extension  Nutritionist 

Massachusetts  State  College 

Not  long  ago  I  picked  up  at  random  an  issue  of  "Dental  Survey."  It 
happened  to  be  the  April,  1931  issue.  I  was  somewhat  surprised  to  find 
in  it  three  articles  in  which  diet  in  relation  to  sound  teeth  was  the  theme. 
One  was  "Care  of  Teeth  During  Pregnancy,"  one  "Diet  in  Development  of 
the  Dental  Machine,"  and  one  "Dieting  to  Prevent  Pyorrhea."  Dr.  LaVake, 
in  the  first  article  says,  "Pregnancy  adds  to  the  everyday  problem  of 
dental  decay  due  to  dietary  deficiency,"  and  goes  on  to  recommend  a  diet 
"rich  in  whole  milk,  eggs,  fruits  (especially  the  citrus  fruits),  whole 
grain  cereals  and  vegetables,  with  emphasis  upon  green,  leafy  vegetables, 
and  meat  no  oftener  than  once  a  day."  Dr.  Quinby,  author  of  the  second 
article,  who  also  has  an  article  elsewhere  in  this  issue,  develops  his  theory 
of  building,  care,  and  repair  of  the  dental  machine,  and  says  "Our  machine 
must  first  of  all  be  built  strongly,  to  stand  stress.  It  must  be  obvious  to 
any  serious  thinker  on  this  subject  that  it  is  of  little  avail  to  talk  about 
seeing  the  little  patient  at  the  age  of  three  years  and  commence  a  scheme 
of  repair;  we  should  set  about  measures  for  building  the  skeleton  and 
teeth  at  least  six  months  before  the  oncoming  child  is  visible.  In  other 
words,  the  prospective  mother  should  receive  careful  instructions  as  to 
her  diet  not  later  than  the  third  month  of  pregnancy." 

In  the  pyorrhea  article,  the  author  again  recommends  a  diet  of  milk, 
eggs,  whole  wheat  bread,  fruit  and  vegetables,  mostly  raw. 

And  again,  Dr.  Mitchell  of  Memphis,  Tennessee,  makes  this  statement, 
"Although  we  do  not  wish  to  discourage  proper  mouth  hygiene,  yet  it  has 
been  definitely  shown  that  a  properly  fed  tooth  will  not  become  carious, 
even  in  a  dirty  mouth.  Plenty  of  sunshine  and  a  well  balanced  diet,  in- 
cluding milk,  egg  yolk,  fresh  vegetables  and  cod  liver  oil  are  needed  by 
every  infant.  Early  attention  to  the  factors  will  result  in  better  teeth 
for  the  next  generation." 

These  are  new  developments  in  dentistry,  we  all  know,  and  even  those 
who  had  made  a  specialty  of  the  study  of  nutrition  have  only  recently,  to 
any  large  extent,  connected  mouth  hygiene  with  proper  nutrition. 

In  the  extension  service  we  are  meeting  each  year  all  over  the  State, 
mothers  in  study  groups,  and  influencing  even  larger  groups  at  general 
meetings,  through  the  press,  and  over  the  radio.  In  our  nutrition  groups 
we  always  discuss  food  as  it  builds,  repairs,  furnishes  fuel  and  is  health- 
giving.  The  average  mother  can  see  what  is  happening  to  the  teeth  and 
so  we  emphasize  foods  which  build  and  keep  the  teeth  in  good  repair,  and 
try  to  show  that  what  is  true  of  the  teeth  is  true  of  other  parts  of  the 
body  as  well.  Our  food  habits  score  card  is  used  at  all  nutrition  meetings. 
This  interests  the  mother  in  checking  her  own  food  habits  and  those  of 
her  family. 


36 
Food  Habits  Score  Card 


Credits 


MILK 

(adults) 

1  pint  or  more  daily 25 

1  cup    daily    10 

(juniors) 
1  quart    daily 25 

1  pint    daily     15 

VEGETABLES    (include   potatoes   once) 

3  servings   daily    15 

2  servings   daily    10 

If  one  serving  is  green  or  raw  add    5 

FRUITS    (fresh,   canned  or  dried) 

2  or  more   servings   daily    10 

1  serving  daily   5 

TOMATO,  ORANGE,  GRAPEFRUIT  OR  RAW  CABBAGE 

1  serving  daily    10 

4  servings   weekly    5 

MEAT    (lean)    or  MEAT   SUBSTITUTES 

( adults ) 
1  or  2  servings  daily 15 

(juniors) 
1  serving    daily     10 

EGGS 

(juniors)    1    daily    5 

WHOLE  GRAIN  PRODUCTS 
( adults ) 

1  or  more  servings   daily    10 

(juniors) 

2  servings   daily    10 

1  serving  daily   5 

WATER 

(adults) 

6  to  8  glasses  daily    10 

4  to  6  glasses  daily    , 5 

(juniors) 
4  to  6  glasses  dally     10 

Deductions 

Adults  and  Juniors 

Complaining    about    food     10 

Sweets  between   meals    10 

Adults 

Coffee  or  tea,  more  than  2  cups  daily   10 

Juniors 

No    breakfast    10 

Use  of  tea  or  coffee    10 


At  most  meetings  some  food  is  prepared,  always  emphasizing  milk, 
vegetables,  fruits  and  whole  grain  cereals,  and  menus  and  recipes  are 
furnished.  At  all-day  meetings  a  well  balanced,  simple,  attractive  and 
inexpensive  luncheon  is  served.  We  believe  in  the  old  precepts,  "Seeing 
is  believing,"  and  that  the  "proof  of  the  pudding  is  in  the  eating."  If  a 
woman  sees  a  simple,  attractive  cabbage  salad  made,  and  has  an  oppor- 
tunity to  taste  it,  she  will  undoubtedly  go  home  and  make  some  for  her 
family. 

THE  DENTAL  HYGIENIST  IN  THE  SCHOOLS 

OSIRENE  E.  ROWELL,  D.  H. 

Dental  Hygienist,  School  Department 
Arlington,  Massachusetts 

To  do  the  greatest  amount  of  good  to  the  largest  number  of  children  is 
the  foundation  upon  which  I  place  all  my  thought,  plans  and  work  as  Den- 
tal Hygienist  in  the  schools. 


37 

In  my  present  work  I  have  eight  elementary  schools  or  one  hundred 
and  twenty-two  classes.  These  classes  include  the  first  six  grades.  I 
visit  each  of  these  groups  about  six  or  eight  times  a  year.  After  each 
round  of  visits,  to  the  respective  schools,  a  report  is  sent  to  each  prin- 
cipal explaining  conditions  found.  The  school  having  the  highest  per- 
centage of  children  with  teeth  satisfactorily  brushed  is  placed  at  the  top 
of  the  list.  The  other  schools  follow  in  respective  order,  according  to 
their  grading  in  mouth  cleanliness.  The  schools  are  also  listed  according 
to  their  standing  in  relative  percentage  of  dental  certificates  received. 
This  list  also  includes  the  three  highest  classes  in  each  school  and  the 
percentages  attained. 

Such  a  report  helps  to  stimulate  both  interest  and  competition  between 
the  classes  in  each  school  and  between  the  different  schools. 

My  program  is  built  upon  the  following  plan,  which  includes : 

1.  The  cooperation  of  the  principals  and  teachers. 

The  first  necessity  for  success  in  mouth  hygiene  is  the  cooperation  of 
the  principals  and  teachers.  The  success  of  this  work  is  largely  de- 
pendent upon  their  faithful  support  and  help. 

2.  The  development  of  correct  habits  and  attitudes   in  the  children 

regarding  mouth  cleanliness  and  health. 

My  second  step  is  to  create  among  the  children  a  desire  for  clean, 
healthy  mouths.    The  greatest  help  for  this  is: 

(a)  Personal  attention  and  praise  for  those  who  are  successful  in 
acquiring  and  keeping  a  clean  mouth. 

(b)  Encouragement  for  those  who  try. 

A  reward,  in  the  form  of  a  pin,  is  given  to  each  child  who  succeeds  in 
having  all  necessary  dental  work  completed  and  who  brings  a  dental 
certificate  to  school. 

For  satisfactory  brushing  of  the  teeth  each  child  is  given  a  colored  dot 
for  his  "clean  teeth"  card.  The  rainbow  colors  are  used.  We  start  with 
red  and  add  the  successive  colors  at  each  visit  after  inspection,  thus  giving 
the  faithful  workers  a  complete  rainbow  at  the  end  of  the  school  year. 

Because  of  lack  of  time  I  do  not  give  any  prophylactic  treatment.  I  con- 
sider the  prophylactic  treatment  of  little  value  to  the  child  who  has  neither 
the  habit  nor  desire  to  keep  his  own  teeth  clean.  Such  habits  and 
desires  are  created  only  after  constant  follow-up  work  on  the  part  of 
the  dental  hygienist  with  the  loyal  support  of  the  teachers.  Very  few 
children  are  given  such  training  at  home. 

One  dental  hygienist  in  a  large  school  system  does  not  have  time  for 
both  the  prophylactic  and  educational  work. 

I  believe  most  children  heartily  dislike  the  bother  of  brushing  their 
teeth.  To  brush  one's  teeth  thoroughly  requires  thought  and  time.  Most 
children,  of  all  ages,  can  and  will  give  their  teeth  excellent  care  when  it 
is  required  of  them  and  when  unsatisfactory  brushing  of  the  teeth  is  not 
accepted.  I  believe  that  only  the  trained  eye  of  the  dental  hygienist  can 
give  the  teacher  the  necessary  support  for  insisting  upon  work  well  done. 

One  day  of  my  time  each  week  is  spent  in  escorting  twenty  children  to 
the  Forsyth  Dental  Infirmary.  Fifteen  children  go  to  have  teeth  filled, 
five  go  to  receive  prophylactic  treatment.  Children  who  need  extractions 
are  formed  in  a  special  group  and  are  taken  occasionally  for  this  particu- 
lar work.  An  interesting  feature  about  this  is  that  nearly  all  the  children 
want  and  are  happy  to  join  these  groups  so  as  to  have  their  dental  work 
done  and  receive  their  Dental  Certificates.  This  not  only  helps  those  chil- 
dren who  could  not  otherwise  have  their  teeth  cared  for,  but  creates  the 
desired  mental  attitude  toward  the  dentist. 

3.  The  presentation  of  the  knowledge  of  oral  hygiene  to  the  children, 

which  will  be  most  valuable  to  them  throughout  life. 

My  final  and  dominant  thought  is  to  give  each  child  a  general  knowledge 


38 
of  his  teeth  and  their  needs  in  relation  to  his  health,  which  will  be  valu- 
able to  him  throughout  life. 
The  child  should  know: 

(a)  The  general  condition  of  his  own  mouth. 

Parents  should  be  notified  of  the  condition  of  the  child's  mouth. 

(b)  That  the  dentist  is  one  of  his  best  friends. 

(c)  Why  people  need  to  go  to  the  dentist. 

(d)  Why  we  have  teeth. 

(e)  How  to  brush  his  teeth  correctly. 

(f )  The  best  type  of  toothbrush  to  use. 

(g)  The  way  to  properly  care  for  his  toothbrush, 
(h)   Something  about  dental  anatomy. 

(i)  The  importance  of  diet  in  relation  to  teeth  and  health. 

(j)   The  need  of  good  teeth  in  maintaining  good  health. 

There  should  be  constant  encouragement  of  corrections  and  follow-up 
work,  if  necessary,  in  individual  cases. 

I  consider  it  necessary  in  practically  every  lesson,  to  present  some  form 
of  demonstration  project,  or  illustrative  material,  with  which  to  make 
the  lesson  more  clear  and  interesting. 

The  above  is  but  a  brief  summary  of  the  work  which  I  am  doing  as 
dental  hygienist  in  the  schools.  And  although  there  is  a  constant  change 
in  the  personnel  of  the  school  population  and  it  seems  impossible  to  attain 
the  goal  of  our  desire,  namely,  to  help  every  child  have  a  clean,  healthy 
mouth,  yet  we  feel  that  we  are  able  to  accomplish  a  great  deal  that  is  very 
much  worth  while  in  this  type  of  work. 

THE  TEACHING  OF  ORAL  HYGIENE  TO  NEWSBOYS 

Harry  Goldinger,  D.  M.  D. 

Clinical  Director,  Medical  Department 

Harry  E.  Burroughs  Newsboys'  Foundation 

The  teaching  of  Oral  Hygiene  and  the  teaching  of  General  Hygiene 
are  so  closely  connected  that  it  is  impossible  to  intelligently  discuss 
one  without  the  other.  As  we  understand  it,  the  mouth  is  not  a  separate 
and  independent  unit  in  the  body  but  is  a  part — an  important  part — of 
the  body,  or  a  vital  cog  in  the  human  machine. 

There  is  in  the  city  of  Boston,  an  institution  known  as  the  Harry  E. 
Burroughs  Newsboys'  Foundation  which  conducts  a  medical  clinic  that 
follows  out  this  idea  of  teaching  Oral  Hygiene  through  a  program  of 
instruction  in  General  Hygiene.  Before  discussing  the  medical  clinic, 
it  would  be  better  to  start  at  the  beginning  by  acquainting  the  reader 
with  a  few  facts  about  the  Foundation  as  a  whole,  and  why  this  type 
of  clinic  anyhow.  To  begin  with,  the  Harry  E.  Burroughs  Newsboys' 
Foundation  was  founded  by  Mr.  Harry  E.  Burroughs  for  the  purpose 
of  guiding  and  helping  the  newsboy  receive  educational  assistance  in 
any  subjects  he  wishes.  Naturally  enough,  a  medical,  educational  health 
clinic  was  included,  because  physical  health  is  a  prime  requisite  of 
mental  health  and  the  latter  is  the  most  important  of  all.  The  duty  of 
this  health  clinic  is  to  examine  every  boy  who  becomes  a  member  of 
the  Foundation,  and  should  any  physical  defects  be  observed,  to  arrange 
for  and  to  guide  in  their  correction  at  outside  clinics.  This  educational 
health  clinic  is  directed  by  a  medical  council  and  under  the  direction 
of  the  Harvard  University  Dental  School. 

Again,  coming  back  to  the  question  of  Oral  Hygiene  and  how  it  is 
taught  to  the  boys,  naturally  enough,  the  first  procedure  is  to  give  the 
boys  a  careful  medical  and  dental  examination.  This  permits  us  to  find 
out  more  about  the  boy  than  a  dental  examination  alone  would  reveal. 
It  allows  us  to  trace  the  association  of  defects  between  oral  and  general 
conditions  and  enables  us  to  make  a  more  correct  diagnosis. 

For  instance,  a  boy  comes  to  the  clinic  for  an  examination.  It  re- 
veals, let  us  say,  nothing  wrong  physically  except  a  poor  physical 


39 
hygiene  together  with  an  equally  neglected  oral  hygiene.  (It  is  sur- 
prising how  often  these  two  conditions  are  found  together.)  Also  it  is 
observed  that  the  boy  is  undernourished  and  underweight  with  a  cor- 
respondingly poor  posture.  His  mental  attitude  is  also  indifferent  and 
listless. 

The  first  approach  to  this  boy  is  to  gain  his  confidence  and  then  to 
assist  him  in  clearing  up  any  mental  disquietness  influenced  by  con- 
ditions either  inside  or  outside  the  home.  This  correction,  when  neces- 
sary, is  greatly  assisted  by  the  information  obtained  by  our  home- 
contact  worker  who  visits  the  home  and  school  of  the  boy.  If  the  home 
conditions  are  found  to  be  a  cause,  the  parents  are  invited  to  visit  us 
and  to  become  acquainted  with  the  Foundation  and  to  see  for  them- 
selves what  we  are  trying  to  do  for  their  boy. 

Then  the  question  of  cleanliness  comes  up.  Here  we  start  by  requir- 
ing every  boy  coming  into  the  examining  rooms  to  first  take  a  shower 
bath.  Then  after  he  has  dressed,  attention  is  called  to  the  importance 
of  clean  nails,  combed  hair  and  general  care  of  Tiis  clothing.  Here  we 
pause  for  a  moment  and  go  into  a  detailed  explanation  about  the  im- 
portance of  a  clean  and  healthy  mouth.  The  attention  of  teeth  is  empha- 
sized as  being  one  of  the  first  things  an  employer  will  see  when  he  inter- 
views the  boy  for  a  job,  it  being  the  natural  thing  for  anyone  while 
talking  to  look  the  individual,  to  whom  he  talks,  directly  in  the  face. 
Of  course,  dirty  teeth  would  be  quickly  observed  when  the  boy  would 
answer  any  questions  put  to  him  and  the  noting  of  dirty  teeth  would  be 
a  black  mark  against  him  towards  the  securing  of  the  job.  This,  there- 
fore, is  an  important  consideration  and  registers  more  effectively  than 
were  the  boy  told  that  clean  teeth  are  necessary  because  of  health  or 
any  other  reason.  The  earning  of  money  for  these  boys  is  very  im- 
portant because  most  of  them  are  practically  the  heads  of  their  families 
in  so  far  as  money  earning  ability  goes. 

After  cleanliness  comes  health.  This  is  accomplished  by  the  forma- 
tion of  nutrition  and  corrective  posture  classes.  In  the  nutrition  sec- 
tions are  grouped  the  underweight  and  undernourished.  Incidentally, 
this  section  contains  many  boys  with  very  dirty  and  neglected  mouths. 
The  purpose  of  this  nutrition  class  is  to  balance  the  diets  of  the  indi- 
vidual boys,  using  as  a  basis  the  type  of  food  they  usually  eat,  and 
also  to  show  them  how  to  prepare  a  few  simple  dishes  for  themselves, 
because  in  the  homes  from  which  they  come,  there  are  practically  no 
regular  meals  or  mealtimes,  and  for  most  of  their  meals  they  are  in 
the  habit  of  preparing  themselves  whatever  they  eat.  Here  again,  the 
nutrition  teacher  does  not  forget  the  importance  of  correct  foods  for 
the  building  up  of  healthy  teeth.  The  posture  classes  while  they  do  not 
directly  have  a  bearing  on  the  mouth,  do  through  their  physical  correc- 
tions, improve  the  general  health  of  the  mouth.  Then  comes  general 
health  and  special  dental  health  instruction,  through  the  use  of  motion 
pictures,  playlets,  dental  prophylaxis,  and  health  lectures. 

In  conclusion,  we  note  that  teaching  dental  health  through  instruc- 
tion in  general  health  produces  permanent  and  lasting  oral  improve- 
ments, that  when  the  health  and  habits  of  the  boy  improve,  his  oral 
health  also  improves  without  making  the  boy  aware  of  any  special 
effort  on  his  part.  And  last  of  all  the  oral  improvement  must  remain  as 
long  as  the  general  physical  gains  are  upheld. 

INSTITUTIONAL  DENTISTRY 

Emanuel  Kline,  D.  M.  D. 

Dental   Clinician,   Lakeville   State   Sanatorium 

Institutional  dentistry  described  herewith  is  the  type  of  dentistry 

as  practiced  in  state  institutions,  so  different  to  the  popular  belief  of 

the  day  in  regard  to  institutional  dentistry  as  related  to  pay  clinics, 

group  clinics  and  dental  school  clinics. 


40 
With  the  miraculous  advances  in  both  preventive  medieine  and  den- 
tistry it  has  become  definitely  established  that  dentistry  is  a  necessary 
adjunct  in  the  treatment  of  disease.  The  evolution  of  institutional 
dentistry  is  even  more  romantic  than  that  of  dental  practice  in  private 
offices.  It  was  only  two  or  three  decades  ago,  that  the  only  dentistry 
done  in  an  institution  was  the  administration  of  toothache  drops  and 
extraction  of  teeth,  these  being  done  by  the  attending  physician.  Some- 
times the  extraction  was  successful  and  sometimes  just  the  upper  part 
was  removed.  No  removing  of  foci  of  oral  infections,  no  radiographs 
to  search  for  hidden  cysts,  roots  and  impactions,  no  periodical  prophy- 
laxis and  certainly  no  repair  of  carious  teeth  or  restoration  of  missing 
teeth.  This  period  of  dental  neglect  was  followed  by  the  somewhat 
improved  method  of  allowing  patients  needing  dental  treatment  to  go 
to  some  outside  dentist  who  practiced  in  the  near  vicinity  of  the  insti- 
tution. But  only  ambulatory  patients  in  fair  condition  could  do  this. 
Very  ill  patients,  or  those  confined  to  bed  were  still  neglected.  This 
was  followed  by  the  period  of  visiting  dentist,  who  probably  spent  one 
whole  day  at  the  institution,  but  if  he  arrived  on  Monday  and  a  patient 
was  unfortunate  enough  to  contract  a  toothache  on  Tuesday,  well  that 
was  just  "too  bad"  and  treatment  would  probably  consist  of  drops  or 
pills  until  the  ache  ceased  or  the  visiting  dentist  made  another  appear- 
ance. Gradually  the  era  of  two  days  a  week  visiting  men  approached, 
and  this  necessitated  the  purchase  of  some  secondhand  dental  equip- 
ment, usually  antiques,  and  its  installation  in  some  cubby  hole  that 
could  not  be  used  for  anything  else.  To  see  some  of  these  old  time 
institutional  dental  offices,  with  their  collection  of  instruments  is  to 
wonder  how  the  patients  had  the  courage  and  the  respect  for  dentistry 
that  they  did  have.  This  era,  thanks  to  the  persistence  and  ardent 
labors  of  some  few  medical  and  dental  health  officers,  was  followed  by 
the  period  of  appointments  of  full-time  dentists  and  the  purchase  of 
new  equipment,  supplies,  and  the  erection  of  well  lighted  and  ventilated 
dental  offices.  This,  together  with  the  increase  in  salaries  given  to 
resident  dentists,  has  attracted  a  finer  type  of  dental  man  to  the  insti- 
tutions. Every  dental  office  in  the  group  of  five  Sanatoria  in  the  Di- 
vision of  Tuberculosis  of  the  Massachusetts  Department  of  Public 
Health  is  something  to  be  proud  of  and  a  credit  to  the  officers  in  charge. 

Purpose  of  Institutional  Dentistry 

The  purpose  of  institutional  dentistry  is  to  establish  and  maintain 
a  healthy  and  efficient  oral  machine  while  the  patient  is  hospitalized, 
whether  for  a  short  time,  or,  as  is  usually  the  case,  for  a  long  period  of 
time.  Today,  dentistry  in  our  institutions  is  on  a  well  organized  basis 
and  carried  on  in  the  same  manner,  even  better  than  some  private 
offices.  Every  bit  of  cooperation  is  extended  the  Department,  and  it 
functions  in  importance  next  to  the  medical  department. 

Every  attempt  is  made  to  help  those  who  already  are  acquainted  with 
the  benefits  of  good  dentistry  and  to  teach  those  ignorant  of  modern 
dentistry  the  advantages  obtained  from  establishing  and  maintaining 
good,  healthy,  oral  conditions.  Treatment  is  given  in  the  following 
order: 

1.  Relief  of  pain. 

2.  Elimination  of  all  possible  foci  of  infection. 

3.  Periodical  prophylaxis. 

4.  Repair  of  injured  members. 

5.  Restoration  of  missing  members. 

Methods  and  Treatments  Employed 

The  patient  is  brought  to  the  dental  room  for  the  examination  as 
soon  as  possible  after  admission  to  the  hospital.    At  this  first  visit  a 


41 
chart  is  made  of  the  oral  condition  and  the  following  points  are  noted : 

1.  Missing  teeth. 

2.  Crowned  teeth. 

3.  Carious  teeth. 

4.  Condition  of  occlusion. 

5.  Condition  of  the  oral  tissues. 

6.  The  tongue  and  tonsils. 

The  teeth  are  cleaned  and  the  patient  is  classified  according  to  the 
dental  disabilities. 

If  the  patient  does  not  require  any  dental  service,  his  card  is  placed 
in  the  closed  file.  According  to  the  susceptibility  to  decay,  the  patient's 
name  is  placed  in  another  file,  the  notification  file,  to  be  seen  either 
six  months  or  one  year  following.  If,  at  the  first  visit,  the  patient 
presents  a  condition  which  will  require  treatment,  his  card  is  placed 
in  the  open  file.  If  it  is  any  condition  which  requires  relief  of  pain, 
this  is  taken  care  of  at  the  initial  visit.  If  it  is  not  a  condition  which 
requires  relief  of  pain,  but  patient  presents  a  great  many  extensive 
cavities  or  some  oral  condition  which  will  require  immediate  treat- 
ment, a  red  marker  is  attached  to  his  dental  card  which  signifies  that 
this  patient  requires  urgent  treatment. 

Children  who,  at  the  first  visit,  present  a  condition  which  will  require 
extraction  of  many  teeth  are  placed  on  the  general  ethyl  chloride  list. 
This  means  that  the  office  is  notified  immediately  that  the  dental  clinic 
requests  a  permit  for  the  administration  of  a  general  anesthetic  for 
the  removal  of  teeth.  The  office  in  turn  sends  a  notice  and  encloses  a 
form  to  the  child's  parents  or  guardian  for  signature.  As  soon  as  pos- 
sible after  the  permit  is  received  and  the  dental  clinic  is  notified,  the 
child  is  sent  for  and  the  condemned  teeth  removed  under  ethyl  chloride, 
administered  as  a  general  anesthetic.  If  the  patient  presents  a  con- 
dition which  requires  treatment,  but  which  is  not  urgent,  he  is  classi- 
fied as  a  non-urgent  case  and  a  green  marker  is  attached  to  his  dental 
card.  In  this  way  it  can  be  seen  at  a  glance  what  patients  are  to  re- 
ceive preference.  This  facilitates  matters  when  the  file  is  consulted  to 
determine  what  patients  are  to  constitute  the  following  day's  work. 

The  subsequent  visits  are  dependent  on  the  following: 

1.  Condition  of  the  patients — if  confined  to  bed  by  order  of  the 
physician  and  unable  to  be  moved  for  several  days,  a  week,  or  even 
longer;  or  patients  in  quarantine;  or  those  who  have  recently  been 
operated  upon. 

2.  Method  of  transportation.  Some  patients  are  able  to  walk  from 
the  ward  to  the  dental  office,  some  require  transportation  by  wheel 
chair  and  others  by  truck. 

3.  Weather  conditions.  Weather  conditions  call  for  a  classification 
of  patients  which  we  term  "fair"  patients  and  "stormy"  patients.  This 
means  that  those  individuals  who  are  transported  by  wheel  chair  or 
truck  can  only  keep  their  dental  appointments  on  fair  days,  especially 
in  institutions  like  ours,  where  they  must  be  taken  out-of-doors.  Am- 
bulatory patients  who  can  walk  to  the  dental  office  can  do  so  even  on 
stormy  days. 

No  appointments  are  made  in  advance.  The  system  of  calling  for 
patients  by  telephone  the  same  day  that  work  is  to  be  done,  has  proven 
to  be  most  satisfactory.  This  eliminates  the  possibility  of  broken 
appointments.  At  the  beginning  of  the  day,  the  wards  are  contacted 
by  telephone  and  the  patient  requested  to  make  his  appearance  as 
soon  as  possible.  If,  for  any  reason  the  patient  is  unable  to  attend 
the  dental  clinic  that  day,  the  nurse  in  charge  of  the  ward  will  make 
a  report  to  the  assistant  in  charge  to  that  effect.  All  patients  visiting 
the  dental  clinic  are  given  the  same  courteous  treatment  that  they 


42 
would  receive  in  a  private  office.   A  patient  who  presents  a  clean  and 
well  kept  set  of  teeth  is  complimented;  others  are  offered  advice. 

All  dental  operations  are  performed,  such  as  repair  of  carious  teeth 
with  amalgam,  cement,  and  synthetic  porcelain,  even  inlays,  providing 
the  patient  is  willing  to  pay  for  them.  Root  canal  treatments  are 
attempted  only  on  the  anterior  teeth,  posterior  teeth  which  involve  the 
pulp  are  extracted.  Treatments  are  instituted  for  incipient  pyorrhea 
only;  advanced  cases  are  advised  to  have  the  teeth  removed. 

For  any  question  regarding  oral  infection  in  the  soft  tissue,  facili- 
ties are  available  for  the  diagnosis  of  smears  or  sections  of  tissue  by 
the  laboratory.  In  cases  regarding  the  possible  involvement  of  the  deep 
structures  they  are  referred  to  the  X-ray  department  for  the  necessary 
radiographs.  These  two  departments,  the  laboratory  and  X-ray,  are 
well  made  use  of  by  the  dental  department.  Treatment  is  even  admin- 
istered to  the  simple  cases  requiring  orthodontic  treatment.  The  fol- 
lowing anesthetics  are  used: 

Local :  Novocaine,  ethyl  chloride,  cocaine  and  perdentin. 
General :  Ethyl  chloride  for  children,  nitrous  oxide  and  ether. 
No  effort  is  made  to  replace  missing  teeth  by  bridgework  or  are  crowns 
inserted  unless  there  is  no  other  way  of  replacement  and  only  when  the 
patient  wishes  to  take  the  responsibility.  In  the  majority  of  cases  miss- 
ing teeth  are  replaced  by  dentures  both  full  and  partial,  constructed 
of  vulcanite  or  gold  or  a  combination  of  both.  In  cases  where  restora- 
tion involving  mechanical  laboratory  work  are  concerned,  this  subject 
is  taken  up  with  the  medical  supervisor  and  after  authorization  is  re- 
ceived the  work  is  paid  for  by  the  patient.  A  patient  may  be  considered 
a  closed  case  when  all  the  dental  work  necessary  is  completed  except 
the  construction  of  artificial  teeth. 

Exo-orthodontia  is  an  ideal  way  of  doing  justice  to  many  children 
while  hospitalized  at  the  institution,  who  present  crowded  teeth  and 
poor  occlusion.  It  is  a  very  inexpensive  procedure,  demands  very  little 
extra  time,  is  a  very  specific  prophylactic  measure  from  the  standpoint 
of  eliminating  future  caries,  and  acts  as  a  permanent  benefit  to  the 
patient  in  later  life.  I  am  an  earnest  practitioner  and  an  enthusiastic 
advocate  of  the  work  of  the  Doctors  Libby  of  Boston,  who  are  the 
originators  and  teachers  of  this  form  of  dental  relief. 

Records  of  the  dental  work  done  for  each  patient  are  kept  on  an 
individual  dental  card.  Daily  records  are  kept  in  the  dentist's  record 
book.  At  periodic  intervals  records  are  dictated  from  the  daily  record 
book  to  one  of  the  stenographers  in  the  Record  Office  and  she  in  turn 
inserts  every  dental  operation  into  the  dental  record  of  the  patient's 
case  history.  Monthly  reports  are  tabulated  and  submitted  to  the  Medi- 
cal Superintendent  and  then  forwarded  to  the  Director  of  the  Department. 
Yearly  reports  are  tabulated  and  submitted  to  the  Medical  Superintend- 
ent for  the  same  purpose.  The  yearly  report  contains,  in  detail,  all 
operations  completed  during  the  current  year,  also  a  survey  of  any 
important  investigations  which  are  held  during  the  year.  It  also  con- 
tains suggestions  and  recommendations.  There  is  a  standardized 
sheet  listing  all  dental  supplies  and  equipment  from  which  the  dental 
clinic  makes  orders  through  the  office  of  the  steward.  This  list  contains 
the  best  material  obtainable  and  no  effort  is  made  to  conserve  expense 
by  the  use  of  inferior  material.  An  inventory  is  taken  once  at  the  end 
of  each  year. 

Benefits  derived  from  institutional  dentistry  are  manifold.  A  patient 
in  an  institution  no  longer  need  sacrifice  the  health  and  efficiency  of 
the  oral  machine  by  being  subjected  to  treatment  for  some  other  dis- 
ease. It  naturally  follows  that  if  a  patient's  resistance  is  lowered,  and 
the  patient  must  undergo  operation  or  treatment  for  some  systemic 
disease,  and  if  such  a  patient  is  taken  to  a  dental  clinic  and  has  treat- 
ment for  any  oral  infection,   and  all  carious  teeth  removed  or  filled, 


43 

according  to  the  condition  in  which  they  are,  and  has  all  missing  teeth 
replaced  by  artificial  teeth,  this  will  tend  to  shorten  the  convalescent 
period. 

By  employing  a  full-time  dentist  the  patients  are  given  the  advantage 
of  not  having  to  wait  any  appreciable  time  for  relief  of  pain.  An 
effort  is  made  to  reexamine  all  patients  prior  to  their  discharge.  If  the 
patient's  mouth  is  not  considered  a  completed  case,  he  is  advised  as  to 
the  necessary  work  which  is  still  to  be  done,  and  to  visit  his  home 
dentist  as  soon  as  possible.  In  the  case  of  children  who  leave  the  insti- 
tution and  who  are  to  return  to  school  on  their  arrival  home,  a  dental 
certificate  is  awarded  if  the  case  is  a  completed  one.  When  they  are 
dismissed,  patients'  cards  are  returned  to  the  Record  Office  and  are 
filed  together  with  the  dental  record  in  the  case  history. 

PITS  AND   FISSURES 

"If  it  were  not  for  pits  and  fissures  in  teeth,  caries  would  rarely  occur 
in  occlusal  surfaces."       C.  N.  Johnson 

"Operative  dentistry  formerly  dealt  with  methods  of  removing  decay 
from  the  teeth ....  but  in  the  light  of  present  knowledge,  the  logical  time 
for  operative  procedure  is  when  a  tooth  is  found  to  be  defective — before 
decay  is  present."      M.  D.  Huff 

Advantages  gained  by  the  practice  of  prophylactic  odontotomy : 

"Small  fillings,  therefore  no  pulp  irritation  and  no  secondary  dentin." 

"Painless  operation,  as  the  cavity  is  wholly  in  the  enamel;  this  re- 
sults in  the  increase  of  confidence  of  the  patient  in  the  operator." 

"Reduces  danger  of  recurrent  decay.  Infection  has  not  penetrated 
into  the  interior  of  the  tooth,  therefore  there  is  no  chance  of  leaving  in- 
fected dentin  under  the  filling."       C.  F.  Bbdecker. 

"Fill  all  fissures  and  pits  as  soon  after  eruption  as  possible."  Dental 
Policy  of  the  Massachusetts  Department  of  Public  Health. 


44 


Editorial  Comment 


We  feel  sure  that  the  many  admirers  of  both  Dr.  Chapin  and  Dr. 
Scamman  will  be  interested  to  read  the  letter  Dr.  Chapin  sent  at  the 
time  Dr.  Scamman  was  leaving  us  to  join  the  staff  of  the  Commonwealth 
Fund.  Considering  that  Dr.  Scamman  came  to  this  Department  from  Dr. 
Chapin's  staff  we  feel  that  in  this  letter  he  has  exemplified  that  restraint 
so  characteristic  of  all  his  work. 

Health  Department 

Office  of  the  Superintendent  of  Health 

City  Hall,  Providence,  R.  I.  April  30,  '31. 

George  H.  Bigelow,  M.  D., 
Commissioner  of  Public  Health, 
State  House,  Boston,  Mass. 

Dear  Doctor  Bigelow: 

I  thank  you  for  giving  me  the  honor  of  an  invitation  to  the  dinner 
in  honor  of  Doctor  Scamman  on  May  first.  Nothing  in  the  world  would 
give  me  greater  pleasure,  but  I  do  not  feel  able  to  do  it.  I  am  awfully 
sorry  that  Doctor  Scamman  is  going  to  New  York,  for  New  York  is  so 
much  more  of  a  journey  for  an  old  man,  than  is  a  trip  to  Boston.  Still,  I 
understand  that  Doctor  Scamman  will  be  coming  back  again  to  New 
England  at  frequent  intervals. 

When  he  was  sent  up  to  see  me  from  the  Harvard  School  of  Public 
Health  in  1922  he  looked  pretty  good  to  me,  but  I  did  not  realize  then  how 
valuable  he  was  going  to  be.  I  soon  became  very  fond  of  him  and  as  long 
as  we  live  shall  consider  it  a  great  privilege  to  count  him  as  one  of  my 
best  friends.  His  genial  ways,  his  constant  good  humor,  his  willingness 
to  do  favors  and  his  unfailing  tact  made  him  an  invaluable  assistant  to 
me  and  I  was  pretty  sore  when  you  took  him  away  from  me,  though,  of 
course,  I  would  not  put  anything  in  the  way  of  his  advancement  and  I 
don't  know  but  I  am  generous  enough  to  have  been  willing  to  let  him  go 
for  the  sake  of  the  greater  good  he  could  do  in  Massachusetts.  Somebody 
in  my  office  the  other  day  asked  me  what  he  is  going  to  do  for  the  Com- 
monwealth Fund.  I  said  I  did  not  quite  know,  but  I  supposed  that  his 
job  would  be  to  keep  everybody  good  natured  and  working  loyally  together 
for  the  cause  of  public  health.  The  answer  was  "They  sure  picked  out 
the  man  who  can  do  it." 

Another  reason  why  I  think  so  much  of  Doctor  Scamman  is  because  of 
his  work  in  public  health.  Scamman  and  I  often  laughed  over  Professor 
Wilson's  remark  that  he  judged  that  thinking  must  be  a  very  painful  pro- 
cess. Evidently  Doctor  Scamman,  at  some  time  in  his  life,  got  immunized 
so  that  it  doesn't  seem  to  hurt  him  at  all.  In  fact,  he  likes  it.  We  need 
such  people  in  public  health.  There  are  so  many  doctors  and  health  officers 
who  never  think,  but  believe  the  last  thing  that  they  hear  or  read.  It 
is  a  great  thing  to  have  a  man  in  our  line  of  business  like  our  friend  who 
is  constantly  studying  the  problems  of  public  health  and  seeking  the 
truth.  Not  only  that,  he  tries  to  make  his  practice  fit  the  facts.  I  cer- 
tainly hope  he  will  have  as  great  an  opportunity  in  the  future  as  in  the 
past  to  study  the  problems  of  public  health.  I  wish  him  the  most  abund- 
ant success  in  his  new  field  of  endeavor.  I  think,  Doctor  Bigelow  that  the 
Commonwealth  Fund  showed  great  wisdom  in  stealing  him  from  you. 
I  am  truly  sorry  for  you  and  you  know  that  I  can  sympathize  with  you, 
for  you  stole  him  from  me.  Yours  truly, 

(signed)  Charles  V.  Chapin,  M.  D., 
Superintendent  of  Health. 


45 

Several  times  it  has  been  brought  to  the  attention  of  the  Department 
that  in  speaking  of  physicians  and  dentists  the  term  "Doctors  and  Den- 
tists" has  been  used.  As  both  medical  men  and  dentists  are  doctors  we 
have  been  asked  to  use  correct  titles. 

No  affront  to  the  dental  profession  has  been  intended  but  because  the 
coupling  of  Doctors  and  Dentists  is  so  incorporated  in  the  thinking  of  the 
people,  the  term  has  crept  into  our  speaking  and  writing.  We  will  en- 
deavor to  be  more  accurate  in  the  future. 

***** 

We  are  again  offering  an  elementary  and  an  advanced  course  for  school 
nurses  at  the  Summer  Session  of  Hyannis  Normal  School. 

Several  new  and  particularly  interesting  courses  which  will  give  two 
points  degree  credit  are  to  be  added  this  year. 

The  prospectus  giving  detailed  information  will  be  out  soon,  and  will 

be  mailed  to  all  school  nurses.    Others  who  are  interested  may  obtain  one 

by  writing  to  the  State  Department  of  Public  Health,  546  State  House, 

Boston,  Mass. 

*  *  *  *  * 


Mother's  Day 


Plans  for  a  nation-wide  Mother's  Day  Campaign  to  obtain  better  mater- 
nity care  for  expectant  mothers  are  taking  concrete  form  among  women's 
clubs,  church  and  civic  organizations,  health  departments,  medical  socie- 
ties and  nursing  groups,  according  to  details  which  have  been  made  public 
by  the  Maternity  Center  Association,  1  East  57th  Street,  New  York  City. 

Last  year  the  Campaign  sponsored  by  the  Association  culminated  in  a 
meeting  of  prominent  citizens  which  included  Mrs.  Herbert  Hoover,  Mrs. 
Theodore  Roosevelt,  Sr.,  Mrs.  Charles  A.  Lindbergh  and  many  of  the  most 
eminent  physicians  of  the  country.  They  voiced  an  indignant  protest 
against  the  high  maternity  death  rate  in  this  country,  and  demanded 
America  provide  its  mothers  with  more  adequate  maternity  care,  by  means 
of  which,  authorities  maintain,  10,000  of  the  16,000  mothers  who  die  an- 
nually in  childbirth  could  be  saved. 

Mrs.  John  Sloane,  president  of  the  Maternity  Center  Association  in  a 
recent  letter  expresses  surprise  that  the  campaign  last  year  interested 
fully  as  many  men  as  women,  and  indicated  that  special  efforts  are  to  be 
made  in  1932  to  awaken  prospective  fathers  to  the  fact  that  a  well  baby 
and  a  healthy  mother  require  more  than  simply  to  let  nature  take  its 
course. 

"The  Maternity  Center  Association,"  states  Mrs.  Sloane,  "will  be  glad 
to  help  local  organizations  everywhere  to  call  the  attention  of  their  com- 
munities to  the  vital  need  for  adequate  maternity  care.  Mother's  Day  is 
Sunday,  May  8th.  Material  for  speeches,  programs  for  women's  clubs, 
outlines  for  church  services  and  other  helps  for  local  campaigns  are  avail- 
able free  of  charge  to  anyone  interested  in  improving  conditions  in  their 
locality." 

Among  prominent  persons  on  the  Board  of  Directors  of  the  Maternity 
Center  Association  are:  Miss  Mabel  Choate,  Mrs.  E.  Marshall  Field,  Mrs. 
John  R.  Drexel,  Mrs.  Robert  L.  Gerry,  Mrs.  Shepard  Krech  and  Mrs. 
Jeremiah  Milbank. 


Bool%  Notes 


Body  Mechanics:  Education  and  Practice.  Report  of  the  Subcom- 
mittee on  Orthopedics  and  Body  Mechanics  of  the  White  House  Con- 
ference on  Child  Health  and  Protection.  Published  by  The  Century 
Company,  1932.    Price:  $1.50. 


46 
"This  is  a  report  of  a  searching  investigation  made  for  the  White 
Conference  on  Child  Health  and  Protection  into  the  relation   of  body 
mechanics  and  posture  to  the  health  and  well-being  of  children. 

"  There  is  positive  evidence,'  the  report  says,  'to  prove  that  not  less 
than  two-thirds  of  the  young  children  of  the  United  States  exhibit  faulty 
body  mechanics,'  and  that  this  condition  is  likely  to  continue  into  adult 
life.  The  evidence  gathered  shows  that  improvement  in  body  mechanics 
is  associated  with  improvement  in  health  and  efficiency. 

"An  important  distinction  is  made  in  the  report  between  training  in 
the  principles  of  good  body  mechanics  and  training  in  various  physical  ex- 
ercises. 

"The  detailed  recommendations  and  the  suggested  program  of  correc- 
tive exercises  presented  here  will  be  of  value  to  all  those  concerned  with 
the  care  and  training  of  children." 

Psychology  and  Psychiatry  in  Pediatrics:  The  Problem.  Report  of 
the  Suscommittee  on  Phychology  and  Psychiatry  of  the  White  House 
Conference  on  Child  Health  and  Protection.  Published  by  The  Cen- 
tury Company,  1932.    Price  $1.50.    146  pp. 

This  publication  of  the  White  House  Conference  on  Child  Health  and 
Protection  brings  forcibly  to  our  minds  the  idea  that  medical  care  of 
children  alone,  however  complete,  is  not  sufficient.  If  there  are  any  emo- 
tional or  intellectual  difficulties  present  they  must  receive  at  least  intelli- 
gent consideration. 

Not  every  doctor  can  study  psychology  and  psychiatry  in  detail  but 
every  physician  can  recognize  that  each  child  has  a  distinct  personality 
and  that  many  so-called  delinquencies  have  their  origin  in  emotional  or 
mental  disturbances.  Also,  every  doctor  can  become  familiar  with  avail- 
able resources  for  helping  the  unadjusted  child,  if  he  feels  unequal  to 
the  task  himself. 

Personality  is  defined  as  "The  individual  with  all  his  emotional  and 
intellectual  peculiarities,  trying  to  realize  happiness  and  efficiency  in  the 
environment  in  which  he  lives." 

Above  all,  the  physician  studies  motives — to  do  this  he  must  talk  with 
the  child  and  study  his  environment  with  "patience,  curiosity,  tolerance 
and  almost  invincible  optimism."  The  general  practitioner  and  pediatri- 
cian will  need  to  possess  all  these,  but  his  technical  resources  should  be 
derived  from  a  psychiatrist  just  as  technical  resources  in  any  other 
specialty  would  be  derived  from  the  appropriate  specialist. 

All  doctors  should  acquire  a  "psychiatric  intelligence,"  we  are  told, 
even  though  but  few  become  psychiatrists,  and  by  so  doing  prevent  the 
complete  transfer  of  this  important  work  to  organizations  or  to  individ- 
uals who  have  no  medical  experience — such  a  transfer  would  surely  be 
most  undesirable  outcome  of  the  modern  effort  to  bring  the  very  valuable 
aid  of  psychology  and  psychiatry  within  reach  of  all  needing  such  help. 

Institute  for  Child  Guidance  Studies — Selected  Reprints. 
Edited  by  L.  G.  Lowrey,  M.  D.,  Director  of  the  Institute. 
The  Commonwealth  Fund,  New  York,  1931.  290  pp. 

The  volume  covers  contributions  from  four  fields,  social,  medical,  psycho- 
logical and  child  training,  the  papers  all  being  by  members  of  the  Institute 
for  Child  Guidance  staff. 

In  the  social  field  the  paper  by  Charlotte  Towle  covers  in  a  small  space, 
yet  in  a  remarkably  comprehensive  way,  the  history  and  development 
of  "Certain  Changes  in  the  Philosophy  of  Social  Work"  and  is  perhaps  the 
most  interesting  in  this  group. 

Among  the  medical  contributions,  research  done  on  the  problem  of 
"Restlessness  in  Infancy,"  the  problem  of  the  hypertonic  infant,  is  taken 


47 

up  and  the  adjustment  of  enyironment  and  the  successful  use  of  atropine 
discussed  in  detail. 

"The  Rorschach  Test  and  Personality  Diagnosis"  is  covered  in  the 
section  on  psychological  research. 

Dr.  Lowrey  contributes  an  excellent  article  on  "Training  for  the  Pro- 
fession of  Parenthood." 

The  other  topics  covered  are : 

Social  Field 

The  Problems  of  Meeting  the  Needs  of  the  Social  Worker  Who  Refers 
Cases  to  a  Psychiatric  Clinic  —  Christine  Robb 

Contribution  of  Mental  Hygiene  to  the  Differentiated  Fields  of  Social 
Work  —  L.  G.  Lowrey,  M.  D. 

Psychiatric  Social  Service  in  a  General  Hospital  Clinic  —  Katharine  Moore 

The  Role  of  the  Psychiatric  Social  Worker  in  Therapy 

—  Bertha  C.  Reynolds 

The  Incidence  of  First-Born  among  Problem  Children 

—  Curt  Rosenow,  Ph.  D. 

Medical  Field 

Competitions  and  the  Conflict  over  Difference:     The  "Inferiority  Com- 
plex" in  the  Psychopathology  of  Childhood        —  L.  G.  Lowrey,  M.  D. 

Finger  Sucking  and  Accessory  Movements  in  Early  Childhood 

—  DavidTL  Levy,  M.  D. 

The  Study  of  Personality  —  L.  G.  Lowrey,  M.  D. 

Delinquency:  Problems  in  the  Causation  of  Stealing 

—  H.  M.  Tiebout,  M..  D.      Mary  Coburn 

Psychiatric  Methods  and  Technique  for  Meeting  Mental  Hygiene  Pro- 
blems in  Children  of  Preschool  Age  —  L.  G.  Lowrey,  M.  D. 

Psychological  Field 

One  More  Definition  of  Heredity  and  of  Instinct  —  Curt  Rosenow,  Ph.  D. 

Child  Training  Field 

Character  Building  and  Stealing    —  H.  M.  Tiebout,  M.  D.    Mary  Coburn 

There  is  a  bibliography  attached  to  some  of  the  papers  and  a  list  is 
given  of  other  papers  published  by  members  of  the  staff. 


48 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS. 

During  the  months  of  October,  November  and  December  1931, 
samples  were  collected  in  135  cities  and  towns. 

There  were  693  samples  of  milk  examined,  of  which  105  were  below 
standard;  from  4  samples  the  cream  had  been  in  part  removed,  and  6 
samples  contained  added  water.  There  were  5  samples  of  Grade  A  milk 
examined,  all  of  which  were  above  the  legal  standard  of  4.00%  fat. 
There  were  893  bacteriological  examinations  made  of  milk.  There  were 
26  samples  examined  for  hemolytic  streptococci,  4  of  which  were  posi- 
tive, and  22  samples  were  negative. 

There  were  771  samples  of  food  examined,  of  which  159  were  adulter- 
ated or  misbranded.  These  consisted  of  21  samples  of  butter  which 
were  below  the  standard  in  milk  fat;  2  samples  of  cream,  each  bear- 
ing a  cap  not  labeled  as  to  grade;  104  samples  of  eggs,  74  samples  of 
which  were  cold  storage  not  so  marked,  12  samples  were  decomposed, 
and  18  samples  of  eggs  which  were  sold  as  fresh  eggs  but  were  not 
fresh;  4  samples  of  hamburg  steak,  2  samples  of  which  were  decom- 
posed, and  2  samples  contained  a  compound  of  sulphur  dioxide  not 
properly  labeled;  15  samples  of  sausage,  13  samples  of  which  contained 
a  compound  of  sulphur  dioxide  not  properly  labeled,  1  sample  of  which 
also  contained  starch  in  excess  of  2  per  cent,  and  2  samples  contained 
starch  in  excess  of  2  per  cent;  1  sample  of  liver  which  was  decom- 
posed; 1  sample  of  fish  which  was  rancid;  1  sample  of  maple  syrup 
which  contained  cane  sugar;  1  sample  of  breakfast  food  which  had  an 
odor  of  naphthalene ;  and  9  samples  of  vinegar  which  were  low  in  acid. 

There  were  10  samples  of  drugs  examined,  of  which  6  were  adulter- 
ated or  misbranded.  These  consisted  of  3  samples  of  headache  powders 
which  contained  acetanilid,  the  packages  not  being  so  labeled;  and  3 
samples  of  spirit  of  nitrous  ether  which  were  deficient  in  the  active 
ingredient. 

The  police  departments  submitted  1,217  samples  of  liquor  for  exam- 
ination, 1,199  of  which  were  above  0.5%  in  alcohol.  The  police  depart- 
ments also  submitted  35  samples  of  narcotics,  etc.,  for  examination,  8 
of  which  were  morphine,  5  opium,  2  samples  of  methyl  alcohol;  2 
samples  which  contained  potassium  hydroxide;  1  sample  which  con- 
tained sodium  hydroxide ;  1  sample  which  contained  alcohol,  water  and 
anoleo  resin;  1  sample  which  contained  soap  and  washing  soda;  2 
samples  of  ointments  which  contained  sulphur;  1  sample  of  a  brown 
liquid  and  a  sample  of  pills  responded  to  tests  similar  to  those  for 
ergot — some  pills  from  the  same  source  contained  quinin;  a  sample  of 
liquid  contained  approximately  43%  alcohol;  one  sample  of  a  greenish 
herb  which  was  tested  for  narcotics  with  negative  results;  one  sample 
of  a  liquid  which  was  tested  for  chloroform,  alkaloids  and  heavy  metals, 
with  negative  results — this  sample  contained  a  trace  of  ethyl  alcohol; 
2  samples  which  were  tested  for  narcotics  with  negative  results;  4 
samples,  upon  which  the  examinations  were  not  completed,  because  of 
insufficient  material  or  at  the  request  of  the  officer  submitting  the 
sample;  a  sample  of  pills  contained  a  substance  which  was  probably 
euphthalmine,  but  the  sample  was  too  small  for  positive  identification ; 
and  a  sample  of  pills  was  tested  for  alkaloids  with  negative  results. 

There  were  58  hearings  held  pertaining  to  violations  of  the  laws. 

There  were  55  cities  and  towns  visited  for  the  inspection  of  pasteur- 
izing plants,  and  175  plants  were  inspected. 

There  were  66  convictions  for  violations  of  the  law,  $1,360  in  fines 
being  imposed. 

Arthur  Clark  of  Easthampton,  Clark's  Spas,  Incorporated,  of  Cam- 
bridge; H.  P.  Hood  &  Sons,  Incorporated,  3  cases,  of  Lawrence;  Arthur 
E.  Law,  2  cases,  of  Methuen;   George  Panaitias  of  Lynn;   Lester  E. 


49 
Berry  of  Berlin;  and  John  Silva  of  Hudson,  were  all  convicted  for 
violations  of  the  milk  laws. 

Manuel  Corey  and  Sylvia  Fortier  of  Fall  River;  Cape  Ann  Dairy, 
Incorporated  of  Essex;  Dunajski  Brothers  of  Peabody;  Anthony  Michal- 
owski  of  Danvers;  John  A.  Sellars  of  Lexington;  United  Farmers  Co- 
operative Creamery  Association,  2  counts,  of  Charlestown;  Peter 
Frydich,  2  counts,  of  Worcester;  and  William  Spohr  of  Haverhill,  were 
all  convicted  for  violations  of  the  pasteurization  law  and  regulations. 
Anthony  Michalowski  of  Danvers  appealed  his  case. 

Thomas  Deary  of  Dudley  was  convicted  for  violation  of  the  Grade 
A.  Milk  regulations. 

Hyman  Racoff  of  Roxbury;  Ellias  Cohn,  Grand  Union  Grocery  Stores, 
Incorporated,  Sam  Tillman,  Isidore  Tillman,  and  Leon  Colapietro,  all  of 
Springfield;  Maude  Sotes  of  Onset;  Francesco  G.  Baldo  of  New  Bed- 
ford; Aaron  J.  Berenson  and  Maurice  I.  Paresky  of  Lawrence;  First 
National  Stores,  Incorporated,  of  Mattapan  and  Ipswich;  Gray  United 
Stores,  Incorporated,  of  Essex;  Morris  Sigman  of  Beverly;  Anthony 
Morakis  of  Cambridge;,  and  Gray  United  Stores,  Incorporated,  of 
Stoughton,  were  all  convicted  for  violations  of  the  food  laws.  Hyman 
Racoff  of  Roxbury  appealed  his  case. 

Alfonse  L.  Frechette;  Andrew  Mazzone  of  Newton  Upper  Falls;  and 
Thomas  A.  Spitz  of  West  Newton,  were  all  convicted  for  violations  of 
the  bakery  laws. 

James  B.  Humphrey  of  Winchendon;  Louis  Lavine  of  Northampton; 
Lawrence  Wholesale  Drug  Company  of  Lawrence;  and  William  Ferris 
of  Springfield,  were  all  convicted  for  violations  of  the  drug  laws. 

Samuel  Checkoway  of  Amesbury;  and  Leo  A.  Branchi  of  Springfield, 
were  both  convicted  for  false  advertising. 

The  Great  Atlantic  &  Pacific  Tea  Company  of  Oak  Bluffs,  Benjamin 
Kaplan  of  Southbridge;  Carl  Gold,  Swift  &  Company,  Nocola  Curto, 
Carlo  Ditivre,  Alfonso  Gentile,  Joseph  Kutzenko,  and  Joseph  Boucher, 
all  of  Springfield;  Warren  R.  Ladd  of  Winchendon;  John  Ross  of 
Clarksburg;  James  O'Shea  of  Arlington;  Samuel  Sidorov  of  Lawrence; 
Frank  Bonsignori  of  Cambridge;  Harold  Holmes  of  Bourne;  Felix 
Klys  of  Webster;  Cosimo  Leo  and  Joseph  A.  Toscano  of  Worcester; 
Charles  J.  Murphy  of  Stoughton;  and  Abraham  Shapiro  of  Lynn,  were 
all  convicted  for  violations  of  the  cold  storage  laws.  Abraham  Shapiro 
of  Lynn  appealed  his  case. 

Peter  Adzima  of  Belchertown  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: 

Two  samples  of  milk  which  contained  added  water  were  produced  by 
John  Silva  of  Hudson. 

One  sample  of  milk  from  which  a  portion  of  the  cream  had  been 
removed  was  produced  by  Lester  E.  Berry  of  Berlin. 

Butter  which  was  below  the  standard  in  milk  fat  was  obtained  as 
follows : 

Three  samples,  from  Holland  Butter  Company  of  Boston;  2  samples 
each,  from  H.  L.  Handy  Company  of  Springfield,  and  Swift  and  Com- 
pany of  Boston;  and  1  sample  each,  from  Land-O-Lakes,  Mohican 
Company,  First  National  Stores,  Incorporated,  A.  E.  Mills  &  Son,  and 
Charles  H.  Stone,  all  of  Boston ;  North  River  Creamery  of  Jacksonville, 
Vermont;  and  Fairmont  Creamery  of  Boston  and  Worcester. 

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

One  sample  each,  from  Joseph  Boucher  of  West  Springfield;  Rosa 
Allen  Roberge  of  Fall  River;  Maurice  Dovner  of  Taunton;  and  Al- 


50 
phonse  Archambeau,  Raone  Page,  Casper  Pallot,  and  Market,  444  High 
Street,  all  of  Holyoke. 

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

One  sample  each,  from  Frederick  A.  Pelletier  of  Taunton ;  and  John 
Ross  of  Briggsville. 

One  sample  of  sausage  which  contained  a  compound  of  sulphur 
dioxide  not  properly  labeled,  and  also  contained  starch  in  excess  of 
2  per  cent,  was  obtained  from  Joseph  Mach  of  Holyoke. 

One  sample  of  hamburg  steak  which  contained  a  compound  of  sul- 
phur dioxide  not  properly  labeled  was  obtained  from  Casper  Pallot  of 
Holyoke;  and  Isidore  Tillman  of  Springfield. 

One  sample  of  hamburg  steak  which  was  decomposed  was  obtained 
from  Grand  Union  Company  of  Springfield ;  and  Economy  Meat  Market 
of  Gloucester. 

One  sample  of  liver  which  was  decomposed  was  obtained  from  First 
National  Stores  of  Cambridge. 

One  sample  of  fish  which  was  rancid  was  obtained  from  Burns 
McKeon  Company  of  South  Boston. 

One  sample  of  maple  syrup  which  contained  cane  sugar  was  obtained 
from  Apple  Tree  Lunch,  Incorporated,  of  Waltham. 

Nine  samples  of  vinegar  which  were  low  in  acid  were  obtained  from 
A.  Dupuis  of  Fall  River. 

Three  samples  of  headache  powders  which  contained  acetanilid, 
the  packages  not  being  so  labeled,  were  obtained  from  John  A.  Haley 
of  Haverhill. 

There  were  seven  confiscations,  consisting  of  25  pounds  of  decomposed 
chickens;  96  pounds  of  decomposed  fowl;  18  pounds  of  decomposed 
turkeys;  538  pounds  of  decomposed  beef;  40  pounds  of  decomposed 
beef  liver;  and  32  pounds  of  decomposed  veal  sweetbreads. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  September,  1931: — 343,350  dozens  of 
case  eggs;  385,021  pounds  of  broken  out  eggs;  1,085,852  pounds  of 
butter;  1,269,965  pounds  of  poultry;  1,722,920  pounds  of  fresh  meat 
and  fresh  meat  products;  and  3,508,950  pounds  of  fresh  food  fish. 

There  was  on  hand  October  1,  1931: — 7,573,350  dozens  of  case  eggs; 
2,694,270  pounds  of  broken  out  eggs;  7,708,099  pounds  of  butter;  3,186,- 
214  pounds  of  poultry;  5,169,265y2  pounds  of  fresh  meat  and  fresh 
meat  products;  and  22,276,116  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  October,  1931: — 353,040  dozens  of 
case  eggs;  231,463  pounds  of  broken  out  eggs;  814,978  pounds  of  but- 
ter; 1,114,349  pounds  of  poultry;  2,007,lll3/4  pounds  of  fresh  meat  and 
fresh  meat  products;  and  3,394,590  pounds  of  fresh  food  fish. 

There  was  on  hand  November  1,  1931 : — 5,261,910  dozens  of  case  eggs; 
2,335,431  pounds  of  broken  out  eggs;  5,215,199  pounds  of  butter; 
3,663,926  pounds  of  poultry;  3,581,922%  pounds  of  fresh  meat  and  fresl 
meat  products;  and  21,003,355  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  November,  1931: — 194,310  dozens  of 
case  eggs;  323,347  pounds  of  broken  out  eggs;  668,704  pounds  of  but- 
ter; 1,966,501  pounds  of  poultry;  2,662,406%  pounds  of  fresh  meat  anc 
fresh  meat  products;  and  2,799,093  pounds  of  fresh  food  fish. 

There  was  on  hand  December  1,  1931 : — 2,757,750  dozens  of  case 
eggs;  2,003,429  pounds  of  broken  out  eggs;  3,374,889  pounds  of  butter; 
4,426,471  pounds  of  poultry;  4,304,254  pounds  of  fresh  meat  and  fresh 
meat  products;  and  19,726,208  pounds  of  fresh  food  fish. 


51 
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  Child  Hygiene 
Division   of  Tuberculosis 
Division  of  Adult  Hygiene 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Director, 

Gaylord  W.  Anderson,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 

Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  Pittsfield. 


Publication  op  this  Document  approved  by  the  Commission  on  Administration  and  Finance 
10M.  3-'82.  Order  5004. 


T     '      '     ' 


iit  umM OFMASSASUl 


25    » 


e 


THE 


HOUSf,  BOSTON 

COMMONHEALTH 


Volume  19 
No.  2 


APR.- MAY-JUNE 
1932 


Nutrition 


MASSACHUSETTS 
DEPARTMENT   OF  PUBLIC  HEALTH 


19 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  op 
Public  Health 

Sent  Free  Vb  amy  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston   Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

Nutrition,   With   or   Without   an   Advisory   Committee,   by   George 

H.  Bigelow,  M.D 55 

Sleep  and  Nutrition,  by  Harold  C.  Stuart,  M.D.       .  .  .56 

Good  Eating  Habits  in  Children,  by  Stanton  Garfield,  M.D.     .  59 

Posture  and  Nutriton,  by  Alma  Porter  .  .  .  .  .  .62 

Food  for  the  Adult,  by  Octavia  Smillie  .  .  .  .  .35 

Nutrition  Emergency,  by  Mary  Spalding,  M.A.,  B.S.       .  .  .67 

The  Minimum  Food  Budget  in  1932,  by  Blanche  F.  Dimond,  B.S.  .  70 
Teaching  Nutrition  in  an  Out-Patient  Department,  by  Gertrude  T. 

Spitz,  A.B.,  A.M.    .  ...  .  .    '      .     74 

Staff  Education  in  Nutrition — Springfield,  Massachusetts,  by  Florence 

G.   Dorward    .........     77 

The  Value   of   a  Nutritionist   in   the    Schools,   by   Mary   Elizabeth 

O'Connor          ......  78 

4-H  Club  Food  Work,  by  Helen  E.  Doane  and  Albertine  P.  McKellar, 

B.S.  80 

An  Echo  Returns,  by  Mildred  L.  Swift 83 

Nutrition   Phase   of  the   Chadwick   Clinics,   by   Lillian   Stuart   and 

Catherine  Leamy     ........      84 

Recommendations  for  Training  of  a  Nutritionist   .  .  .87 

The  Value  of  Health  Education  to  the  Community,  by  Michele  Nigro, 

M.D 87 

Health  Education  Procedure  .......      89 

Epidermophytosis   (Athlete's  Foot) — Its  Prevention  and  Treatment, 

by  C.  Guy  Lane,  M.D.     ...  ...     91 

Care  of  the  Mouth  During  Pregnancy,  by  Fred  L.  Adair,  M.D.  and 

Howard  M.   Service,  D.D.S 96 

Safe  But  Unpalatable,  by  Joseph  C.  Knox       .  .  .97 

White  House  Conference  Publications  on  Nutrition         .  .  .    100 

Some  Interesting  Articles  on  Nutrition  .....    100 

The  Bellevue-Yorkville  Health  Demonstration — Annual  Report  1931  100 
International  Hospital  Association — Postgraduate  Course  on  Hospital 

Technique        .........   101 

Economy  and  Health    .........    101 

Book  Note 

Principles  and  Practices  of  Public  Health  Nursing   .  .    101 

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

March,  1932 ...    102 


NUTRITION,  WITH  OR  WITHOUT  AN  ADVISORY  COMMITTEE 

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

In  the  nutrition  field  as  in  all  other  fields  of  public  health  interest, 
or  life  in  general,  today  there  are  the  right  and  left  wings  of  thought. 
O/.ie  would  have  us  believe  that  our  sense  of  taste  and  cravings  for  this 
or  that  diet  are  safe  guides  to  the  growth  and  nutritional  needs  of  the 
I  varied  tissues  of  the  body.   Set  before  the  child  everything  from  caviar 
ito  carrots  and  the  integrity  of  the  bony  structure  will  be  assured !   This 
\faith  in  the  inherent  soundness  of  human  cravings  is  rather  popular 
(oday  and  should  logically  lead  to  making  attendance  at  free  movies 
j  fcompulsory  and  charging  for  attendance  at  our  schools. 
!  I    The  other  wing  claims  that  anything  short  of  the  last  word  is  worse 
^Ihan  nothing,  yet  how  can  one  recognize  the  last  word  when  everyone 
i«  talking  at  once?   These  protagonists  would  aim  for  a  nutritionist  in 
eVery  home  by  Christmas  or  possibly  the  New  Year,  and  scorn  the  use- 
fulness of  general  propaganda  except  as  a  means  of  raising  interest  in 
[the  abysmal  need  of  individual  nutritionists  as  we  now  rather  generally 
appreciate  the  need  of  individual  drinking  cups.   This  theory  of  perfec- 
tio  1   (granting  that  all  nutritionists  are  equally  perfect")   would  lead 
logically  to  a  prohibition  of  practically  all  home  made  music  with  all 
the  domestic  emotions  that  it  lets  out  and  in,  and  all  home  made  har- 
monies would  be  limited  to  post-prandial  efforts  of  members  of  the 
symphony  orchestra  who  might  be  cajoled  in  for  the  evening.  Of  course 
both  extremes  are  absurd  and,  as  always,  the  truth  lies  somewhere 
between. 

There  never  was  a  time  when  the  nutrition  of  the  people  was  more 
critically  important,  not  even  excepting  the  war.  The  scars  of  these 
parlous  times  will  rest  more  permanently  on  our  children  than  on  any- 
thing else  in  our  civilization.  How  can  the  cumulatively  crushing  bur- 
dens of  the  next  generation  be  solved  if  the  thinking  must  be  done  in- 
side soft-boned,  anemic,  flat  chested  and  lordosed  bodies?  Lethargy  or 
violence  is  all  that  can  come  out  of  such  twisted  temples. 

Again,  far  more  important  just  now  with  constricted  resources  than 
spending  less  money  is  spending  what  we  have  more  discriminatingly. 
For  relief  agencies  to  spend  enough  money  on  food  but  to  spend  it  un- 
wisely is  far  more  reprehensible  than  not  to  spend  enough,  yet  is  far 
more  likely  to  go  undetected.  A  basic  factual  sophistication  in  these 
matters  is  preeminently  needed. 

Again,  there  are  tricks  in  the  trade.  There  is  a  popular  myth  that 
he-men  and  New  Englanders  (and  there  is  a  difference)  are  bred  on 
meat,  potato  and  pie,  with  a  scattering  of  doughnuts  for  breakfast, 
fishcakes  on  the  Sabbath,  and  baked  beans  and  brown  bread  with  the 
bath.^  If  such  a  diet  ever  had  an  excuse  it  was  its  association  with 
frontier  physical  violence,  not  mechanistic  inactivity.  Again  one  level 
of  dietary  is  needed  to  maintain  a  given  nutritional  level,  and  quite 
another  to  assure  growth,  so  that  the  problem  of  feeding  our  children 
must  be  doubly  discriminating.  Again  there  are  tastes,  usually  base- 
less, which  parents  would  egotistically  and  perhaps  unconsciously  per- 
petuate in  their  children.  The  fat-bellied  father,  who  was  perhaps  a 
famous  center  if  records  are  to  be  trusted,  revolts  at  the  thwarting  of 
his  ambition  for  his  son  by  seeing  him  eat  effeminate  salads  and  other 
rabbit  food.  "The  boy  will  be  playing  with  dolls  next!"  The  throwing 
away  of  pot  liquor  makes  the  New  England  sewer  more  nourishing  than 
the  New  England  table.  To  suggest  Americanized  breakfast  cereal  to 
the  Italian  family  is  as  futile  as  to  offer  the  horse  sufficient  calories  in 
prickly  pears.  And  the  cost!  Meat,  the  most  expensive  and  least  im- 
portant, with  milk,  vegetables  and  cereals  at  the  other  end.  Can  we  get 


56 
over  all  this  that  is  really  simple  and  elementary  so  that  it  will  become 
alimentary? 

As  usual  we  call  to  our  help  an  advisory  committee  for  group  think- 
ing, which  Ray  Lyman  Wilbur  indicates  as  so  important  in  any  field. 
As  usual  Massachusetts  offers  generously  in  this  field,  generously  in 
skill  and  willingness  to  serve.  Our  committee  is:  Dr.  Alice  Blood,  Mrs. 
Annette  T.  Herr,  Professor  Curtis  M.  Hilliard,  Professor  Murray  P. 
Horwood,  Dr.  Florence  McKay,  Dr.  Howard  F.  Root,  Mrs.  Octavia 
Smillie  and  Miss  Frances  Stern.  \ 

Under  their  guidance,  Federal  and  privately  prepared  printed  ma- 
terial has  been  procured.    Also,  as  in  this  number  of  The  Common-  i 
health,  we  have  filled  in  with  our  own.    Printed  and  consultative  ser-  i 
vice  has  been  offered  to  relief  agencies  of  which  we  know.  Newspapers,  / 
addresses,  short  courses,  the  whole  mess  of  verbiage  has  been  employed. 
Through  dental  hygiene  much  effective  nutritional  work  has  been  done.  | 
Under  the  direction  of  the  Forsyth  Dental  Infirmary  a  nutritional  ex- 
periment in  our  sanatoria  for  children  has  been  instituted  and  is  threat-; 
ened  by  shortage  of  funds.   In  the  schools  health  education  may  under-r 
mine  some  of  the  parental  nutritional  perversity.   Perhaps  fortunately/ 
the  young  look  on  the  ideas  of  their  parents  as  out-dated. 

And  so  it  goes!    A  slow  thing,  the  change  in  the  eating  habits  of  a  ] 
people,  and  critically  needed  quickly.  May  this  number  of  The  Common-    i 
health  help  somewhat  in  the  quickening  process. 

SLEEP  AND  NUTRITION 

Harold  C.  Stuart,  M.D. 

Assistant  Professor  of  Pediatrics  and  Child  Hygiene 
Harvard,  School  of  Public  Health 

The  term  "nutrition"  should  make  us  think  not  of  weight  or  the 
amount  of  tissues,  but  rather  of  the  series  of  biological  and  chemical 
processes  which  make  possible  the  maintenance  and  growth  of  those 
tissues.  These  processes  have  to  do  with  the  taking  of  different  foods 
and  their  conversion  into  new  substances,  suitable  for  the  building  of 
body  tissues  and  for  energy  to  carry  on  the  multiplicity  of  body  func- 
tions. Thought  of  in  this  way,  it  is  obvious  that  sleep  and  nutrition  are 
intimately  related. 

Sleep  protects  our  nutritional  processes  in  two  ways:  First,  by  re- 
ducing the  demands  made  by  the  body  on  these  processes;  and  secondly, 
by  giving  the  tissues  and  organs  an  opportunity  for  inactivity  and  re- 
cuperation, so  that  they  may  be  fit  to  function  normally  and  not  suffer 
irom  fatigue. 

We  have  some  direct  evidence  relating  to  the  effects  of  sleep  upon 
nutritional  requirements.  We  know  that  our  bodies  are  burning  fewer 
calories  per  hour  in  sleep  than  at  any  other  time.  According  to  the  . 
recent  report  of  the  White  House  Conference  Committee  on  Nutrition, 
sleep  depresses  the  basal  metabolism  (i.e.  the  metabolic  rate,  while 
absolutely  quiet  and  recumbent  but  awake)  to  the  following  extent: 

(a)  in  infancy  6.1%  to  14.8%— Benedict 

(b)  in  childhood  11.3%  to  26.9%— Wilson  et  al 

(c)  in  the  adult  12.0%  to  13.0%— Benedict 

Benedict  further  gives  the  calories  per  hour  burned  by  a  man  asleep 
as  65,  while  sitting  quietly  awake  as  100.  These  figures  more  nearly 
represent  the  real  saving,  for  few  individuals  remain  long  in  the  con- 
dition called  for  by  basal  metabolism  while  awake.  It  is  evident  that 
caloric  requirements  will  be  influenced  both  by  the  number  of  hours 
we  sleep  and  by  the  nature  of  that  sleep,  whether  it  is  near  the  border 
line  of  wakeful  activity  or  whether  it  is  deep  enough  to  allow  all  activ- 
ity to  be  profoundly  depressed.    We  know  something  of  the  depth  of 


57 

sleep  at  different  hours  and  under  different  circumstances.  Electrical 
recording  devices  have  been  used  to  study  the  nature  of  sleep  under 
varying  circumstances  and  in  different  individuals.  We  know  that  night 
sleep  quickly  becomes  more  quiet,  bodily  movements  decreasing  rapidly 
in  the  first  hour  after  falling  asleep.  Following  a  short  period  of  pro- 
found quiet,  activity  gradually  increases  up  to  the  level  of  wakefulness. 
Some  individuals  regularly,  and  most  of  us  occasionally,  continue  ex- 
tensive body  movements  throughout  much,  or  all,  of  the  night.  The 
rapidity  of  establishing  the  most  complete  inactivity,  as  well  as  its 
degree  and  duration,  varies  with  individuals,  and  is  influenced  by  many 
mental  and  physical  factors.  All  kinds  of  sensory  stimulations  effect 
the  intensity  of  sleep  and  increase  muscular  activity  and  blood  flow. 
Although  our  knowledge  on  this  subject  is  not  yet  complete,  we  may 
rest  assured  that  our  requirements  for  food  are  profoundly  influenced 
by  our  habits  of  sleep. 

Let  us  now  consider  the  part  which  sleep  plays  in  providing  recupera- 
tion, and  the  effects  of  fatigue  upon  nutrition.  It  is  difficult  to  discuss 
sleep  without  considering  the  broader  aspects  of  rest  in  relation  to 
activity.  A  suitable  balance  between  exercise,  sleep,  and  relaxation 
while  awake  is  of  great  importance  in  providing  for  adequate  nutrition. 
Sleep  is  the  most  complete  form  of  rest,  and  for  the  infant  and  young 
child  practically  the  only  means  of  securing  rest.  In  the  early  years 
wakefulness  is  practically  synonymous  with  activity,  and  the  nervous 
effort  necessary  to  inhibit  activity  is  in  itself  very  fatiguing.  Some- 
thing can  be  accomplished  at  this  age  by  varying  activity  and  provid- 
ing quiet  play,  but  in  the  main  the  young  child  obtains  his  rest  in  sleep. 
For  the  older  child  and  adult  additional  rest  may  be  secured  in  wake- 
ful hours.  Much  can  be  accomplished  in  this  way  by  the  person  who 
has  learned  how  to  relax  and  rest  at  will.  Some  people,  however,  never 
learn  how  to  relax,  and  their  health  often  suffers  in  consequence. 

Rest  for  purposes  of  recuperation  must  follow  activity  in  all  physio- 
logical processes,  but  it  may  be  only  a  relative  matter.  Rest  is  com- 
monly provided  by  reduced  activity,  rather  than  complete  inactivity; 
and  this  is  true  even  in  the  rest  of  sleep.  While  asleep  our  various 
organs  and  tissues  are  not  completely  inactive.  The  beating  of  the 
heart,  the  constant  movements  of  respiration,  and  peristalsis  in  the  in- 
testinal tract  all  continue  during  the  quietness  of  sleep.  All  of  these 
involve  contraction  of  muscles  and  expenditure  of  energy.  But  if  sleep 
is  sound  and  undisturbed,  the  body  should  be  in  the  state  of  relaxa- 
tion and  repose  most  conducive  to  recuperation.  Our  digestive  pro- 
cesses_  undoubtedly  share  in  this  opportunity  for  recuperation.  But 
there  is  very  little  evidence  that  motility  in  the  gastro-intestinal  tract 
is  modified  by  sleep.  Digestion  not  only  goes  on  during  sleep,  but  there 
is  some  evidence  that  a  glass  of  milk  or  some  other  small  meal  at  bed- 
time actually  contributes  to  producing  more  quiet  sleep.  The  gastric 
contractions  of  hunger  may  be  more  active  and  disturbing  than  the 
quiet  motility  of  normal  digestion.  The  other  nutritional  processes  car- 
ried on  by  the  blood  and  cellular  interchanges  are  largely  chemical  in 
their  action  and,  although  continuous  during  sleep,  do  not  involve 
bodily  activity. 

Fatigue  effects  nutrition  in  various  ways.  The  efficiency  of  the  or- 
gans and  tissues  involved  in  the  nutritional  processes  is  undoubtedly 
reduced.  For  example,  emptying  of  the  stomach  is  prolonged  under 
conditions  of  fatigue,  due  to  faulty  gastric  motility.  Appetite  is  usually 
diminished,  and  thus  the  intake  of  food  is  interfered  with.  Fatigue 
renders  all  muscular  activity  less  efficient  and  less  precise.  Therefore, 
activities,  carried  out  under  conditions  of  fatigue,  call  for  extra  energy 
to  provide  for  waste  motion.  In  the  chronically  tired  child  even  main- 
taining the  correct  posture  often  calls  for  constant  muscular  effort  and 
great  expenditure  of  energy.  The  tired  muscles  of  support  fail  to  main- 


58 
tain  normal  tone  and  balance  without  effort  on  the  part  of  the  central 
nervous  system.  Although  adequate  sleep  is  not  the  only  essential  for 
the  prevention  of  chronic  fatigue,  it  is  an  important  part  of  such  pre- 
vention. Suitable  habits  of  sleep,  ample  amounts  of  sleep,  and  desirable 
conditions  of  sleep  provide  the  best  possible  preventive  against  chronic 
fatigue,  and  hence  against  interference  with  normal  nutrition. 

Thus  we  see  that  desirable  habits  of  sleep  diminish  the  requirements 
for  food  and  at  the  same  time  increase  the  tolerance  for  food.  They  thus 
provide  a  broad  margin  of  safety  between  capacity  and  requirements 
for  food,  and  tremendously  reduce  the  likelihood  of  nutritional  dis- 
order. The  well  rested  child  with  a  suitable  margin  of  safety  in  his 
tolerance  can  be  allowed  a  greater  latitude  in  his  diet.  He  can  take 
more  food  than  his  immediate  requirements  dictate,  and  thus  provide 
a  better  storage  in  his  tissues.  Other  things  being  equal,  he  will  be 
less  likely  to  suffer  from  malnutrition,  and  will  have  less  interference 
with  his  growth  and  development. 

The  infant  or  child  whose  growth  has  been  retarded  by  nutritional 
disturbances  must  progress  more  rapidly  than  normal  during  conva- 
lescence if  his  retardation  is  to  be  overcome.  Under  these  circumstances 
it  is  not  sufficient  to  plan  his  diet  with  care,  but  his  daily  routine  must 
be  considered  from  the  standpoint  of  balance  between  sleep  and  wake- 
fulness, between  rest  and  exercise.  These  considerations  are  too  fre- 
quently overlooked,  and  the  well-planned  diet  is  either  not  taken  or  is 
poorly  utilized.  From  a  practical  standpoint  sleep  deserves  more  atten- 
tion on  the  part  of  those  interested  in  improving  the  nutrition  of  our 
children  than  it  customarily  receives. 

A  word  should  be  said  about  the  factors  which  commonly  interfere 
with  normal  sleep.  Among  the  first  of  these  is  undoubtedly  failure  to 
establish  and  maintain  regularity  in  habits  of  sleep.  Faulty  habits  are 
quickly  acquired  from  a  variety  of  seemingly  minor  causes,  and  once 
acquired  are  often  hard  to  break.  They  may  be  due  to  lack  of  regularity 
in  the  hours  provided,  a  nap  occasionally  omitted  or  bedtime  postponed 
to  suit  the  family  convenience.  They  may  be  due  to  picking  the  baby 
up  frequently  on  slight  provocation,  thus  intensifying  a  tendency  to 
occasional  wakefulness  and  fixing  as  a  habit  what  would  otherwise  be 
a  temporary  disturbance,  or  they  may  be  due  to  unsuitable  conditions 
of  sleep,  improper  clothing,  insufficient  fresh  air,  noisy  surroundings, 
and  the  like.  They  may,  of  course,  be  due  to  disease  or  some  abnormal 
physical  condition  which  should  be  discovered  by  the  physician  and 
corrected  as  promptly  as  possible.  Infants  who  fail  to  gain  or  to  do 
well  from  a  nutritional  standpoint,  despite  the  most  careful  attention 
to  formula  and  details  of  feeding,  will  not  infrequently  progress  nor- 
mally when  attention  is  directed  to  their  habits  of  sleep.  When  these 
habits  have  become  totally  unsatisfactory  and  the  infant's  nutrition 
has  suffered,  the  temporary  use  of  mild  sedatives  prescribed  only  by  a 
physician  at  the  hours  of  desired  sleep  will  often  do  more  to  facilitate 
normal  progress  than  much  attention  to  diet. 

In  addition  to  faulty  habit  formation  or  disease  as  causes  of  inter- 
rupted sleep,  an  unduly  stimulated  nervous  system  is  frequently  ac- 
countable. The  nervous  and  mental  activity  prior  to  retiring  at  night, 
or  just  before  hours  set  aside  for  naps,  often  make  sleep  out  of  the 
question.  Few  children  can  jump  at  will  from  excitable  play  to  pro- 
found quiet.  Mothers  often  complain  that  they  do  put  their  children  to 
bed  regularly,  but  cannot  make  them  sleep.  One  cannot  make  a  child 
sleep  without  sedatives  if  his  waking  hours  have  been  so  abnormal  as 
to  make  sleep  impossible  when  the  need  for  it  has  arisen,  but  one  can 
so  correct  the  errors  in  a  child's  daily  routine  that  the  normal  physio- 
logical responses  to  activity  will  automatically  lead  to  satisfactory 
sleep  at  the  appropriate  time  and  under  suitable  conditions.  We  can 
provide  these  conditions.   We  can  remove  the  mental  and  physical  fac- 


59 

tors  which  commonly  interfere,  and  we  can  train  from  early  infancy  in 
regular  habits  of  sleep  which  will  stand  the  child  in  good  stead  if  illness 
develops  unexpectedly. 

GOOD  EATING  HABITS  IN  CHILDREN 

Stanton  Garfield,  M.D. 

Assistant  in  Pediatries  and  Child  Hygiene 
Harvard  School  of  Public  Health 

During  the  course  of  daily  rounds  in  and  out  of  the  home  and  hos- 
pital, part  of  the  doctor's  most  essential  equipment  consists  in  his 
knowledge  of  proper  diets.  For  those  of  us  who  devote  ourselves  en- 
tirely to  pediatrics,  the  feeding  of  infants  and  children  is  one  of  our 
major  responsibilities.  Not  infrequently  many  of  us  find  it  convenient 
to  keep  on  hand  printed  lists  of  proper  diets  for  children  of  different 
ages.  The  foods  on  these  lists  are  known  to  contain  the  proper  number 
of  calories,  vitamins,  and  so  forth,  necessary  for  nutritional  require- 
ments. The  intrinsic  value  of  each  article  of  food,  as  well  as  its  im- 
portance as  part  of  the  balanced  diet  is  well  understood.  The  purpose 
of  eating,  however,  is  primarily  to  nourish  the  body,  and  the  nutritive 
value  of  food  depends  on  several  factors  other  than  its  composition. 
Proper  preparation  and  pleasing  appearance  of  food,  as  well  as  ade- 
quate bodily  elimination,  are  necessary  so  that  the  child  may  have  a 
good  appetite.  The  degree  of  fatigue,  as  well  as  anger  or  excitement, 
affects  digestion. 

Such  factors  as  these  are  to  a  large  extent  dependent  on  habits.  It 
is  through  good  habits  that  we  achieve  health.  The  child  who  is  con- 
stantly on  the  go  and  is  allowed  to  wear  himself  down  to  the  point 
where  irritability  is  always  on  surface,  cannot  be  expected  to  master 
such  control  of  his  emotions  as  may  be  necessary  for  good  habits  of 
behavior.  Too  much  attention  can  not,  therefore,  be  placed  on  the  im- 
portance of  starting  good  habits  at  the  earliest  age  possible. 

Habits  are  the  means  by  which  all  actions  are  carried  out  with  the 
least  resistance  and  the  greatest  efficiency.  Habits  start  as  soon  as  the 
individual  is  capable  of  performing  the  act  or  acts  upon  which  these 
are  based.  Therefore,  certain  habits,  among  them  eating,  start  at  birth. 
All  habits  are  developed  through  imitation,  repetition  and  consistency 
in  the  manner  in  which  the  act  is  done.  In  order  to  assure  the  con- 
tinuation of  the  performance  of  the  act  the  interest  of  the  individual 
must  be  maintained  until,  through  constant  practice,  the  act  is  done 
with  no  conscious  effort. 

Interest  in  obtaining  nourishment  is  present  in  the  new  born  baby, 
and  his  earliest  eating  habits  are  developed  primarily  by  the  regularity 
of  hours  and  the  composition  of  his  food.  In  a  few  months  he  reaches 
the  stage  where  the  different  types  of  foods  themselves  fascinate  him. 
Then  comes  the  desire  to  master  the  toast  or  the  spoon  without  outside 
assistance.  Before  he  has  reached  the  point  where  the  more  mechanical 
sides  of  eating  have  lost  their  charm,  we  find  his  attention  held  or  di- 
verted by  people  and  things  around  him.  Then,  for  the  child  to  arrive 
at  the  stage  where  eating  becomes  such  an  habitual  act  as  to  be  uncon- 
sciously performed,  we  see  the  necessity  of  establishing  habits  con- 
trolling other  actions,  thoughts  and  emotions,  all  of  which  are  linked 
together. 

In  dealing  with  the  manner  in  which  good  eating  habits  may  be 
established,  we  must  bear  in  mind  that  there  are  certain  physiological 
influences  and  laws  which  we  must  not  attempt  to  violate.  We  must 
continue  regularity  of  hours,  allowing  nothing  between  meals  which  in 
any  way  impairs  the  appetite  at  meal  time.  This  holds  true  not  merely 
for  the  small  baby  needing  frequent  feedings  to  supply  the  proportion- 


60 
ately  large  number  of  calories  for  rapid  growth,  but  also  for  the  older 
child  who  can  assimilate  enough  at  one  time  to  require  only  three  meals 
a  day.  In  every  person  we  must  remember  that  digestion  is  a  physio- 
logical process  requiring  the  regular  and  adequate  periods  for  relaxa- 
tion and  activity  essential  to  all  bodily  functions.  Hunger  is  the  signal 
that  the  digestive  processes  have  rested  and  are  ready  to  work  again. 
To  stave  off  an  occasional  real  hunger  between  meals  by  a  small 
quantity  of  healthy  food  is  very  different  from  interrupting  the  regular 
schedule  which  has  been  found  best  adapted  to  nature's  demands. 

Normal  physiological  reactions  are  also  affected  by  thoughts  and 
emotions.  In  preparing  the  system  for  the  meal,  nature  demands  a 
period  of  emotional  quiet  in  order  that  these  hunger  impulses  may 
register  in  the  conscious  mind  and  that  digestion  may  function  unhind- 
ered. Five  or  ten  minutes  for  washing  hands  and  brushing  hair  may 
serve  as  a  diversion  of  mind  away  from  the  excitement  of  school  or 
play.  The  child  who  enters  the  dining  room  all  upset  over  a  failure  at 
school  is  so  emotionally  disturbed  that  the  food,  if  taken  at  all,  can  not 
be  properly  assimilated. 

Then,  too,  during  the  meal  itself  we  should  be  careful  to  maintain 
this  emotional  quiet.  The  meal  should  not  be  regarded  as  a  competition 
or  a  task.  It  should  be  a  time  when  we  sit  down  to  enjoy  mental  and 
physical  relaxation.  To  reward  the  owner  of  the  first  empty  plate  has 
as  its  obvious  purpose  the  prevention  of  dawdling,  but  is  apt  to  lead  to 
the  wrangles  of  competition.  It  is  also  likely  that  the  unwilling  eater 
will  resent  this  as  well  as  any  other  method  used  in  forcing  down  a 
distasteful  food.  We  should  not  try  to  make  the  food  more  pleasant  by 
centering  attention  on  what  it  is  or  how  it  is  eaten.  Such  attempts  will 
result  only  in  fostering  special  dislikes  through  the  associations  with 
unpleasant  thoughts  and  emotions. 

In  this  matter  of  likes  and  dislikes,  is  it  not  true  that  the  cultivation 
of  tastes  is  largely  a  question  of  habit?  We  must,  of  course,  realize 
that  a  child  has  natural  preferences  and  prejudices  just  as  we  have. 
We  must  not,  however,  either  cater  entirely  to  the  former  or  insist  upon 
the  latter.  We  must  also  be  careful  that  we  do  not  create  dislikes 
through  outside  influences.  If  the  father  always  pushes  aside  a  certain 
dish  with  a  peevish  complaint,  then  the  small  boy  may  be  justified  in 
holding  his  opinion  of  the  same  dish.  There  is  a  logical  mean  between 
allowing  a  child  to  dictate  his  own  menu  and  cramming  food  down  an 
unwilling  throat.  There  is  also  logic,  at  least  in  the  child's  mind,  in 
imitating  his  parents'  actions  and  reactions  toward  certain  things.  If 
we  recognize  a  child's  dislike  for  a  certain  food,  whether  this  be  in- 
herent or  acquired,  let  us  realize  that  tastes  as  well  as  emotions,  or 
perhaps  through  emotions,  have  a  physiological  effect  upon  appetite  and 
digestion.  We  can  at  least  minimize,  and  often  overcome,  an  unfavor- 
able food  prejudice  by  complete  removal  from  the.  diet  of  this  specific 
article  of  food  for  a  certain  length  of  time,  or  by  serving  a  small  por- 
tion of  it  on  a  plate  otherwise  extremely  inviting. 

If  we  bear  in  mind  the  fact  that  appetite  and  digestion  are  affected 
by  attitudes  and  emotions  of  the  child  and  his  environment,  we  can 
more  easily  follow  methods  suitable  to  maintain  interest  in  developing 
good  eating  habits.  We  must  recognize  the  child's  desire  for  approval, 
but  not  reward  so  liberally  as  to  center  the  interest  on  the  reward  or 
approbation.  To  do  so  would  result  in  the  approbation's  becoming  the 
incentive  and  the  process  of  eating  an  opportunity  for  getting  attention. 

Furthermore,  before  interest  in  the  food  itself  has  slackened,  we 
must  encourage  the  child's  desire  to  conquer  the  next  step.  Assistance 
should  be  given  to  help  master  the  handling  of  the  spoon  and  interest 
be  stimulated  in  the  child's  responsibility  for  the  manner  in  which  the 
food  is  eaten.  We  are  constantly  urging  and  assisting  progress,  and 
constantly  establishing  new  habits.    New  interests  are  coming  up  and 


61 

many  of  them  are  aroused  by  the  environment.  The  mere  repetition  of 
the  physical  acts  involved  in  feeding  himself  no  longer  holds  the  inter- 
est or  keeps  the  child  contented. 

Contentment  and  joy  at  meal  times  go  hand  in  hand  with  rest  and 
quiet.  Children  are  happy  by  nature.  They  will  find  happiness  in  quiet, 
as  well  as  in  boisterousness,  if  allowed  to  do  so.  Their  minds,  however, 
must  be  occupied,  and  the  responsibility  for  satisfying  this  demand 
rests  to  a  large  extent  on  the  adult  environment.  To  expect  the  child  to 
be  seen  and  not  heard  at  table  is  wrong.  To  allow  him  a  certain  share 
in  the  conversation  without  monopolizing  it,  is  a  training  for  a  future 
social  adjustment.  Taking  turns  in  telling  of  the  day's  experiences  or 
interesting  oneself  for  part  of  the  time  in  the  child's  thoughts  serves 
the  purpose  of  keeping  the  latter's  mind  pleasantly  occupied  and  thus 
diverting  his  concentrated  attention  away  from  the  food  itself  or  from 
the  method  of  its  being  eaten. 

In  some  types  of  children  the  establishment  of  good  eating  habits 
comes  easily  and  naturally,  but  in  others  we  find  difficulties.  These 
may  be  due  to  many  causes,  such  as  dependence  on  the  mother,  resent- 
ment resulting  from  forced  feedings,  lack  of  quiet  and  harmony  at  the 
table,  and  so  forth.  From  whatever  reason  poor  habits  do  result,  the 
principle  underlying  the  treatment  is  the  same  as  in  the  case  of  estab- 
lishing routine  good  habits,  but  the  course  of  action  varies.  If  we  are 
constantly  reprimanding  in  a  manner  such  as  to  focus  the  child's  atten- 
tion on  the  object  or  reaction  which  causes  the  antagonism,  we  do  not 
get  very  far.  Let  us  not  draw  attention  to  the  chip  on  the  shoulder. 
Trying  to  rationalize  to  the  child  on  the  value  of  spinach  is  merely 
emphasizing  the  fact  that  it  is  spinach.  Even  deeper  than  that  is  the 
fact  that,  having  said  he  would  not  eat  what  has  been  put  on  his  plate, 
the  child  must  then  publicly  humiliate  himself  by  having  to  lose  his 
battle  with  all  eyes  centered  on  him.  I  think  we  would  minimize  our 
difficulty  if  less  direct  attention  were  paid  to  the  child  and  if  an  atti- 
tude of  apparent  indifference  were  assumed  by  the  parents.  This  atti- 
tude should  be  maintained  even  in  carrying  out  actual  disciplinary 
measures,  such  as  depriving  the  child  of  dessert  or  of  the  right  to 
remain  at  the  table  if  his  actions  become  too  boisterous.  If  this  atti- 
tude is  assumed  by  the  parents,  the  child  quickly  learns  to  appreciate 
the  fact  that  asocial  behavior  on  his  part  nets  him  no  gain,  not  even 
the  satisfaction  of  attention  from  others.  In  addition  to  this  no  unde- 
sirable fear  of  parental  authority  arises,  nor  any  other  conflicting 
emotional  reactions  associated  with  the  environment. 

To  attempt  to  cover  every  contingency  would  be  impossible,  but  in 
order  to  understand  the  fundamental  attitude  which  should  be  de- 
veloped in  the  child  and  maintained  by  his  environment,  it  does  not 
seem  to  me  necessary  to  delve  too  deeply  into  the  psychology  of  be- 
havior. The  parent  is  the  party  most  directly  responsible  in  establish- 
ing good  habits  of  the  child's  routine  daily  life.  Outside  assistance  and 
advice  should  logically  be  sought  from  all  those  who  have  a  share  in  the 
general  health  and  training  of  the  child.  This  includes  primarily 
nurses  and  teachers  as  well  as  doctors.  From  my  point  of  view,  I  can 
not  but  feel  that  the  pediatrician  (whose  intimate  contact  with  the 
child  at  the  start  places  him  in  the  best  position  to  offer  guidance) 
should  assume  more  responsibility  for  habit  training  as  it  relates  to 
the  general  health,  whether  he  consider  the  physical  or  mental  side  of 
prime  importance. 

As  to  this  specific  question  of  eating,  it  is  absolutely  essential  that 
good  habits  be  established  early  and  thoroughly.  The  point  of  attack 
in  such  a  case,  where  the  habit  does  begin  so  young  in  life,  is  entirely 
through  environment.  No  appeal  can  be  made  directly  to  the  infant. 
Everything  depends  on  what  the  mother  does  and  how  much  she  allows 
the  baby  to  do,  as  well  as  on  what  her  reactions  mental  and  physical 


62 
are  towards  him.   Later  on,  when  we  can  deal  directly  with  the  child, 
it  must  be  in  as  impersonal  a  manner  as  possible,  and  in  a  way  which 
appeals  to  his  intelligence. 

POSTURE  AND  NUTRITION 

Alma  Porter  i 

Assistant  Supervisor  of  Physical  Education 
State  Department  of  Education 

That  there  is  a  positive  correlation  between  the  two,  posture  and 
nutrition,  has  never,  as  far  as  I  know,  been  proven  conclusively.  There 
is,  however,  the  testimony  of  orthopedic  physicians  and  nutritionists 
and  physical  education  teachers  based  on  wide  experience,  which  rein- 
forces the  faith  of  educators  in  their  recognition  of  nutrition  as  a 
factor  to  be  considered  in  the  posture  programs  in  the  schools.  Ortho- 
pedists have  been  teaching  body  mechanics  to  individuals  for  years  as 
a  corrective  measure,  as  a  means  of  remedying  certain  physiological 
difficulties.  The  educators  have  had  a  different  problem,  however, — 
that  of  preventing  bad  posture  habits,  with  the  attendant  physiological 
symptoms  from  developing  in  the  mass  of  children  in  their  schools. 
Obviously  the  two  situations  are  very  different  and  the  emphasis  of 
this  paper  must  necessarily  be  in  the  direction  of  the  educational  pro- 
grams rather  than  toward  those  of  a  medical  aspect. 

But  whether  we  are  interested  in  the  medical  aspect  or  the  educa- 
tional aspect  of  posture  we  are  all  concerned  with  the  normal  growth 
and  development  of  all  children.  The  White  House  Conference  on  Child 
Health  and  Protection  comes  to  certain  definite  conclusions  concerning 
growth  and  development,  when  it  suggests  that  nutrition  in  all  ages, 
fatigue,  and  such  other  factors  as  the  competence  of  parents,  educational 
opportunities,  the  unusual  hazard  of  disease,  mental  and  emotional 
factors,  history,  race,  background,  etc.,  are  of  the  utmost  importance 
in  a  consideration  of  the  whole  child.  And  it  further  suggests  that  the 
thorough  physical  examination  by  a  competent  physician,  with  its 
appropriate  follow-up,  is  one  great  educational  means  for  determining 
and  correcting  defects  which  may  lie  at  the  base  of  what  we  call 
growth  and  development  deficiencies. 

That  these  deficiencies  may  be  due  to  such  social  and  economic  fac- 
tors, as  well  as  physical  factors  as  are  noted  above,  should  however, 
not  confuse  us  in  the  consideration  of  the  main  issue:  that  a  child 
comes  into  the  world  with  potential  capacities.  He  is  due  everything 
that  science  can  contribute  toward  developing  those  mental,  physical 
and  spiritual  capacities  to  the  maximum.  If  that  must  come  through 
education,  let  there  be  education.  If  it  must  come  through  law,  let 
there  be  carefully  enforced  law.  If  it  must  come  through  social  and 
economic  reform,  let  there  be  such  reform.  If  it  must  come  through  a 
combination  of  these,  let  there  be  a  combination.  But  let  us  also  re- 
member the  child  is  not  static  and  waiting  for  us  to  perfect  our  pro- 
cesses, that  we  must  reach  him  with  the  best  we  have  as  early  as 
possible. 

So  when  we  speak  of  growth  and  development  we  mean  not  only  in- 
crease in  size  or  bulk  but  actual  increase  in  the  number  and  complexity 
of  living  cells.  While  gain  in  weight  under  normal  conditions  of  diet 
commonly  accompanies  growth,  it  is  only  one  measure  of  it,  for  growth 
may  be  conditioned  by  two  factors :  one,  capacity  for  growth  inherent 
in  the  organism,  and  the  other,  suitable  and  environmental  conditions, 
the  most  important  of  which  is  probably  nutrition.  Growth  in  height, 
or  skeletal  growth,  is  not  so  quickly  affected  by  nutrition  as  growth  in 
weight,  but  even  growth  in  height  will  not  continue  indefinitely  toward 
the  individual's  normal  without  adequate  food. 


63 

What  we  call  good  nutrition  contributes  to  well-being  even  before 
the  child  is  born,  and  the  food  the  pregnant  mother  eats,  as  well  as 
her  regard  for  other  hygienic  measures,  influences  the  child  who  is  to 
come.  The  White  House  Conference  is  very  frank  in  its  statement  that 
there  are  two  great  phases  of  child  life  that  need  further  and  intensive 
study — the  first  few  weeks  of  life  and  the  period  of  adolescence.  While 
this  may  be  true  in  general,  the  theories  of  nutrition  which  are  the 
result  of  careful  and  long  experimentation,  seem,  so  far  as  they  have 
gone,  to  be  sound  and  practice  bears  out  their  efficiency  to  a  remark- 
able degree.  For  instance,  rickets  usually  develop  in  the  early  months 
of  a  baby's  life,  according  to  McCollum  and  Simonds  in  their  book,  "The 
Newer  Knowledge  of  Nutrition";  never  before  the  third  month,  and 
more  frequently  between  the  sixth  and  twenty-fourth.  Rickets  has  been 
proven  to  be  a  disease  which  can  be  prevented  and  controlled  by  proper 
food  and  hygiene,  but,  unchecked,  it  leaves  in  its  wake  deformities  and 
handicaps  which  are  carried  through  life. 

It  may  be  safely  assumed  that  often  most  of  the  energy  which  is 
available  in  growing  children  must  be  used  to  satisfy  the  upward 
growth  and  consequently  the  much  needed  fat  and  muscle  may  be  sacri- 
ficed. It  is  at  this  point  that  we  are  justified  in  taking  careful  measure- 
ment of  the  activity  that  we  impose  on  these  children.  The  American 
Child  Health  Association  has  recently  completed  a  study  which  changes 
our  nutrition  outlook  radically.  For  years  the  age,  height,  weight 
tables  of  averages  were  used,  upon  which  to  measure  the  nutritional 
status  of  children.  Under  Raymond  Franzen,  Ph.D.,  these  averages 
have  been  disproved  as  scientific  evidence  of  the  growth  of  an  indi- 
vidual, and  in  its  place  he  suggests  that  records  of  steady,  even  growth 
tend  to  show  nutritional  status  as  the  direct  result  of  certain  important 
factors,  including  food  and  freedom  from  disease. 

Now  exactly  what  the  relation  of  posture  to  nutrition  is,  or  nutrition 
to  posture,  has  yet  to  be  proven.  But  one  study  by  Armin  Klein,  M.D., 
recently  completed,  and  to  which  reference  will  later  be  made,  con- 
cludes that  "Between  posture  and  the  child's  nutritional  condition  there 
is  undoubtedly  a  relationship,  but  it  is  difficult  to  evaluate  since  it  is 
probable  that  improvement  in  either  may  lead  to  improvement  in  the 
other." 

And  so  we  come  back  to  the  original  idea — because  of  the  long  experi- 
ence and  observation  of  orthopedic  surgeons,  nutritionists,  and  physi- 
cal education  teachers,  the  belief  is  very  strong  that  there  is  a  relation- 
ship between  posture  and  nutrition  and  that  if  they  influence  each 
other,  together  they  probably  influence  growth  and  development  of 
children  immeasurably. 

In  describing  the  appearance  of  undernourished  children,  the  agree- 
ment by  physicians  upon  certain  characteristics  is  quite  universal: 
decreasing  or  static  weight,  condition  of  the  mucous  membrane,  color, 
endurance,  expression  of  the  eyes,  body  mechanics,  musculature,  sub- 
cutaneous tissue,  relation  of  weight  to  skeletal  build,  etc.  But  no  matter 
what  the  list  may  not  include,  it  invariably  does  include  reference  to  the 
so-called  "fatigue  posture,"  as  being  one  of  the  noticeable  character- 
istics. This  does  not  mean  that  other  children  do  not  show  evidences 
of  bad  body  mechanics,  but  that  most  undernourished  children  do.  In 
other  words,  poor  posture  may  be  the  result  of  retarded  growth  and 
development  in  terms  of  the  nutritional  status,  or  it  may  be  that  bad 
mechanics  so  react  that  the  nutritional  status  is  adversely  affected. 
Or  it  may  be,  and  probably  is  in  the  majority  of  children,  bad  habit. 

Doctor  Klein's  study  of  children  in  Chelsea,  Massachusetts,  is  inter- 
esting. A  full  report  is  to  be  found  in  a  pamphlet,  "Posture  and 
Physical  Fitness,"  by  Armin  Klein,  M.D.,  and  Leah  Thomas,  published 
by  the  United  States  Department  of  Labor,  Children's  Bureau  Bulletin 
No.  205.    There   he  worked  with    1,708   elementary   school   children, 


64 
divided  into  a  posture  group  and  a  control  group.  All  the  children  were 
examined  by  an  orthopedist  and  carefully  detailed  records  were  kept. 
The  first  group  was  then  given  special  posture  training  by  the  physical 
education  teachers,  and  the  classroom  teachers  under  supervision,  over 
a  specified  length  of  time.  The  second  group  continued  with  the  regular 
physical  education  program,  planned  for  every  child  in  Chelsea.  At  the 
end  of  the  period  there  was  a  reexamination,  careful  analysis  of  results 
and  comparisons  with  the  following  conclusions,  in  brief.  "The  preva- 
lence of  poor  body  mechanics  was  strikingly  reduced  by  the  posture 
group.  During  the  period  of  observation  six  children  in  the  posture 
group  improved  in  posture,  to  every  one  of  the  children  in  the  control 
group  who  improved ....  Improvement  in  body  mechanics  was  associ- 
ated with  improvement  in  health  and  efficiency.  More  of  the  children 
who  started  with  poor  posture,  when  given  training,  improved  their 
nutrition  when  they  improved  their  posture,  than  did  those  who  did  not 
improve  their  posture.  .  .  Among  the  children  without  posture  train- 
ing, improvement  in  posture  occurred  more  frequently  with  those  in 
the  best  nutritional  condition.  .  ..  Since  nutrition  has  been  accepted  as 
an  important  index  of  the  child's  health,  posture  training  would  seem 
to  be  an  important  factor  favorable  to  health,  as  indicated  by  its  as- 
sociation with  improved  nutrition.  .  .  ." 

There  is  some  evidence,  also,  that  the  other  aspect  is  true.  This  evi- 
dence, provided  largely  by  observation  of  children  under  treatment, 
seems  to  show  that  children  whose  nutrition  is  improved  by  food,  rest 
and  freedom  from  disease,  show  signs  of  improved  posture  under  ordin- 
ary conditions  without  special  attention  to  posture  training.  If  we  may 
assume,  then,  that  there  is  truth  on  both  sides,  we  may  have  reason  to 
be  encouraged. 

Now  the  posture  problem  of  the  school  is  to  reach  in  the  best  way 
possible  all  the  children,  well  nourished,  undernourished,  those  with 
bad  habits  and  those  with  good.  In  other  words,  a  program  of  remedy, 
yes;  but  primarily,  a  program  of  prevention. 

In  most  schools  the  program  is  carried  on  through  the  physical  edu- 
cation department  and  the  classroom  teacher,  occasionally  with  an 
orthopedist  in  charge,  but  generally  without  one. 

Ideally,  we  should  conceive  of  good  body  mechanics  of  children  as 
the  inevitable  outgrowth  of  right  activity  and  health  habits,  were  we 
able  to  provide  those.  The  background  of  children  from  birth  seems  to 
show  that  such  was  intended.  In  his  first  months,  his  life  is  a  cycle  of 
vigorous  stretchings,  and  rollings,  and  twistings,  then  sleep,  then  food. 
As  time  goes  on,  he  begins  to  struggle  to  lift  his  head,  and  to  see,  reach 
for  and  grasp  play  things ;  his  periods  of  activity  are  longer,  and  pres- 
ently he  struggles  to  achieve  the  sitting  position — and  wins.  His  first 
clumsy,  undirected  movements  become  calculated,  and  his  abilities  to 
handle  and  grasp  things  rapidly  become  more  skillful.  Then  comes  the 
creeping  age  and  presently  the  "runabout"  age.  The  studies  by  Doctor 
Gesell,  of  Yale  University,  are  fascinating  studies  of  the  little  child 
and  his  play,  for  the  psychologist  tells  us  that  all  these  activities  are 
play — play  that  so  strengthens  and  develops  the  muscles,  directs  skill 
and  habits,  that  in  it  lies  the  foundation  for  your  adult  activities  and 
mine. 

Now  if  we  could  provide  in  proper  quantity  and  kind  the  activities 
that  would  develop  our  youngsters  freely  and  naturally,  the  problem 
would  be  solved.  Instead  we  must  adapt  and  adjust  and  teach  under 
conditions  that  hamper  and  restrict. 

But  our  programs  aim  through  three  avenues,  all  parts  of  a  broad 
physical  education  program,  to  influence  children  toward  habitual  good 
posture  in  terms  of  each  one's  body  type  and  peculiar  mechanical  pos- 
sibilities: (1)  To  inspire  a  desire  to  stand  as  straight  as  he  can;  (2) 
To  give  knowledge  of  what  is  straight  for  him,  and  the  "feeling"  of  it; 


65 

(3)  To  provide  activities  that  give  him  strength  and  endurance  to  hold 
the  positions  habitually.  These  are  logically  arranged  but  probably  not 
psychologically,  since  in  actual  use  they  are  not  broken  up  into  neat 
slices  but  are  interwoven. 

It  is  the  opinion  of  most  teachers  that  in  so  far  as  children  can  be 
taught  the  fundamentals  of  good  posture,  through  indirect  means,  on 
play  apparatus  or  through  stunts,  so  much  the  better.  But  under  the 
conditions  existing  in  most  elementary  schools  today  a  certain  amount 
of  direct  teaching  seems  to  be  necessary,  not  as  a  separate  procedure 
but  as  a  part  of  a  regular  physical  education  instruction  period.  And 
furthermore,  that  the  activities  which  tend  to  strengthen  muscle  should 
be  primarily  those  natural  to  children,  climbing,  running,  jumping, 
stretching,  bending,  pulling,  lifting  and  playing  games. 

It  is  the  belief  also  of  many  of  those  who  have  observed  children  for 
many  years  that  proper  teaching,  direct  and  indirect,  as  a  part  of  a 
vigorous  activity  program  of  the  right  sort,  will  in  the  course  of  time 
show  results  for  most  of  the  children,  comparable  to  the  results  of  a 
specialized  posture  training.  Furthermore,  that  the  broad  activity  pro- 
gram will  have  provided  opportunity  for  the  social,  physical  and  mental 
adjustments  which  are  inherent  in  the  play  life  of  children,  but  which 
must  necessarily  be  left  out  in  a  highly  intensified  corrective  class. 

Doctor  Klein's  study,  has  perhaps,  given  a  little  different  slant  to  the 
posture-nutrition  problem  of  children.  On  the  whole,  however,  it  has 
seemed  safer  to  suggest  that  school  children  who  are  undernourished 
should  have  consideration  of  their  food,  rest  and  relief  from  physical 
defect  before  they  are  given  extra  activity  which  may  result  in  undue 
fatigue.  In  any  case,  they  should  come  from  the  doctor  to  the  physical 
education  teacher,  with  suggestions  as  to  limitations  and  plans  for 
checking  progress. 

There  are  a  few  children  who  may  need  the  attention  of  an  ortho- 
pedic surgeon  and  the  special  attention  of  the  physical  education 
teacher,  but  by  and  large  the  need  seems  to  be  the  teaching  of  funda- 
mentals and  fine  activity  programs. 

In  so  far  as  we  may  consider  that  nutrition  and  posture  are  related, 
and  that  they  reflect  themselves  in  the  growth  and  development  of 
children,  just  so  far  may  we  consider  our  teaching  important. 

FOOD  FOR  THE  ADULT 

OCTAVIA  SMILLIE 
Waban,  Massachusetts 

One  day  not  so  long  ago  several  thousand  women  were  all  hurrying 
to  get  into  a  lecture  hall.  They  were  going  to  hear  another  woman  tell 
them  how  to  cook  new  and  unusual  recipes.  Today  we  may  open  almost 
any  magazine  and  find  large,  full-page  advertisements  of  foods  giving 
recipes  on  how  to  prepare  them.  The  daily  newspaper  now  devotes  a 
page  to  food — menus,  recipes,  and  questions  and  answers  about  food 
problems.  The  radio,  if  tuned  to  almost  any  chain  station  will  produce 
several  hours  a  day  of  information  about  foods  and  their  preparation. 

A  momentary  relaxation  may  be  gained  at  the  tense  bridge  game,  if 
some  member  happens  to  mention  how  many  pounds  have  been  lost  as 
a  result  of  following  some  diet.  Let  the  bonds  of  matrimony  be  de- 
clared, and  soon  a  new  student  will  be  enrolled  in  some  school  of 
cookery. 

Food  is  before  the  public  eye.   Food  has  become  a  fad! 

The  life  of  a  fad  is  very  short — soon  people  lose  interest  and  take 
up  something  new.  So  now  is  the  time  common  sense  must  come  to  the 
rescue.  Knowledge  about  food  must  become  well  established  and  not 
a  passing  interest.  Good  wholesome  food  should  be  a  matter  of  course. 


66 
Every  one  should  know  a  few  simple  facts  as  to  what  foods  should  be 
in  the  daily  diet. 

A  well  known  doctor  says  "Eat  what  you  want  after  you  have  eaten 
what  you  should."  Psychologically,  this  may  seem  a  bit  bad  as  it  con- 
veys the  idea  that  what  you  should  eat  is  not  what  you  want  to  eat. 
However,  this  should  not  be  true  if  you  were  given  the  proper  foods 
in  infancy  and  childhood.  Not  so  many  of  you  can  truthfully  say  that 
what  you  wanted  to  eat  was  just  what  you  should  have  eaten. 

Are  you  a  doctor  or  a  nurse  or  a  business  man  or  woman,  or  just 
some  one  called  "Mother"  who  runs  the  home?  No  matter  who  you  are, 
you  will  be  interested  in  a  few  simple  rules  that  may  be  applied  to  your 
food  costs.  Do  you  know  how  much  you  spend  each  week  for  your  food? 
You  can  easily  keep  account  of  how  much  you  spend  this  coming  week. 
While  you  are  doing  this,  see  if  you  are  spending  your  money  approxi- 
mately as  follows: 

One  fifth  or  more  for  milk  and  cheese 

One  fifth  for  fresh  fruits  and  vegetables 

One  fifth  or  less  for  meats,  fish  and  eggs 

One  fifth  or  more  for  bread  and  cereals 

One  fifth  or  less  for  fats,  sugar  and  other  groceries. 

Many  of  you  will  find  that  you  are  spending  too  much  for  meats ;  not 
enough  for  milk  and  fresh  vegetables  and  fruit. 

At  the  present  food  prices,  you  will  find  that  these  percentages  will 
be  helpful  to  you. 

Advertisers  believe  that  repetition  is  the  way  to  make  people  believe 
what  they  have  to  say.  So  here  is  still  another  way  to  check  up  how 
nearly  your  food  for  the  day  comes  to  being  what  food  experts  say  is 
necessary  for  health: 

2  glasses  of  milk 

2  servings  of  fruit  (1  raw) 

2  servings  of  green  vegetables  (1  raw) 

1  serving  of  either  meat,  fish,  eggs,  peas,  or  beans 

1  ounce  of  butter 

2  slices  of  whole  grain  bread  or  a  serving  of  whole  grain  cereal 
Enough  starchy  foods  and  fats  to  satisfy  the  appetite. 

Some  of  you  may  have  to  plan  very  carefully  to  meet  the  above  re- 
quirements. Perhaps  you  don't  like  milk,  or  eggs,  and  only  a  few  kinds 
of  vegetables.  Milk  may  be  used  in  soups  and  desserts  so  that  you  do 
not  need  to  drink  milk.  There  are  also  twenty-five  or  more  common 
vegetables  on  the  market  most  of  the  time.  Surely  you  can  choose  out 
of  this  number  those  vegetables  that  you  will  like.  Do  not  think  that 
because  you  dislike  some  vegetables  or  fruits  that  you  know  are  good 
for  you,  there  are  not  some  good  substitutes.  Recently  a  Japanese  man 
was  describing  the  foods  that  are  habitually  eaten  in  his  country.  He 
said,  "Spinach,  in  our  country,  has  a  great  popular  dislikeness."  If  a 
food  has  a  "great  popular  dislikeness"  with  you  or  with  your  family, 
don't  try  to  serve  it.  The  time  to  educate  your  taste  was  in  childhood. 
Very  few  of  you  learn  to  like  foods  as  you  grow  older. 

This  month  in  a  well  known  woman's  magazine,  there  is  a  plea  from 
a  disturbed  husband.  Some  of  the  things  that  he  complains  about  are 
the  new  recipes  his  wife  insists  upon  trying.  Fancy  foods,  such  as 
elaborately  decorated  salads  or  desserts  do  not  as  a  rule  appeal  to  the 
men  of  the  household.  Simple,  well  cooked  food  of  a  good  quality  seems 
to  satisfy  both  the  men  and  children. 

Those  of  you  who  plan  the  menus  in  your  homes  will  find  that  you 
will  have  a  greater  variety  and  spend  less  money  if  you  plan  for  at 
least  one  day,  or  more,  in  advance.  Seeing  a  bargain  in  your  local  store 
on  several  cans  of  beans  or  packages  of  macaroni  will  result  in  a  daily 
repetition  of  these  foods  for  the  next  week  or  two  unless  you  plan 
carefully.   The  family  becomes  tired  of  this  repetition  and  does  not  eat 


67 
what  is  served.   Thus  your  bargain  may  become  an  added  expense. 

Those  of  you  who  eat  in  restaurants  will  do  well  to  keep  in  mind  the 
simple  list  given  in  this  article.  There  are  only  a  few  things  to  re- 
member. You  can  mentally  check  these  off  from  your  list  each  evening 
as  you  are  ordering  your  dinner  or  as  you  are  serving  yourself  in  a 
cafeteria. 

A  newspaper  article  by  a  Dr.  Craig  in  Chicago  graphically  asserts 
that  in  our  bodies  we  have  about  enough  lime  to  whitewash  a  hen  coop 
and  enough  iron  to  make  a  ten  penny  nail.  What  with  a  small  amount 
of  copper,  phosphorus,  and  even  smaller  amounts  of  manganese,  iodine 
and  many  other  minerals,  he  finds  that  man  is  worth  actually  about 
ninety-eight  cents.  In  these  hard  times,  this  statement  is  especially  dis- 
heartening if  you  stop  to  consider  how  much  money  you  have  invested 
in  yourself.  To  keep  yourself  in  the  best  condition,  then,  is  only  good 
business. 

Should  there  be  a  lack  of  iron  in  your  body,  the  blood  soon  becomes 
pale.  Copper  is  also  necessary;  the  body  cannot  use  the  iron  unless 
copper  is  present.  Iodine  must  also  be  supplied  to  the  body  in  order 
that  the  thyroid  gland  may  perform  its  regular  duties.  Manganese  in 
the  body  seems  to  be  connected  with  the  reproduction  of  young.  The 
lack  of  manganese  in  the  diet  of  rats  caused  the  mother  rats  to  kill  or 
desert  their  young.  From  this  fact,  a  newspaper  reporter  asserted  not 
long  ago  that  manganese  was  necessary  to  mother-love.  This  no  doubt 
is  overdrawn  but  it  serves  to  illustrate  the  fact  that  the  minerals  in  our 
food  are  really  vitally  important.  Vitamins  are  discussed  everywhere. 
They  are  a  very  necessary  part  of  our  diet.  Again,  however,  you  need 
not  pay  attention  to  them  if  you  are  following  the  outline  given  earlier 
in  this  article.  Vitamin  D  is  the  only  vitamin  which  does  not  exist  to  a 
goodly  extent  in  our  daily  food.  In  the  winter,  when  you  are  not  getting 
sunshine,  cod  liver  oil  or  some  of  the  foods  in  which  vitamin  D  extracts 
are  used  should  prove  beneficial. 

Feeling  tired  or  out  of  sorts  with  the  world  when  you  are  going  to  sit 
down  to  the  dinner  table  is  a  very  bad  beginning.  The  digestion  of 
food  has  been  found  to  be  delayed  or  hindered  by  fatigue  or  bad  humor. 
Relax  and  think  of  pleasant  things  before  you  sit  down  to  eat.  The 
time-honored  custom  of  dinner  speakers  starting  with  a  few  would-be 
funny  stories  is  thus  not  without  a  good  foundation. 

Try  eating  the  foods  you  should — your  health  and  disposition  will  be 
better  and  you  will  find  that  your  money  has  been  spent  to  better 
advantage. 

NUTRITION  EMERGENCY 

Mary  Spalding,  M.A.,  B.S. 

Consultant  in  Nutrition 
Massachusetts  Department  of  Public  Health 

In  the  emergency  of  war  in  1918,  we  used  the  slogan,  "Food  will  win 
the  war."  Again  in  this  emergency,  in  the  year  of  Our  Lord,  1932,  we 
are  saying,  "Food  will  fight  the  depression."  At  that  time,  we  saved 
meat,  sugar  and  white  flour — foods  which  kept  well — to  send  to  the 
soldiers,  by  planting  war  gardens  and  by  eating  dark  grained  breads. 

Today  we  are  again  planning  subsistence  gardens  whereby  men  out 
of  work  may  put  in  labor  and  produce  more  food  for  their  families  for 
this  coming  winter.  This  measure  is  a  good  health  measure.  Massachu- 
setts children  do  not  eat  enough  vegetables  in  the  best  of  times,  accord- 
ing to  Dr.  Davies'  study* — and  men  need  productive  work  to  help  keep 
up  their  morale. 

*  "The  Food  Consumption  of  Rural  School  Children  in  Relation  to  their  Health,"  Esther  S. 
Davies,  Agricultural  Experiment  Station,  Amherst,  Massachusetts,   March,   1928. 


68 

Many  Red  Cross  chapters  in  Massachusetts  are  supplying  families 
with  milled  flour.  This  will  give  needed  calories.  We  are  suggesting 
that  some  of  this  flour  be  made  into  breads  like  oatmeal  and  ginger 
bread,  and  that  whole  grained  breakfast  cereals  be  used  so  that  the 
iron  and  vitamin  B,  taken  out  in  milling,  may  be  partially  supplied. 

Safe,  clean  milk  is  another  economic  necessity.  The  Children's  Bur- 
eau of  the  United  States  Department  of  Labor  says  that  each  child 
should  have  daily  at  least  one  pint  of  milk. 

This  year  the  Department  of  Public  Health  has  tried  to  meet  the 
demands  made  on  it  to  help  people  spend  their  lessened  food  money  to 
the  best  advantage.  Here  are  some  problems  which  homes,  schools  and 
agencies  are  giving  us,  and  here  are  some  of  our  ways  of  meeting  them. 

Home 

Home  makers,  men  as  well  as  women,  are  setting  their  shoulders  to 
the  wheel  and  getting  up  tremendous  momentum  towards  better  ways 
of  living  at  a  low  cost.  They  are  cooking  economical  foods  so  that  their 
families  may  have  attractive  meals.  This  is  a  definite  task  that  home 
makers  can  do  to  keep  their  families  in  a  good  state  of  mental  and 
physical  health.  Infinite  care  and  thought  are  being  used  in  the  prep- 
aration of  well  rounded  though  cheap  meals.  Often  these  may  be  in 
the  form  of  a  one-dish  meal  containing  all  the  good  "pot  likker,"  yet 
saving  in  cost  of  fuel.  We  find  many  are  making  bread  who  have 
previously  bought  their  whole  family  supply. 

The  store  as  well  as  the  kitchen  is  now  a  great  scene  of  action.  More 
real  selective  purchasing  is  done.  Lively  discussion  is  carried  on  there 
not  only  as  to  prices  but  as  to  relative  food  values.  Weekly  bargains 
are  sought.  Vitamin  and  mineral  content  is  considered.  Ask  any  store- 
keeper if  he  does  not  think  that  marketing  is  being  revived  as  an  art. 
Some  storekeepers  are  even  asking  in  self  defense  for  courses  in  nu- 
trition. 

The  "Survey"  shows  a  picture  of  Victorian  ladies  on  the  curbside 
discussing,  "What  can  we  feed  our  husbands?"  Today  the  woman  is 
asking,  "How  can  I  best  spend  one-fifth  of  my  food  dollar  for  my  whole 
family — children  and  husband?" 

Our  nutritionists  find  through  personal  conferences  with  mothers  of 
preschool  children  and  of  tuberculous  children  that  the  greatest  num- 
ber of  questions  still  come  in  the  food-habit  class — "How  can  I  teach 
my  child  to  like  vegetables?  How  can  I  get  my  husband  to  eat  this 
cheaper  type  of  food?"  The  answer  of  the  nutritionist  is  to  try  not  to 
play  this  game  alone.  It  is  the  problem  of  the  whole  family — not  exclu- 
sively the  mother's — to  eat  this  wholesome  and  cheaper  food  pleasantly. 

We  would  like  to  give  these  valiant  home  makers  some  such  medal  as 
Dr.  Joslin  awards  diabetic  children  "for  a  scientific  and  moral  vic- 
tory." Instead,  we  are  encouraging  them  and  giving  them  sound  nutri- 
tion information  through  personal  conferences  and  group  talks,  and 
material  on  the  preparation  of  wholesome,  inexpensive  meals,  food 
budgeting  and  changing  food  habits. 

Schools 

Teachers  and  school  nurses  are  using  every  effort  to  see  that  the 
children  bring  or  select  a  good  lunch.  These  children  have  a  right  to 
three  good  meals  a  day,  and  the  school  lunch  must  count  as  one.  This 
lunch  has  to  be  supplied  at  low  cost  yet  be  nourishing.  To  these 
teachers  and  nurses  we  are  trying  to  give  correct  facts  on  nutrition 
and  how  to  present  them  to  the  children  through  group  meetings. 

Knowing  the  unusual  urgency  this  year,  the  Extension  Service  and 
the  Department  of  Public  Health  are  encouraging  community  organ- 
izations such  as  the  local  Parent  Teacher  Associations  to  appoint  com- 
mittees to  back  the  school  lunch.    Even  if  a  teacher  or  a  nurse  leaves 


69 

a  community,  a  permanent,  actively  functioning  committee  will  carry 
on  and  make  better  this  important  meal  for  children.  Such  a  com- 
munity reinforcement  in  favor  of  the  school  lunch  should  make  for 
fewer  improperly  nourished  children. 

Agencies 

The  social  agencies  have  only  so  much  money.  They  have  never  had 
so  many  clients.  For  this  reason,  it  is  absolutely  necessary  that  the 
food  budget  be  most  meticulously  planned  for  the  requirements  of 
nutrition.  Our  nutritionists  have  helped  local  communities  in  working 
out  such  food  budgets.  It  is  the  poorest  kind  of  economy  for  food 
money  to  be  spent  by  clients  so  that  health  is  endangered.  In  one 
southern  Worcester  town  where  the  Department  of  Public  Health  sent 
food-budget  material,  the  town  fathers  said,  "We  find  our  people  cannot 
even  get  the  low  cost  food  recommended,  on  the  money  we  allow  them. 
We  will  have  to  make  a  tremendous  effort  and  raise  this  food  budget." 
And  they  did !  We  expect  this  effort  will  repay  the  community  in  good 
health  and  so  will  actually  cost  less  in  future  economic  and  social  loss. 

When  such  a  maintenance  sum  for  food  is  given  families,  every  bit 
of  knowledge  that  the  nutritionist  posesses  must  be  at  the  service  of 
the  food  purchaser.  For  this  reason,  we  have  given  courses  and  talks 
on  nutrition  to  groups  of  social  workers,  nurses  and  camp  directors  who 
are  giving  aid  and  who  are  trying  to  maintain  health  under  the  present 
handicap.  We  are  glad  to  work  with  them  on  their  food  slips  and  their 
many  problems. 

Summary 

By  keeping  parents,  teachers  and  children  alive  to  the  necessity  of 
adequate  nutrition  at  low  cost,  we  have  great  hopes  for  the  health  of 
the  people  this  year.  This  depression  of  1932  must  not  be  allowed  to 
produce  children  deformed  physically  and  mentally  as  was  the  case  in 
the  war  countries.  Massachusetts  children  must  be  guarded  by  nour- 
ishing though  cheap  food  and  by  extra  rest  from  deficiency  diseases 
and  lowered  morale. 

Large  quantities  of  the  following  bulletins  on  the  nutrition  emerg- 
ency have  been  distributed  throughout  the  State  by  the  Massachusetts 
Department  of  Public  Health. 

Bulletins — Nutrition  Emergency 

I — For  mothers — may   be   obtained   free   of   charge   from   the   Mass- 
achusetts Department  of  Public  Health: 

1 — "Food  at  Low   Cost"   by  Lucy   H.    Gillett,   American   Child 

Health  Ass'n.,  450  7th  Ave.,  New  York,  N.  Y. 
2 — "Hotv  to  Spend  Your  Food  Money" — Children's  Bureau,  U.  S. 

Dept.  of  Labor  and  Bureau  of  Home  Economics,  U.  S.  Dept. 

of  Agriculture,  Washington,  D.  C. 
3 — "Buy  Health  Protection  with  Your  Food  Money" — A  Guide 

for  a  Series  of  Four  Food  Budgets  for  a  Family  of  Five, 

planned  by  Community  Health  Ass'n.:  distributed  by  N.  E. 

Dairy  and  Food  Council,  Boston,  Mass.;  this  pamphlet  free 

from  the  Mass.  Dept.  of  Public  Health  in  places  not  covered 

by  N.  E.  Dairy  and  Food  Council. 
4 — "Two    Dozen    Ways    of    Using    Cabbage" — a    mimeographed 

sheet — Massachusetts  Department  of  Public  Health. 
5 — "One-Dish     Meals" — multigraphed     cards — Mass.     Dept.     of 

Public  Health. 
6 — "Keeping  Well  On  A  Low  Wage" — a  mimeographed  sheet — 

(translated    into    French,    Italian,    Polish,    Lithuanian    and 

Portuguese) — Mass.  Dept.  of  Public  Health. 


70 

II — For  nutritionists,  social  workers,  home  economics  teachers,  nurses 
and  others: 

1 — "Emergency  Food  Relief  and  Child  Health" — Published  by 
U.  S.  Dept.  of  Labor,  Children's  Bureau  and  U.  S.  Dept.  of 
Agriculture,    Bureau    of    Home    Economics.     This    pamphlet 
may  be  obtained  from  Massachusetts  Department  of  Public 
Health. 
2 — "Adequate  Diets   for  Families  with  Limited  Incomes" — by 
Hazel  K.  Stiebeling,  Senior  Food  Economist,  Bureau  of  Home 
Economics    and    Miriam    Birdseye,    Extension    Nutritionist, 
Office  of  Cooperative  Extension  Work.    This  pamphlet  may 
be  obtained  from  the  Superintendent  of  Documents,  Wash- 
ington, D.  C.  for  five  (5c.)  cents. 
Ill — For  Speakers: 

1 — "Emergency  Nutrition"  by  Henry  C.  Sherman,  Columbia  Uni- 
versity.   This  pamphlet  may  be  obtained  from  the  American 
Child  Health  Association,  450  7th  Avenue,  New  York,  New 
York,  or  from  Mass.  Dept.  of  Public  Health. 
IV — For  Boys  and  Girls: 

1 — "How  Boys  and  Girls  Can  Help  In  the  Drought  Emergency" 
by  Mina  M.  Langvick,  Senior  Specialist  in  Elementary  School 
Curriculum,  Office  of  Education,  and  Clyde  B.  Schuman,  Di- 
rector of  the  Nutrition  Service,  American  Red  Cross.  This 
pamphlet  encourages  children  to  plant  home  gardens  and  to 
choose  good,  cheap,  school  lunches.  It  may  be  obtained  from 
Office  of  Education,  Department  of  Interior,  Washington, 
D.  C. 
V — For  Country  School  Teachers: 

1 — "School  Lunch — The  Hot  Dish  For  the  Country  School."  A 
mimeographed  sheet — Massachusetts  Department  of  Public 
Health. 

THE  MINIMUM  FOOD  BUDGET  IN  1932 

Blanche  F.  Dimond,  B.S. 

Nutrition  Supervisor 
Community  Health  Association 

What  do  we  mean  by  a  minimum  food  budget?  We  are  apt  to  use  this 
term  glibly  with  no  clear  conception  of  its  meaning.  We  used  to  hear 
it  only  from  nutritionists  and  some  social  workers  in  the  days  before 
"the  depression,"  but  since  then,  many  people  are  discussing  it.  You 
however,  may  have  escaped  hearing  this  term  and  may  feel  as  be- 
wildered as  Mrs.  Jones  did.  She  is  an  attractive  young  woman  with 
three  small  children.  Her  husband's  wages  were  recently  cut  from 
thirty-five  dollars  to  twenty  dollars  a  week.  This  twenty  dollars  must 
cover  all  the  living  expenses,  including  rent,  heat,  light,  clothing,  food 
and  all  the  other  necessary  expenses  for  herself,  her  husband  and  their 
three  children.  She  was  spending  fourteen  dollars  a  week  for  food  alone. 
One  day,  Mrs.  Jones  was  discussing  her  financial  difficulties  with  her 
next  door  neighbor  who  had  recently  attended  a  lecture  on  "Food  Bud- 
geting." "Why  Mrs.  Jones,"  the  neighbor  said,  "the  speaker  at  that  lec- 
ture said  you  could  feed  a  family  of  five  for  seven  dollars  and  eighty- 
six  cents."  "I'd  like  to  know  how  she  would  do  it,"  answered  Mrs. 
Jones,  but  just  how  she  learned  to  do  it  does  not  belong  in  this 
discussion. 

Mrs.  Jones'  experience  is  typical  of  that  of  many  thousands  of  fam- 
ilies at  the  present  time.  Their  incomes  have  been  drastically  reduced 
and  they  must  learn  how  to  stretch  the  food  dollar  as  far  as  possible. 
In  addition  to  this  group,  there  is  an  increasing  number  of  families  in 


71 
which  the  wage  earner  is  unemployed  so  that  the  family  is  dependent 
on  public  or  private  relief. 

It  is  for  families  of  this  type  who  must  make  every  penny  count  yet 
who  are  still  trying  to  maintain  good  health,  that  the  minimum  food 
budget  is  planned. 

What  is  this  minimum  food  budget?  It  represents  the  lowest  possible 
amount  of  money  which  a  family  can  spend  for  food  and  receive  ade- 
quate nourishment.  In  other  words,  it  is  the  amount  of  food  which  will 
meet  the  generally  accepted  prevailing  standards  for  calories — protein, 
minerals  and  vitamins — which  will  protect  the  health  needs  of  the  fam- 
ily and  the  growth  needs  of  the  children.  We  stress  the  word  minimum 
since  it  is  not  an  optimal  standard  which  would,  of  course,  be  more 
desirable  but  cannot  always  be  met,  especially  in  times  like  these.  Some 
day,  we  hope  every  one  can  be  on  an  optimal  food  budget.  When  that 
time  comes,  authorities  assure  us  we  shall  be  a  more  vigorous  and 
healthy  people. 

This  minimum  food  budget  is  not  a  new  thing.  Years  before  "the 
depression,"  the  Community  Health  Association  of  Boston  was  issuing 
twice  a  year  a  "Guide  for  Estimating  Minimum  Family  Expenditures" 
for  the  use  of  its  own  and  other  workers  who  were  trying  to  help  fam- 
ilies who  are  obliged  to  live  on  a  low  income.  So  much  interest  was 
aroused  in  this  subject  that  the  Budget  Council  of  Boston  was  formed 
— a  large  group  of  representative  social  workers  from  various  social 
agencies  in  Boston.  This  group  has  been  working  on  the  problem  of 
the  low  cost  budget  for  several  years  and  their  recently  revised 
pamphlet  "Budgeting  the  Low  Income"  is  now  available.  The  minimum 
food  budget  is  sometimes  called  the  ten  dollar  order  as  the  cost  of  the 
amount  of  food  which  will  adequately  feed  a  family  of  five  is  usually 
around  ten  dollars.  In  January  1930,  it  was  ten  dollars  and  seventy 
cents,  a  peak  figure,  but  it  has  steadily  dropped  in  price  until  in  Janu- 
ary 1932,  the  same  amount  of  food  could  be  purchased  for  seven  dollars 
and  eighty-six  cents. 

Your  thoughts  here  may  be  "I  am  not  interested  in  all  this.  I  want  to 
know  what  kind  of  meals  you  can  get  for  this  money.  Would  they  give 
a  child  the  right  food  for  growth  and  development?  Would  they  satisfy 
a  hungry  man?"  These  questions  are  worth  considering  because  we  all 
realize  that  making  budgets  and  menus  is  one  thing  and  getting  people 
to  follow  them  is  another. 

The  following  grocery  order  and  sample  menus  illustrating  the  use  of 
the  order  show  that  food  can  cost  little  but  still  provide  for  the  needs 
of  the  body. 


Amount 

Unit  Cost 

Cost 

21  qts. 

.08  qt. 

$1.68 

y2  lb. 

.28  lb. 

.14 

4  oz. 

.16  lb. 

.04 

1  doz. 

.24  Fresh  West 

'n  .24 

%  doz. 

.47  local 

.12 

3V2  lbs. 

.19  lb. 

.665 

2y2  lbs. 

.09  lb. 

.225 

y2  lb. 

.20  lb. 

.10 

15  lbs. 

.19  pk. 

.19 

17  lbs. 

.05-.09  lb. 

1.00 

72 


January  1932 

*Weekly  Grocery  order  for  "A"  or  Minimum  Allowance 

(Prices  will  vary  in  different  localities  at  different  seasons  of  the  year. 
It  is  not  intended  that  this  grocery  order  be  followed  exactly  but  used 
only  as  a  guide.    These  are  averages  of  Boston  prices.) 

Food 

Milk 

Cheese   (mild) 

Cheese  (cottage) 

Eggs 

Meat  (cheaper  cuts) 

Fish,  fresh 

Salt  fish 

Potatoes 

Green  and  root  vegetables 

(7  lbs.  cabbage,  2  lbs.  carrots, 

2  lbs.  beets,  2  lbs.  onions,  2 

lbs.   canned   tomatoes,   2   lbs. 

spinach) 
Beans 
Peas 
Fresh  fruit 

(6     oranges, 

apples) 
Dried  fruit 

(prunes,  raisins,  dates  or 

apricots) 
Bread,  white 
Bread,  dark 
Cereals  and  flour 

flour 

graham 

oatmeal 

rice,  cornmeal,  wheatena 

macaroni 
Fats 

(butter,  olive  oil,  margerine, 

lard,  salt  pork,  etc.) 
Peanut  butter 
Sugar 
Molasses 
Cocoa 
Tea 
Coffee 
Seasonings 


6    bananas,    8 


1  lb. 

.07  lb. 

.07 

y2  ib. 

.08  lb. 

.04 

20  servings 

.0162  each 

.325 

1  lb.  prunes 

.09  lb.  ] 

.235 

x/2  lb.  raisins 

.10  lb.   \ 

%  lb.  apricots 

.19  lb.  J 

8  lbs. 

.056  lb. 

.45 

6  lbs. 

.056  lb. 

.34 

8y2  lbs. 

.04-.16  lb. 

.58 

2  lbs. 

.04 

1  lb. 

.06 

2  lbs. 

.06 

, 

x/i  lb.  each 

.06.-16 

2  lbs. 

.09 

3*4  lbs. 

.24  lb. -average 
of  all  fats 

.78 

y4  ib. 

.18  lb. 

.045 

2y2  lbs. 

.05  lb. 

.125 

1  can — 18  oz. 

.14  can 

.14 

y4  lb. 

.36  lb. 

.095 

2  oz. 

.45  lb. 

.055 

1/3  lb. 

.25  lb. 

.08 

.10 

$7.86 


*  The  cost  of  the  grocery  order  is  7.2%  less  than  in  June  1931,  18.5%  less  than  in  January 
1931  and  29.7%  less  than  in  January  1930.  The  cost  of  the  grocery  order  was  higher  in  January 
1930  than  at  any  other  time  during  the  past  ten  years. 


73 


Meals  Based  on  The  "A"  Grocery  Order 


BREAKFAST 
Sunday 

Wheatena,   sugar   and   milk 
Cinnamon   toast,   butter 
Cocoa    (for   children) 
Coffee     (for    adults) 
V2    orange   for   3   yr.   old 


DINNER 

Beef    Loaf 

Mashed    Potatoes 

Cabbage,   carrot,   raisin   salad 

Bread    and    butter 

Tea    (for   adults) 

Milk    (for   children) 

Custard 


SUPPER 


Potato   soup    with   onion 
Graham    biscuit 
Apples 


Monday 

Cornmeal,   sugar,   milk 
Bread    and    Molasses 
Coffee    (for   adults) 
Milk    (for  children) 
%    orange   for   3   yr.   old 


Tuesday 

Oatmeal,    sugar,   milk 
Rye   bread,   butter 
Cocoa    (for    children) 
Coffee     (for    adults) 
%    orange    for   3    yr.    old 


Wednesday 

Rice,    sugar,    milk 
Bread    and   butter 
Cocoa    (for   children) 
Coffee    (for   adults) 
V2    orange   for    3    yr.    old 


Thursday 

Oatmeal,    sugar,    milk 
Graham    bread,    butter 
Milk    (for  children) 
Coffee    (for    adults) 
V2    orange   for   3   yr.   old 


Friday 

Milk   toast 
Bread   and   butter 
Cocoa    (for   children) 
Coffee    ( for    adults ) 
Vs    orange    for    3    yr.    old 


Saturday 

Oatmeal,   sugar,   milk 

Muffins 

Cocoa    (for   children) 

Coffee    (for    adults) 

V2    orange   for   3    yr.    old 


American  Chop  Suey  (hamburg 
steak,  onion,  macaroni,  rice, 
tomatoes) 

Bread    and   butter 

Milk    (for    children) 

Tea    (for   adults) 

Fruit   jelly 


Lamb    stew     (carrots,    onions, 

potators) 
Bread    and    butter 
Tea    (for   adults) 
Milk    (for   children) 
Bread   pudding 


Creamed    cod    fish 
Baked    potato 
Buttered   beets 
Dark   bread,    butter 
Milk    (for    children) 
Tea    (for   adults) 
1   egg  for   3   yr.   old 


Beef    casserole    (onion,    carrots, 

potatoes ) 
Bread   and  butter 
Milk    (for    children) 
Tea    ( for   adults ) 
Rice   pudding   with   raisins 


Baked   haddock 

Baked   potato 

Spinach 

Corn    bread    and   butter 

Banana  and   top   milk 

Milk    (for   children) 

Tea    (for   adults) 


Macaroni    (with   cheese  and 

tomato ) 
Cole   slaw 

Dark   bread    and   butter 
Milk    (for   children) 
Tea    (for   adults) 


Vegetable   Chowder    (onion, 
milk,    carrots,    cabbage, 
potato ) 

Dark  bread  and  butter 

Stewed    apricots 

Gingerbread 


Baked   beans 

Brown  bread 

Cabbage   and   apple   salad 

Milk    (for    children) 

Egg   for   3   yr.   old 


Baked  bean  soup    (cold  baked 

beans,    onion,   tomato) 
Baking    powder    biscuit 
Carrot    salad 
Stewed    prunes 
Milk    (for   children) 


Scalloped   cabbage  and 

cheese 
(Dark  bread  and   cottage 

cheese    for    3    yr.    old) 
Muffins   and  butter 
Molasses 


Goldenrod  eggs 
Graham  Bread 
Stewed  Prunes 
Milk    (for   children) 


Split   pea   soup 
Biscuits  and  butter 
Chocolate    pudding 
Tea    (for  adults) 


This  grocery  order  meets  the  minimum  requirements  for  children 
and  adults,  furnishing  the  necessary  "protective  foods,"  those  which 
will  build  up  body  resistance  to  disease,  promote  bone  and  muscle 
development,  allow  for  growth,  and  generally  maintain  the  individual 
in  a  state  of  health.  The  tables  which  follow  show  the  foods  in  the 
grocery  order  which  are  especially  high  in  these  protective  elements 
and  offer  a  guide  for  meal  planning.  If  we  are  to  have  a  diet  adequate 
over  a  long  period  of  time,  these  standards  should  be  followed. 


74 


Children 

Milk  3  c.  a  day. 

Eggs  3  or  4  a  week. 

Vegetables,  green  or  yellow,  1  a 
day  besides  potato,  and  a  raw 
green  one  5  times  a  week. 

Fresh  fruit  4  times  a  week,  citrus, 
if  possible. 

Dried  fruit  3  times  a  week. 

Dark  bread  and  cereal  daily. 

Butter  daily. 


Adults 
Milk  iy2  c.  a  day. 
Eggs  2  a  week. 
Vegetables — same  as  child. 


Fresh  fruit  4  times  a  week. 

Dried  fruit  3  times  a  week. 
Dark  bread  and  cereal  daily. 


This  is  not  an  ideal  diet.  It  has  less  protein  than  the  average  person 
enjoys  and  not  as  many  green  vegetables  and  fruit  as  we  like.  It  is 
high  in  cereals  and  bread,  but  when  food  money  is  restricted,  the 
amount  of  bread  and  cereals  must  increase  in  the  diet  as  they  are -the 
cheapest  energy  foods  and  if  whole  grain  products  are  used  these  are 
also  a  valuable  source  of  minerals  and  vitamins.  The  proportion  of 
milk  seems  high  perhaps  but  "milk  builds  bone  and  muscle  better  than 
any  other  food."  The  complaint  may  be  made  that  the  diet  is  monoto- 
nous but  as  Dr.  Sherman  says  in  his  pamphlet  "Emergency  Nutrition," 
"Let  no  one  be  misled  by  the  extravagant  phrase  'deadly  monotony.' 
No  deaths  are  ever  caused  by  monotony  of  diet  if  the  diet,  however 
simple  and  cheap  provides  the  actually  necessary  nutrients,  while  short- 
ages of  these  nutrients  do  cause  all  too  many  deaths,  if  not  directly,  then 
by  lowering  the  resistance  to  disease."  It  may  be  questioned  if  the 
meat,  potato  and  bread  of  the  average  diet  is  not  more  monotonous 
than  the  menus  given  above. 

In  planning  a  minimum  food  budget,  it  is  best  first  to  decide  on  the 
amount  of  milk  which  will  meet  the  needs  of  the  family.  This  can  be 
done  by  allowing  l1/^  pints  for  each  child  and  IV2  cups  for  each  adult. 
It  is  also  desirable  to  spend  as  much  for  vegetables  and  fruits  as  for 
meat,  fish  and  eggs. 

Of  course,  you  are  all  interested  to  know  if  this  minimum  food  bud- 
get is  really  helpful.  Has  any  one  tried  it  successfully  or  is  it  one  of 
"those  theoretical  budgets?"  Among  the  cases  carried  by  the  nutrition 
workers  of  the  Community  Health  Association  are  many  similar  to 
that  of  Mrs.  Jones.  These  women  have  been  taught  to  cut  their  food 
budget  almost  in  half  without  sacrificing  any  of  the  essentials.  They 
have  changed  their  food  habits  greatly,  have  reduced  their  meat  bills, 
bought  more  vegetables  and  fruit,  increased  the  amount  of  milk  in 
many  cases  by  two  or  three  hundred  per  cent  and  as  a  consequence, 
their  families  are  having  a  much  more  adequate  diet,  are  much  more 
healthy,  and  are  spending  less  for  their  food. 


TEACHING  NUTRITION  IN  AN  OUT-PATIENT  DEPARTMENT 

Gertrude  T.  Spitz,  A.B.,  A.M. 
Chief  of  Food  Clinic,  Beth  Israel  Hospital 

"Shure  is  this  where  they  teach  the  calories?"  I  glanced  up  as  the 
rich  Irish  brogue  struck  my  ears,  and  beheld  a  capable  looking  woman, 
with  a  thin  overgrown  girl,  in  hand,  bearing  a  refer  slip  from  the  medi- 
cal clinic  recommending  "high  caloric  diet." 

"Do  you  know  about  them?"  I  inquired  as  I  waited  for  Mary  Clap- 
ham's  record  with  its  medical  findings,  laboratory  data,  height,  weight, 
etc.  to  arrive.  "Well,  she  gets  them  to  eat,"  said  the  woman,  "but  she 
don't  gain  on  them."  "Let's  see  about  that,"  said  I,  glad  to  get  down  to 
the  facts  of  Mary's  every  day  life — school,  home  and  play — and  a  de- 
tailed account  of  her  daily  food  intake.   And  then,  because  Mary's  diet 


75 

seemed  fairly  adequate,  and  Mary's  aunt,  for  so  she  proved  to  be,  in- 
telligent about  food,  we  went  on  to  talk  of  the  body's  needs  for  girls 
of  the  adolescent  period.  Mary  was  going  through  a  time  of  rapid 
growth,  I  told  her,  in  which  not  only  total  calories,  sufficient  for  activ- 
ity and  development,  were  necessary  but  Mary  must  have  sufficient 
protein,  the  food  for  muscle  and  tissue,  a  food  which  none  other  could 
replace.  This  first  of  all  meant  milk — three  to  four  glasses  to  drink, 
or  in  soups,  puddings,  etc. — and  then  in  the  same  group  came  eggs, 
meat,  fish  and  cheese,  the  body  builders;  with  peas,  beans  and  nuts 
not  quite  so  complete  but  improved  when  combined  with  milk  in  the 
diet. 

And  Mary  must  be  sure  to  get  adequate  calcium  for  bones  and  teeth. 
This  her  milk  will  furnish.  Iron  for  good  red  blood  she  gets  from  her 
egg,  from  meat,  eaten  two  to  three  times  a  week,  from  green  vegetables, 
from  prunes  and  raisins  and  from  molasses  in  ginger  bread  and  pud- 
ding. The  most  important  minerals  taken  care  of,  next  in  line  come 
those  vitamins  which  I  was  sure  such  a  thorough  person  as  Mary's  aunt 
had  heard  about.  Her  milk,  egg  and  butter  would  provide  vitamins  A 
and  D.  The  whole  grain  cooked  cereal  recommended  for  breakfast  in- 
stead of  the  raw  one,  and  her  whole  wheat  or  graham  bread  sandwiches, 
vitamin  B,  with  orange,  cabbage  or  tomato  for  vitamin  C.  Really  with 
this  change  for  breakfast,  a  little  additional  bread  and  butter,  and  an 
extra  vegetable,  Mary's  diet  would  be  increased  in  calories  and  ade- 
quacy and  Mary  would  be  on  the  way  to  gain  weight. 

It  seems  Mary's  aunt  worked  in  a  lunch  room  at  a  select  girl's  school, 
and  had  learned  a  good  deal  about  nutrition  which  she  was  applying  to 
Mary's  eating  habits,  with  much  distress  however,  because  Mary  was 
still  several  pounds  underweight,  listless,  and  tired  as  well. 

So  we  discussed  together  other  factors  in  Mary's  life  that  would  aid 
in  weight  gain.  Mary  was  a  busy  and  happy  person  outside  her  school 
day.  Mary's  mother  worked;  Mary  helped  at  home;  Mary  went  to  bed 
late;  Mary  had  no  day  time-  rest.  It  was  not  so  much  more  food  that 
Mary  needed,  or  different  food,  as  it  was  more  rest,  and  I  explained  to 
them  both  how  all  the  food  that  Mary  ate  was  being  used  for  growth, 
and  to  repair  waste,  and  to  furnish  heat  and  energy  for  school  and  play, 
with  nothing  left  over  to  accumulate  as  fat.  But  if  Mary  would  go  to 
bed  earlier  and  rest  one-half  hour  after  school  and  fifteen  minutes 
before  supper,  then  she  wouldn't  use  up  quite  so  many  calories  and  a 
few  would  be  left  to  bring  about  that  gain  in  weight.  "Only  a  slow 
gain,"  I  warned  Mary,  "so  don't  expect  the  impossible.  It's  much  easier 
to  lose  weight  by  cutting  down  food  than  to  gain  by  adding  it." 

During  all  this  time  Mary's  nutritional  history  had  been  written  on 
the  Food  Clinic  sheet  and  Mary  had  for  her  own  guidance  a  daily  menu 
with  hours  for  rising,  bed  time,  and  rest.  Mary,  it  seemed,  didn't  learn 
about  food  at  her  school  so  the  "State  House"  pamphlet  on  Food  for 
the  Adolescent  was  given  her  to  take  home  in  order  that  she  and  her 
aunt  might  review  the  information  brought  out  in  the  discussion.  Be- 
cause Mary's  chief  problem  was  rest,  a  leaflet  from  the  Elizabeth 
McCormick  Memorial  on  Sleep  and  Rest,  was  added. 

This  is  nutrition  as  taught  in  the  Food  Clinic  of  an  out-patient  de- 
partment, individualized  to  fit  the  needs  and  mentality  of  the  patient. 
Not  all  of  them  have  Mary's  interest  and  intelligence,  but  many  of 
them  read  the  health  columns  in  the  newspapers,  listen  to  the  radio, 
believe  the  advertisements,  and  each  one  is  vitally  concerned  with  his 
own  health,  or  with  the  diseased  condition  which  has  brought  him  to 
the  hospital  and  caused  him  to  be  sent  to  the  Food  Clinic  for  diet.  If 
he  has  an  ulcer,  we  believe  that  the  knowledge  that  an  ulcer  is  like  a 
sore,  and  that  it  must  be  protected  by  soft  food,  and  that  frequent  feed- 
ings prevent  further  irritation,  helps  him  to  keep  his  diet.  If  he  has 
diabetes,  the  fact  that  an  organ  in  his  body,  the  pancreas,  doesn't  make 


76 
enough  juice — insulin — to  digest  the  starches  and  sugars,  convinces 
him  that  he  must  cut  down  on  these.  He  learns  the  5%  vegetables: 
lettuce,  tomato,  celery,  spinach,  cabbage  and  other  greens;  the  10% 
ones:  carrots,  onions,  beets,  squash  and  other  roots;  the  10%  fruits 
like  oranges,  peaches,  strawberries,  fresh  pineapple,  and  realizes  that 
these  are  his  best  sources  of  carbohydrate  and  that  he  can  only  eat  a 
minimum  amount  of  the  more  concentrated  breads  and  cereals.  Three 
and  a  half  lumps  of  sugar  to  represent  the  amount  in  a  dish  of  cereal 
(1  oz.  dry),  a  slice  of  bread  or  a  small  potato,  placed  before  him,  with 
only  one  lump  representing  a  half  head  of  lettuce,  a  large  dish  of 
cabbage,  one-half  small  grapefruit  or  one  Uneeda  bring  this  out 
graphically. 

This  illustration  does  as  well  for  the  obese  person  too,  who  must  cut 
down  his  total  calories  and  his  fats  and  carbohydrates.  But.  in  each  of 
these  cases  we  stress  the  normal  diet,  explain  that  the  strength  giving 
food — the  protein — must  still  be  sufficient  and  by  no  means  cut  down 
in  most  of  the  diets  prescribed.  And  we  talk  about  the  body's  needs 
in  general,  the  minerals,  vitamins  and  water  with  his  diet  changed  only 
to  meet  the  diseased  condition  which  has  required  the  change. 

Because  many  of  these  people  are  on  inadequate  diets  to  begin  with, 
a  little  lesson  on  normal  diet  helps  the  family  as  a  whole.  Since  this 
is  so,  it  is  necessary  to  take  an  intake  on  each  patient  and  to  adapt  the 
diet  therapy  to  family  life,  racial  customs,  economic  condition,  mental 
ability  and  emotional  pattern.  General  directions  and  class  or  group 
teaching  is  not  sufficient.  An  occasional  informal  talk  or  "health"  party 
makes  for  pleasant  relations  and  stimulates  questions  but  does  not  take 
the  place  of  the  individual  interview  and  advice.  Sometimes  very  little 
instruction  can  be  given  because  of  language  difficulty  or  mental  lack, 
in  which  case  we  set  out  the  three  meals  by  means  of  wax  models  or 
actual  food  stuffs,  so  that  the  patient  knows  what  he  is  to  eat;  and 
sooner  or  later  some  relative  or  friend  comes  in  and  interprets  the  les- 
son. All  this  is  not  accomplished  in  one  visit,  for  eating  habits,  even 
of  the  sick,  are  not  changed  so  rapidly,  and  new  learning  in  food  ways 
comes  like  other  learning,  only  with  repetition. 

As  in  every  hospital,  our  first  duty  in  the  Food  Clinic  is  to  the 
patient,  but  there  are  others  who  must  be  taught  if  the  doctrine  of 
good  nutrition  is  to  be  spread  in  every  possible  way.  Next  to  the 
patient  comes  the  student  dietitian.  The  Beth  Israel  Hospital  offers  a 
six  months'  course  to  graduates  of  schools  of  home  economics  and  one 
month  of  these  six  is  spent  in  the  Food  Clinic.  Before  they  come  to  us 
they  have  served  in  the  diet  kitchen  and  are  supposed  to  be  familiar 
with  special  diets  and  how  to  calculate  them.  They  have  been  used  to 
sending  weighed  and  reckoned  diets  to  the  patient's  bedside  from  a 
well  stocked  and  equipped  kitchen.  Now  they  must  plan  the  diet  to 
suit  the  patient's  needs,  from  food  purchased  and  prepared  by  the 
patient  herself  along  with  the  family  food,  bought  with  a  meagre  in- 
come and  with  no  nurse  standing  by  to  see  that  it  and  nothing  else  is 
eaten.  So  they  have  first  of  all  to  learn  about  people,  how  they  live, 
where  they  buy,  what  they  have  to  cook  with;  and  they  have  to  learn 
how  to  make  the  patient  want  to  follow  the  diet,  how  to  interest  him 
in  health;  all  the  newer  devises  of  progressive  education;  all  the 
simple  psychology  that  will  make  the  lesson  fit  the  patient's  mentality. 
Then  because  a  patient  is  a  live,  active  individual  who  has  come  to  the 
hospital  with  a  gastric  ulcer,  or  diabetes,  or  a  food  allergy,  or  nephritis, 
they  must  learn  to  recognize  from  the  medical  history  the  symptoms 
and  physical  findings  that  concern  them  as  dietitians.  So  they  visit  the 
adult  medical  and  children's  clinics,  and,  because  we  are  a  teaching 
hospital,  the  doctors  generously  show  them  a  physical  examination, 
gastric  analysis,  skin  tests,  basal  metabolism.  Once  a  week  too  they 
attend  the  medical  staff  conference  and  become  familiar  with  the  in- 


77 
teresting  types  of  cases  presented  in  an  out-patient  discussion  group. 
They  make  a  home  visit  with  the  Social  Service  Department,  learn 
about  budgets  from  the  Bureau  of  Home  Economics  of  the  Allied  Jew- 
ish Philanthropies,  listen  to  Dr.  Joslin  teach  his  diabetic  patients,  see 
how  the  clinics  at  the  Boston  Dispensary  and  the  Massachusetts  Gen- 
eral Hospital  are  run,  collect  material  from  the  State  House,  and  the 
New  England  Dairy  and  Food  Council,  become  familiar  with  all  the 
various  cooperating  agencies  that  join  together  for  the  good  of  the 
patient.  Whether  they  do  out-patient  work  or  not,  these  visits,  their 
reading,  their  experience  in  calculating  a  special  diet  and  prescribing 
it  for  the  patient,  in  the  patient's  presence,  will  be  a  help  to  them  in 
interpreting  therapeutic  diets  or  in  teaching  nurses  if  they  choose  the 
administrative  type  of  dietetics. 

In  addition  to  these  students,  we  take  seniors  from  the  Home 
Economics  Department  at  Simmons  College  for  one  period  a  week  for 
one  semester,  for  observation  and  instruction;  give  talks  to  our  own 
Social  Service  Department  on  diet  therapy;  and  give  informal  demon- 
strations and  discussions  on  the  normal  diet  and  its  modification  to 
meet  diseased  conditions  to  third  year  Harvard  Medical  School  stud- 
ents, who  are  having  their  clinical  medicine  in  the  out-patient  depart- 
ment and  have  asked  for  the  opportunity  to  learn  about  food. 

In  these  days  of  new  discoveries  in  the  field  of  dietetics  and  new 
methods  in  the  treatment  and  prevention  of  disease  by  diet,  the  alert 
dietitian  must  be  well  informed  and  willing  to  disseminate  new  knowl- 
edge. Cooperation  with  the  medical  staff  in  this  direction  is  a  further 
means  of  learning  and  teaching. 

STAFF  EDUCATION  IN  NUTRITION 
SPRINGFIELD,  MASSACHUSETTS 

Florence  G.  Dorward 
Springfield  Nursing  and  Public  Health  Association 

The  public  health  nurse  should  have  some  training  along  nutritional 
lines.  She  should  be  able  to  lead  the  community  she  serves  to  higher 
standards  of  healthful  living.  To  her  as  well  as  to  the  doctor  will  her 
patients  look  expectantly,  not  only  for  the  alleviation  of  their  suffer- 
ings, but  also  for  information  that  will  aid  in  the  prevention  of 
sickness. 

Nutrition  is  a  basic  science  in  the  field  of  preventive  medicine  and 
has  much  to  do  with  raising  the  vitality  of  a  community.  Much  of  the 
teaching  of  nutrition,  by  which  we  mean  the  education  of  individuals 
in  the  selection  of  proper  diet  for  themselves  and  their  families,  and 
education  in  habits  of  living  which  definitely  influence  the  state  of 
nutrition,  must  of  necessity  come  from  the  nurses  as  they  come  and  go 
from  the  homes  they  visit  professionally.  This  is  especially  true  where 
but  one  trained  nutritionist  is  available  to  the  nursing  organization  of 
a  large  city  and  confronted  with  meeting  its  needs. 

In  our  Nursing  and  Public  Health  Association  there  have  been  three 
approaches  to  staff  education  in  nutrition.  Our  plan  this  year  has  been 
to  select  several  outstanding  health  problems,  and  have  the  nursing  staff 
study  these  problems  from  a  bibliography  which  was  furnished  them 
together  with  such  aids  as  the  public  library  and  local  health  organ- 
izations might  afford,  and  then  come  back  and  do  their  own  reporting 
at  the  next  staff  conference,  which  meets  once  in  every  two  weeks.  We 
have  thought  that  this  was  a  much  more  satisfactory  plan  than  the  one 
followed  last  year,  when  the  nutritionist  herself  presented  the  subject. 
There  seemed  much  more  interest  on  the  part  of  the  nurses,  and  a  better 
appreciation  of  the  subject  matter. 


78 
For  example,  one  of  the  problems  this  year  was  a  study  of  rickets, 
of  which  the  following  is  a  brief  outline  for  the  two  conferences  held : 

1. 

(a)  Cause — 

Environmental  factors. 
Dietary  deficiencies. 

(b)  Symptoms. 

(c)  Prevention 

(d)  Prognosis  and  treatment. 
2. 

(a)  Experimental  work  of  Dr.  Elliot  in  New  Haven  and  Porto  Rico. 

(b)  State  work  on  rickets — 

Prevention  and  statistics. 

(c)  Work  done  at  Shriners  Hospital  in  Springfield. 

The  second  phase  in  our  staff  education  is  that  of  office  conferences, 
which  are  also  held  once  every  two  weeks,  intermediate  with  the  first 
mentioned.  These  are  much  more  informal  than  the  regular  staff  con- 
ferences, the  various  groups  being  smaller  and  the  subject  matter  on  a 
more  limited  scope.  The  nutritionist  presents  her  subject  and  encour- 
ages questions  which  she  hopes  will  bring  out  some  of  the  immediate 
problems  which  the  nurses  may  have  had  to  encounter  in  their  duty 
calls  during  the  week.  At  the  conferences  a  specific  case  may  be  dis- 
cussed, a  questionnaire  answered,  suggestions  for  emergency  nutrition 
given,  child  training  in  food  habits  brought  out. 

The  third  phase  is  that  in  which  the  nutritionist  acts  as  a  consultant, 
coming  in  direct  and  personal  contact  with  the  nurse  herself  by  visit- 
ing a  home  with  her  and  by  discussing  with  her  some  nutritional  prob- 
lems of  which  she  may  be  in  doubt. 

Poster  and  educational  material  which  the  nurses  are  free  to  take 
into  the  homes  they  visit  are  constantly  kept  available.  The  proper  use 
of  this  educational  material  is,  we  believe,  an  important  means  of  carry- 
ing needful  lessons  to  the  patient  in  a  permanent  form  for  present  and 
future  reference. 

We  have  in  our  organization,  student  affiliates  from  local  hospitals. 
With  these  students  the  nutritionist  holds  classes  in  which  the  impor- 
tance of  nutrition  in  a  public  health  program  is  given,  together  with  an 
outline  of  our  particular  nutritional  program,  stressing  their  relation- 
ship to  it. 

"Staff  Education"  is  not  only  the  education  of  the  staff  itself  in  the 
rudiments  of  nutrition  and  in  its  newer  developments,  but  also  the 
putting  of  material  into  their  hands  in  such  a  form  that  it  can  easily 
and  readily  be  utilized  by  them  in  their  home  teaching.  The  field  is 
wide,  the  problems  are  many,  and  with  present  day  lowered  incomes 
and  in  many  cases  only  incomes  from  relief  agencies,  conditions  are 
becoming  more  complicated.  If  ever  the  personal  attention  of  trained 
workers  were  needed,  it  is  now.  Yet  this,  far  too  often,  is  impossible, 
and  if  such  work  is  to  be  carried  by  the  nursing  staff  so  as  to  meet  the 
greatest  need,  much  time  must  go  into  this  phase  of  nutrition. 

THE  VALUE  OF  A  NUTRITIONIST  IN  THE  SCHOOLS 

Mary  Elizabeth  O'Connor 

Supervisor  of  Elementary  Schools 
Natick,  Massachusetts. 

The  health  program  in  any  school  system  soon  brings  to  the  fore  the 
dire  need  of  special  interest  and  special  attention  to  what  children  eat, 
when  they  eat  it  and  how  they  eat.  Not  long  ago  I  heard  a  third  grade 
teacher  ask  her  class  what  the  greatest  business  of  a  people  was.   She 


. 


79 
was  working  hard  for  the  answer,  "farming,"  of  course,  but  up  piped  a 
little  girl  with  the  answer  "eating."  I  wonder  if  she  wasn't  right.  Com- 
ing from  a  family  of  eight  children,  she  had  seen  her  mother  buying, 
baking,  cooking,  serving  food  the  greater  part  of  the  day  and,  interest- 
ing little  helper,  she  may  have  had  the  by-product,  all  of  those  dishes 
to  wash.  She  knew  from  experience.  Eating  is  the  never  failing  busi- 
ness of  any  people.  Think  how  much  success  not  only  physically,  but 
mentally  and  spiritually,  depends  on  what  people  eat  and  how  little 
definite  constructive  work  we  have  done  in  that  line  compared  with 
other  lines  in  the  public  schools.  In  our  modern  progressive  school 
systems  we  are  realizing  as  never  before  what  attitudes  and  habits 
mean  in  life,  how  early  they  are  formed  and  consequently  what  an  im- 
portant part  of  our  early  school  life  they  must  be.  Isn't  it  strange  that 
we  should  have  arrived,  last  of  all,  at  this  most  important  habit  of 
eating ! 

Just  as  psychology  for  the  normal  was  forced  upon  us  by  psychology 
of  the  abnormal  so  proper  nutrition  work  with  all  our  children  will 
grow  out  of  this  remedial  work  in  nutrition  to  which  any  health  pro- 
gram, building  up  and  weeding  out,  soon  brings  us.  We  soon  find  a 
group  which  must  have  special  attention  in  nutrition.  Then,  who  is  to 
do  it?  How  is  it  to  be  done?  And  I  can  hear  a  third  question  asked  in 
every  meeting  of  public  school  superintendents — Is  it  the  business  of 
the  schools? 

In  the  school  system  in  which  it  is  my  good  fortune  to  work  we  had 
built  up  with  the  ever  present  help  of  the  State  Health  Department  a 
health  program  including  beside  the  regular  work  usually  done  by 
school  doctors  and  nurses  and  a  fairly  modern  physical  education  de- 
partment, the  following  clinics :  dental  clinic,  special  posture  clinic, 
State  tuberculosis  clinic,  mental  hygiene  clinic,  Summer  Round-Up, 
diphtheria  prevention  clinic  and  special  affiliations  with  specialists  for 
eye  and  ear,  glandular  and  pathological  difficulties.  But  in  spite  of 
home  visiting  done  by  the  school  nurse  and  all  the  side  work  done  by 
the  many  people  included  in  our  health  department  we  had  a  couple  of 
hundred  children  marked,  "fair"  or  "poor,"  by  the  doctors  in  the  fall 
examinations  every  year.  So  we  decided  to  try  a  nutritionist  to  do 
"follow-up"  or  remedial  work  with  this  group.  Not  that  we  believed 
this  was  the  only  work  that  a  nutritionist  should  do  in  a  school  system 
but  it  was  a  crying  need  we  had  to  meet  at  the  time.  Space  forbids  my 
going  into  details  of  this  program.  Sufficient  to  say,  the  nutritionist 
worked  four  months  for  each  of  two  consecutive  years  with  the  chil- 
dren, mothers,  teachers  and  specialists  in  our  health  department,  indi- 
vidually and  in  groups.  From  this  experiment  we  found  a  definite  im- 
provement in  weight  and  height  of  these  malnourished.  There  was  a 
greater  reduction  in  physical  defects.  More  teeth  were  fixed  up,  more 
diseased  tonsils  and  adenoids  removed.  The  popularity  of  rest  was 
greatly  promoted  and  increase  in  general  health  was  made  a  vital  thing 
with  most  of  the  mothers.  This  last  was  not  easy  where  habits  of  eat- 
ing had  been  brought  from  foreign  countries  where  climate  and  living 
conditions  are  very  different  from  ours  and  new  attitudes  and  habits 
have  to  be  built  up  tactfully  and  slowly.  The  nutritionist  getting  the 
mothers  together  in  small  groups  in  various  localities  and  going  into 
the  homes  has  the  most  favorable,  if  difficult,  opportunity,  of  course, 
to  do  this. 

The  school  needs  to  teach  more  about  nutrition  in  the  classroom  and 
here  a  nutritionist  can  do  much  through  instructing  the  teachers,  help- 
ing them  to  get  material  and  subject  matter  and  build  up  a  program  on 
the  pupils'  level  of  interest  and  ability  that  daily  shall  integrate  itself 
into  the  whole  school  life.  Through  her  work  with  the  store  keepers 
in  the  town  she  can  build  up  an  interest  and  pride  in  selling  clean  and 
proper  food.  She  can  set  right  food  consciousness,  standards  and 
fashions. 


80 

Nutrition  is  such  an  important  item  in  successful  and  happy  living 
that  I  have  come  to  believe  no  health  program  can  ever  go  over  the  top, 
can  ever  be  complete  without  a  nutrition  worker.  Oh,  there  are  many- 
handicaps  to  be  met,  many  mistakes  to  be  avoided  and  a  host  of  valu- 
able by-products  sure  to  come.  One  of  the  first  handicaps  to  be  over- 
come is  getting  the  intelligent,  active  enthusiasm  on  the  part  of  class- 
room teachers  and  school  officials.  So  much  is  involved  in  this  and  such 
is  our  present  situation  that  the  nutrition  worker  is  extremely  valu- 
able in  what  she  does  with  this  group  in  changing  the  school  attitudes 
and  habits  of  work.  To  integrate  nutrition  work  into  a  school  program 
already  full  is  no  small  job.  It  means  a  nice  weighing  of  values  and 
much  clever  salesmanship.  The  carrying  of  new  ideas  on  food,  eat- 
ing and  rest  into  homes  hide-bound  with  tradition  requires  the  utmost 
tact  and  sympathy.  But  here  comes  the  wonderful  by-products.  The 
right  kind  of  nutritionist  going  into  the  home  not  only  changes  the 
eating  habits  of  the  child  but  usually  those  of  the  whole  family,  for  the 
child  eats  what  the  father  eats,  what  they  all  eat  as  a  rule.  She  im- 
proves the  health  of  the  whole  family.  Her  sympathy  brings  the  home 
and  school  closer  together  for  she  is  working  on  a  line  they  all  under- 
stand and  she  also  has  a  wonderful  chance  in  these  visits  to  wipe  out 
many  misunderstandings  that  grow  between  the  home  and  school  from 
other  causes. 

From  an  economic  point  of  view  she  is  a  wise  school  investment.  Re- 
tardation is  a  serious  waste  in  school  life  today.  How  much  retarda- 
tion is  due  to  malnutrition  we  do  not  know  but  we  are  sure  that  there 
is  a  decided  correlation  between  the  two.  Paying  over  and  over  again 
for  the  same  schooling  of  a  child  because  he  is  malnourished  is  inex- 
cusably bad  business  procedure.  The  social  waste  due  to  malnourish- 
ment  we  can  but  faintly  guess. 

The  value  of  a  nutritionist  in  the  schools  depends  in  no  small  meas- 
ure on  her  personality.  It  is  more  true  of  her  than  most  educators  for 
the  variety  of  people  with  whom  she  works  is  so  great  and  the  depths 
of  privacy  she  touches  so  sensitive  that  the  greatest  wisdom  and  sym- 
pathy are  needed.  She  needs  not  only  to  be  highly  and  widely  trained 
in  her  particular  line  of  work,  but  she  needs  to  have  had  much  social 
experience,  have  made  many  contacts  with  young  and  old,  rich  and 
poor,  foreign  and  native  born.  She  needs  to  know  how  folks  get  that 
way  and  what  you  do  about  it,  socially  as  well  as  physically.  Ah  but 
I  hear  you  say,  "Such  a  woman  could  sell  nutrition  in  Heaven!"  Yes, 
but  she  can  be  found.  She  is  a  fine  public  investment  and  she  is  much 
needed  here  and  now. 

4-H  CLUB  FOOD  WORK 

Helen  E.  Doane 

Assistant  State  Club  Leader 

Massachusetts  State  College  Extension  Service 

and 

Albertine  P.  McKellar,  B.S. 

Public  Health  Education  Worker 
Massachusetts  Department  of  Public  Health 

When  in  1914  the  bill  for  appropriating  federal  money  to  be  used  to 
teach  agriculture  and  home  economics  in  rural  communities  was 
passed,  there  were  groups  of  boys  organized  into  agricultural  clubs  in 
a  lew  of  the  southern  and  middle  western  states.  These  clubs  were 
the  beginning  of  boys'  and  girls'  clubs  in  agriculture  and  home 
economics  which  sprang  up  all  over  the  country  soon  after  the  passing 
of  the  Smith-Lever  Bill  in  1914.    Sometimes  it  was  known  as  junior 


81 

agriculture  and  home  making  clubs,  but  more  often  as  boys'  and  girls' 
club  work. 

Ten  years  passed,  the  junior  work  spread  and  grew  as  did  the  adult 
work,  and  with  the  growth  and  purpose  of  the  organization  it  adopted 
national  standards.  Now,  eighteen  years  later,  we  have  a  most  worth 
while  organization,  based  wholly  on  the  finer  things  of  life,  and  offer- 
ing opportunity  and  education  to  some  850,000  boys  and  girls  in  this 
country.  The  purpose  of  this  article  is  to  give  a  mental  picture  of  only 
one  phase  of  the  work.  As  we  can  deal  with  only  one  small  part  let 
us  just  outline  the  organization  of  the  4-H  Food  Club  work,  a  project 
chosen  by  many  of  these  boys  and  girls. 

Under  the  United  States  Department  of  Agriculture  is  the  depart- 
ment to  which  the  work  of  the  4-H  Club  belongs.  This  depart- 
ment is  known  as  the  "Extension  Service  Bureau."  In  Massachusetts 
the  Extension  Service  is  a  department  of  the  Massachusetts  State  Col- 
lege. The  state  extension  4-H  leaders  supervise  the  county  extension 
workers  who  are  known  as  club  agents  and  assistant  club  agents.  An 
assistant  club  agent  works  with  the  girls.  The  organization  then  be- 
comes voluntary,  and  it  is  the  large  group  of  volunteer  leaders,  re- 
ceiving training  from  trained  county  leaders  and  state  specialists,  that 
pass  on  the  greatest  help  to  their  communities. 

The  clubs  are  known  as  "4-H  Clubs"  and  their  club  pledge  is: 
I  pledge 

My  Head  to  clearer  thinking, 

My  Heart  to  greater  loyalty, 

My  Hands  to  larger  service, 

My  Health  to  better  living 

For  my  Club,  my  Community,  my  Country. 

Each  club  member  recognizes  as  his  emblem  the  green  four-leaf 
clover  with  an  "H"  on  each  leaf.  The  national  colors  are  green  and 
white,  while  the  slogan  is  "To  make  the  best  better."  In  Massachusetts 
the  state  slogan  is  "Hop  to  it,"  or  "When  asked  I  serve."  Each  4-H 
Club  member  is  proud  of  her  accomplishments,  and  many  of  them  are 
carrying  real  responsibilities  in  their  homes. 

In  the  growth  of  4-H  Club  food  work  in  the  last  ten  years,  the  entire 
plan  for  food  study  has  been  changed.  When  programs  and  require- 
ments were  first  outlined  for  girls  between  the  ages  of  ten  and  twenty- 
one  years,  the  clubs  were  known  as  bread  clubs.  Each  club  member 
made  so  many  loaves  of  white  bread  and  kept  a  careful  record  of  the 
number  of  hours  each  home  task  required.  Her  record  was  the  number 
of  hours  of  work  she  had  done. 

Today  our  4-H  food  girl  enrolls  in  a  food  project  based  on  the  study 
of  the  meal.  Beginning  with  the  ten  year  old,  an  elementary  program 
is  outlined.  This  program  includes  the  first  necessary  steps  in  food 
preparation  and  very  simple  health  teachings  in  the  way  of  making 
health  posters. 

When  a  club  girl  is  ready  for  the  second  year  of  food  work,  she 
studies  a  breakfast  program.  Here  comes  an  opportunity  to  teach  the 
health  reasons  for  eating  breakfast  foods  which  are  simple  and  easily 
prepared,  and  which  have  an  appeal  for  the  early  morning.  The  pro- 
gram teaches  simple  nutrition,  the  value  of  milk  drinks,  milk  dishes 
for  breakfast,  cereals,  fruits,  and  whole  grain  muffins,  and  attractive 
ways  of  serving  eggs.  In  the  study  of  each  food,  something  of  interest 
Of  its  history,  where  grown,  etc.,  together  with  different  ways  of  serv- 
ing it  and  its  food  value  add  to  the  popularity  of  preparation. 

The  next  program  is  based  on  the  luncheon  or  supper.  Oftentimes  it 
seems  as  if  this  program  needed  the  most  help  of  any.  Club  girls  and 
club  families  lack  imagination  and  knowledge  of  what  a  large  variety 
of  simple  inexpensive  dishes  there  are  for  lunches.  The  old  idea  of 
fried  or  warmed  over  potato,  with  cold  meat,  white  bread,  tea  and  apple 


82 
pie  still  prevails  in  the  homes  of  many.  Club  girls  often  face  difficulties 
when  it  comes  to  adapting  their  training  and  knowledge  of  foods  into 
the  family  habits  and  traditions.  But  to  a  4-H  leader  the  possibilities 
of  teaching  food  values  in  this  program  are  unlimited.  A  splendid 
foundation  and  understanding  of  simple  nutrition  is  taught. 

The  dinner  program  is  attractive  to  groups  interested  in  showing  a 
community  the  things  learned  about  foods.  In  addition  to  home  din- 
ners, the  club  girls  often  serve  mother-daughter  meals,  community 
meals,  father-daughter  dinners,  etc.  The  food  value  and  the  learning 
of  what  vegetables  to  serve,  together  with  the  reasons,  add  interest. 
New  planning  for  the  buying  of  foods  of  greatest  value  for  the  least 
money  makes  marketing  a  part  of  this  year's  work. 

A  special  program  for  advanced  work  includes  the  study  of  refresh- 
ments for  family  and  4-H  Club  parties.  In  this  program  the  club  girl 
has  an  opportunity  to  learn  more  of  the  social  niceties  of  entertaining 
and  being  entertained. 

Many  high  school  groups  want  still  more  advanced  work  in  foods  and 
so  programs  are  outlined  for  them  by  planning  with  each  individual 
club.  In  the  state  this  year  one  group  is  studying  community  meals, 
learning  to  plan,  prepare  and  serve  attractive  economical  meals  in  their 
community.  Another  group  is  studying  nutrition  and  marketing.  This 
group  plans  to  begin  another  fall  and  serve  a  hot  dish  at  lunch  time  in 
a  grammar  school.  Another  group  is  combining  a  social  etiquette  pro- 
gram with  a  health  program. 

Outdoor  cookery  has  won  popularity,  particularly  among  the  boys, 
although  girls  have  gone  back  from  county  and  state  camps  enthusi- 
astic about  it.  It  is  an  opening  for  teaching  something  of  foods  and 
nutrition  to  boys  in  a  sugar-coated  form.  The  study  of  what  can  be 
cooked  over  an  open  fire  out-of-doors  lends  its  charms.  Then  when 
spring  comes  and  suppers  practiced  in  the  leader's  kitchen  can  actu- 
ally be  cooked  out-of-doors,  a  boy's  heart  is  happy. 

Hot  lunch  work  has  won  its  way  among  several  4-H  club  groups  in 
small  and  rural  schools.  The  work  which  these  groups  do  is  well  worth 
while.  In  a  rural  school  in  Lanesboro,  the  junior  leader,  a  girl  of  about 
twenty  years,  who  is  through  school,  arrives  with  the  children  on  a 
school  bus.  Different  members  of  the  club  take  turns  helping  prepare 
the  noon  lunch  for  about  thirty  children.  The  parent-teachers'  organ- 
ization finances  the  work,  and  the  children  bring  from  home  anything 
which  they  can  spare.  It  may  be  milk,  it  may  be  carrots,  sugar,  eggs, 
fruit,  etc.  They  bring  only  as  they  want  to,  and  nothing  is  expected. 
Some  children  can  not  bring  anything.  At  the  end  of  the  first  month 
the  total  expense  had  been  less  than  $5.00  with  all  the  donations. 

In  West  Newbury  a  high  school  girl  is  supervising  the  preparation 
and  serving  of  one  hot  dish  at  lunch  time.  This  group  pays  the  cost  of 
the  dish  served. 

In  addition  to  all  of  this  work,  which  includes  the  study  of  food 
preparation,  food  knowledge,  etc.  the  4-H  clubs  are  seeking  to  develop 
the  health  H  equally  as  well  as  the  other  three  H's.  Every  4-H  girl's 
club  this  last  year  has  included  health  in  its  club  program.  This  has 
been  done  through  the  scoring  and  following  up  of  their  health  habits. 
Many  groups  have  given  demonstrations  in  good  health  for  feet,  for 
posture,  etc.  Short  health  plays,  out-of-doors'  sports  for  health,  exer- 
cises for  the  improving  of  posture,  pantomimes,  etc.,  have  been  used. 

The  Charm  School 

The  4-H  Charm  School,  really  a  part  of  the  4-H  health  work  has 
recently  been  held  in  ten  counties.  We  wanted  particularly  to  reach 
the  older  club  girl  and  realizing  that  she  is  almost  without  exception, 
interested  in  clothes,  in  looking  well,  in  having  charm — we  planned  to- 
gether with  the  State  Departments  of  Public  Health  and  Education  our 
Charm  School. 


83 

About  fifteen  girls  in  each  county  (one  from  each  local  club)  were 
chosen  to  attend  the  school.  "Charm  in  Dress"  was  discussed  with  the 
girls  and  then  each  had  an  individual  conference,  when  her  food  habits, 
her  posture  and  her  general  charm  (which  was  no  more  or  less  than 
the  old  familiar  health  habits)  were  carefully  checked  and  scored. 
Recommendations  for  improvement  were  made  and  in  the  posture  con- 
ference certain  exercises  stipulated.  An  exhibit  of  a  school  girl's  outfit, 
and  a  proper  breakfast  were  displayed  and  described.  The  girls  agreed 
to  take  the  message  of  the  Charm  School  back  to  the  members  of  their 
separate  clubs  and  to  follow  the  recommendations  given  them. 

This  older  girl  (about  high  school  age  or  over)  we  found  to  have 
only  fair  food  habits.  The  recommendation  made  most  often  was  to 
drink  more  water  (many  of  them  said  that  it  was  inconvenient  to  drink 
at  school).  More  vegetables,  more  milk,  less  coffee  and  less  eating 
between  meals  were  the  other  recommendations  occurring  most  fre- 
quently. The  majority  of  the  girls  were  rated  B  in  posture  while  there 
were  more  with  a  C  grade  than  with  an  A. 

In  the  so-called  "General  Charm"  conference,  more  recommendations 
were  made  for  care  of  the  hands  than  for  any  other  one  thing.  We 
found  that  over  half  of  the  girls  were  wearing  high  heeled  shoes  to 
school.  Neatness,  cleanliness,  wearing  of  round  garters,  biting  of  the 
nails  and  appropriateness  of  dress  were  included  in  this  rather  inti- 
mate discussion. 

About  six  weeks  after  the  first  meeting  as  many  of  the  same  girls  as 
possible  came  to  the  second  Charm  School.  We  found  really,  a  splendid 
improvement.  With  very  few  exceptions  food  habits  were  improved. 
Much  of  the  posture  showed  improvement  and  every  girl  had  managed 
to  raise  her  score  in  general  charm.  Four  girls  proudly  displayed 
finger  nails  no  longer  bitten,  several  pairs  of  good  looking  low  heeled 
oxfords  greeted  us  and  the  grooming  of  every  group  we  saw,  the  second 
time,  was  proof  that  a  great  many  of  our  suggestions  had  been  taken 
to  heart.  A  Worcester  County  girl  improved  her  food  score  35  points, 
went  from  C  to  A  posture  and  added  five  points  to  her  general  charm 
score,  totaling  an  improvement  of  84  points.  At  the  second  Charm 
School,  "Charm  in  Manners"  and  "Charm  in  Voice"  were  presented.  In 
the  final  discussion  of  the  Charm  School  the  girls  concluded  that  per- 
sistence and  perseverance  were  the  characteristics  most  essential  if 
the  benefits  of  the  Charm  School  were  to  be  made  lasting. 

Many  girls  and  boys  have  been  carrying  our  state  health  program, 
which  requires  an  examination  and  scoring  by  a  doctor  at  the  begin- 
ning of  the  club  project  in  the  fall,  a  second  scoring  in  the  spring;  and 
the  best  physically  fit  girl  or  boy,  and  the  one  who  has  made  greatest 
improvement,  are  selected  for  this  state  contest  and  examination.  This 
year  there  are  to  be  ribbon  awards  and  stress  upon  the  honor  of  being 
first  in  the  4-H  Health  Contest. 

AN  ECHO  RETURNS 

Mildred  L.  Swift 

Massachusetts  Department  of  Public  Health 
Formerly  Public  Health  Nutrition  Worker 

"Here  are  our  children — tell  us  what  to  do."  Thus  has  the  White 
House  Conference  spoken. 

What  has  been  an  echo  over  eons  of  time  now  takes  form,  color  and 
depth,  and  above  all  an  increasing  momentum,  challenging  all  peoples 
to  a  clearer  vision  and  a  greater  cooperative  effort  in  human  understand- 
ing, with  those  our  parents  and  our  children.  Perhaps  the  very  essence 
of  this  crescendo  echo  is  embodied  in  the  Well  Child  Preschool  Confer- 
ences which  have  been  conducted  in  the  State  of  Massachusetts.    To 


84 
the  conference  come  the  parents,  saying,  "Here  are  our  children — tell 
us  what  to  do." 

The  physical  set-up  of  the  conference  includes  a  physician,  nurse, 
dental  hygienist  and  nutritionist,  and  the  procedure  is  a  case  history 
taken  by  the  nurse,  a  physical  examination  by  the  physician  and  a 
dental  examination  by  the  dental  hygienist. 

The  nutritionist  records  the  type  foods  and  amounts  eaten  by  the 
child  and  her  recommendations  involve  not  only  kinds  and  quantities, 
but  also  fundamental  learnings  and  the  process  of  unlearning.  In 
order  to  understand  the  child's  food  idiosyncrasies,  it  becomes  neces- 
sary to  understand  the  parent  guidance  procedure.  It  then  becomes  a 
matter  of  parental  education.  Recommendations  must  be  given  to  meet 
the  intellectual  level  of  the  parent  and  with  such  simplicity  that  she 
may  practice  the  advised  guidance  procedure.  That  is  not  enough. 
Frequently  a  point  of  view  or  an  attitude  must  be  changed  or  built  into 
the  present  pattern.  A  parent  often  seeks  help  on  the  family  budget — 
this  counsel  is  given  with  the  aid  of  a  local  food  price  list  prepared  by 
the  local  nurse  previous  to  the  conference.  Economic  problems  perti- 
nent to  that  particular  family  are  discussed — these  are  vital  prob- 
lems; for  example  a  family  of  eight  children  of  school  age  has  a 
purse  of  $5.00  weekly;  another  family  has  a  mother  incapacitated  and 
a  father  trying  to  buy,  cook  and  serve  five  children  of  school  age  with 
a  purse  of  $3.50  for  four  days.  He  is  mightily  concerned  and  eager  to 
buy  the  right  food,  to  cook  it  properly  and  to  serve  the  right  amounts. 

An  attempt  is  made  to  offer  counsel  for  the  physical,  mental  and 
emotional  health  of  the  child  with  economic,  social  and  often  emotional 
guidance  for  the  mother.  She  may  have  left  her  farm  for  the  first  time 
in  many  months  and  here  finds  neighbors  and  neighbors'  children,  a 
social  contact  unanticipated. 

The  conference  endeavors  to  give  each  parent  a  whole  picture  of  her 
child  and  a  concept  of  his  place  as  an  individual  human  being. 

In  one  county  (twenty-four  towns)  in  Massachusetts,  the  Well  Child 
Preschool  Conference  has  returned  five  years  in  succession  and  while 
conclusive  figures  are  not  yet  available,  the  return  of  parents  year 
after  year  evidences  a  sincere  longing  for  help  and  an  awareness  of 
its  possible  fulfilling  in  the  conference. 

The  conference  counsels  sincerely  and  eagerly,  presenting  its  stimuli 
in  such  a  fashion  as  to  hope  for  interest  and  modified  behavior  on  the 
part  of  the  parent,  understanding  and  guidance  for  the  child,  and  per- 
haps a  better  home. 

Now  that  we  have  counselled  them  what  to  do,  shall  we  wait  for  the 
millennium?  But  isn't  it  gratifying  to  have  been  part  of  that  crescendo 
echo? 

NUTRITION  PHASE  OF  THE  CHADWICK  CLINICS 

Lillian  Stuart  and  Catherine  Leamy 

Public  Health  Nutrition  Workers 
Massachusetts  Department  of  Public  Health 

s  The  nutritionist's  work  on  the  Chadwick  Clinics  is  not  only  varied 
and  wide  in  scope,  but  is  also  a  vital  part  of  the  clinic  as  a  whole.  As 
the  Chadwick  Clinic  through  experience  has  changed  and  progressed, 
the  nutritionist  has  come  to  be  recognized  as  one  of  the  most  essential 
parts  of  the  unit,  since  upon  her  advise  the  foundation  of  physical 
well-being  and  improvement  has  been  found  to  be  dependent. 

The  object  of  the  Chadwick  Clinic  is  to  discover  and  prevent  tuber- 
culosis in  its  early  forms.  Through  the  cooperation  of  the  public 
school  authorities  and  parents,  it  has  been  possible  to  examine  large 
groups  of  children.  By  means  of  the  Von  Pirquet  test  and  X-ray,  the 
school  children,  who  are  either  susceptible  to  or  infected  with  this  dis- 


85 
ease,  are  discovered.  These  children  are  given  a  thorough  physical 
examination,  the  report  of  which  gives  the  nutritionist  a  basis  for  her 
first  contact  with  the  parent  and  child,  who  come  to  her  following 
their  interview  with  the  doctor.  Because  of  the  large  numbers  present 
at  the  clinic,  it  is  impossible  for  the  nutritionist  to  see  each  child  at 
that  time.    Consequently,  home  visits  are  made  when  necessary. 

The  work  of  the  Chadwick  Clinic  has  merely  begun  with  this  physical 
examination  and  nutritional  consultation.  For  nine  succeeding  years, 
through  the  medium  of  the  "Follow-Up"  clinic,  composed  of  a  doctor 
and  nutritionist,  the  welfare  of  the  child  is  carefully  observed  and 
guided.  Thus,  each  year  it  is  possible  to  check  the  child's  habits,  make 
new  recommendations  on  the  basis  of  improvement  and  encourage 
further  effort.  It  also  makes  possible  sanatorium  or  summer  camp 
treatment  for  some,  but  since  the  largest  majority  remain  in  the  home, 
the  nutritionist's  advice  with  medical  recommendations  from  the  doctor 
must  act  as  substitute  for  those  not  needing  institutional  care.  When 
the  physical  condition  warrants,  the  child  is  discharged  from  the  clinic. 
Since  the  nutritionist  plays  such  an  important  part,  the  atmosphere 
created  by  her  surroundings  must  be  of  major  consideration.  An 
attractive  picture  of  a  child  drinking  milk  may  appeal  to  some  young- 
ster, while  an  adolescent  boy  may  change  his  program  of  daily  living 
by  learning  that  an  admired  athlete  follows  the  rules  of  health.  It  is 
possible  to  revolutionize  a  whole  family  diet  by  an  interesting  food 
exhibit  from  which  a  mother  can  learn  the  fundamentals  of  meal  plan- 
ning. Posters  are  supplemented  by  printed  matter  given  to  meet  the 
individual  child's  special  need  such  as  that  pertaining  to  posture,  con- 
stipation, teeth  and  school  lunches.  In  addition  to  this  material,  an  in- 
dividual card  written  by  the  nutritionist,  noting  the  doctor's  recom- 
mendation and  recording  nutritional  advice,  is  given  to  be  taken  home. 
To  obtain  the  most  effective  result,  therefore,  it  is  obvious  that  a  light, 
airy,  quiet  room,  with  space  for  exhibit  material,  is  by  far  the  most 
desirable. 

This  exhibit  material  often  serves  as  a  medium  through  which  the 
interview  may  be  opened.  For  instance,  a  child  on  entering  the  room, 
noticing  a  poster,  may  not  only  give  the  nutritionist  an  idea  of  his  in- 
terests, but  also  a  good  opportunity  to  carry  a  point  which  might  other- 
wise be  lost.  The  nutritionist  tries  to  include  in  the  brief  time  spent 
with  each  child,  not  only  a  discussion  of  all  the  habits  which  make  up 
his  daily  life,  such  as  those  pertaining  to  food  hygiene  and  activity, 
but  also  to  obtain  a  clear  picture  on  which  intelligent  advice  can  be 
given.  In  talking  over  the  daily  schedule,  food  habits,  racial  tend- 
encies, parental  intelligence  and  control,  and  economical  status,  all 
must  be  taken  into  account. 

For  instance,  a  child  who  for  religious  education  attends  school  two 
hours  daily  after  he  has  been  released  from  public  school,  the  child 
whose  playtime  is  of  necessity  devoted  to  music,  elocution,  or  dancing, 
or  the  high  school  girl  or  boy  whose  study  time  and  social  life  leave 
no  room  for  recreation  and  rest, — all  present  special  problems.  Such 
programs  make  good  food  habits  as  well  as  rest  practically  impossible. 
Breakfast  is  often  omitted,  lunch  hastily  consumed,  and  dinner  made 
a  haphazard  affair.  This  makes  it  most  difficult  for  the  mother  to  cor- 
rect her  child's  food  idiosyncrasies. 

Teaching  a  child  to  eat  properly  is  a  process  which  requires  time, 
effort  and  intelligence.  A  little  girl,  in  the  nutritionist's  presence, 
when  urged  by  her  sister  to  eat  carrots  because  they  would  give  her  red 
cheeks  and  make  her  pretty,  turned  to  her  mother,  an  especially  un- 
attractive woman,  and  said,  "But  mother  eats  carrots."  Whereupon 
the  nutritionist  had  to  tactfully  produce  another  argument.  The  re- 
sults of  deficiencies  in  diet  were  shown  by  a  girl  who,  when  reproved 
for  not  brushing  her  teeth,  said,  "Oh,  I  can't  brush  my  teeth  for  they 
crumble.    I  have  to  have  them  extracted."    If  her  choice  of  food  had 


86 
been  guided  previous  to  her  contact  with  the  clinic,  such  a  disastrous 
result  might  have  been  avoided. 

Many  mothers  find  that  although  they  have  honestly  endeavored  to 
teach  good  food  habits,  the  added  incentive  given  by  a  trained  person 
proves  more  effective.  It  seems  hardly  necessary  to  include  a  discus- 
sion of  personal  hygiene  in  the  interview,  yet  one  girl  when  urged  to 
take  a  daily  bath,  said,  "Oh,  but  only  people  like  Edna  Wallace  Hopper 
have  time  to  take  a  bath  every  day."  Children  have  been  found  sewed 
into  their  clothes  for  the  winter,  and  it  is  a  common  occurrence  to  find 
children  not  opening  their  windows  at  night. 

Although  most  difficult  to  measure,  it  is  felt  that  the  results  of  the 
work  are  far  reaching.  Constant  examples  appear  to  demonstrate  this 
fact.  A  little  boy  at  his  second  yearly  visit  to  the  clinic  said  that  he  had 
sent  his  little  brothers  and  sisters  to  bed  according  to  a  schedule  which 
he  had  received  the  year  before.  A  mother  said  she  wished  the  clinic 
was  held  every  three  months,  because  its  good  effect  was  obvious  until 
its  memory  was  gradually  dimmed  in  the  child's  mind.  Through  the 
clinic's  efforts,  shool  lunches  carried  from  home  are  supplemented  by 
milk,  and  cafeteria  menus  have  been  revised.  The  most  important  re- 
sult is  a  definite  plan  of  follow-up  by  the  nurse.  The  scope  of  this 
last  result  depends  upon  the  cooperation  of  the  school  nurses  whose 
efforts  in  following  the  medical  and  nutritional  recommendations  influ- 
ence the  gain  of  each  child  and  the  permanent  effect  of  the  clinic. 

In  regard  to  the  attached  chart,  it  must  be  remembered  that  these 
figures  are  taken  from  the  statement  of  the  individual  children  or 
parents  and  are  therefore  subject  to  inaccuracy. 

The  chart  seems  to  indicate  that  through  this  program  outstanding 
progress  is  made  in  nutrition  education. 

Rest  seems  to  be  the  only  factor  in  which  advancement  has  not  been 
made.  This  is  not  strange  because  although  it  is  one  of  the  most  im- 
portant considerations  in  tuberculosis,  it  is  also  one  of  the  hardest 
points  to  make  both  with  parent  and  child. 

Chart  Showing  a  Year's  Progress  in  Nutrition  in  an  Average 
Massachusetts  City 

Total  number  of  children  interviewed  by  nutritionist  233 

Number  of  children  found  improved  on  reexamination  224 

Number  of  children  classified  as  "malnourished" — first    year        .  63 

Number  of  children  classified  as  "malnourished" — second   year  17 

Number  of  children  classified  as  having  poor  posture — first  year  110 

Number  of  children  classified  as  having  poor  posture — second    year  91 

Total  number  of  pounds  underweight — first   year        .  1,043 

Total  number  of  pounds  underweight — second  year  737 

Total  number  of  pounds  gained  in  one  year  908 

Average  gain  in  pounds  for  one  child  3.90 

Nutrition  Recommendations  Made  For  —  First  Yr.  —  Second  Yr. 

Better  breakfast  55  34 

More  milk  73  42 

More  fruit  104  49 

Use  of  meat  26  7 

More  cereal  79  52 

Use  of  eggs  43  39 

More  vegetables  90  78 

Less  candy  25  25 

Earlier  bedtime  125  76 

More  rest  116  141 

Better  care  of  teeth  103  41 

More  baths  21  5 

Less  extra  activity  17  10 

Constipation  13  8 


87 
The  following  list  of  the  occupations  of  the  parents  shows  the  types 
of  families  from  which  the  children  come. 


Mechanic 

Clerk 

Factory  worker 

Laundry  worker 

Laborer 

Shoe  polisher 

Manufacturer 

Manager 

Engineer 

Inspector 

Carpenter 
Window  washer 
Barber 
Foreman 
Weaver 


5 
15 
62 

4 

27 


11 
6 
2 


Painter 

Draftsman 

Plumber 

Truckman 

Mailman 


3      Printer 
8     Plumber 
Mechanist 
Electrician 
Farmer 


Merchant 
Janitor 
Mason 
Baker 


RECOMMENDATIONS  FOR  TRAINING  OF  A  NUTRITIONIST 

Subcommittee  on  Nutrition,  White  House  Conference 

Lucy  H.  Gillett,  Superintendent  Nutrition  Bureau, 

A.  I.C.  P.,  New  York  City 

I  —  That  every  worker  employed  as  a  nutritionist  have  training  in 
nutrition,  chemistry  of  food,  and  allied  sciences  equivalent  to  that 
required  for  a  major  in  food  and  nutrition,  in  an  accredited  school 
of  home  economics;  that  every  worker  thus  employed  have  train- 
ing in  child  psychology  and  in  methods  of  teaching. 
II  —  That  facilities  be  developed  for  the  training  of  nutritionists  in: 

Preventive  measures  and  factors  other  than  food  which  influ- 
ence nutrition. 

Social  problems  and  racial  characteristics  which  will  influence 
plans  and  recommendations. 

Food  economics  and  the  use  of  the  budget  as  related  to  the  low 
income  group. 

Methods  of  doing  educational  work  in  the  community,  of  de- 
veloping programs  in  an  organization  or  a  community,  and  of 
presenting  scientific  facts  in  clear,  simple,  convincing  non- 
technical terms. 

The  making  of  reports  and  evaluation  of  results. 
The  scope  of  related  phases  of  child  health  work,  thereby  en- 
abling the  nutritionist  to  appreciate  the  problems  of  her  co- 
workers and  to  adjust  her  service  to  their  needs,  with  emphasis 
on  the  value  of  cooperation  and  coordination. 
Supervised  field  work  in  a  public  health  or  welfare  organization 
or  in  a  well  organized  school  system. 


THE  VALUE  OF  HEALTH  EDUCATION  TO  THE  COMMUNITY 

MlCHELE  NlGRO,  M.D. 
Revere,  Massachusetts 

I  have  been  asked  to  say  a  word  about  the  value  of  Health  Educa- 
tion to  the  community. 

To  my  mind  the  term  Value  has  two  distinct  meanings.  The  physical, 
economical  value  in  shape  of  dollars  and  cents  and  the  other  the  higher 
value  which   is   the   real   worth — the   spiritual   value — both   of   which 


88 
mean  so  much  to  the  ultimate  happiness  and  prosperity  of  the  com- 
munity. 

It  is  a  common  knowledge  that  our  profession,  especially  our  great 
medical  heroes  such  as  Galen,  DaVinci,  Jenner,  Pasteur,  Erlic  and 
Reed  and  numerous  other  great  medical  minds,  from  times  immemorial, 
from  the  age  of  Hippocrates,  400  years  before  the  coming  of  Christ, 
and  down  through  the  ages  to  our  present  day,  have  devoted  their  time 
unselfishly  in  the  study  of  the  nature  of  diseases  and  their  treatment. 

These  great  studies  have  led  the  modern  physician  to  formulate  ways 
and  means,  not  only  to  treat  these  ailments  but  to  prevent  them.  The 
twentieth  century  has  done  more  medically  for  mankind  than  any  other 
age  gone  before  it.  This  century  has  seen  an  intensive  fight  against 
such  dreadful  diseases  as  diphtheria,  malaria,  cholera,  typhus,  typhoid 
fever,  yellow  fever.  We  have  won  major  victories  over  these  diseases 
and  we  have  a  fairly  good  control  over  such  diseases  as  scarlet  fever, 
pneumonia,  tuberculosis,  and  the  majority  of  ailments  including  in- 
fantile paralysis,  which,  by  the  way,  according  to  the  latest  research 
of  the  last  few  weeks,  we  are  in  a  fair  way  to  wipe  out  among  children. 

All  this  knowledge  so  gained  throughout  the  centuries  is  available 
to  our  fellow  men.  For  as  the  old  book  says,  "Knowledge  shall  make 
you  free"  so  the  knowledge  of  health  laws  and  prevention  will  make 
us  free  from  many  ailments. 

We  medical  men  are  only  too  glad  to  dispense  what  we  know  to  our 
patients  and  to  whomsoever  is  willing  to  listen  to  us.  It  is  our  desire 
that  our  people  should  partake  of  this  knowledge  to  the  end  that 
medical  men  and  lay  people  shall  labor  together  to  make  our  future 
generation  happy  and  strong.  From  this  desire  has  sprung  many 
agencies  for  improving  health  conditions.  And  so  we  find  the  doctor 
is  working  shoulder  to  shoulder  with  our  public  health  associations,  the 
public  clinics  of  our  great  hospitals  and  children's  clinics  in  most  of 
our  cities.  Above  all  there  is  the  advice  of  the  family  physician  to  his 
patients — a  tremendous  influence. 

So  we  ask  every  individual,  every  father  and  mother  in  the  com- 
munity to  willingly  comply  with  such  rules  and  advice  prescribed  by 
the  family  physician  or  agents  of  the  public  health. 

We  should  realize  that  these  rules  work  for  the  benefit  not  only  of 
the  individual  but  of  the  members  of  the  community  at  large.  And 
this  principle  is  especially  applicable  to  the  management  of  all  con- 
tagious and  infectious  diseases.  Do  not  propagate  disease  by  careless 
contact.  It  may  prove  costly  to  yourself,  others  in  your  family,  your 
neighbor  or  your  city. 

A  concrete  example  may  illustrate  what  I  have  in  mind:  A  school 
child  has  measles.  If  allowed  to  go  to  school,  or  mingle  with  other  little 
boys  and  girls,  the  disease  will  spread  from  one  to  the  other  into  a 
chainless  number  so  that  from  one  case  we  may  have  an  indefinite 
number  of  cases.  The  same  holds  true  for  scarlet  fever  and  septic  sore 
throat  and  other  infectious  and  contagious  diseases.  Now,  if  proper 
precaution  is  taken  by  the  intelligent  parent  or  teacher,  just  imagine 
what  it  will  mean  to  our  family  in  the  shape  of  a  saving  of  reduplica- 
tion of  the  work  for  the  pupil  and  for  the  teacher,  and  that,  of  course, 
will  be  a  great  saving  to  our  city.  It  will  mean  to  the  adults  no  loss  of 
time  or  labor  or  cost  of  sickness  but  best  of  all  it  will  prevent  the 
mental  and  bodily  agony  of  those  who  are  sick  and  will  allay  the 
anxiety  of  those  who  take  care  of  their  dear  ones  and  will  keep  them 
from  being  snatched  by  pain  and  death,  the  greatest  reward  in  pre- 
vention of  disease. 

There  are  certain  diseases  that  can  be  prevented  by  methods  of  im- 
munization such  as  smallpox,  diphtheria  and  even  scarlet  fever.  Then 
the  application  of  modern  methods  of  taking  care  of  our  children  such 
as  the  boiling  of  milk,  the  early  use  of  orange  juice,   cod   liver  oil, 


89 

viosterol,  will  prevent  many  of  the  childhood  systemic  deficiencies  such 
as  scurvy,  rickets,  tuberculosis  and  infectious  diarrheas. 

I  well  remember  some  fifteen  or  twenty  years  ago  when  the  value  of 
boiling  the  milk  was  little  understood,  how  literally  hundreds  of  little 
children  would  die  from  infectious  diarrhea  and  allied  diseases.  Now 
that  condition  does  not  exist  any  more  owing  to  the  simple  methods  of 
boiling  the  milk.  Just  imagine  how  many  heartaches  and  how  much 
actual  economic  savings  these  few  simple  measures  have  accomplished 
in  the  last  few  years. 

There  is  now  on  foot  another  great  movement  which  bids  fair  to  be- 
come the  most  important  of  all  these  preventive  measures  and  that  is 
the  movement  to  preserve  the  mental  health  of  our  people.  Back  of  all 
this  stands  the  idea  that  unless  our  lives  begin  with  the  education  of 
the  mind  by  the  formation  of  proper,  healthy,  mental  habits,  the  whole 
fabric  of  all  our  civilization  stands  to  fall.  We  realize  in  these  days, 
particularly,  the  great  need  of  not  only  caring  for  the  body  but  more 
than  all  of  taking  care  of  the  mind.  No  healthy  body  can  be  controlled 
by  an  insane  mind.  Crime  waves  whether  in  our  age,  or  ages  past,  can 
always  be  laid  at  the  door  of  wrong  thinking.  Wrong  thinking  gen- 
erally starts  early  in  our  childhood  by  improper  impressions  derived 
from  our  surroundings.  How  important  then  it  is  for  us  to  begin  aright 
in  the  training  of  our  little  children.  It  is  important  that  we  should  be 
very  careful  how  we  care  for  the  bodily  health  of  our  children;  but 
even  more  important  it  is  how  we  care  for  the  mental  health  of  our 
children;  for  the  children  of  today  are  the  men  and  women  of  to- 
morrow. They  will  be  the  parents  of  our  grandchildren,  they  will  be 
teachers,  they  will  be  the  legislators,  they  will  be  the  physicians  and 
so  on,  of  tomorrow. 

Much  depends  on  the  attitude  of  mind  we  take  toward  our 
surroundings. 

Just  think  what  all  this  means  in  happiness  and  prosperity  to  our 
nation.  The  medical  profession  has  pledged  itself  to  do  all  that  is 
humanly  possible  to  consummate  this  ideal,  that  is,  to  impart  health 
and  happiness  to  the  world,  to  plant  a  sound  mind  in  a  robust  body; 
but  much  depends  upon  you,  ladies  and  gentlemen,  "Go  ye  and  preach 
the  gospel"  to  your  neighbor. 

HEALTH  EDUCATION  PROCEDURE* 

Health  Education  is  one  phase  of  the  school  health  program,  the 
other  two  phases  being  the  school  health  services  and  physical  educa- 
tion. It  involves  the  development  of  habits,  attitudes  and  knowledge 
contributing  to  physical,  mental  and  emotional  health.  Contributions 
are  made  to  health  education  not  only  by  class  instruction  but  also 
through  school  sanitation,  the  hygienic  arrangement  of  the  school  pro- 
gram, communicable  disease  control,  the  correction  of  physical  defects, 
physical  education  and  such  routine  procedures  as  weighing  and  meas- 
uring, the  morning  inspection  or  health  review,  and  school  lunches. 
All  of  these  activities  influence  the  child's  health  behavior  and  to  that 
extent  contribute  to  health  education. 

Concerning  the  administration  of  the  whole  program  of  school  health 
work  the  White  House  Conference  on  Child  Health  and  Protection 
makes  the  following  recommendations  with  which  the  New  England 
Health  Education  Association  is  in  hearty  accord: 

"Function  and  Control 

1.  This  activity  should  be  under  the  full  control  of  the  board  of 
education,  and  administered  exclusively  by  educational  au- 
thorities,   with    the    closest    cooperation    with    other    health 


*A  statement  from   the  New  England   Health   Education   Association. 


90 

agencies  of  the  community  and  state.    (In  Massachusetts  cities 
have  option  by  law.    In  ten  cities,  school  health  is  under  the 
Board  of  Health.) 
2.    The  head  of  the  department  should  be: 

a.  An  able  administrator  ranking  as  a  director  or  assistant 

superintendent  with  experience  in  education  and  pre- 
paration as  a  school  administrator:   (or) 

b.  A  physician  with   educational   training   and   experience; 

(or) 

c.  An  educator  with  a  Ph.D.  degree  with  a  major  in  health 

and  other  related  fields." 
Concerning    health    education    the    recommendations    of    the    White 
House  Conference  are  as  follows: 

"Elementary  Schools 

1.  Health  education  in  elementary  schools  should  be  in  charge  of 
the  elementary  grade  teacher  under  the  sympathetic  guidance 
of  an  efficient  advisor  or  supervisor  of  health  education,  who 
has  had  special  and  adequate  professional  training  for  this 
complex  task. 

Secondary  Schools 

1.  A  school  health  committee  is  one  important  means  of  co- 
ordinating all  aspects  of  health  education  in  secondary  schools. 

2.  Some  one  person  should  be  delegated  by  the  principal  to  keep 
in  contact  with  all  phases  of  the  health  program  and  to  pro- 
mote it  in  every  way  possible. 

3.  This  health  counselor  or  coordinator  should: 

a.  See  that  health  is  given  its  proper  place  in  the  curriculum. 

b.  Study  all  available  data  relating  to  health  in  the  school. 

c.  Plan  the  most  effective  use  of  the  school  health  service. 

d.  Obtain    the    physician's    and    nurse's    advice    relative    to 

health  matters  in  home  or  school. 

e.  Maintain    adequate    cumulative    records    of    each    pupil's 

health  history. 

f.  On  the  basis  of  information  thus  assembled,  advise  with 

reference  to  modification  of  policies." 
Supervisor  of  Health  Instruction 

a.  The  supervisor  in  charge  of  health  instruction  should  hold 

a  master's  degree  with  a  major  in  health  education. 

b.  She  should  be  well  trained  in  the  biological  sciences  and  in 

modern  trends  in  supervision  and  curriculum  building. 

c.  She   should  have  had  at  least  three  years'   experience   in 

classroom  teaching. 

Health  Coordinator  or  Counselor 

a.  The  health  coordinator  or  counselor  in  the  high  school 
should  be  the  person  best  qualified  by  natural  traits,  pro- 
fessional training  and  experience. 

Classroom  Teachers 

a.  Health  instruction  should  be  given  by  the  regular  classroom 
teachers  in  elementary  schools.  All  teachers  in  high 
schools  should  make  contributions  to  health  instruction, 
under  the  guidance  of  the  health  education  supervisor, 
counselor  or  coordinator,  who  has  had  adequate  profes- 
sional training.  Teachers  now  in  service  without  specific 
training  for  this  teaching  should  be  given  in-service 
training." 


91 

EPIDERMOPHYTOSIS  (ATHLETE'S  FOOT) 
ITS  PREVENTION  AND  TREATMENT 

C.  Guy  Lane,  M.D. 

Instructor  in  Dermatology 
Harvard  Medical  School 

Athlete's  foot,  so-called,  has  numerous  synonyms — epidermophytosis, 
dermatophytes  is,  fungus  infection,  ringworm  of  hands  and  feet,  tinea, 
etc.  It  is  a  very  frequent  disease  and  many  studies  of  its  occurrence 
among  normal  and  diseased  individuals  have  been  published.  In  thirty- 
five  universities  there  have  been  found  from  50  to  90  per  cent  of  in- 
dividuals affected.  In  general  it  is  safe  to  say  that  50  per  cent  of  our 
population  is  affected  with  it  at  some  time,  men  and  boys  being  more 
often  affected  than  women  and  girls.  To  visualize  this  frequency  think 
of  some  of  our  large  audiences — perhaps  50,000  people  at  a  football 
game.  It  is  probable  that  the  same  number  of  feet  are  affected  to  some 
extent.  No  wonder  it  pays  to  advertise  remedies  for  the  treatment  of 
this  affection! 

The  condition  is  a  modern  one  apparently — well  named  one  of  the 
curses  of  civilization.  Typical  cases  were  first  described  in  England  in 
1908,  and  the  cause  of  the  infection  was  found  in  1910  by  a  French 
scientist,  Sabouraud,  and  the  name  epidermophytosis  was  derived  from 
the  organism  which  he  described.  In  one  of  our  local  hospitals  83  cases 
were  found  in  1919,  and  in  1931,  376  cases  were  admitted  with  this 
diagnosis.  These  figures  indicate,  to  some  extent,  the  rapid  spread  of 
the  disease. 

The  disease  deserves  very  serious  consideration. 

First,  it  is  potentially  disabling.  In  one  series  of  160  cases  which 
were  studied,  it  was  found  that  14  of  them  were  totally  disabled  at 
some  time,  and  30  were  partially  disabled  during  its  occurrence.  Such 
disability,  furthermore,  may  persist  for  several  months,  even  with  good 
treatment. 

Secondly,  other  areas  of  the  body  are  not  infrequently  affected.  The 
hands  show  the  disease  most  often,  but  its  manifestations  appear  in 
the  groins,  between  the  buttocks,  on  the  nails,  or  perhaps  well  dis- 
tributed over  the  body  surface. 

Thirdly,  cracks  in  the  skin,  or  erosions  caused  by  this  disease  may 
become  the  avenues  of  entrance  for  pus  organisms  and  facilitate  the 
development  of  serious  septic  conditions  in  foot,  leg,  or  groin. 

Fourthly,  this  infection  is  becoming  a  frequent  complication  of 
simple  irritations  of  the  skin  in  one  form  or  another,  thus  increasing 
or  prolonging  any  existing  disability. 

The  Cause 

The  cause  of  the  disease  is  a  vegetable  parasite  of  the  ringworm 
group,  and  it  has  been  found  that  many  different  varieties  may  pro- 
duce diseased  skin  conditions.  This  organism  is  a  jointed  filamentous, 
threadlike  affair,  frequently  branching  and  breaking  up  at  the  ends  of 
the  filaments  to  form  smaller  divisions,  or  spores,  which  can  be  com- 
pared to  seeds.  In  the  same  general  botanical  group  are  the  moulds 
which  appear  on  bread,  the  moulds  and  rusts  on  plants,  and  other  simi- 
lar, parasitic  forms.  If  the  scales  from  diseased  areas  of  the  skin  are 
examined  under  the  microscope,  these  spores  and  mycelial  threads,  as 
they  are  called,  can  be  found  in  about  one-half  the  cases  when  the  feet 
are  involved.  It  is  much  more  difficult  to  confirm  the  diagnosis  on  other 
parts  of  the  body. 


92 
Conditions  Affecting  the  Parasite 

The  growth  of  these  organisms  is  favored  in  various  ways.  Warmth 
is  a  very  large  factor  in  many  cases.  The  disease  is  worse  in  the  sum- 
mer time  and  many  more  cases  develop  during  these  months. 

Moisture  is  another  element  which  increases  tremendously  the  spread 
of  the  disease.  The  increased  moisture  of  summer  weather,  together 
with  the  warmth,  provide  excellent  conditions  for  the  devlopment  and 
growth  of  this  parasite.  Individuals  with  moist  feet  are  much  more 
frequently  affected  than  those  with  dry  feet. 

Wool  socks  seem  to  encourage  the  development  of  the  disease  in  some 
cases,  but  whether  this  is  direct  infection  from  the  wool,  or  because  of 
the  induced  perspiration,  I  am  not  sure.  Heavy  footwear,  with  reduced 
ventilation  and  increased  moisture,  is  likewise  a  factor. 

Athletic  crowding  is  undoubtedly  of  importance.  Improper  or  inade- 
quate sanitary  facilities  in  shower  baths,  locker  rooms,  bath  houses, 
etc.,  which  are  visited  by  crowds  of  people  for  exercise  or  bathing, 
promote  a  free  interchange  of  infectious  material  from  feet. 

This  parasite  has  been  cultured  from  many  different  articles.  Ma- 
terial from  pure  cultures  has  been  planted  on  wood,  wool,  paper, 
leather,  cotton,  etc.,  and  at  the  end  of  forty  days  at  room  temperature 
it  has  been  possible  to  regain  these  organisms  in  pure  culture,  indicat- 
ing that  they  can  easily  exist  under  ordinary  conditions  of  heat  and 
moisture.  In  this  condition  the  action  of  soap  is  of  interest.  The  same 
investigator  has  made  up  his  culture  media  incorporating  various 
percentages  of  soap  solution,  using  five  different  kinds  of  soap.  In  all 
kinds  a  4  per  cent  soap  solution  mixed  with  the  media  failed  to  stop 
the  growth.  A  rather  large  bit  of  a  culture  was  placed  in  a  5  per  cent 
soap  solution,  and  a  growth  was  obtained  at  the  end  of  four  days.  The 
thickness  of  the  particle  used  probably  prevented  the  soap  from  reach- 
ing all  parts  of  the  culture,  but  this  experiment  indicates  in  a  general 
way  the  resistance  of  this  group  to  a  chemical  attack.  Growth  has  also 
been  obtained  from  water  (both  tap  water  and  distilled  water)  one 
week  after  a  small  bit  of  a  culture  has  been  shaken  up  with  the  water. 
Other  tests  are  being  done  to  ascertain  whether  the  use  of  chlorine  or 
copper  sulphate  added  to  water  offers  any  opposition  to  its  growth. 

Manifestations 

The  disease  shows  itself  usually  in  the  web  between  the  fourth  and 
fifth  toes.  Others  webs  are  affected  but  this  one  shows  abnormal  ap- 
pearances most  frequently.  There  may  be  only  a  little  scaling,  or  a 
small  fissure,  but  the  scales  will  be  literally  crowded  with  filaments 
and  spores.  There  is  frequently  found  in  these  spaces  pure  white, 
soggy,  macerated,  friable  skin  which  comes  off  in  layers.  Associated 
with  this  manifestation  are  often  rather  deep  fissures,  especially  on 
the  under  surface  of  the  little  toe  where  it  joins  the  foot.  Soft  corns 
are  frequently  found  in  this  connection  and  may  be  another  manifesta- 
tion. The  scaly  type  may  appear  elsewhere  on  the  foot,  often  on  the 
sole,  in  very  sharply  denned  areas,  or  on  the  upper  surface  of  the  foot 
extending  out  from  the  webs  in  fanlike  areas. 

Another  type  appears  as  blisters,  frequently  in  areas  on  the  inner  side 
of  the  arch  of  the  foot,  often  sharply  outlined.  These  blisters  art 
rather  superficial,  and  when  opened  up  a  thick,  glairy,  stringy  cleai 
fluid  can  be  expressed  in  tiny  drops.  Often  there  is  some  slight  second- 
ary infection  and  the  fluid  is  whitish  and  slightly  cloudy.  This  type 
and  the  fissured  type  may  develop  a  severe  secondary  infection  at  times. 

Thickening  of  the  horny  layer  of  the  skin  may  develop,  like  calluses, 
especially  along  the  edge  of  the  sole  and  heel. 

Thickened,  discolored  abnormal  nails  are  frequently  found  to  be  in- 
fected, and  Williams  of  New  York  indicates  that  these  nails  may  be 


93 

the  source  of  reinfection  in  numerous  cases. 

The  hands  will  show  very  similar  appearances  due  to  this  infection. 
The  marked  maceration  between  the  fingers  and  the  marked  thickening 
of  the  plantar  type  do  not  occur. 

In  the  groins,  marked  redness  and  scaling  may  occur,  with  sharply 
defined,  semicircular  areas  on  the  upper  and  inner  thigh.  This  consti- 
tutes the  well-known  "jock-strap  itch"  or  "red  flap." 

Between  the  buttocks  may  appear  similar  areas  with  more  macerated, 
white  skin  at  the  depth  of  the  fold  because  of  the  increased  retention 
of  moisture. 

The  general  appearance  of  the  disease  on  the  skin  is  not  usual,  but 
there  may  be  seen  superficial,  widespread,  slightly  scaly  and  red  areas 
in  which  it  is  often  hard  to  make  a  definite  diagnosis.  The  feet  are 
usually  found  involved  in  these  cases. 

I  have  already  mentioned  the  secondary  infection  which  can  occur. 
With  invasion  by  pus  cocci  there  is  usually  pain,  swelling,  redness  and 
pus,  perhaps  with  fever  and  the  appearance  of  red  streaks  up  the  leg 
or  arm,  and  large  tender  glands  in  groin  or  axilla.  These  cases  often 
require  operative  interference  and  are  frequently  disabled  for  long 
periods. 

Itching  is  usually  a  marked  symptom.  It  is  particularly  distressing 
in  the  type  with  blister  formation  and  is  often  not  relieved  until  the 
blisters  are  opened. 

Not  all  eruptions  on  the  feet  are  epidermophytosis  by  any  means. 
Numerous  other  diseases  appear  on  the  feet  and  in  most  cases  the 
diagnosis  is  clear.  Where  routine  examination  of  athletes  is  carried 
out  it  is  probably  better  to  exclude  the  suspicious  cases  until  a  definite 
opinion  can  be  rendered. 

Individual  Prevention 

In  the  matter  of  individual  prevention,  the  factor  of  greatest  import- 
ance is  perhaps  the  prevention  of  perspiration  so  far  as  possible.  In 
those  individuals  who  have  much  perspiration  it  is  very  important  to 
avoid  wool  socks,  or  at  least  not  to  wear  them  for  any  longer  than  is 
necessary.  The  footwear  should  be  light,  well  ventilated,  and  changed 
frequently.  The  use  of  an  instringent  powder  is  advisable.  Boric  acid 
powder,  Fuller's  earth,  or  a  combination  of  20  per  cent  sodium  thio- 
sulphate  in  boric  acid  powder  can  be  used  for  this  purpose.  Various 
combinations  of  these  and  other  powders  are  also  used.  Occasional 
soaks  of  saturated  boric  acid  solution,  or  potassium  permanganate, 
1:2,000,  are  additional  helps  in  this  respect.  Staining  from  the  per- 
manganate can  be  removed  very  easily  with  fresh  peroxide  of  hydrogen 
to  which  a  little  lemon  juice  has  been  added. 

Secondly,  and  perhaps  of  equal  importance,  is  the  avoidance  of  con- 
tact of  bare  feet  on  floors,  particularly  in  locker  rooms,  bathrooms, 
shower  baths,  etc.  This  means,  of  course  the  use  of  slippers  (and  one's 
own  slippers  too),  or  the  use  of  bathing  shoes,  or  sandals,  or  something 
of  the  sort.  Susceptible  individuals  will,  of  course,  contract  infection 
very  easily  from  damp  moist  floors,  perhaps  from  infected  material 
which  has  been  left  by  other  individuals. 

Thirdly,  is  the  matter  of  personal  hygiene.  It  is  hardly  necessary  to 
use  the  word  own  in  connection  with  clothing,  towels,  socks,  slippers, 
etc.  In  individuals  with  the  disease  the  feet,  after  bathing,  should,  of 
course,  be  wiped  on  the  towel  last.  The  areas  between  the  toes  should 
be  dried  very  thoroughly,  perhaps  even  using  gauze  or  paper  towels 
and  then  throwing  them  away  in  order  to  avoid  infecting  other  areas 
of  the  body.  Routine  sterilization  of  athletic  suits,  supporters,  and 
socks  is  also  essential.   The  frequent  renewing  of  socks  is  self-evident. 

As  a  part  of  any  prevention  program  it  must  be  remembered  that 
there  are  many  sources  of  infection.    No  single  complete  list  of  pos- 


94 
sible  sources  has  been  published,  but  reinfection  is  possible  from  such 
articles  as  shoes,  socks,  articles  of  clothing,  athletic  apparel,  various 
kinds  of  floors,  and  it  has  even  been  suggested  that  door  knobs,  stair 
rails,  and  street  car  straps  are  not  above  suspicion.  Old,  discolored, 
fissured  toe  nails  may  be  a  very  definite  source  of  reinfection  in  the 
the  opinion  of  Dr.  Charles  M.  Williams  of  New  York,  who  has  called 
attention  to  the  frequency  with  which  organisms  are  found  in  such 
nails. 

A  card  containing  the  following  directions  is  a  sample  of  the  advice 
often  given  to  office  or  dispensary  patients: 

1.  Wash  the  feet  with  soap  and  water  daily. 

2.  Dry  the  feet  with  a  paper  towel  or  with  a  towel  which  will  not 
be  used  on  the  rest  of  the  body. 

3.  Stand  on  a  clean  bath  mat,  a  newspaper  or  paper  towel  when 
you  get  out  of  the  bath. 

4.  Never  walk  on  any  floors  barefoot. 

5.  Do  not  wear  wool  stockings  next  to  the  skin — wear  thin  socks 
inside  which  can  be  boiled. 

6.  Do  not  wear  shoes  which  heat  the  feet. 

7.  Use  a  suitable  dusting  powder  on  your  feet,  in  your  shoes  and 
in  your  bath  slippers. 

8.  Wash  your  hands  after  touching  your  feet. 

9.  Don't  scratch  if  your  feet  itch — put  on  some  ointment. 

10.    If  the  feet  get  worse  in  spite  of  your  precautions,  consult  your 
doctor  about  it. 

Individual  Treatment 

Individual  treatment  is,  I  believe,  essentially  a  matter  for  the 
physician.  Cases  which  are  under  suspicion  should  be  seen  by  the 
physician  in  attendance,  or  referred  for  a  confirmation  of  diagnosis  and 
for  treatment  to  a  physician  if  the  patient  is  able  to  pay,  or  to  one  of 
the  many  skin  clinics  if  he  is  unable  to  afford  a  physician's  services. 

I  emphasize  this  especially  because  in  the  last  six  months  or  so  I 
have  seen  numerous  cases  in  which  treatment  has  been  too  strenuous 
for  the  particular  individual's  skin.  I  know  that  some  clubs  and  gym- 
nasiums are  in  the  habit  of  dispensing  certain  remedies  to  individuals 
who  are  found  to  be  infected  upon  a  routine  examination.  The  use  of 
these  remedies  is  often  very  inefficiently  carried  out.  They  are  perhaps 
used  continually,  or  perhaps  used  on  other  areas  of  body  skin,  or  per- 
haps given  to  other  members  of  the  family  for  use  elsewhere,  with  a 
resulting  irritation. 

I  recall  two  cases  to  emphasize  this  point:  One  in  which  iodin  was 
used  daily  over  a  period  of  months  with  a  resulting  eczema  which  took 
a  very  long  time  to  clear  up.  Iodin  is,  of  course,  an  excellent  remedy, 
but  the  skin  has  very  definite  limitations  so  far  as  daily  application  is 
concerned.  The  second  case  consulted  me  with  a  condition  of  "athlete's 
foot"  which  had  been  present  for  some  twelve  years.  At  the  instiga- 
tion of  a  friend  he  applied  an  ointment  which  had  a  very  high  per- 
centage of  carbolic  acid,  and  at  the  time  when  I  saw  him  it  was  neces- 
sary for  him  to  stay  away  from  work  for  three  days  because  of  the 
resultant  irritation  from  the  carbolic  acid.  He  was  fortunate  that  no 
more  serious  situation  resulted  from  the  continued  use  of  a  strong 
carbolic  acid  application. 

Strong  remedies  are  often  necessary,  but  in  using  these  there  must 
be  a  judicious  alternation  of  strong  agents  and  milder  remedies  in 
order  to  avoid  irritation  to  the  skin.  Rational  treatment  depends  upon 
various  factors.  It  is  necessary  to  take  into  account,  first,  the  type  of 
disease — that  is,  whether  we  have  a  scaly  type — a  type  with  many 
blisters — a  soggy  moist  type — or  a  very  dry  type ;  secondly,  the  amount 
of  secondary  infection;  thirdly,  the  type  of  skin  which  the  individual 


95 

has;  and  fourthly,  the  areas  which  are  infected,  for  a  sole  or  palm 
infection  will  need  to  be  treated  far  more  vigorously  than  a  groin  area. 
Persistence  in  intermittent  treatment  is  important  even  after  evi- 
dence of  disease  has  gone  in  order  to  avoid  recurrence.  The  disease  is 
frequently  obstinate  and  thorough  treatment  is  often  required  over  a 
long  period  of  time. 

Group  Prevention 

Of  importance  in  general  prevention  are  two  fundamental  facts : 
first,  that  locker  rooms  and  shower  baths,  with  resultant  warmth  and 
moisture,  are  excellent  incubators;  and  secondly,  that  perspiration- 
soaked  clothes  and  damp,  moist  skin  between  closely  covered  toes 
make  excellent  culture  media  for  the  growth  and  development  of  these 
organisms.  In  any  program  of  group  prevention,  inspection  of  all  appli- 
cants for  admission  to  athletic  activities  is  of  primary  importance. 
This  inspection  should  include  the  usual  areas  of  involvement,  and  it 
is  probably  safest  to  include  reinspection  at  stated  intervals  as  an 
additional  part  of  such  a  program.  The  corollary  to  this,  of  course,  is  the 
exclusion  of  individuals  with  suspicious  lesions  until  a  proper  diagnosis 
has  been  made,  or  until  the  diagnosis  has  been  confirmed  and  treat- 
ment has  cleared  up  the  condition.  Thirdly,  comes  the  inspection  and 
checking  up  of  sanitary  conditions.  You  are  probably  all  aware  of  the 
work  which  has  been  done  by  a  Committee  of  State  Sanitary  Engineers 
and  the  Public  Health  Engineering  Service  of  the  American  Public 
Health  Association  which,  after  six  years  of  investigation,  published 
a  rather  complete  code  of  standards  for  the  design,  construction,  equip- 
ment and  operation  of  swimming  places.  In  this  code  great  attention 
is  paid  to  details  connected  with  the  proper  maintenance  of  such  places. 
There  is,  as  you  know,  state  regulation  of  such  places  in  some  states. 
So  far  as  this  particular  subject  is  concerned,  elimination  of  wooden 
floors  is  of  great  importance.  The  elimination  of  bath  mats  or  wooden 
racks  is  equally  important.  Absolute  cleanliness  should  be  insisted 
upon,  and  cleaning  preferably  with  hot  water  under  pressure  and  actual 
scrubbing  with  fairly  strong  soap  are  of  course  a  necessary  feature. 
In  other  words,  it  is  essential  to  accomplish  the  adoption  of  very  defi- 
nite sanitary  regulations  and  the  enforcement  of  these  regulations  so 
far  as  possible.  The  value  of  such  regulations  has  been  shown  very 
well  in  several  instances  where  there  has  been  the  opportunity  for 
comparison  between  newer  and  better-kept  gymnasiums  which  have 
been  most  usually  built  for  women  and  girls,  and  the  older,  more  un- 
sanitary and  ill-kept  gymnasiums  which  have  been  used  by  boys  and 
men,  with  a  subsequent  lessening  in  the  incidence  of  the  infection 
among  girls  as  compared  to  boys. 

Group  prevention  and  treatment  has  recently  been  studied  very  care- 
fully in  three  different  campaigns  which  have  been  carried  on  with 
very  excellent  results  in  Albany,  Buffalo  and  Detroit. 

In  Albany,  Dr.  Gould  found  in  1929  that  50  per  cent  of  his  pupils 
were  excluded  from  athletic  activity  because  of  ringworm  infections 
of  the  feet.  He  started  using  foot  baths  containing  10  to  15  per  cent 
sodium  thiosulphate  between  the  locker  and  the  shower  rooms,  and 
each  pupil  leaving  the  shower  was  requested  „to  immerse  the  feet  in 
this  chemical  bath  on  the  way  to  the  locker.  These  solutions  were 
changed  after  every  class  of  thirty  or  fifty  pupils.  If  the  crystals  were 
used  it  was  not  an  expensive  process.  The  results  reported  by  him 
were  excellent,  and  he  stated  that  ringworm  infection  had  entirely  dis- 
appeared from  this  school  in  about  one  month.  He  has  also  advised  the 
sodium  thiosulphate  and  boric  acid  powder  which  I  have  mentioned 
previously. 

In  Buffalo,  Osborne  used  last  year  a  solution  of  0.5  to  1  per  cent 
solution  of  sodium  hypochlorite  in  his  schools.    The  solution  of  this 


96 

strength  was  employed  after  some  experimentation  with  cultures  to 
determine  the  amount  of  chemical  necessary  to  kill  the  fungus.  Rubber 
troughs  were  used  in  the  floor  at  first,  but  more  recently  "wells"  have 
been  built  in  the  tile  floor  the  entire  width  of  the  corridor  through  which 
the  pupils  pass,  and  this  well  is  filled  with  the  sodium  hypochlorite 
solution.  He  states  that  no  instances  of  ringworm  infection  have 
appeared  since  this  prophylactic  method  was  introduced. 

From  Los  Angeles,  Ayres  has  reported  excellent  results  from  sterili- 
zation by  formaldehyde.  He  has  burned  formaldehyde  candles  in  rooms 
in  which  contaminated  clothing  and  cultures  have  been  left.  Exam- 
ination of  these  cultures  and  contaminated  materials  after  exposure 
has  shown  no  growth,  while  control  cultures  and  inoculated  material 
left  outside  the  room  have  shown  positive  cultures. 

All  these  investigations  will  need  review  but  I  believe  they  offer 
opportunities  for  controlling  the  spread  and  extension  of  this  disease. 
It  is  possible  that  a  combination  of  these  methods  may  prove  to  be  the 
most  satisfactory  means  of  protecting  athletic  groups. 

Conclusion 

In  conclusion,  I  desire  to  emphasize  four  salient  features  in  the  man- 
agement of  these  infections. 

First,  it  is  necessary  to  educate  the  infected  individual  so  far  as 
possible  in  thorough,  conscientious  treatment. 

Secondly,  we  must  advise  individuals  in  considerable  detail  in  mat- 
ters of  personal  prophylaxis. 

Thirdly,  there  is  need  of  careful  inspection  of  those  engaged  in 
group  athletics  and  the  exclusion  of  suspicious  cases,  and  thorough 
treatment  of  those  infected. 

Fourthly,  it  is  necessary  that  attention  be  paid  to  rather  strict  sani- 
tary regulations  in  club  houses,  athletic  quarters,  etc. 

These  four  methods  of  attack  are  essential  factors  in  any  program 
for  decreasing  the  incidence  of  this  very  frequent  infection. 

CARE  OF  THE  MOUTH  DURING  PREGNANCY 

Fred  L.  Adair,  M.D.  and  Howard  M.  Service,  D.D.S. 
Chicago,  Illinois 

Prenatal  care  brings  with  it  a  higher  standard  of  obstetrical  prac- 
tice. The  expectant  mother  should  be  kept  in  the  best  of  health.  At  the 
first  prenatal  visit  and  as  a  part  of  the  physical  examination,  the  mouth 
and  teeth  should  be  inspected  and  if  necessary  the  doctor  should  send 
the  patient  to  a  dentist. 

There  has  been  much  superstition  and  prejudice  against  dental  care 
during  pregnancy.  This  false  idea  should  be  abandoned  as  the  prospec- 
tive mother  with  oral  caries  and  infection  is  handicapped.  Both  of 
these  affections  can  and  should  be  treated  during  pregnancy.  There  are 
two  main  reasons  for  such  attention.  One  is  because  such  conditions  are 
progressive  and  permanent  damage  will  occur  in  the  mouth.  The  other 
is  that  a  continuation  of  this  oral  condition  may  affect  the  general 
nutritive  condition  and  the  infection  may  produce  various  systemi( 
diseases  which  result  from  foci  of  infection. 

During  pregnancy  there  is  an  altered  metabolism  and  this  is  some- 
times associated  with  progressive  dental  caries.  The  fetus  calls  vigor- 
ously upon  the  mother  for  calcium  and  if  her  dietary  is  deficient  the 
teeth  may  be  affected. 

Many  conditions,  well  tolerated  ordinarily  in  the  non-pregnant  state, 
are  quite  troublesome  during  pregnancy.  The  teeth  are  subject  to 
cervical  decay  and  their  necks  may  become  quite  sensitive.    The  tend- 


97 
ency  to  caries  should  be  recognized  and  treated  early  and  not  allowed 
to  reach  an  advanced  stage.  This  may  lead  to  exposed  pulps,  toothache, 
etc.,  with  lessened  resistance  of  the  patient. 

The  proper  treatment  is  both  local  and  general.  The  former  includes 
prophylaxis  with  good  oral  hygiene  curative  with  careful  removal  of 
all  carious  material  and  the  placing  of  at  least  temporary  cement  fill- 
ings.  It  may  be  better  to  avoid  extensive  reparative  work. 

Hyperemia  of  the  gums  is  often  observed  during  pregnancy.  Red- 
ness of  the  gingival  margins  and  hypertrophy  of  the  tissues  are  fre- 
quently seen.  Gingivitis  is  more  common  in  those  who  have  poor  oral, 
personal  hygiene  and  in  women  in  poor  health.  The  causation  of  these 
conditions  is  obscure;  possibly  altered  oral  secretions  and  changed 
metabolism  during  pregnancy  are  factors  playing  roles.  The  treatment 
is  largely  hygienic  and  dental  prophylactic  treatment  is  important  and 
valuable.  Such  alterations  in  the  gums  favor  the  growth  of  bacteria 
with  resultant  caries  and  infection. 

Many  expectant  mothers  have  had  little  or  no  dental  care,  either 
prior  to  or  during  their  pregnancy,  and  most  of  them  probably  do  not 
receive  any  dental  attention  at  all.  Among  those  who  do  come  under 
observation,  there  are  many  with  extreme  caries  and  bad  infections. 
They  have  exposed  pulps,  pyorrhea  and  often  abscesses.  These  cases 
must  be  treated  carefully,  but  thoroughly,  and  will  require  extractions, 
repair  and  treatment  to  eradicate  the  infection.  It  is  better  to  see  the 
patient  and  institute  the  necessary  treatment  early  in  pregnancy.  In- 
struction in  prophylaxis  should  be  given  and  the  patient  should  be  edu- 
cated in  the  proper  care  of  the  teeth  and  mouth. 

Prophylactic  treatments  should  be  given  as  required,  carious  areas 
should  be  removed,  extractions  should  be  performed,  reparative  work 
should  be  done  as  seems  necessary.  If  done  carefully  in  cases  selected 
with  good  judgment,  most  dental  procedures  can  be  carried  out  without 
detriment  to  the  mother  or  fetus.  Much  good  can  be  done  by  bettering 
the  status  of  the  prospective  mother,  which  improvement  reacts  fav- 
orably upon  the  fetus. 

The  diet  during  pregnancy  is  important,  mainly  for  its  general  effect 
upon  the  mother  and  the  fetus,  but  its  benefit  is  also  reflected  in  im- 
proved oral  conditions.  The  fetus  requires  minerals,  proteins  and  vita- 
mins and  if  there  is  a  deficiency  in  the  maternal  diet,  one  may  see  un- 
favorable reactions  in  the  mother.  Any  deficiency  in  minerals,  espe- 
cially in  calcium  metabolism,  or  in  the  vitamins,  might  manifest  itself 
quickly  in  deleterious  oral  conditions,  such  as  gingivitis,  caries  and  in- 
fection. Proper  oral  hygiene,  general  hygiene  and  diet  are  important, 
not  only  for  the  welfare  of  mother  and  fetus  in  general,  but  for  oral 
conditions  as  well. 

SAFE  BUT  UNPALATABLE 

Joseph  C.  Knox,  Junior  Sanitary  Engineer 
Division  of  Sanitary  Engineering 

Public  water  supplies  were  first  introduced  to  insure  the  communities 
of  a  water  suitable  for  domestic  uses.  The  first  requisite  was  that  it 
should  be  safe  for  human  consumption,  that  is,  it  should  contain  no 
water-borne  disease  bacteria.  The  key  note  of  public  water  supplies 
has  always  been  "safety,"  and  while  the  purity  of  the  water  has  always 
been  taken  for  granted  by  the  public  at  large  they  further  demand 
that  the  water  be  palatable. 

During  February,  1932,  certain  communities  of  greater  Boston  sup- 
plied with  water  from  Spot  Pond,  a  reservoir  on  the  Metropolitan  water 
system,  complained  of  a  very  disagreeable  odor  and  taste  in  the  water, 
a  condition  which  has  not  been  experienced  with  the   Metropolitan 


98 
supply  for  a  great  many  years  as  this  supply  has  always  been  noted 
for  its  purity  and  palatability.  The  trouble  was  immediately  recog- 
nized by  sanitary  engineers  as  caused  by  the  presence  of  certain  micro- 
scopic organisms  in  the  water, — minute  plant  and  animal  life  which 
are  present  in  all  surface  waters.  Microscopical  examinations  disclosed 
the  presence  of  the  organisms  Uroglena,  Synura,  Dinobryon,  and 
Asterionella.  These  first  three  are  classified  as  Protozoa  or  organisms 
of  animal  life,  while  the  organism  Asterionella  is  a  blue  green  algae  or 
plant  life.  These  organisms  produce  essential  oils  which  impart  a  fishy, 
oily  and  pungent  taste  and  odor  to  the  water,  in  some  cases  even  when 
present  in  small  numbers  when  they  break  up  or  upon  decay.  Uroglena 
in  small  numbers  produce  an  oily,  fishy  taste  and  when  present  in 
large  numbers  they  impart  a  taste  and  odor  which  resembles  cod  liver 
oil.  Synura  when  present  in  only  a  few  units  imparts  a  taste  described 
as  cucumber,  fishy,  musky,  etc.  and  leaves  a  persistent  bitter  after- 
taste. Dinobryon  and  Asterionella  also  cause  a  fishy  taste  and  odor 
when  present  in  large  numbers.  These  microscopic  organisms  while 
producing  disagreeable  conditions  have  never  been  known  to  be  in- 
jurious to  health. 

Temperature  is  probably  one  of  the  factors,  especially  in  the  time  of 
the  starting  of  the  growths  of  the  organisms,  and  while  certain  classes 
of  organisms  thrive  only  in  warm  water  Synura  and  Uroglena  prefer  a 
lower  temperature  and  grow  under  the  ice. 

The  Metropolitan  District  Commission  requested  the  advice  of  the 
State  Department  of  Health  on  February  23,  1932,  relative  to  the  best 
methods  of  removing  these  troublesome  organisms  and  the  Department 
recommended  the  treatment  of  the  pond  with  copper  sulphate  as  soon 
as  possible.  This  method  of  treatment  has  proved  very  satisfactory  in 
various  surface  water  supplies  in  the  State  but  unfortunately  in  the 
case  of  Spot  Pond,  which  was  partly  covered  with  ice  when  the  com- 
plaints were  first  received,  it  was  impracticable  to  use  the  popular 
method  of  application,  which  consists  of  dragging  burlap  bags  con- 
taining copper  sulphate  through  the  water  by  means  of  a  power  boat, 
while  the  thinness  of  the  ice  would  not  permit  the  application  of  copper 
sulphate  through  holes  cut  in  the  ice. 

On  March  27,  the  entire  pond  was  treated  with  copper  sulphate,  the 
dosage  to  kill  these  objectionable  organisms  being  estimated  at  2 
pounds  per  million  gallons,  and  as  the  capacity  of  Spot  Pond  Reservoir 
is  about  1800  million  gallons  approximately  2  tons  of  copper  sulphate 
were  used.  The  maximum  amount  of  copper  in  the  water  after  dosing, 
as  shown  by  chemical  analysis,  was  0.071  of  a  part  of  copper  to  a  mil- 
lion parts  of  water.  From  a  public  health  standpoint  this  amount  is 
infinitesimal,  as  there  is  no  record  of  copper  in  water  being  injurious 
to  health  when  present  in  less  than  1.40  parts  per  million.  This  treat- 
ment completely  destroyed  the  more  objectionable  organisms  in  the 
pond  within  a  few  days,  but  the  general  improvement  was  not  noticed 
by  the  consumers  for  nearly  two  weeks  because  of  the  time  required 
to  remove  the  previous  objectionable  water  and  the  accumulations  of 
organisms  from  the  distribution  system. 

When  this  disagreeable  condition  first  made  itself  manifest,  the  pub- 
lic immediately  abandoned  the  safe  although  unpalatable  public  supply 
and  resorted  to  the  practice  of  securing  water  from  springs  and  wells, 
many  of  which  had  been  unused  for  years  and  produced  water  of 
questionable  quality.  Many  of  these  springs  and  wells  used  by  the 
public,  while  apparently  producing  a  desirable  water,  when  examined 
by  the  State  Department  of  Health  proved  to  be  unsafe  sources  of  water 
supply  for  domestic  use,  and  added  to  this  danger  was  the  practice  of 
using  various  types  of  containers  and  receptacles  for  transporting  the 
water  and  the  practice  of  transporting  and  selling  bottled  water  of 
questionable  quality. 


99 

Such  experiences  with  a  public  water  supply  and  the  resulting  dan- 
gerous practices  should  serve  as  a  warning  to  both  the  public  and  our 
water  works  officials.  It  should  impress  the  public  with  the  danger  of 
the  use  of  wells  and  springs  furnishing  water  of  questionable  quality 
when  the  public  supply  is,  in  spite  of  odor  and  taste,  known  to  be  safe 
for  drinking,  and  to  those  in  charge  of  our  public  supplies  it  is  a  chal- 
lenge to  so  control  the  factors  which  affect  the  palatability  of  our  sup- 
plies that  the  public  may  be  assured  of  a  water  palatable  as  well  as  safe. 


100 

WHITE  HOUSE  CONFERENCE  PUBLICATIONS  ON  NUTRITION 

Nutrition  Service  in  the  Field — Child  Health  Centers:  A  Survey.   The 

Century  Company,  New  York.    Price  $2.00 
Growth  and  Development  of  the  Child — Part  III  Nutrition.    The  Cen- 
tury Company,  New  York.  Price  $4.00. 

SOME  INTERESTING  ARTICLES  ON  NUTRITION 

Sherman,  Henry  C,  Some  recent  advances  in  chemistry  of  nutrition: 
Journal  of  the  American  Medical  Association,  November  14,  1931. 

Eddy,  Walter  H.,  The  adult's  need  for  vitamins:  Medical  Jolurnal  and 
Record,  March  2,  1932. 

Koehne,  Martha,  Ph.D.,  Present-day  theories  of  the  cause  of  dental 
caries:    Journal  of  the  American  Dietetic  Association,  March,  1932. 

Peirce,  Ethel  Girdwood,  M.D.,  Can  rheumatism  be  prevented?:  Child 
Health  Bulletin,  January,  1932. 

Newburgh,  L.  H.,  M.D.,  The  cause  of  obesity:  Journal  of  the  American 
Medical  Association,  December  5,  1931. 

Maurer,  Siegfried  and  Tsai,  Loh  Seng,  The  effect  of  partial  depletion 
of  Vitamin  B  complex  upon  the  learning  ability  of  rats:  Jourhal  of 
Nutrition,  November,  1931. 

Shukers,  Carroll  F., — Macy,  Icie  G., — Donelson,  Eva — Nims,  Betty, 
and  Hunscher,  Helen  A.,  Food  intake  in  pregnancy,  lactation,  and 
reproductive  rest  in  human  mother:  Journal  of  Nutrition,  Sep- 
tember, 1931. 

Rose,  Mary  Swartz,  Our  children  and  their  nutrition  needs:  Teacher's 
College  Record,  February,  1932. 

Preston,  Frances,  Present  plans  for  nutrition  work  in  Cleveland:  Child 
Health  Bulletin,  March,  1932. 

McCOLLUM,  E.  V.,  Ph.D.,  Where  we  stand  now  in  our  knowledge  of  nutri- 
tion,  The  Medical  Searchlight  and  Science  Bulletin,  January,  1932. 

Horhe  economics  and  social  work  in  the  United  States — A  paper  pre- 
pared for  American  Committee  of  the  Second  International  Confer- 
ence of  the  Social  Work,  to  be  held  in  Frankfurt-am-Main,  July  11  to 
14,  1932:  Journal  of  Home  Economics,  May,  1932. 

Gillett,  Lucy  H.  and  Rice,  Penelope  B.:  Influence  of  education  on  the 
food  habits  of  some  New  York  City  families:  A  pamphlet  published 
by  the  New  York  Association  for  Improving  Conditions  of  the  Poor. 
1931. 

THE   BELLEVUE-YORKVILLE   HEALTH  DEMONSTRATION- 
ANNUAL  REPORT  1931. 

The  annual  report  of  the  Bellevue-Yorkville  Health  Demonstration  for 
1931  gives  an  excellent  resume  of  the  year's  work  and  the  illustrations 
add  much  to  the  pleasure  of  its  perusal.    The  activities  covered  are: 
Health  clinics  Dental  service 

Nursing  service  Research  and  records 

Health  education  Organization  and  finances 

The  infant  death  rate  dropped  from  80  per  1,000  live  births  in  1930  to 
70  in  1931;  maternal  deaths  increased  from  3.3  to  4.6.  The  population 
of  the  Bellevue-Yorkville  section  is  147,000. 

The  clinic  service  is  quite  complete — heart,  lungs,  nose  and  throat, 
general  medical  for  infants  and  preschool  children,  and  it  also  includes 
a  complete  mental  hygiene  unit  and  dental  service. 

A  new  X-ray  film  on  paper  was  used  in  the  chest  work  but  they  will 
not  be  ready  to  report  on  its  efficiency  and  cost  in  diagnosing  lung 
lesions  for  some  months  yet.  They  state,  however,  that  should  it  prove 
successful  "it  will  probably  decrease  materially  the  expense  of  X-ray 
photography." 


101 
One  special  study  of  great  importance  is  being  made  on  maternal 
and  infant  care.  The  value  of  this  research  should  be  great. 

INTERNATIONAL  HOSPITAL  ASSOCIATION 

Postgraduate  Course  on  Hospital  Technique 

Headquarters :  Municipal  and  University  Hospital,  Frankfort  (Allge- 
meine  Stadtische  and  Universitats-Krankenanstalten,  Frankfurt  am 
Main,  Sud  10,  Eschenbacherstr.  14). 

Duration:    From  September  29th  to  October  8th,  1932. 

Enrollment  Fees:  30  marks  for  the  full  course  or  5  marks  per  single 
day. 

Applications  for  Enrollment  to  be  addressed,  preferably  before  July 
1st,  1932,  to  Geheimrat  Dr.  Alter,  5,  Moorenstrasse,  Dusseldorf,  Germany. 

ECONOMY  AND  HEALTH 

Dr.  William  H.  Welch 

Dean  of  American  Medicine,  in  a  Speech 

Before  the  Advisory  Council,  Milbank 

Memorial  Fund 

Any  undue  retrenchment  in  health  work  is  bound  to  be  paid  for  in 
dollars  and  cents  as  well  as  in  the  impairment  of  the  people's  health 
generally.  We  can  demonstrate  convincingly  that  returns  in  economic 
and  social  welfare  from  expenditures  for  public  health  service  are  far 
in  excess  of  their  costs. 

Too  great  economy  as  far  as  health  is  concerned,  because  of  the  cur- 
rent depression,  is  particularly  dangerous  to  the  welfare  of  growing 
children.  Undernourishment  of  children,  for  example,  is  not  likely  to 
show  itself  immediately,  but  is  bound  to  show  its  effects  later,  when 
it  is  probably  too  late  to  remedy.  The  ground  lost  by  undernourishment 
in  childhood  may  never  be  regained. 


Book  Note 


Principles  and  Practices  of  Public  Health  Nursing.  Prepared  by 
the  National  Organization  for  Public  Health  Nursing.  The  Macmillan 
Company,  New  York.  $1.75. 

"New  developments  in  medicine  and  in  public  health  are  constantly 
putting  upon  the  shoulders  of  the  public  health  nursing  agencies  the  re- 
sponsibility of  enlarging  and  expanding  their  programs  and  staffs  to 
meet  the  newer  needs.  This  expansion  calls  for  the  development  of  sound 
organization  and  financing,  for  safe  techniques,  and  for  better  standards 
of  performance  by  which  the  quality  of  the  service  may  be  gauged. 

"To  assist  the  public  health  nursing  agencies  throughout  the  country  to 
meet  these  demands,  the  N.  O.  P.  H.  N.  through  its  service  Evaluation 
Committee  has  prepared  this  handbook  of  'Principles  and  Practices' 
which  underlie  those  factors  of  organization  and  administration  of 
public  health  nursing  having  a  bearing  on  the  quality  and  cost  of  nursing 
service." 

This  handbook  is  to  be  used  in  connection  with  the  Board  Members 
Manual  and  the  Manual  of  Public  Health  Nursing.  "It  has  been  pre- 
pared especially  for  the  guidance  of  executives,  of  supervisors,  and  of 
board  members,  that  they  may  compute  the  cost  of  a  visit  and  may 
maintain  a  standard  of  service  consistent  with  the  best  public  health 
and  medical  practice." 


102 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  January,  February  and  March  1932,  samples 
were  collected  in  138  cities  and  towns. 

There  were  811  samples  of  milk  examined,  of  which  119  were  below 
standard;  from  23  samples  the  cream  had  been  in  part  removed,  and  6 
samples  contained  added  water.  There  were  26  samples  of  Grade  A 
milk  examined,  24  samples  of  which  were  above  the  legal  standard  of 
4.00%  fat,  and  2  samples  were  below  the  legal  standard.  There  were 
1,062  bacteriological  examinations  made  of  milk.  There  were  222 
samples  examined  for  hemolytic  bacteria,  19  of  which  were  positive, 
and  203  samples  were  negative. 

There  were  768  samples  of  food  examined,  of  which  93  were  adulter- 
ated or  misbranded.  These  consisted  of  7  samples  of  butter  which  were 
below  the  standard  in  milk  fat;  26  samples  of  eggs,  21  samples  of 
which  were  cold  storage  not  so  marked,  2  samples  were  decomposed, 
and  3  samples  of  eggs  which  were  sold  as  fresh  eggs  but  were  not 
fresh;  5  samples  of  maple  syrup  which  contained  cane  sugar;  7  samples 
of  hamburg  steak,  1  sample  of  which  was  decomposed,  and  6  samples 
contained  a  compound  of  sulphur  dioxide  not  properly  labeled;  24 
samples  of  sausage,  13  samples  of  which  contained  a  compound  of 
sulphur  dioxide  not  properly  labeled,  10  samples  contained  starch  in 
excess  of  2  per  cent,  and  1  sample  was  moldy;  1  sample  of  sausage 
submitted  by  the  Health  Department  of  Lowell,  was  made  with  decom- 
posed meat,  deodorized  with  sodium  sulphite ;  18  samples  of  vinegar,  1 
sample  of  which  was  incorrectly  labeled,  and  17  samples  were  low  in 
acid;  1  sample  of  cream  which  was  below  the  legal  standard  in  fat; 
2  samples  of  figs  which  contained  sulphur  dioxide  and  were  not  prop- 
erly labeled ;  1  sample  of  liver  which  was  decomposed ;  and  1  sample  of 
pickles  which  was  decomposed. 

There  were  72  samples  of  drugs  examined,  of  which  24  were  adulter- 
ated or  misbranded.  These  consisted  of  17  samples  of  argyrol  solution 
not  corresponding  to  the  professed  standard  under  which  it  was  sold; 
1  sample  of  Koffnot  Cough  Syrup  which  was  not  properly  labeled;  and 
6  samples  of  spirit  of  nitrous  ether  which  were  deficient  in  the  active 
ingredient. 

The  police  departments  submitted  1,013  samples  of  liquor  for  exam- 
ination, 998  of  which  were  above  0.5%  in  alcohol.  The  police  depart- 
ments also  submitted  44  samples  of  narcotics,  etc.,  for  examination,  8 
of  which  were  morphine,  1  sample  examined  for  presence  of  morphine 
gave  negative  results;  3  samples  contained  opium;  1  heroin;  1  sample 
contained  alcohol,  1  sample  contained  alcohol,  phenolphthalein, 
saponin,  oil  of  lemon  and  syrup,  9  samples  contained  alcohol,  but  gave 
negative  tests  for  other  poisons;  1  sample  of  pills  gave  positive  tests 
for  ergot,  1  sample  of  pills  contained  cincophen,  1  sample  of  pills 
contained  pyramidon,  1  sample  of  pills  containing  phenolphthalein, 
1  sample  of  blue  pill  contained  strychnine,  1  sample  of  black  pill  con- 
tained substance  partially  identified  as  oil  of  tansy,  the  sample  being 
too  small  for  positive  identification,  1  sample  of  pills  contained  a  pro- 
tein material  but  gave  negative  tests  for  poisons,  1  sample  of  white 
tablets  which  was  identified  as  chlorazene;  1  sample  of  clear  liquid 
which  contained  oil  of  wintergreen,  1  sample  of  colorless  liquid  which 
contained  ethyl  alcohol;  1  sample  consisted  of  a  tea  made  from  hops; 
1  sample  consisted  of  a  mineral  oil  in  which  no  poisons  were  found; 
and  a  sample  of  beer,  a  sample  of  brown  liquid,  a  lamb  chop,  and  5 
other  samples  were  all  tested  for  the  presence  of  poisons  with  negative 
results.  One  sample  submitted  by  the  Division  of  Fisheries  and  Game 
contained  strychnine. 

There  were  58  hearings  held  pertaining  to  violations  of  the  laws. 


103 

There  were  91  cities  and  towns  visited  for  the  inspection  of  pasteur- 
izing plants,  and  285  plants  were  inspected. 

There  were  63  convictions  for  violations  of  the  law,  $1,020  in  fines 
being  imposed. 

John  G.  Carter  of  Sherborn;  Louis  G.  LaFrance  of  Taunton;  Manuel 
Raposa  of  Westport;  and  Edward  Lalley  of  Attleboro,  were  all  con- 
victed for  violations  of  the  milk  laws.   Louis  G.  LaFrance  of  Taunton 

fl-DDPSlGci    lllS    C  £1 S  6 

Simon  Cohen  of  Gloucester;  Maurice  Dovner  and  Frederick  Pelle- 
tier  of  Taunton;  Casper  Pallot,  Alphonse  Archambault,  and  Joseph 
Beaudoin,  all  of  Holyoke;  McLellans  Store,  The  Great  Atlantic  and 
Pacific  Tea  Company,  Thomas  Kilcourse,  Frank  Romito,  and  Erhart 
F.  Vogel,  all  of  Springfield;  Adjutor  Dupuis,  6  cases,  of  Fall  River; 
Camillo  Buonaugurio  of  Somerville;  Gaudenze  Luzio  of  Dorchester; 
Fitts  Brothers,  Incorporated,  of  Framingham ;  Arthur  Corey  of  Law- 
rence; and  Bernard  Ladow  of  Providence,  Rhode  Island,  were  all  con- 
victed for  violations  of  the  food  laws.  Simon  Cohen  of  Gloucester 
appealed  his  case. 

Saul  Brand  of  Roxbury;  Herbert  Joseph  of  Gloucester;  James  Van 
Dyke  Company  of  Fall  River;  and  Richard  C.  Dauch  of  Holyoke,  were 
all  convicted  for  false  advertising.  Saul  Brand  of  Roxbury,  and  Her- 
bert Joseph  of  Gloucester  appealed  their  cases. 

Harold  F.  Dowst,  2  cases,  of  Peabody;  Dennis  L.  Hennessy,  2  cases, 
of  Danvers;  and  Louis  K.  Liggett  Company  of  Salem,  were  all  con- 
victed for  violations  of  the  drug  laws. 

Maurice  Dovner  and  Frederick  A.  Pelletier  of  Taunton;  George 
Galan  of  Roxbury;  Casper  Pallot  of  Holyoke;  Charles  Pontone  of  Bos- 
ton; Philip  Fleishman,  Baldassara  Mangoglio,  Joseph  Mazzariello, 
Thomas  Shakarian,  and  Charlie  Zohn,  all  of  East  Boston;  William 
Allaire  of  Williamansett;  Konstanty  Janowski,  Adolph  Koval,  Eramdo 
Morini,  and  John  Uservitch,  all  of  Norwood;  and  Alfredo  Rolli  of  Lynn, 
were  all  convicted  for  violations  of  the  cold  storage  laws. 

Emmanuel  Mortis  of  Peabody;  Konstanty  Niezgoda  of  Holyoke; 
Marlboro  Dairy  Company,  Incorporated,  of  Marlborough;  Henry  Whit- 
taker  of  Fairhaven;  and  Joseph  Bernard  of  South  Dartmouth,  were 
all  convicted  for  violations  of  the  pasteurization  law  and  regulations. 

Marlboro  Dairy  Company,  Incorporated,  of  Marlborough  was  convicted 
for  violation  of  the  Grade  A  Milk  Regulations. 

George  Bradford  and  Wilbur  T.  Scott  of  Buckland;  Clemens 
Strycharz  of  Blackstone;  and  Frederick  Hepburn  and  Stephen  Burgess 
of  Wareham,  were  all  convicted  for  violations  of  the  slaughtering  laws. 
Wilbur  T.  Scott  of  Buckland  appealed  his  case. 

Emmanuel  Mortis  of  Peabody  was  convicted  for  obstruction  of  an 
inspector. 

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. 

Butter  which  was  below  the  standard  in  milk  fat  was  obtained  as 
follows : 

Three  samples,  from  Davis  Cleaver  &  Company  of  Quincy,  Illinois; 
and  one  sample  each,  from  Sugar  Creek  Creamery  Company  of  Dan- 
ville, Illinois,  and  Argentos  Market  of  Worcester. 

Maple  syrup  which  contained  cane  sugar  was  obtained  as  follows: 

One  sample  each,  from  Samuel  Tuvman  and  McLellan's  Store  of 
Springfield;  Malvina  Andrews  of  Boston;  Nestor  Pialtos  of  Worcester; 
and  Peter  Panos  of  Watertown. 

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

One  sample  each,  from  Pleasant  Street  Market  of  Northampton; 
Economy  Fruit  Market  of  New  Bedford;  The  Great  Atlantic  &  Pacific 


104 
Tea  Company  of  Charlestown ;  Jacob  D.  Glass  of  Allston;  Transfer 
Market  of  Salem;  and  Louis  Bernstein  of  Springfield. 

One  sample  of  hamburg  steak  which  was  decomposed  was  obtained 
from  Colin  Barrett,  Jr.  of  New  Bedford. 

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

Two  samples  each,  from  Premier  Market  of  Lawrence,  and  Gaudenze 
Luzio  of  Dorchester;  and  1  sample  from  Wadie  Maloof  of  Lawrence. 

One  sample  of  sausage  which  was  moldy  was  obtained  from  Hagop 
S.  Tamajan  of  Dorchester. 

One  sample  of  liver  which  was  decomposed  was  obtained  from  Fitts 
Brothers,  Incorporated,  of  Framingham. 

Two  samples  of  figs  which  contained  sulphur  dioxide  not  properly 
labeled  were  obtained  from  Acme  Fruit  Packing  Company,  Incorpor- 
ated, of  New  York. 

Vinegar  which  was  low  in  acid  was  obtained  as  follows:  6  samples, 
from  Carbon  Products  Company  of  Providence,  Rhode  Island;  5  sam- 
ples, from  A.  Dupuis  of  Fall  River;  and  1  sample  each,  from  Pure 
Products  Company  of  West  Springfield,  and  Rhode  Island  Sales  Com- 
pany of  Providence,  Rhode  Island. 

One  sample  of  vinegar  which  was  incorrectly  labeled  was  obtained 
from  Puritan  Grocery  Stores,  Incorporated,  of  Fall  River. 

There  were  three  confiscations,  consisting  of  500  pounds  of  beef 
affected  with  septicaemia;  300  pounds  of  pork  affected  with  hog  chol- 
era; and  1,750  pounds  of  decomposed  lemon  sole. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  December,  1931 : — 240,120  dozens  of 
case  eggs;  288,813  pounds  of  broken  out  eggs;  500,669  pounds  of  butter; 
3,435,270  pounds  of  poultry;  4,194,9501/2  pounds  of  fresh  meat  and 
fresh  meat  products;  and  1,730,326  pounds  of  fresh  food  fish. 

There  was  on  hand  January  1,  1932: — 816,870  dozens  of  case  eggs; 
1,729,401  pounds  of  broken  out  eggs;  1,886,632  pounds  of  butter;  6,856,- 
670%  pounds  of  poultry;  6,009,7321/2  pounds  of  fresh  meat  and  fresh 
meat  products;  and  17,484,057  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  January,  1932: — 209,670  dozens  of 
case  eggs;  316,184  pounds  of  broken  out  eggs;  612,740  pounds  of  butter; 
1,512,230  pounds  of  poultry:  3,810,035  pounds  of  fresh  meat  and  fresh 
meat  products;  and  1,797,215  pounds  of  fresh  food  fish. 

There  was  on  hand  February  1,  1932: — 136,530  dozens  of  case  eggs; 
1,575,833  pounds  of  broken  out  eggs;  1,538,961  pounds  of  butter;  7,292,- 
2121/4  pounds  of  poultry;  7,544,814  pounds  of  fresh  meat  and  fresh 
meat  products ;  and  13,917,354  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  February,  1932: — 229,890  dozens  of 
case  eggs;  217,000  pounds  of  broken  out  eggs;  450,377  pounds  of  but- 
ter; 1,011,196%  pounds  of  poultry;  4,626,635  pounds  of  fresh  meat  and 
fresh  meat  products;  and  728,288  pounds  of  fresh  food  fish. 

There  was  on  hand  March  1,  1932: — 93,270  dozens  of  case  eggs; 
1,293,179  pounds  of  broken  out  eggs;  1,031,179  pounds  of  butter;  6,523,- 
101%  pounds  of  poultry;  9,827,474  pounds  of  fresh  meat  and  fresh 
meat  products;  and  8,334,348  pounds  of  fresh  food  fish. 


105 
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  Child  Hygiene 
Division   of  Tuberculosis 
Division  of  Adult  Hygiene 


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Director, 

Gaylord  W.  Anderson,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  Pittsfield. 


Publication  of  this  Document  approved  by  the  Commission  on  Administration  and  Finanob 
5M.      <3-*3?,     Order  5633. 


$79 


THE 
COMMONHEALTH 


Volume  19 
No.  3 


JULY.-AUG.-SEPT. 
1932 


Rural   Health 


MASSACHUSETTS 
DEPARTMENT   OF  PUBLIC  HEALTH 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  op 
Public  Health 

Sent  Free  #b  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston  Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

Foreword,  by  George  H.  Bigelow,  M.D.  .....    109 

Development  of  Full-Time  County  Health  Service  in  the  United 

States,  by  Wilson  G.  Smillie,  M.D.,  D.P.H.       .  .110 

Rural  Health  Development  in  Massachusetts,  by  Wilson  W.  Knowl- 

ton,   M.D 112 

Cooperative  Rural  Health  Work  —  The  Experience  of  Cape  Cod,  by 

G.  Webster  Hallett 115 

Southern  Berkshire  Health  District,  by  Frederick  S.  Leeder,  M.D., 

D.P.H 118 

The  Nashoba  Health  District,  by  G.  Fletcher  Reeves,  M.D.     .  .    121 

The  Evaluation  of  Rural  Health  Work,  by  W.  F.  Walker,  D.P.H.  .  124 
Medical  Practice  in  Rural  Areas,  by  Frank  H.  Washburn,  M.D., 

F.A.C.S 129 

Special  Problems  of  Communicable  Disease  in  the  Small  Com- 
munity, by  Gaylord  W.  Anderson,  M.D.  ....  132 
The  Problem  of  Gonorrhea  and  Syphilis  in  Rural  Areas,  by  N.  A. 

Nelson,  M.D. 135 

A  Program  for  Public  Health  Nursing  in  a  Country  Community, 

by  Marion  C.  Woodbury,  R.N 137 

Rural  Child  Hygiene  in  Massachusetts,  by  Susan  M.  Coffin,  M.D.  .  140 
Private  Water  Supply  and  Sewage  Disposal  Problems,  by  Francis 

H.  Kingsbury  ........    142 

Rural  Nuisances  and  Their  Control,  by  Willard  S.  Little       .  .    148 

The  Home  Economics  Extension  Service  Program  in  Rural  Districts 

of  Massachusetts,  by  Annette  T.  Herr,  B.S.,  A.M.  .   154 

The    Massachusetts    Parent-Teacher   Association    and    the    Rural 

School,  by  Mrs.  George  Hoague  .....  156 
4-H  Club  Work,  by  George  L.  Farley,  M.S.  .  .  '.  .   157 

The  Vegetable  Cupboard  for  the  Country  School,  by  Mary  Spalding, 

M.A.,  B.S.       . .159 

Book  Notes : 

The  School  Health  Program  .......    161 

Milk  Production  and  Control  ......    161 

News  Note: 

American  Red  Cross  Annual  Roll  Call  .  .  161 

Report  of  Division  of  Food  and  Drugs,  April,  May  and  June  1932  .   162 


FOREWORD 

THE  IMPORTANT  AND  DIFFICULT  PROBLEM  OF 
RURAL  PUBLIC  HEALTH 

George  H.  Bigelow,  M.D.* 

As  a  people  we  are  faddists,  and  it  has  been  said,  in  public  health  at 
least,  that  the  major  modern  fad  is  the  child.  So  much  so  that  a  dis- 
tinguished psychiatrist  recently  complained  that  adulthood  was  being 
looked  on  almost  as  a  malignant  and  degenerative  growth  superimposed 
on  the  ideal — the  child.  This,  of  course,  overlooks  the  perfectly  obvious 
fact  that  in  the  adult  physiological  and  psychological  abnormalities  are 
largely  fixed  and  unalterable,  but  that  through  the  intelligent  use  of 
prophylactic  measures  in  the  child  the  maximum  may  be  obtained  in 
the  way  of  normal  healthy  adults  for  the  future,  the  crying  need  of 
which  today  can  hardly  be  gainsaid. 

So  with  rural  public  health!  So  much  is  said  and  written  about  it 
that  it  bids  fair  to  become  a  fad.  Then,  too,  in  an  industrial  state  like 
Massachusetts  with  83  per  cent  of  our  population  in  towns  of  10,000  or 
more  and  with  96  per  cent  of  our  people  served  by  public  water  sup- 
plies, why  should  we,  of  all  parts  of  the  country,  Consider  this  problem 
important?  It  is,  of  course,  a  truism  that  disease  is  no  respecter  of 
town,  city,  state  or  national  lines.  With  the  young,  and  for  that  matter 
all  ages,  migrating  to  the  cities,  and  the  city  population  utilizing  more 
and  more  freely  the  recreational  opportunities  of  the  country,  the  inter- 
dependence of  the  two  is  apparent.  Then,  through  taxes  and  philanthropy 
all  the  people,  particularly  the  more  fortunate,  become  in  a  sense  their 
brother's  keepers,  since  permanent  economic  stability  must  be  postulated 
on  a  reasonable  degree  of  health.  So  rural  public  health  over  the  country, 
in  New  England,  and  even  in  Massachusetts,  is  a  matter  of  very  real 
importance. 

But  why  is  it  so  difficult?  Lots  of  fresh  air,  and  grass,  and  cows,  and 
no  hideous  jostling  of  people  spraying  you  with  their  menacing  saliva! 
It  used  to  be  that  the  morbidity  and  mortality  rates  of  the  country  were 
better  than  those  of  the  early  unsanitary  cities.  But  not  so  today  since 
our  knowledge  has  been  put  to  work.  It  is  true  that  in  every  field  the 
rural  aspect  offers  a  particular  problem — recreation,  education,  the  whole 
gamut  of  cultural  matters,  theology,  medicine,  nutrition,  dentistry,  trans- 
portation, etc.,  etc.  To  put  knowledge  to  work  seems  to  be  easier  in  the 
cities  than  in  the  country.  Perhaps  the  most  obvious  difficulty  is  eco- 
nomic. The  delivery  of  a  given  standard  of  quality  of  service  in  any  of 
the  fields  just  mentioned  to  a  given  unit  of  the  population  costs  more  per 
unit  the  more  sparsely  settled  are  the  people  served.  This  raises  the 
very  vexing  question  of  how  much  more  can  be  paid  from  whatever 
source  for  this  rural  service,  or  how  much  can  the  standard  of  service  be 
lowered  without  too  much  loss.  We  must  keep  the  costs  "reasonable," 
particularly  now.  And  Heaven  knows  no  one  would  say  that  the  rural 
population  must  indefinitely  be  doomed  to  inferior  service,  although  in 
every  field  mentioned,  and  in  many  more,  that  is  the  case  today.  For 
these  reasons  and  others,  rural  public  health  is  a  difficult  problem,  and 
as  a  guide  to  its  solution  we  have  gathered  articles  by  persons  informed 
in  various  aspects  of  the  matter  and  present  them  in  this  number  of 
"The  Commonhealth." 

*  State  Commissioner  of  Public  Health. 


110 

DEVELOPMENT  OF  FULL-TIME  COUNTY  HEALTH 
SERVICE  IN  THE  UNITED  STATES 

Wilson  G.  Smillie,  M.D.,  D.P.H.* 
Historical 

In  1911  a  devastating  epidemic  of  typhoid  fever  occurred  in  Yakima 
County,  Washington.  Dr.  L.  L.  Lumsden  of  the  United  States  Public 
Health  Service  was  assigned  to  study  the  epidemic.  He  recommended 
to  the  county  authorities  that  the  best  method  for  prevention  of  a  repe- 
tition of  such  a  disaster  would  be  the  organization  of  a  county  health 
department,  supported  by  county  funds,  with  a  full-time  physician  in 
charge.  As  a  direct  result  of  this  recommendation,  the  first  county 
health  unit  in  the  United  States  was  established.  Meanwhile,  the  Rocke- 
feller Sanitary  Commission  had  been  conducting  a  campaign  for  the 
control  of  hookworm  disease  in  the  southern  states.  The  Commission 
found  that  the  campaign  for  treatment  of  cases  and  education  of  the 
people  was  of  great  value  in  alleviating  suffering  in  any  area,  but  that 
permanent  results  leading  to  improvement  of  sanitary  conditions  and 
eventual  prevention  of  infection  could  not  be  secured  unless  there  re- 
mained in  the  area  a  small,  permanent  nucleus  with  a  continuous  com- 
prehensive program  of  gradual  sanitary  betterment.  In  order  to  assure 
stability  and  continuity,  it  was  obvious  that  such  an  organization  must 
have  official  sponsorship  and  local  support.  The  Rockefeller  Founda- 
tion, therefore,  developed  the  policy  of  stimulation  of  the  organization 
of  county  health  service  with  full-time  personnel  by  temporary  grants 
toward  the  development  of  county  health  units.  Aid  was  not  given 
directly  to  the  county  government,  but  through  the  State  Health  De- 
partment. The  State  Department  of  Health  in  turn  assumed  all  re- 
sponsibility for  the  development  and  supervision  of  the  service  and 
also  gave  a  subsidy  to  the  county  for  the  health  unit  work.  A  very 
similar  plan  of  federal  aid  in  establishment  of  county  health  units  was 
developed  by  the  United  States  Public  Health  Service. 

From  the  very  first,  the  method  proved  effective  and  met  with  popu- 
lar approval  and  support.  There  was  an  experimental  period  of  about 
five  years  during  which  time  a  great  variety  of  types  of  organization, 
of  administrative  method,  and  of  personnel  were  tried.  The  method  of 
trial  and  error  was  followed,  mistakes  were  made  and  rectified,  and  a 
satisfactory  workable  plan  finally  developed  which  was  of  almost  uni- 
versal application.  From  1918  on,  the  growth  of  county  health  units 
has  been  rapid.  In  that  year  there  were  some  thirty  county  health  units 
with  full-time  personnel  in  the  United  States. 

By  1932,  the  principle  had  been  adopted  in  over  500  counties  in  the 
United  States,  and  over  25  per  cent  of  the  rural  population  in  the 
country  had  secured  a  public  health  service  with  full-time  personnel 
under  the  county  plan.  Not  only  had  the  quantity  of  work  increased 
enormously,  but  the  quality  of  service  had  improved  to  such  a  degree 
that  many  rural  areas  were  given  just  as  adequate  health  supervision 
as  that  of  the  large  municipalities.  There  is  every  reason  to  believe 
that  this  type  of  service  will  be  extended  gradually,  and,  with  modifica- 
tions to  meet  local  situations,  and  with  improvements  of  technique  and 
administrative  method  that  are  being  developed  continuously,  will 
eventually  reach  all  parts  of  the  country. 

*  Dr.  Smillie,  who  is  Professor  of  Public  Health  Administration  at  the  Harvard  School  of  Pub- 
lic Health,  has  had  extensive  and  intimate  contact  with  health  work  in  widely  scattered  por- 
tions of  the  United  States,  as  well  as  foreign  countries.  Few  are  better  acquainted  in  public 
health  circles.  Since  rural  health  work,  as  we  now  know  it,  developed  largely  in  those  states  in 
which  the  county  is  the  governmental  unit,  it  is  inevitable  that  health  projects  should  have  grown 
along  these  lines.  In  New  England  the  town  is  so  much  the  unit  of  government,  that  the  county 
assumes  relatively  little  importance.  Except  in  rare  instances,  adequate  health  service  for  rural 
areas  must,  therefore,  rest  on  cooperation  between  several  towns.  Although  the  unit  is  different 
and  the  .details  thus  varied,  the  basic  principles  which  Dr.  Smillie  describes  hold  as  well  in 
Massachusetts  as  in  other  states. 


Ill 

Organization 

The  organization  of  county  health  department  service  is  based  on 
the  county  as  a  unit  of  government.  This  has  the  advantage  that  the 
county  is  an  accepted  administrative  unit  with  all  the  various  estab- 
lished departments  of  governmental  activity — education,  police,  the 
judiciary,  public  welfare,  roads,  agriculture,  etc.  It  is  also  the  taxing 
unit  and,  to  a  lesser  degree,  a  political  and  social  unit. 

Any  city  in  the  county  with  a  population  of  50,000  or  more  may  have 
its  own  health  department;  though  it  is  often  more  practicable  to  in- 
clude all  cities  and  towns  of  whatever  size  under  the  unified  county 
health  service.* 

In  a  county  having  a  population  of  25,000  or  less,  it  has  not  been 
found  feasible  to  organize  standard  county  health  unit  service  for  rea- 
sons that  will  become  apparent.  Even  in  counties  with  a  population  of 
25,000  to  30,000  people,  but  with  a  large,  sparsely  settled  area  and  a 
total  annual  income  of  $10,000,000  ($300.00  per  capita)  a  standard 
county  health  unit  is  not  a  feasible  organization.  In  these  areas  one 
of  the  various  modifications  of  the  standard  plan  would  be  attempted. 

The  essential  principles  in  the  organization  of  a  county  health  unit 
are: 

1.  The  major  part  of  the  budget  must  be  met  from  local  govern- 
mental sources.  The  chief  of  these  sources  should  be  from  county  tax 
money.  Incorporated  villages  and  towns  in  the  county  should  make  an 
additional  appropriation  toward  the  budget  since  they  receive  more 
and  special  services  than  the  country  areas. 

2.  The  health  service  must  be  generalized.  Each  locality  in  the 
United  States  has  its  own  special  health  problems  which  it  must  solve 
in  accordance  with  local  needs.  A  frequent  mistake  that  is  made  is  to 
concentrate  on  one  obvious  or  interesting  phase  of  activity  and  to 
neglect  other  equally  important  activities. 

3.  The  essential  personnel  of  the  unit  must  be  employed  on  a  full- 
time  basis,  and  should  not  carry  on  any  other  type  of  work.  They  must 
possess  necessary  technical  qualifications  and  training. 

4.  The  health  department  must  be  an  integral  part  of  the  govern- 
mental services,  and  just  as  in  the  school  department,  department  of 
justice,  police,  agriculture,  etc.,  the  state  health  department  should 
bear  the  same  relationship  to  the  county  health  department  as  the 
state  department  of  education  bears  to  the  county  school  department; 
that  is,  the  state  should  have  a  limited  supervision  of  activities,  aid  in 
development  of  technique  and  in  selection  of  personnel,  and  provide  a 
definite,  permanent  subsidy. 

5.  All  the  health  activities  in  the  county  should  be  carried  out  under 
the  direction  of  the  county  health  unit.  Non-official  agencies  should 
either  fuse  their  activities  with  the  county  health  unit  or  correlate 
their  activities  with  those  of  the  official  organization. 

Standard  Plan 

After  much  experimentation  with  various  types  of  organizations  and 
a  great  variety  of  combinations  of  personnel,  a  standard  plan  has  been 
developed  which  is  of  general  application. 

The  basic  personnel  consists  of  a  health  officer,  one  or  more  nurses, 
a  sanitary  inspector  and  a  secretary.  All  are  on  a  full-time  basis.  The 
standard  budget  for  a  minimum  personnel  is  in  the  neighborhood  of 
$10,000.   The  basic  activities  of  the  health  unit  are: 

1.  Collection  and  analysis  of  mortality  and  morbidity  statistics. 

2.  Communicable  disease  control. 

3.  Environmental  sanitation. 


*  Birmingham,  Alabama,  for  example,  is  a  city  of  over  200,000  people.    The  city  has  no  auton- 
omous health  organization,  but  its  organization  is  a  part  of  the  Jefferson  County  Health  Unit. 


112 

4.  Maternal  and  infant  hygiene. 

5.  Preschool  and  school  hygiene. 

6.  Health  education. 

Environmental  sanitation  includes  supervision  of  water  supplies  and 
sewage  disposal,  the  inspection  of  food,  milk  sanitation,  nuisance  abate- 
ment as  well  as  special  problems  which  are  peculiar  to  the  area,  as 
mosquito  control. 

School  hygiene  includes  a  wide  variety  of  activities,  such  as  peri- 
odic medical  examination  of  school  children,  regular  school  health 
examination  by  the  nurse,  aid  in  correction  of  physical  defects,  etc. 

Bedside  nursing  obviously  could  not  be  developed  under  a  plan 
where  only  one  nurse  is  employed  for  the  whole  county.  The  nurse's 
activities  are  preventive  in  nature  in  contrast  to  curative.  The  skele- 
ton organization  can  carry  out  only  the  most  essential  and  elementary 
health  activities,  and  as  the  work  develops  it  has  been  frequently  found 
necessary  to  add  additional  nurses  to  the  staff. 

The  county  health  unit  has  made  a  real  place  for  itself  in  the  ma- 
chinery of  government.  It  serves  a  useful  and  very  effective  purpose 
and  has  come  to  stay.  In  principle  it  is  sound,  but  the  general  plan 
must  be  modified  in  its  various  details  to  suit  the  particular  needs  of 
the  area  which  it  is  intended  to  serve. 

RURAL  HEALTH  DEVELOPMENT  IN  MASSACHUSETTS 

Wilson  W.  Knowlton,  M.D.* 

Someone  has  said  that,  if  the  scientific  knowledge  now  available  in 
preventive  medicine  could  be  applied  to  existing  problems,  civilization 
in  terms  of  public  health  would  advance  fifty  to  one  hundred  years.  It 
is  the  difficulty  of  this  application  which  rises  to  haunt  many  a  sincere 
board  of  health  not  only  in  Massachusetts  or  in  New  England  but  the 
world  over. 

In  former  days  when  noxious  odors,  dead  animals,  and  night  air 
were  looked  upon  as  conveyers  of  specific  diseases,  some  lay  member 
of  the  local  board  of  health  was  able  to  serve  as  part-time  health  officer 
with  at  least  a  reasonable  degree  of  success.  Of  late  it  has  been  dis- 
covered that  the  infectious  individual — rather  than  the  environment — 
is  the  danger  point  in  the  spread  of  communicable  disease;  and  local 
board  of  health  members  are  finding  that  the  efficient  yet  not  unneces- 
sarily severe  control  of  this  infectious  individual  presents  problems 
the  solution  of  which  can  justly  be  expected  only  of  one  who  has  had 
the  opportunity  of  scientific  education  and  training  along  these  lines. 
Consequently,  the  local  boards  of  health  in  the  more  progressive  cities 
have  selected  full-time,  properly  trained  health  officers  to  execute  the 
plans  and  programs  outlined  by  the  Board  in  advisory  session.  Such 
an  executive  health  officer  may  then  surround  himself  with  the  sub- 
ordinate personnel  necessary  for  guarding  the  community's  health  and 
promoting  well-balanced  work  in  individual  hygiene. 

The  smaller  cities  and  towns,  however,  are  faced  with  a  serious  prob- 
lem indeed  when  they  try  to  modernize  their  health  programs.  These 
communities  are  not  large  enough  in  terms  of  population  to  require, 
and  in  terms  of  taxable  wealth  to  support,  a  group  of  full-time,  ade- 
quately trained  health  workers.    What  is  the  solution  to  their  problem? 

Is  not  the  solution  the  grouping  of  towns  and  small  cities  into  unified 
districts  for  purposes  of  local  public  health  administration?  In  the 
past,  intertown  cooperation  has  been  tried  successfully  in  Massachu- 
setts along  various  lines.  For  example,  starting  in  1888,  234  of  the  355 
communities  in  the  State  have  grouped  themselves  into  districts  of 

*  As  State  District  Health  Officer,  Dr.  Knowlton  did  much  of  the  preliminary  work  leading  to 
the  organization  and  establishment  of  the  Southern  Berkshire  and  Nashoba  Health  Units.  He 
discusses  here  some  of  the  problems  of  rural  health  work  in  Massachusetts  and  their  possible 
solution  through  cooperative  enterprise. 


113 

from  two  to  seven  towns  each  for  the  purpose  of  employing  full-time 
school  superintendents.  Such  intertown  cooperation  has  been  found  to 
be  practical,  efficient,  and  of  tremendous  benefit  to  the  school  children. 
Similarly,  communities  have  cooperated  in  the  support  of  farm  agents 
and  home  demonstration  workers.  More  recently,  communities  have 
combined  for  such  specific  health  activities  as  the  employment  jointly 
of  school  nurses  or  of  milk-sanitary  inspectors.  Towns  have  also  united 
in  the  establishment  of  community  hospitals. 

In  terms  of  health  work,  the  final  object  in  intertown  cooperation  is, 
of  course,  union  for  a  generalized  health  program.  This  idea  was  first 
tried  some  nineteen  years  ago  (1913)  when  eight  communities  in  the 
eastern  part  of  Massachusetts  combined  for  a  generalized  program  cen- 
tered in  a  public  health  laboratory  service.  Although  that  union  was 
later  dissolved,  it  served  to  point  the  way  for  similar  work  to  come  in 
other  parts  of  the  State. 

In  1920  a  group  of  eleven  towns  in  Barnstable  County  on  Cape  Cod 
joined  voluntarily  for  health  work.  After  several  years  of  such  vol- 
untary union,  local  leaders  petitioned  the  State  Legislature  to  place 
the  project  upon  an  official  county  basis.  It  thus  exists  today  as  the 
only  county  health  department  in  New  England.  Through  this  co- 
operative venture,  the  fifteen  communities  in  Barnstable  County  enjoy 
a  degree  of  service  from  and  balance  in  their  local  health  programs 
quite  unknown  to  the  average  small  New  England  community.  In  gen- 
eral, however,  it  does  not  seem  feasible  to  organize  public  health  work 
in  Massachusetts  on  the  county  basis,  since  the  county  is  not  the  unit 
of  local  government  as  it  is  in  other  parts  of  the  United  States  and 
hence  does  not  serve  as  a  taxation  and  population  unit. 

One  turns  then  to  the  problem  of  grouping  communities  together  into 
health  districts  and  of  making  these  unions  permanent.  Such  a  district 
should,  of  course,  be  large  enough  in  terms  of  population  (certainly  not 
less  than  20,000)  to  support  an  adequate  public  health  program. 

Two  such  health  districts  have  recently  been  organized — one  in  the 
southwestern  corner  of  the  State,  known  as  the  Southern  Berkshire 
District,  and  the  other  near  the  north  central  part  of  the  State,  known 
as  the  Nashoba  Health  District.  The  Southern  Berkshire  Health  Unit 
was  officially  organized  on  February  1,  1931,  while  the  Nashoba  Unit 
followed  three  months  later.  The  staff  of  each  Unit  is  headed  by  a  full- 
time  medical  health  officer.  With  this  individual  are  associated  a  group* 
of  full-time  subordinate  personnel  who  assist  the  director  in  carrying 
on  the  different  phases  of  his  local  public  health  program.  The  basic 
activities  of  a  district  health  unit  may  be  outlined  as  follows : 

1)  Controlling  communicable  diseases:  This  is,  of  course,  the  primary 
function  of  any  health  department.  Here  the  health  officer  serves 
as  an  epidemiologist  and  as  a  consultative  diagnostician  for  the  local 
physicians.  The  public  health  nurse  serves  to  help  in  the  isolation 
and  treatment  by  the  family  of  infectious  individuals.  The  sanitary 
inspector  comes  into  the  picture  in  connection  with  those  diseases 
associated  with  environmental  factors,  such  as  typhoid  fever  and 
septic  sore  throat.  The  laboratory  technician  also  plays  her  part 
in  the  matter  of  diagnosis  and  the  supervision  of  patients  and  car- 
riers. The  office  clerk  plays  her  part  in  the  control  of  communicable 
diseases,  as  well  as  in  the  other  phases  of  public  health  work,  by 
the^  keeping  of  accurate  data  which  may  be  used  for  studying  past 
activities  and  for  developing  plans  for  the  future. 

2)  Guarding  the  Hygiene  of  the  Individual:  Interest  in  individual 
hygiene,  of  course,  centers  around  child  health.  Here,  as  in  com- 
municable disease  control,  all  members  of  the  health  department's 
staff  play  a  part,  although  this  phase  of  the  work  naturally  falls 
particularly  into  the  realm  of  the  public  health  nurse  and  the  medi- 
cal health  officer  working  together  so  as  to  supplement  but  never  to 
supplan.t  the  family  physjc}a.n. 


114 

3)  Promoting  Sanitation:  The  protection  of  the  public  milk,  water,  and 
food  supplies  is  a  most  important  function  of  a  health  department, 
since  little  can  be  accomplished  in  individual  hygiene  if  the  strategic 
points  in  general  sanitation  are  allowed  to  go  unprotected.  Con- 
versely, a  protection  of  the  environment  cannot  be  expected  to  take 
the  place  of  defects  in  service  to  the  individual.  The  modern  con- 
cept of  a  sanitary  inspector  is  more  that  of  a  teacher  than  that  of  a 
law  enforcement  officer.  He  must  show  a  nice  discrimination  in  his 
work,  however,  lest  he  place  undue  emphasis  upon  those  minor  en- 
vironmental factors  commonly  known  as  nuisances  which,  while 
offensive  to  the  senses,  are  in  no  wise  specific  health  menaces. 

4)  Assembling  Records  and  Statistics:  Mention  has  already  been  made 
of  the  importance  of  record  keeping  for  the  purpose  of  statistical 
studies  as  guides  to  new  program  planning.  Vital  and  morbidity 
statistics  furnished  by  local  registrars  and  attending  physicians 
respectively  are  of  tremendous  help  to  the  alert,  properly-trained 
health  officer  who  sees  therein  a  "health  barometer"  for  his  com- 
munity. 

5)  Carrying  on  Public  Health  Education:  In  connection  with  all  of  the 
above  activities  of  a  health  department,  there  must  be  carried  on  a 
program  of  popular  health  instruction.  This  should  bring  to  each 
citizen  a  realization  of  what  he  owes  to  himself  in  terms  of  personal 
hygiene,  to  his  neighbor  in  terms  of  environmental  and  infectious 
individual  control,  and  to  his  health  department  in  terms  of  finan- 
cial support. 

This  district  health  unit  program  in  Massachusetts  is  being  made 
possible  at  the  present  time  by  the  generous  assistance  of  the  Common- 
wealth Fund  of  New  York  City.  This  private  foundation  and  the  Massa- 
chusetts State  Department  of  Public  Health  are  bringing  to  the  citizens 
in  the  Nashoba  and  Southern  Berkshire  areas  financial  support  and 
technical  advice  for  their  new  venture  in  local  health  administration. 
As  time  goes  by,  the  work  of  the  health  units  will  become  more  and 
more  closely  integrated  with  the  official  and  private  health  agencies  pre- 
viously at  work  in  the  areas.  It  is  anticipated  that  eventually  the  com- 
munities will  be  able  and  willing  to  support  the  work  of  the  district 
health  units  as  being  that  of  their  local  boards  of  health.  The  extent 
to  which  this  can  be  accomplished  without  undue  financial  burden  will 
depend  upon  the  degree  of  intertown  cooperation  and  the  pooling  of 
local  resources  (both  official  and  private).  On  the  average,  the  citizens 
in  these  health  districts  have  already  been  spending  in  past  years  quite 
reasonable  sums  of  money  for  local  health  work.  The  problem  now  is 
to  combine  resources  for  the  common  good. 

As  these  district  health  units  work  out  their  problems  of  local  co- 
operation, they  will  demonstrate  to  the  rest  of  Massachusetts — in  fact, 
to  all  of  New  England — a  practical  method  whereby  small  cities  and 
towns  may  obtain  for  themselves  that  degree  of  individual  and  group 
health  protection  which  dwellers  in  metropolitan  areas  have  already 
come  to  demand  as  one  of  the  necessities  of  life.  The  development  of 
full-time  health  work  in  rural  Massachusetts  is  indeed  of  vital  impor- 
tance. The  end  is  by  no  means  in  sight  but  solid  foundations  are  being 
laid  for  future  growth. 


115 

COOPERATIVE  RURAL  HEALTH  WORK— 

THE  EXPERIENCES  OF  CAPE  COD 

G.  Webster  Hallett  * 

When  the  Commonwealth  of  Massachusetts  established  in  1797  a 
a  system  of  local  boards  of  health,  it  created  in  those  boards  power 
to  make  certain  regulations  governing  the  control  of  communicable 
diseases  and  of  general  sanitation. 

By  contact  with  the  Department  of  Public  Health  through  the  State 
District  Health  Officers,  local  boards  of  health  have  had  the  oppor- 
tunity of  making  themselves  a  strong  factor  in  the  control  of  com- 
municable diseases  and  in  making  general  living  conditions  better;  but 
there  are  undoubtedly  many  small  towns  that  are  carrying  on  very 
near  to  the  manner  in  which  they  started  135  years  ago. 

A  slight  history  of  the  constructive  work  done  in  Barnstable  County 
during  the  last  twelve  years  may  be  interesting  and  may  show  where 
groups  of  towns  can  get  together  and  work  out  the  cooperative  method 
for  improving  conditions  of  public  health.  Prior  to  1920,  there  were 
only  two  towns  in  Barnstable  County  that  were  doing  a  certain  amount 
of  constructive  health  work,  and,  while  there  were  two  district  nursing 
associations  doing  bedside  nursing,  and  some  attempt  was  being  made 
to  do  public  health  nursing,  the  work  progressed  very  slowly, 
and  to  those  interested,  who  had  a  vision  of  what  could  be  accom- 
plished, it  was  most  discouraging,  because  under  the  form  of  town  gov- 
ernment the  average  person  was  more  interested  in  cutting  down  the 
appropriations  for  the  town  government  and  lowering  the  tax  rate  than 
they  were  in  building  up  a  constructive  program  in  better  health  con- 
ditions. Up  to  1920,  a  plan  of  the  town  expenditures  would  show  large 
amounts  spent  for  school  and  road  work  while  the  public  health  costs 
would  barely  make  a  scratch  on  the  plan. 

About  that  time,  the  Federal  Government  was  doing  a  considerable 
amount  of  work  in  establishing  county  health  units  throughout  the 
South  and  Southwest  with  full-time  health  officers,  and  it  decided  that 
it  might  be  advisable  to  attempt  to  do  some  of  that  work  in  New  Eng- 
land. Two  of  the  members  of  the  United  State  Public  Health  Service, 
with  the  Commissioner  of  Public  Health  for  Massachusetts,  the  late 
Dr.  Eugene  R.  Kelley,  made  a  survey  of  New  England  and  were  im- 
pressed with  Barnstable  County,  or  Cape  Cod,  a  county  of  fifteen  towns, 
with  no  city  and  the  largest  town  at  that  time  having  little  over  5,000 
inhabitants,  and  the  smallest  with  a  population  of  about  150.  They  felt 
it  might  be  possible  to  establish  at  least  a  District  Health  Unit  with  a 
full-time  health  officer. 

With  that  in  view,  a  meeting  was  called  asking  a  representative  from 
every  board  of  health  in  the  county  to  meet  with  these  gentlemen  at  the 
County  Seat  to  discuss  the  matter.  Every  town  was  represented  at  that 
meeting,  largely  through  the  efforts  of  the  State  District  Health  Officer, 
who  put  in  a  considerable  amount  of  time  traveling  through  the  county 
and  explaining  as  best  he  could  the  reason  for  the  meeting.  The  matter 
was  laid  before  the  boards  of  health  very  plainly  by  Doctors  Lumsden 
and  Draper  of  the  United  States  Public  Health  Service  and  Dr.  Kelley 
of  the  State  Department  of  Public  Health.  It  was  plainly  stated  at  that 
time  that  the  Federal  Government  did  not  want  to  finance  the  entire 
enterprise.  They  felt  that  a  certain  amount  of  voluntary  contribution  of 


*  Mr.  Hallett  is  without  question  the  outstanding  figure  in  public  health  on  Cape  Cod.  In  his 
capacity  as  President  of  the  Cape  Cod  Health  Bureau,  he  has  seen  the  growth  of  the  coopera- 
tive health  work,  and  has  been  the  guiding  spirit  in  many  of  the  projects.  In  this  article,  he 
reviews  the  successes  and  failures  of  the  past  ten  years,  and  attempts  to  measure  its  value  as 
seen  by  a  layman.  In  a  letter  to  the  editor,  he  says :  "The  point  that  I  have  tried  to  bring  out  is 
that,  if  health  districts  are  formed,  unless  there  is  a  certain  amount  of  voluntary  support  it  will 
be  quite  difficult  to  get  a  satisfactory  working  organization I  feel  the  five  years  of  vol- 
untary work  we  did  on  Cape  Cod  has  placed  a  value  on  the  work  that  could  have  been  done  in 
no  other  way." 


116 

town  money  should  enter  into  the  project,  which  was,  as  shown  later, 
a  very  valuable  asset  in  the  start  of  the  work. 

After  the  matter  was  thoroughly  discussed,  it  was  left  in  the  hands 
of  the  local  boards  of  health  to  decide  whether  they  would  or  would 
not  attempt  any  such  work.  A  meeting  was  appointed  for  a  later  date 
and  during  that  time  the  State  District  Health  Officer  had  found  the 
man  he  felt  would  be  a  success  in  a  most  conservative  community  like 
the  County  of  Barnstable.  At  this  meeting,  the  matter  was  again  dis- 
cussed and  eleven  of  the  fifteen  towns  in  the  County  decided  that  they 
would  make  the  attempt  and  with  the  offer  of  $2,500  a  year  from  the 
Federal  Government  towards  the  project,  a  check-up  of  the  population 
of  the  towns  was  made  and  it  was  found  an  assessment  of  fifty  cents  per 
capita  would  finance  the  budget  as  laid  out. 

An  organization  was  then  formed  called  the  Cape  Cod  Health  Bureau, 
with  a  President,  Vice-President,  Secretary  and  Treasurer  and  Execu- 
tive Committee — the  latter  consisting  of  the  officers  and  the  State  Dis- 
trict Health  Officer.  With  no  definite  plan  for  operation,  the  Execu- 
tive Committee  met  many  times  to  decide  on  the  best  plan  for  carrying 
out  the  work.  The  District  Health  Officer  spent  a  great  deal  of  time 
going  through  the  different  towns,  meeting  the  boards  of  health,  select- 
men, superintendents  of  schools,  and  getting  in  touch  with  the  Woman's 
Clubs,  Kiwanis  and  Rotary  Clubs  and  any  place  where  he  could  get  an 
invitation  to  present  the  subject,  in  order  to  get  the  public  to  under- 
stand when,  at  the  town  meeting,  the  board  of  health  should  ask  for  an 
appropriation  for  public  health  work. 

There  were  two  distinct  lines  of  work  that  seemed  advisable  to  fol- 
low. One  was  the  control  of  communicable  diseases,  thorough  exami- 
nation of  school  children  and  finding  a  method  of  correcting  defects 
found;  and  the  other  was  general  sanitation  and  working  for  a  safer 
milk  supply.  In  this,  while  the  Health  Officer  was  at  the  head  of  the 
whole  project,  a  Milk  and  Sanitary  Inspector  was  appointed  to  start  on 
the  milk  work  at  the  same  time  we  started  on  the  schools  and  contagious 
disease  activities.  After  six  months  it  was  very  evident  that  this  was 
working  into  genuine  cooperative  work,  and  it  was  not  a  one-man  job 
or  a  job  for  any  group;  but  it  meant  that  if  it  was  to  be  successful,  we 
must  have  the  backing  of  the  entire  eleven  towns  that  formed  the  bu- 
reau. The  eld  method  of  the  town  appointing  the  school  physician  and 
paying  him  possibly  $50.00  a  year,  and  appointing  the  boards  of  health 
and  paying  them  for  putting  up  a  red  flag  where  there  was  a  contagious 
disease,  locating  a  cesspool  or  making  an  attempt  to  abate  a  nuisance, 
was  a  great  handicap  in  getting  the  real  enthusiasm  we  wanted  to 
carry  out  the  work. 

Through  the  work  of  the  Health  Officer  and  the  voluntary  contribu- 
tion by  the  Red  Cross  of  a  full-time  health  nurse,  at  the  end  of  the  first 
year  we  had  made  sufficient  progress  to  feel  it  was  a  project  that  was 
worth  working  for.  The  fact  that  aside  from  the  amount  contributed 
by  the  Federal  Government,  there  must  be  a  voluntary  contribution 
from  the  town,  made  it  extremely  difficult  to  plan  a  program  very  far 
ahead  and  it  was  only  through  the  work  of  a  few,  who,  at  town  meeting 
time  took  off  their  coats  and  went  to  work  and  visited  every  town  meet- 
ing, explaining  to  the  voters  that  the  project  was  worthy  of  their  sup- 
port and  in  most  cases  getting  a  full  contribution  from  each  town,  that 
the  project  succeeded. 

The  Health  Officer  who  started  the  program  had  a  splendid  vision  of 
what  could  be  accomplished.  The  work  that  he  started  was  on  a  solid 
foundation  that  meant,  as  years  went  on,  no  great  change  would  have 
to  be  made  in  the  general  method  of  carrying  on  the  work.  His  work 
for  two  years  in  getting  the  fact  established  in  the  minds  of  the  people 
that  the  project  was  worth  support  was  really  responsible  for  our  being 
able  to  carry  on.   As  a  representative  of  the  Federal  Government  said, 


"If  we  carry  out  the  work  under  the  voluntary  system  for  one  year  it 
would  be  quite  remarkable,  and  if  we  carry  it  on  for  two  years,  it  would 
be  rather  wonderful."  Fortunately,  while  the  Cape  Cod  people  may  be 
slow  to  accept  such  a  proposition,  if  they  do  accept  it  they  usually  carry 
it  through,  carrying  on  at  times  when  it  seems  both  wind  and  tide 
might  be  against  them;  and  in  this  voluntary  work  there  were  times 
when  it  required  careful  management  to  show  the  people  that  the  work 
was  progressing. 

This  work  was  carried  on  under  the  voluntary  system  for  five  years. 
During  that  time  the  Health  Officer  who  laid  the  foundation  and  started 
the  work  was  taken  away  by  death  and  his  successor  was  appointed  by 
the  Federal  Government.  He  is  a  man  who  has  had  long  experience  as 
an  army  surgeon  in  the  Philippine  Islands  and  other  isolated  places. 

At  the  end  of  five  years,  we  found  that  we  were  getting  better  control 
of  contagious  diseases.  Parents  began  to  realize  that  when  children 
were  sick  something  was  the  matter  with  them  and  called  in  the  family 
physician,  which  greatly  aided  us  in  this  type  of  work.  School  children 
had  two  thorough  physical  examinations  during  the  year  and  a  great 
many  small  defects  found  were  corrected.  Dental  and  Well  Baby  Clinics 
were  established  and  the  splendid  results  from  these  clinics  gave  the 
work  a  stronger  hold  in  the  County. 

We  had  made  a  radical  change  in  the  milk  work  relative  to  the  con- 
ditions under  which  milk  was  produced.  Milk  regulations  were  drawn 
up  and  adopted  and  the  tuberculin  testing  of  cattle  was  started.  We 
were  able  to  guarantee  much  better  quality  milk,  especially  as  far  as 
cleanliness  went  at  that  time.  At  the  present  time,  Barnstable  County 
is  considered  100  per  cent  in  accredited  herds  of  cattle.  As  there  is 
always  a  certain  amount  of  "bootlegging"  in  this  work,  it  is  very  diffi- 
cult to  maintain  that  100  per  cent,  but  we  feel  we  are  gaining  on  that 
phase  of  our  work. 

A  survey  was  made  of  all  the  tide  waters  for  sewerage  disposal. 
Owing  to  the  fact  that  Cape  Cod  is  a  large  producer  of  shellfish,  we 
could  not  afford  to  have  any  contaminated  shellfish  areas.  With  the 
help  of  the  State  Department  of  Public  Health,  this  was  cleared  up  in 
a  most  satisfactory  manner. 

We  felt  at  this  time  that,  if  possible,  we  should  turn  the  voluntary 
district  over  to  a  County  Health  Unit,  believing  the  relation  of  one  town 
to  another,  and  having  only  one  connection  with  the  mainland,  war- 
ranted some  method  being  made  to  bring  this  about.  Proper  legislation 
was  decided  upon  and  at  the  cost  of  considerable  hard  work  on  the  part 
of  those  particularly  interested,  legislation  was  secured  for  Barnstable 
County,  allowing  the  County  Commissioners  to  appropriate  money  for 
public  health  work.  When  this  became  a  law,  it  lifted  the  burden  from 
those  who  had  been  fighting  for  five  years  to  maintain  the  voluntary 
system,  and  a  Health  Officer  and  Milk  and  Sanitary  Inspectors  were 
appointed  by  the  County  Commissioners  and  were  paid  from  the  County 
Treasury.  The  towns  were  assessed  their  proportionate  part  for  the 
expense  of  that  budget.  This  automatically  brought  the  fifteen  towns 
into  the  work  and  formed  the  first  county  health  unit  in  New  England, 
with  a  full-time  Health  Officer,  a  Milk  and  Sanitary  Inspector,  an 
assistant  Milk  and  Sanitary  Inspector,  and  nursing  service  for  all  of 
the  fifteen  towns. 

After  twelve  years,  those  who  have  been  active  in  promoting  this 
work  feel  the  expenditure  of  the  County's  money  is  justified  and  returns 
from  the  work  cannot  be  reckoned  in  dollars  and  cents.  We  find  it  is 
much  better  to  be  on  the  offensive  side  of  this  work  than  the  defensive 
side,  and  while  the  few  that  have  been  actually  engaged  in  this  work 
will  pass  out  of  the  picture  long  before  the  plans  that  were  made  in 
1920  will  reach  maturity,  we  believe  it  is  a  legacy  of  which  every  town 
should  be  proud.   To  sum  up  the  matter,  it  is  a  piece  of  slow,  tedious, 


ii8 

uphill  work.  It  is  not  a  one  man  job  or  a  job  for  a  group  of  men,  but 
must  be  brought  about  to  a  cooperative,  community  work  to  realize  the 
many  splendid  benefits  that  accrue  from  it.  The  following  lines  from 
Kipling  seem  to  me  to  cover  the  ground : 

"It  isn't  the  arms  or  the  armament, 
Or  the  funds  that  they  can  pay, 
But  the  close  cooperation, 
That  works  to  win  the  day. 

It  isn't  the  individual, 

Or  the  army  as  a  whole, 
But  the  everlasting  teamwork, 

Of  every  blooming  soul." 

SOUTHERN  BERKSHIRE  HEALTH  DISTRICT 

Frederick  S.  Leeder,  M.D.,  D.P.H.* 

For  some  years  it  has  become  increasingly  apparent  that  the  ultimate 
solution  of  rural  health  problems  in  Massachusetts  must  be  found  in 
the  combining  of  several  small  units  into  districts,  large  enough  to 
obtain  a  sufficient  number  of  people  to  support  economically  a  full-time 
health  service  with  trained  personnel.  Experience  elsewhere  in  the 
country  has  shown  that  from  20,000  to  25,000  people  is  a  feasible  group. 

This  thinking  was  given  an  added  incentive  when  the  Commonwealth 
Fund  of  New  York  City  became  interested  in  the  development  of  rural 
health  work  in  Massachusetts,  and  offered  through  the  State  Depart- 
ment of  Public  Health  financial  assistance  for  a  varying  number  of 
years  to  two  groups  of  small  towns  that  would  like  to  try  such  a  service. 
It  was,  of  course,  extremely  difficult  to  decide  on  just  which  group  of 
towns  to  select,  with  so  many  factors  such  as  area,  accessibility,  need 
and  promise  of  success  involved.  Finally  the  choice  of  the  first  unit 
centered  on  the  sixteen  towns  of  Alford,  Becket,  Egremont,  Great  Bar- 
rington,  Lee,  Lenox,  Monterey,  Mount  Washington,  New  Marlborough, 
Otis,  Richmond,  Sandisfield,  Sheffield,  Stockbridge,  Tyringham  and  West 
Stockbridge,  comprising  approximately  the  southern  half  erf  Berkshire 
County. 

In  this  group  of  towns  there  were  many  of  the  necessary  factors:  a 
reasonably  small  area,  a  population  of  some  22,000,  a  modern  hospital, 
a  tri-town  milk  control  laboratory,  a  visiting  nurse  association  com- 
prising six  towns,  and  from  the  standards  of  the  people  a  reasonable 
hope  for  a  successful  health  district. 

Largely  on  account  of  the  newness  of  the  idea  in  New  England  it 
was  felt  that  the  cost  of  the  Unit  for  the  first  year  at  least  should  be 
met  in  major  part  by  the  Fund,  with  the  exception  of  a  small  sum 
which  would  be  a  permanent  yearly  contribution  from  the  State  De- 
partment of  Public  Health  in  terms  of  part  of  the  health  officer's  sal- 
ary. The  project  will  have  been  shown  to  be  a  proven  success  when  over 
a  period  of  years  the  effectiveness  of  full-time  health  service  has  been 
so  demonstrated  that  the  towns  comprising  the  Health  District  have 
gradually  taken  over  the  costs,  and  the  district  become  locally  self- 
supporting. 

There  are  in  the  United  States  several  hundred  full-time  rural  health 
districts  but  they  are  all  on  the  county  basis,  and  as  such  embrace 
towns  accustomed  to  a  county  form  of  government.  How  much  different 
is  the  situation  in  rural  Massachusetts!    Not  only  are  the  counties 


*  When  in  February  1932,  fifteen  communities  in  the  southern  half  of  Berkshire  County  de- 
cided to  carry  on  cooperative  public  health  work,  Dr.  Leeder  was  selected  as  the  executive 
officer.  He  has  already  seen  the  Unit  through  the  early  formative  stages  and  has  laid  the 
foundation  for  a  more  complete  health  service  to  the  communities.  He  outlines  here  some  of  the 
early  problems  and  accomplishments. 


119 

either  too  large  or  too  populous,  but  as  well,  each  town  is  a  political 
unit  and  a  power  unto  itself,  unused  to  looking  towards  a  common  county 
seat.  The  problem  then  resolved  itself  in  this  new  Health  District 
into  that  of  fusing  sixteen  individual  units  of  government  into  a  com- 
pact group  banded  together  for  the  purpose  of  having  as  modern  and 
efficient  a  health  department  as  can  be  found  in  our  large  cities. 

The  first  step  in  organization  was  a  meeting  of  all  the  practicing 
physicians  in  the  area  for  the  purpose  of  presenting  the  whole  project 
with  its  aims  and  ideals  to  this  group,  which,  in  the  last  analysis,  con- 
stitutes the  backbone  of  any  health  program.  As  could  be  expected 
from  a  progressive  group  of  physicians,  the  idea  of  full-time  health 
service  was  accepted  unanimously,  and  it  was  voted  that  a  serious 
attempt  to  form  a  health  district  in  the  Southern  Berkshires  be  made. 
During  the  ensuing  months  the  boards  of  health  of  the  sixteen  towns 
were  seen  and  the  many  possibilities  of  the  proposed  district  talked 
over.  After  several  meetings  of  the  members  of  the  boards  of  health 
there  was  evolved  the  southern  Berkshire  Health  District,  which  com- 
prised about  the  southern  half  of  Berkshire  County.  The  boards  of 
health  joined  voluntarily,  feeling  that  the  towns  they  represented  de- 
served full-time  health  service,  and  on  the  understanding  that  if  after 
a  fair  trial  the  townspeople  did  not  want  it,  they  were  at  liberty  to 
withdraw.  It  is  pleasant  to  say  at  this  writing,  a  year  and  a  half  later, 
that  none  of  the  original  towns  have  withdrawn  and  one  town,  which 
at  the  time  of  the  inception  of  the  Unit,  wanted  more  time  to  observe 
the  work,  has  since  asked  for  admission  and  has  been  accepted. 

The  organization  has  been  kept  as  simple  as  possible  and  consists 
of  the  members  of  the  boards  of  health  of  the  sixteen  towns  as  an 
executive  committee.  They,  in  turn,  have  a  full-time  medical  health 
officer  to  act  as  their  executive  officer.  The  health  officer  is  part-time 
agent  of  the  board  of  health  of  each  of  the  several  towns  and  as  such 
can  act  for  the  board  of  health  in  each  of  the  towns,  and  moreover,  is 
responsible  to  the  board  of  health  of  the  town  in  which  any  action  is 
taken. 

It  is  obvious  that  if  sixteen  separate  units  of  government  combine 
there  is  bound  to  be  considerable  diversity  in  both  their  sanitary  codes 
and  their  communicable  disease  regulations.  There  are  few  things  in 
the  health  field,  with  the  possible  exception  of  nuisance  complaints, 
carrying  with  them  as  they  so  often  do,  neighborhood  quarrels,  that 
can  create  as  much  trouble  in  a  community  as  communicable  disease 
regulations  which  are  not  consistently  enforced,  or  differ  town  by  town. 
Mrs.  Jones  just  across  the  town  line  objects  strenuously  to  having  her 
little  Johnny  quarantined  for  five  weeks  for  scarlet  fever  when  on  the 
other  side  of  the  town  line  Mrs.  Brown's  little  Willie  is  restrained  only 
three  weeks  for  the  same  disease.  Just  this  variance  in  regulations 
existed  in  neighboring  towns  in  the  new  district  and  the  first  step  made 
was  to  have  each  of  the  sixteen  towns  adopt  the  same  sanitary  code  and 
communicable  disease  regulations.  Following  the  adoption  of  standard 
communicable  disease  regulations  came  the  need  for  uniform  enforce- 
ment. Previous  to  the  health  district  each  of  the  towns  enforced  its  own 
regulations  and  even  with  standard  regulations,  if  they  were  to  be 
interpreted  by  sixteen  different  towns,  there  was  bound  to  be  some 
differences  of  opinion  with  consequent  lack  of  uniformity.  This  was 
obviated  by  placing  the  complete  responsibility  of  the  administration 
of  the  health  regulations  on  the  medical  health  officer. 

Following  this  first  important  step  of  standardization  of  regulations 
the  Unit  Staff  could  turn  to  other  things.  In  the  sixteen  towns,  there 
already  existed  many  excellent  health  agencies,  both  voluntary  and 
official.  In  the  towns  of  Lee,  Lenox  and  Stockbridge  there  was  a  co- 
operative milk  control  service  under  the  direction  of  a  trained  milk- 
sanitary  inspector.  Great  Barrington  had  its  milk  control   service  using 


120 
the  laboratory  of  the  local  hospital  for  the  analysis  of  the  milk  samples. 
The  towns  of  Alford,  Egremont,  Sheffield,  New  Marlborough,  Monterey 
and  Great  Barrington  were  getting  the  efficient  services  of  the  Great 
Barrington  Visiting  Nurse  Association,  an  organization  already  past 
its  twenty-third  birthday  at  the  time  of  the  inception  of  the  Unit.  The 
towns  of  Lee,  Lenox,  Stockbridge  and  Richmond  all  had  their  own  local 
associations,  each  employing  a  single  nurse.  All  sixteen  towns  had  for 
their  use  the  Fairview  Hospital  of  Great  Barrington,  one  of  the  most 
modern  and  complete  hospital  units  that  it  is  possible  to  find.  There 
was  then  a  wealth  of  worth-while  health  projects  already  flourishing  in 
the  new  health  district,  projects  so  worth-while  that  it  was  obvious 
that  the  proper  niche  for  the  health  unit  was  not  to  supersede,  not  to 
replace,  but  instead  to  correlate,  supplement  and  expand. 

From  the  first  the  Unit  Staff  diligently  avoided  any  action  which 
might  be  interpreted  as  infringing  on  the  territory  of  already  existing 
organizations.  Every  effort  was  made,  however,  to  extend  to  them  com- 
plete cooperation  and  to  provide  service  to  the  towns  less  fully  equipped. 
Supervision  of  the  milk  supply  of  the  district  soon  received  attention, 
for  as  outlined  above,  while  existing  service  was  of  high  quality  it  cov- 
ered only  four  of  the  sixteen  towns.  Moreover,  none  of  the  towns  had 
applied  for  tuberculin  testing  of  all  cows.  Rather  than  disturb  the  two 
already  functioning  milk  inspection  services,  arrangements  were  com- 
pleted to  include  the  remaining  towns  in  the  tri-town  and  Great  Bar- 
rington milk  laboratories  for  milk  supervision.  The  milk  inspector  for 
Great  Barrington  extended  his  area  to  include  Alford,  Egremont,  Shef- 
field, Monterey,  New  Marlborough  and  Mount  Washington.  The  in- 
spector for  the  tri-town  unit  included  Richmond,  West  Stockbridge, 
Becket,  Otis,  Tyringham  and  Sandisfield.  At  an  early  date  then,  all  six- 
teen towns  were  getting  supervision  of  their  milk  supply.  Concurrent 
with  this  extension  of  service,  the  milk  sanitary  inspector  of  the  Unit 
canvassed  the  milk  producers  of  each  of  the  towns  and  obtained  signa- 
tures from  sufficient  of  them  to  insure  the  early  tuberculin  testing  of 
all  cows  in  the  health  district. 

Further  strides  were  made  in  sanitation  with  the  starting  of  inspec- 
tion and  supervision  of  summer  camps,  roadside  stands,  restaurants 
and  stores.  As  much  of  the  population  depended  on  wells  and  springs 
for  their  water  supply,  the  Unit  assumed  an  important  place  in  the 
supervision  and  protection  of  sources  of  water. 

Gradually  as  the  people  of  the  district  became  familiar  with  the  serv- 
ices available,  the  scope  of  the  Health  Department's  usefulness  wid- 
ened. The  occurrence  of  an  outbreak  of  infantile  paralysis  in  the  sum- 
mer and  fall  of  1931  demonstrated  to  a  large  degree  the  value  of  full- 
time  health  service.  Through  the  cooperation  of  the  State  Department 
of  Public  Health  and  the  Harvard  Infantile  Paralysis  Commission,  the 
director  of  the  Unit  received  special  instruction  in  the  early  pre- 
paralytic diagnosis  of  infantile  and  was  equipped  to  administer  con- 
valescent infantile  paralysis  serum,  a  supply  of  which  was  kept  on  hand 
at  the  Unit  headquarters  in  Great  Barrington.  This  was  the  first  in- 
tance  of  such  a  service  being  available  outside  the  large  cities  and  did 
much  towards  informing  the  people  of  the  district  about  the  Unit  and 
one  of  its  responsibilities — the  prevention  of  communicable  disease. 
Similarly  when  antipneumococcic  serum  for  the  treatment  of  lobar 
pneumonia  was  made  available  to  selected  areas  throughout  the  Com- 
monwealth, the  Southern  Berkshire  Health  District,  by  virtue  of  its  full- 
time  health  department,  was  chosen  as  one  of  these  areas. 

Meanwhile  the  nursing  service  was  extended  through  the  staff  nurses 
of  the  Unit  to  cover  all  services  except  assistance  at  home  deliveries 
to  the  towns  that  were  not  receiving  attention  from  any  other  associa- 
tion. These  towns  at  first  included  Becket,  Otis,  Sandisfield,  Tyring- 
ham and  West  Stockbridge.    Later  the  Richmond  Community  Health 


121 

Association  extended  its  field  to  include  the  neighboring  town  of  West 
Stockbridge;  New  Marlborough,  which  had  been  receiving  only  school 
nursing  from  the  Great  Barrington  Visiting  Nurse  Association,  changed 
to  full  service  from  the  Unit;  Mount  Washington  became  part  of  the 
Health  District  and  received  full  service  from  the  Unit  staff.  More 
demands  are  being  made  daily  on  the  nursing  division  and  in  many  of 
the  towns  periodic  well  child  medical  conferences  are  being  held.  In 
one  other  town,  in  response  to  the  need,  the  Unit  has  extended  its  nurs- 
ing field  to  include  assistance  to  physicians  at  home  deliveries. 

Believing  that  dental  health  is  a  vital  part  of  public  health,  the  Unit 
has  recently  increased  its  staff  by  the  addition  of  a  dental  hygienist 
and  is  offering  the  towns  supervision  of  the  dental  health  of  the  school 
and  preschool  children.  Where  indicated  arrangements  for  reparative 
work  have  been  made  with  local  organizations.  The  primary  aim  of  the 
Health  District  which  is  a  full-time  health  service  organized  and  staffed 
so  as  to  protect  adequately  the  health  of  the  people  is  rapidly  being  con- 
summated, and  as  one  looks  back  over  the  year  and  a  half  of  the  Unit's 
existence  one  cannot. help  but  feel  that  the  Southern  Berkshires  are 
in  the  vanguard  of  the  advance  in  public  health  methods  and  are  help- 
ing to  break  the  ground  for  adequate  rural  health  service,  not  only  fcr 
Massachusetts,  but  for  all  of  New  England. 

THE  NASHOBA  HEALTH  DISTRICT 

G.  Fletcher  Reeves,  M.D.* 

The  Nashoba  Health  District,  having  a  total  population  of  21,995  and 
an  area  of  287  square  miles,  is  composed  of  the  fourteen  towns  of  Ashby, 
Ayer,  Bolton,  Boxborough,  Dunstable,  Groton,  Harvard,  Littleton,  Lunen- 
burg, Pepperell,  Shirley,  Stow,  Townsend  and  Tyngsbordugh.  The  density 
of  population,  which  averages  76  per  square  mile,  varies  from  22  to  347. 
The  assessed  valuation  of  the  area  averages  $1,250  per  capita  as  com- 
pared with  the  state  average  of  $1,660  per  capita.  Near  the  geographical 
center  of  the  district  is  the  town  of  Ayer. 

The  idea  of  inter-town  cooperation  is  not  entirely  new  to  the  com- 
munities making  up  the  Nashoba  Health  District.  For  many  years  a 
majority  of  the  towns  have  been  united  into  school  districts  for  the  pur- 
pose of  enjoying  the  benefits  of  full-time  school  supervision.  Moreover, 
the  five  towns  of  Ayer,  Groton,  Harvard,  Littleton  and  Shirley  united  in 
the  building  of  the  Community  Memorial  Hospital  at  Ayer,  a  completely 
equipped  and  well-managed  institution  which  stands  as  a  worthy  me- 
morial to  the  cooperative  spirit  of  those  who  made  it  possible. 

The  Nashoba  Health  Unit  officially  started  its  work  on  April  1,  1931. 
Previous  to  that  time,  the  boards  of  health  of  the  fourteen  towns  con- 
cerned had  voluntarily  organized  themselves  into  the  Nashoba  Associated 
Boards  of  Health.  It  was  this  association  that  had  accepted  the  offer  of 
the  Commonwealth  Fund  of  New  York  City,  made  through  the  Mass- 
achusetts State  Department  of  Public  Health,  this  offer  being  one  of 
generous  financial  assistance  for  an  indefinite  but  limited  period  of  years 
in  the  development  of  efficient,  full-time  health  service  for  all  of  the 
fourteen  communities  working  together  as  one  district.  Together  with 
the  help  from  the  Commonwealth  Fund,  the  Associated  Boards  of  Health 
also  accepted  the  offer  of  the  State  Department  of  Public  Health  of  fi- 
nancial and  advisory  assistance  throughout  the  program. 

The  Associated  Boards  of  Health  selected  a  trained  medical  health 
officer  to  act  as  director  of  their  health  unit  and  gave  approval  to  his 
selections  of  subordinate  personnel.  To  facilitate  its  work,  the  Associated 


*  Doctor  Reeves  as  Medical  Director  of  the  Nashoba  Associated  Boards  of  Health  has  had 
immediate  charge  of  the  work  of  the  second  unit  assisted  by  the  Commonwealth  Fund.  He 
describes  here  some  of  the  problems  met  in  the  development  of  full-time  service  on  a  cooperative 
basis,  and  pictures  some  of  the  aims  of  the  Unit.  Prior  to  his  connection  here,  Doctor  Reeeves 
did  similar  work  in  a  county  unit  in  North  Carolina. 


122 
Boards  of  Health  created  within  itself  an  executive  committee  made  up 
of  one  member  from  each  of  the  local  boards  of  health.  This  executive 
committee  meets  once  a  month  in  Ayer  with  the  director  of  the  health 
unit.  The  association  as  a  whole  meets  four  times  a  year,  holding  its 
meetings  in  the  various  towns  in  alphabetical  rotation.  This  constant 
change  of  meeting  place  gives  an  opportunity  for  the  public  to  attend 
the  general  meeting  following  the  discussion  of  business,  this  general 
meeting  serving  as  a  local  source  of  information  and  health  education. 
The  chairman,  vice-chairman  and  secretary-treasurer  of  the  association 
serve  in  the  same  offices  on  the  executive  committee. 

The  first  step  in  planning  the  program  for  the  new  health  unit  was 
the  making  of  an  appraisal  survey  of  the  existing  health  activities  in  the 
fourteen  towns.  This  was  done  by  Dr.  W.  F.  Walker,  then  of  the  American 
Public  Health  Association,  in  accordance  with  that  organization's  "Rural 
Appraisal  Form."  It  was  on  the  basis  of  Doctor  Walker's  report  that 
subordinate  personnel  for  the  unit  were  chosen,  to  fill  the  positions  of 
advisory  nurse,  staff  nurses  (two),  milk-sanitary  inspector,  laboratory 
technician,  and  office  secretary. 

In  the  selection  of  office  headquarters,  the  factors  of  central  location 
and  means  of  communication  and  transportation  to  all  parts  of  the  area 
were  considered.  For  these  reasons  Ayer  was  chosen  as  the  "center"  of 
the  area.  Here,  through  the  generosity  of  the  local  board  of  health,  office 
space  was  provided  in  the  town  hall. 

At,  and  in  cooperation  with,  the  Community  Memorial  Hospital  in 
Ayer  the  health  unit  established  a  laboratory  and  furnished  the  services 
of  a  full-time  technician.  At  this  laboratory,  routine  clinical  work  is  done 
for  the  hospital,  communicable  disease  diagnostic  work  for  the  physicians 
in  the  area,  and  milk  and  water  analyses  for  the  health  unit. 

From  the  start  every  effort  has  been  made  to  integrate  the  activities  of 
the  health  unit  with  those  of  each  of  the  local  boards  of  health.  The  di- 
rector of  the  health  unit  has  been  appointed  agent  for  each  of  the  local 
boards,  thus  giving  him  legal  status.  Similarly,  the  health  unit's  sanitary 
inspector  has  been  appointed  inspector  for  each  of  the  fourteen  towns. 

While  these  efforts  were  being  made  to  take  the  unit's  work  into  each 
of  the  communities,  plans  were  on  foot  to  correlate  the  activities  in  com- 
municable disease  control  and  health  preservation  in  the  several  towns 
so  that  a  unified  program  might  be  carried  on  by  the  area  as  a  whole. 
Such  unified  activity  is,  of  course,  the  only  way  to  attack  problems  not 
confined  to  political  boundaries  or  civil  districts.  The  first  important 
step  in  this  process  of  coordination  was  the  adoption  by  each  of  the  four- 
teen boards  of  health  of  a  set  of  minimum  rules  and  regulations  patterned 
after  the  suggestions  made  by  the  State  Department  of  Public  Health 
and  the  Massachusetts  Association  of  Boards  of  Health.  These  regula- 
tions have  been  officially  adopted  and  in  their  operation  are  doing  much 
to  bring  the  fourteen  boards  of  health  together  in  their  work  of  quaran- 
tine and  isolation  of  communicable  diseases  and  in  the  control  of  the  food 
and  milk  supplies,  general  sanitation,  and  nuisances. 

Although  the  activities  of  the  health  unit  may  be  divided  into  adminis- 
tration, epidemiology,  public  health  nursing,  and  general  sanitation,  in- 
cluding milk  control,  it  must  be  remembered  that  in  actual  practice  the 
unit's  different  activities  are  closely  dovetailed  one  with  the  other.  Each 
member  of  the  staff  through  the  medium  of  frequent  informal  staff  con- 
ferences has  a  clear  conception  of  the  program  as  a  whole  as  well  as  his 
part  in  it. 

The  duties  of  the  director  of  the  health  unit  are  manifold.  As  director 
of  a  group  of  workers,  he  must  direct  each  worker  in  planning  and  ex- 
ecuting his  part  in  the  organization's  program.  As  a  medical  health 
officer,  the  director  acts  as  epidemiologist  for  his  district,  contacting 
cases  of  communicable  disease  both  for  purposes  of  diagnosis  (as  a 
service  to  the  attending  physicians)  and  for  purposes  of  quarantine  or 
isolation  as  required  by  the  uniform  rules  and  regulations  of  the  several 


123 
boards  of  health.  As  agent  for  these  boards  of  health,  the  director  must 
keep  in  touch  with  the  problems  of  the  individual  towns.  As  a  physician 
in  the  area,  the  director  stands  in  a  very  important  relationship  to  the 
practicing  physicians  of  the  district  whom  he  frequently  serves  as  a  con- 
sultant and  with  whom  he  works  on  their  common  problems  of  profes- 
sional improvement  and  service  to  the  public.  Next,  the  director  must 
play  the  part  of  a  vital  statistician,  collecting  area-wide  vital  and  mor- 
bidity statistics  and  case  records.  Once  collected,  he  must  see  to  it  that 
this  material  is  used  to  the  best  advantage  for  the  planning  of  future  pro- 
grams. Someone  has  well  said  that  these  statistics  serve  the  wide-awake, 
energetic  health  officer  as  a  "health  barometer"  of  his  community.  Fi- 
nally, upon  the  health  unit's  director  falls  the  responsibility  for  interpret- 
ing his  organization  to  the  local  public  and  for  conducting  an  efficient 
program  of  popular  health  instruction. 

When  the  health  unit's  advisory  nurse  began  her  work,  she  found  more 
or  less  active  nursing  programs  already  in  existence  in  the  area.  These 
programs,  however,  were  not  coordinated,  each  depending  for  its  quality 
entirely  upon  the  particular  nurse  in  charge  and  upon  her  local  supporting 
committee,  if  any.  All  of  the  fourteen  towns  carried  on  school  nursing 
work  as  required  by  law,  while  nine  of  the  fourteen  had  full-time  com- 
munity nurses  who  spent  a  large  part  of  their  time  in  bedside  service. 
Of  these  nine  nurses  only  one  was  under  the  direction  of  a  private  visit- 
ing nurse  organization.  That  active  programs  had  been  here  and  there 
developed  speaks  well  for  the  ambition  and  foresightedness  of  the  in- 
dividual nurses  working  in  the  different  towns  and  for  the  influence 
brought  to  bear  upon  these  nurses  by  both  local  and  outside  groups.  In 
order  to  supplement  incomplete  local  programs,  the  unit  secured  the  ser- 
vices of  two  staff  nurses.  The  work  of  the  advisory  nurse  is  that  of 
helping  the  local  nurses  to  become  acquainted  personally  and  to  learn 
of  one  another's  professional  programs,  of  correlating  these  programs, 
and  of  bringing  them  up  more  nearly  to  accepted  standards.  All  this 
will  of  course  take  considerable  time.  One  of  the  first  steps  toward  this 
goal  is  now  being  taken  by  instituting  uniform  record  systems  for  each 
of  the  local  nurses.  These  records  are  being  worked  out  in  conjunction 
with  the  Division  of  Health  Studies  of  the  Commonwealth  Fund  of  New 
York  City. 

Milk  inspection  and  sanitary  programs  had  from  the  start  the  advan- 
tage of  a  clear  field,  there  being  no  previous  service  of  this  kind  any- 
where in  the  Nashoba  Health  District.  The  program  as  now  established 
consists  of  the  routine  inspection  of  all  retail  dairies,  of  which  there 
are  some  eighty  serving  the  district,  the  inspection  of  the  thirteen  pas- 
teurizing plants  in  the  area,  and  the  collection  of  milk  samples  at  regular 
intervals  for  laboratory  determinations  of  butter  fat,  total  solids,  and 
bacteria.  Only  about  twenty  per  cent  of  the  milk  consumed  in  the  Nashoba 
District  is  pasteurized.  In  this  connection,  it  is  well  to  remember  that 
pasteurization  is  probably  the  greatest  safeguard  which  can  be  applied  to 
a  milk  supply,  inspection  alone,  even  of  the  highest  type,  being  helpless 
to  detect  the  occasional  entrance  of  dangerous  bacteria  into  the  milk 
from  some  disease  carrier. 

In  line  with  the  milk  inspection  program,  the  fostering  and  encourag- 
ing of  the  state  tuberculin  testing  of  cattle  is  being  carried  on,  more 
than  seventy-five  per  cent  of  the  cattle  owners  in  thirteen  of  the  four- 
teen towns  having  already  applied  for  the  test.  The  eradication  of  bovine 
tuberculosis  is  both  a  matter  of  agricultural  economics  and  a  significant 
step  toward  safeguarding  the  public  (particularly  children)  from  the 
ravages  of  tuberculosis. 

The  health  unit's  sanitary  inspector  makes  periodic  visits  to  local 
public  food  handling  establishments,  such  as  restaurants,  bakeries,  road- 
side stands,  markets,  and  stores.  Attention  is  also  given  to  summer 
camps.  Through  its  sanitary  inspector,  the  health  unit  attempts  to  give 
advisory  service  to  citizens  throughout  the  district  on  problems  of  private 


124 

water  supply  and  private  sewage  disposal.  These  are  particularly  impor- 
tant problems  in  rural  areas  where  public  supplies  and  systems  are  not 
available.  Samples  of  water  for  analysis  are  collected  by  the  unit's  in- 
spector and  done  either  at  the  local  laboratory  or,  upon  occasion,  sent  to 
the  laboratory  of  the  State  Department  of  Public  Health. 

An  attempt  has  been  made  in  this  article  to  describe  the  so-called 
Nashoba  Health  District,  to  tell  of  the  voluntary  organization  effected  by 
the  fourteen  boards  of  health  concerned,  and  to  enumerate  the  activities 
of  the  health  unit's  staff  of  full-time  workers.  What  are  the  unit's  aims? 
They  may,  perhaps,  be  outlined  as  follows : 

1.  Correlating  the  many  local  health  programs; 

2.  Supplementing  these  local  workers,  when  necessary,  with  additional 
staff  members  so  that  a  unified  and  balanced  public  health  program 
may  be  evolved  for  the  Nashoba  District  as  a  whole; 

3.  Demonstrating  to  the  citizens  of  the  several  towns  the  economic  as 
well  as  the  physical  advantage  of  providing  for  themselves  a  suit- 
able program  of  local  health  work;  and 

4.  The  carrying  on  under  local  auspices  of  the  district  health  unit  as  a 
permanent  local  activity  giving  adequate  service  to  each  of  the 
communities  making  up  the  health  district. 

In  what  better  way  than  through  this  program  of  inter-town  coopera- 
tion could  these  fourteen  boards  of  health  try  to  serve  their  respective 
communities  ? 

THE  EVALUATION  OF  RURAL  HEALTH  WORK 

W.  F.  Walker,  D.P.H.* 

The  ultimate  evaluation  of  health  services,  whether  related  to  rural 
or  urban  communities,  must  cf  necessity  be  made  in  relation  to  the  ob- 
jectives of  all  health  work.  We  may  set  up  at  least  three  quite  definite 
objectives  of  community  services  for  health  protection  and  promotion. 

First  may  be  mentioned  an  increase  in  the  span  of  life.  This  is  the 
most  commonly  heard  objective  of  a  public  health  program.  It  is  an 
aim  which  naturally  appeals  to  most  of  us  and  which  has,  through  the 
interest  and  activities  of  life  insurance  companies,  played  a  tremen- 
dous part  in  stimulating  the  development  of  public  health  programs. 

The  second  commonly  stated  objective  of  local  public  health  work  is 
increase  in  human  efficiency.  While  the  rank  and  file  of  individuals 
may  not  be  so  conscious  of  the  importance  of  this  particular  product  of 
lecal  public  health  work,  industry  as  a  unit,  through  the  reduction  of 
disease  (tuberculosis,  malaria,  hookworm,  etc.),  has  been  impressed 
with  and  has  profited  by  the  increased  and  easier  production  of  the 
individual  worker. 

The  third,  and  possibly  the  most  important  result  of  improved  indi- 
vidual and  community  health,  is  increased  enjoyment  of  living.  We 
all  experience,  but  only  occasionally  appreciate,  the  satisfaction  and 
contentment  when  we  ourselves  are  free  from  bodily  ills  and  our  fami- 
lies and  friends  likewise  are  not  incapacitated  by  disease.  The  fear 
and  attendant  depressing  effects  of  even  mild  diseases  in  epidemic  form 
rob  families  and  communities  of  that  freedom  of  action  necessary  to 
an  enjoyable  existence. 

Though  all  these  are  acknowledged  objectives  of  a  general  health  pro- 
gram they  are  so  intangible  as  to  necessitate  the  setting  up  of  certain 
indices  which  are  in  themselves  sufficiently  objective  to  be  measured 
and  which  it  is  believed  reflect  the  movement  of  the  whole  population 
toward  or  away  from  these  desirable  ends. 

*  Dr.  Walker,  who  is  Director  of  the  Division  of  Health  Studies  of  the  Commonwealth  Fund 
of  New  York  City,  has  had  a  singularly  broad  experience  in  the  study  and  evaluation  of  public 
health  programs.  Serving  for  a  number  of  years  as  Field  Secretary  for  the  American  Public 
Health  Association,  his  work  took  him  to  all  sections  of  the  United  States,  giving  him  an  oppor- 
tunity for  first-hand  observation  of  the  merits  and  failings  of  countless  health  departments.  In 
this  article  he  discusses  methods  of  determining  the  adequacy  pf  the  health  program  of  a 
community, 


125 

The  first  objective,  namely  increased  span  of  life,  may  be  measured 
and  determined  quite  accurately  by  a  careful  compilation  of  mortality 
statistics,  indicating  the  age  at  which  death  occurs  in  the  various  mem- 
bers of  the  population.  That  we  have  extended  the  average  span  of 
human  life  by  nearly  nine  years  since  1900,  is  a  significant  fact  and 
indicates  the  gross  effectiveness  of  our  efforts  in  the  control  of  the  com- 
municable diseases,  particularly  diseases  responsible  for  deaths  in  the 
early  years.  This  index,  however,  is  a  very  coarse  measure  of  a  public 
health  program  and  one  which  requires  a  considerable  lapse  of  time 
between  the  initiation  of  a  program  and  the  measurement  of  its  result. 

The  second  objective,  increase  of  efficiency,  may  be  indicated  by 
change  in  the  morbidity  rate  of  a  community.  Through  the  reporting 
of  communicable  diseases  and  a  few  scattered  studies  of  the  general 
incidence  of  incapacitating  illnesses,  we  are  beginning  to  have  some 
slight  comprehension  of  the  sickness  toll  among  various  groups  of  our 
population.  With  the  acute  communicable  diseases,  especially  those 
which  have  high  fatality  rates  and  whose  presence  in  the  community 
galvanizes  the  citizens  into  action  to  demand  protective  and  preventive 
measures,  reporting  has  become  a  sufficiently  well  established  practice 
to  permit  us  to  judge  the  progress  of  a  community  or  state  in  the  con- 
trol of  such  diseases  through  the  trend  of  incidence  over  a  period  of 
years.  However,  it  is  too  late  to  initiate  preventive  measures  when  the 
storm  of  the  epidemic  is  upon  us.  We  must  develop  and  have  at  hand 
some  measures  of  community  protection  which  will  render  the  popula- 
tion safe  though  there  be  disease  prevalent  in  adjoining  areas.  We  will 
need  then  indices  of  the  extent  to  which  these  protective  measures 
have  been  developed  and  are  available.  The  reporting  of  the  less  acute 
communicable  diseases,  malaria,  tuberculosis  and  syphilis,  and  of  the 
chronic  diseases,  is  still  too  far  from  complete  to  be  of  much  value  as 
an  index  of,  incidence. 

For  the  third  objective,  namely  increased  enjoyment  of  living,  there 
is  no  tangible  and  objective  index  as  yet  developed.  Neither  mortality 
nor  morbidity  rates  are  sufficiently  sensitive  to  indicate  our  progress 
toward  the  full  well-rounded  pleasurable  life.  We  must  promote  and 
carry  on  health  activities  designed  to  increase  the  well-being  of  the 
individual,  the  community  and  the  state,  knowing  that  certain  inter- 
mediate results  which  affect  definitely  the  health  of  the  individual, 
will  presumably  bring  about  the  ultimate  attainment  of  this  goal. 

The  development  of  local  health  work  on  a  sound  and  scientific  basis 
makes  it  necessary  for  the  health  officer  to  have  some  more  ready 
means  at  hand  than  gross  morbidity  and  mortality  rates  by  which  to 
evaluate  his  work,  to  measure  the  progress  in  the  development  of  local 
service,  and  to  gauge  quickly  the  adequacy  of  local  efforts  in  relation 
to  the  common  health  problems  of  the  community. 

After  years  of  study  of  health  services,  both  urban  and  rural,  by  the 
various  official  and  voluntary  health  agencies,  including  the  United 
States  Public  Health  Service,  there  has  been  gradually  crystallized 
through  the  work  of  the  Committee  on  Administrative  Practice  of  the 
American  Public  Health  Association,  a  list  of  criteria  which  it  is  be- 
lieved forms  a  reasonably  sound  basis  for  judging  the  character  of  ser- 
vice rendered  in  each  of  the  several  functions  which  are  common  to  the 
health  program  of  most  communities. 

Local  activities  in  the  control  of  communicable  diseases,  for  example, 
may  be  judged  by  the  number  of  immunizations  performed  against 
diphtheria  or  vaccinations  against  smallpox,  the  number  of  cases  of 
communicable  disease  reported  per  death,  and  the  nursing  visits  made 
for  the  instruction  of  a  family  regarding  precautions  to  be  taken  in  the 
handling  of  a  case  in  the  home.  The  number  of  cases  of  tuberculosis, 
recognized  and  brought  under  medical  and  nursing  supervision,  either 
in  the  home  or  in  suitable  sanatoria,  is  undoubtedly  an  index  of  the 
character  of  that  service. 


126 

The  proportion  of  mothers  and  infants  known  to  be  under  competent 
medical  and  nursing  supervision  will  reflect  the  extent  to  which  the 
community  is  conscious  of  the  health  hazards  of  these  two  periods  and 
has  set  up  facilities  so  that  no  mother  or  baby  need  go  without  medical 
or  nursing  service. 

Similar  indices  may  be  found  for  the  sanitary  conditions,  the  per- 
centage of  the  population  supplied  with  safe  drinking  water,  the  num- 
ber of  homes  connected  with  sewers  or  other  satisfactory  means  of 
excreta  disposal,  the  proportion  of  the  milk  supply  of  urban  com- 
munities which  is  pasteurized  and  the  extent  of  the  routine  supervision 
of  milk  production. 

This  list  of  criteria  which  touches  every  phase  of  a  well-rounded 
rural  health  program  is  known  as  an  Appraisal  Form.*  It  combines  a 
series  of  questions  designed  to  call  forth  information  concerning  the 
most  important  phases  of  service  in  each  function,  with  a  set  of  stand- 
ards for  judging  the  adequacy  of  the  service.  These  standards  have 
been  derived  from  actual  experience  in  the  field. 

The  plan  has  been  to  dip  into  each  activity  and  look  at  certain 
selected  samples  of  service  and  from  these  judge  the  worth-whileness 
of  the  whole.  The  standards,  as  originally  set  up,  were  based  upon  the 
group  judgment  of  a  considerable  number  of  individuals  thoroughly 
familiar  with  the  problems  of  urban  and  rural  health  administration. 
Within  the  last  year  the  standards  of  the  rural  form  have  been  revised 
as  the  result  of  a  survey  of  nearly  400  counties  and  the  standards  are, 
in  general,  now  set  at  the  median  of  the  better  half  of  reported  experi- 
ence; that  is,  in  each  item  25  per  cent  of  the  counties  equal  or  exceed 
the  standard.  To  make  scoring  simple,  more  or  less  arbitrary  values 
have  been  assigned  to  the  items.  These  values  represent  the  group 
judgment  of  the  committee  members,  having  in  mind  both  the  effective- 
ness of  the  particular  service  in  a  community  health  program  and  abil- 
ity to  measure  it  with  any  degree  of  accuracy.  It  must  be  pointed  out 
that  these  relative  values  are  transient  and  will  of  necessity  be  changed 
from  time  to  time  as  public  health  work  advances  or  as  newer  knowl- 
edge influences  procedure. 

Those  who  have  had  the  development  of  the  Appraisal  Form  in  hand 
have  given  much  consideration  to  the  nature  of  the  information  to  be 
collected.  They  have  sought  to  avoid  the  collection  of  figures  and  sta- 
tistics as  an  end  in  itself  and  have,  on  the  other  hand,  endeavored  to 
give  to  the  health  officer,  through  objective  criteria  and  standards  re- 
lated to  the  problem  and  through  relative  values  based  on  group  judg- 
ment, a  tool  for  analyzing  past  performances  and  for  developing  future 
programs. 

For  this  purpose  the  entire  field  of  public  health  service  has  been 
divided  into  four  broad  classifications: 

(1)  Vital  statistics; 

(2)  Preventable    disease    activities,    covering   the    acute    communi- 
cable diseases  and  also  tuberculosis  and  the  venereal  diseases ; 

(3)  Activities  for  the  promotion  of  the  health  of  the  individual 
including  maternal,  infant,  preschool  and  school  hygiene; 

(4)  Sanitation,  dealing  with  the  control  of  the  environment,  in- 
cluding milk,  food  and  water  supplies  and  sewage  disposal. 

Following  such  a  guide  enables  one  to  judge  the  comprehensiveness 
and  the  balance  of  the  public  health  program  as  a  whole,  in  a  particu- 
lar local  area.  In  judging  the  details  of  a  particular  service,  for 
example,  maternal  hygiene,  it  is,  for  the  sake  of  convenience,  broken 
up  into  five  subdivisions:  (a)  obstetrical  service,  (b)  medical  con- 
ferences for  the  promotion  of  prenatal  hygiene,  (c)  nursing  service  for 
prenatal  cases,  (d)  laboratory  service,  and  (e)  community  health  edu- 
cation regarding  maternal  hygiene. 


*  The  Appraisal  Form  for  Rural  Health  Work,  2nd  edition,  may  be  obtained  from  the  Ameri- 
can Public  Health  Association. 


127 

Obstetrical  service  may  be  judged  by  the  availability  and  the  exten- 
sive use  of  hospitals  for  delivery  purposes,  the  presence  and  use  of  an 
organized  home  nursing  service  at  time  of  delivery,  and  the  supervision 
of  midwives.  In  a  similar  manner,  the  number  of  mothers  known  to  be 
under  medical  supervision  during  the  prenatal  period  and  the  months  of 
pregnancy  when  they  came  under  supervision,  together  with  the  extent 
of  this  supervision  as  indicated  by  the  number  of  visits,  are  certainly 
indicative  of  the  community's  attitude  toward  and  interest  in  medical 
care  in  the  prenatal  period.  The  percentage  of  mothers  receiving  nurs- 
ing supervision  in  the  prenatal  and  postpartum  period  and  the  char- 
acter of  cooperation  of  the  physicians  of  the  community  and  the  nurs- 
ing staff,  reflect  the  adequacy  of  this  service.  The  value  of  laboratory 
service  in  this  connection  may  be  measured  in  terms  of  numbers  of 
urinalyses  and  routine  serological  examinations  for  syphilis.  The  pro- 
gram of  community  education  may  be  judged  in  part  by  the  distribu- 
tion of  literature  and  the  number  of  persons  reached  through  lectures, 
talks  and  other  group  contacts  for  the  discussion  of  matters  in  pre- 
natal hygiene. 

It  is  unquestionably  true  that  these  criteria  and  the  standards  associ- 
ated with  them  do  not  necessarily  reflect  quality  of  service.  It  is  also 
a  fact  that  to  reach  continuously  the  number  of  mothers  which  would 
entitle  a  community  to  a  high  rating,  the  service  must  possess  real 
merit.  The  mother  must  feel  when  she  goes  to  the  clinic  or  consults 
her  private  physician  that  she  is  obtaining  helpful  information  and 
beneficial  guidance.  In  a  similar  manner,  unless  the  nurse  who  visits 
her  in  her  home  or  cares  for  her  in  the  postpartum  period  renders  real 
service,  the  whole  program  is  apt  to  fall  through  because  of  lack  of 
public  interest.  Neither  the  printing  of  the  Appraisal  Form  nor  its 
application  to  a  particular  community  can  insure  the  quality  of  indi- 
vidual nursing  service.  However,  other  agencies  and  forces  are  work- 
ing in  this  direction  and  it  is  believed  they  are  making  definite  progress 
on  the  standardization  of  content  of  nursing  visits,  and  that  for  this 
reason  the  measure  of  the  average  intensity  per  case  carried  does  re- 
flect to  some  degree  the  quality  of  local  service. 

In  a  similar  manner  we  find  difficulty  in  evaluating  educational  ser- 
vices under  the  several  activities.  The  argument  is  raised  that  we  can- 
not know  the  worth-whileness  of  material  presented  in  pamphlets,  the 
content  of  talks  or  the  newspaper  items,  but  with  much  excellent  ma- 
terial so  readily  available  from  various  state  and  national  agencies  it  is 
believed  that  some  indication  of  the  character  of  local  effort  may  be 
gained  by  analyzing  the  numbers  of  pamphlets  distributed,  lectures  and 
talks  given,  and  the  number  of  newspaper  articles  published.  So  far 
as  possible,  newspaper  publicity  should  be  considered  in  the  way  in 
which  the  news  items,  relating  to  particular  services,  are  turned  to  the 
advantage  of  the  health  department.  It  seems  sound  to  expect  that  the 
local  infant  mortality  rate  might  be  used  as  a  means  of  interesting 
people  in  the  activities  of  the  department,  that  general  advice  and  in- 
formation on  infant  hygiene  may  be  attractively  presented,  and  that 
the  local  program  on  infant  hygiene  may  be  presented,  using  a  particu- 
lar school  or  community  or  even  a  personality  as  the  news  vehicle. 
Obviously,  the  rating  values  on  such  items  must  be  low  since  we  have 
no  direct  way  of  measuring  the  direct  effect  of  the  service. 

A  common  defect  of  the  development  of  local  health  work  in  earlier 
years  was  the  promotion  of  certain  activities  to  the  exclusion  of  others. 
The  committee  in  charge  of  the  development  of  the  Appraisal  Form 
has  felt  that  one  cf  its  major  stimuli  might  be  toward  the  working  out  of 
a  balanced  program.  Though  it  is  recognized  that  developments  in  a 
particular  community  may  not  be  kept  level  at  all  times  and  it  is  prob- 
ably unsound  to  try  to  push  all  services  equally,  there  is  a  distinct  dis- 
advantage when   one  or  more   services   are   entirely  neglected  while 


128 
others  are  built  up  to  a  high  degree  of  efficiency.  Such  neglect  fre- 
quently conies  from  lack  of  interest  on  the  part  of  the  health  officer 
or  from  some  definite  local  obstacle  that  needs  extra  effort  to  overcome 
or  from  failure  to  recognize  local  need.  Because  of  the  importance 
which  a  balanced  program  is  believed  to  hold,  the  scoring  of  services 
as  a  whole  has  been  placed  on  the  basis  of  950  points  out  of  a  possible 
1,000  with  a  certain  additional  credit,  if  each  activity  has  been  de- 
veloped, to  50  per  cent  or  better. 

The  accompanying  table  shows  the  major  section  of  the  Appraisal 
Form,  the  weighting  factor  or  relative  value  assigned  to  each  and  the 
schedule  of  credit  for  a  balanced  program.  It  will  be  noted  that  vital 
statistics,  or  the  bookkeeping  of  public  health,  gets  5  per  cent  of  the 
score;  activities  for  the  prevention  of  disease  2.5  per  cent,  health  pro- 
motion activities  41  per  cent,  community  sanitation  16.5  per  cent,  and  a 
balanced  program,  which  takes  into  consideration  each  of  these  func- 
tions in  its  relative  importance  5  per  cent. 

A  function  of  the  appraisal  principle,  which  was  not  originally  an- 
ticipated, is  its  use  as  a  handbook  of  local  health  administration.  Based, 
as  it  is,  upon  the  judgment  of  a  representative  group  as  to  what  are 
the  important  items  in  each  phase  of  a  local  program,  and  carrying 
standards  which  are  drawn  from  field  experience,  the  health  officer 
cannot  go  far  wrong  in  following  it  in  promulgating  local  work.  Peri- 
odic analysis  of  his  work,  as  a  whole  or  in  any  of  the  fields,  will  quickly 
show  what  advances  have  been  made  and  what  is  still  to  be  done.  The 
periodic  use  of  the  Appraisal  Form  is,  in  general,  like  asking  the  com- 
mittee which  has  had  its  development  in  mind  to  come  in  and  look  over 
a  health  department  with  you.  They  would  inevitably  ask  the  same  or 
similar  questions  in  about  the  same  way  and  judge  the  adequacy  of 
service  on  practically  the  same  standard,  not  because  these  questions 
have  been  arbitrarily  agreed  upon  but  because  they  represent  the 
crystallization  of  what  is  best  in  rural  health  administration  at  the 
moment. 

The  appraisal  of  a  county  or  rural  area,  which  is  about  to  be  organ- 
ized as  a  whole  time  unit,  is  to  the  incoming  health  officer  an  inventory 
of  his  stock  on  hand.  It  provides  him  and  the  state  department  alike 
with  a  mark  from  which  progress  may  be  measured.  The  change  in 
score  from  year  to  year,  though  an  arbitrary  basis  for  expressing  local 
health  status,  is  one  readily  understood  by  the  public  generally,  par- 
ticularly the  business  interests  in  the  community,  and  may  be  used 
with  the  supporters  of  the  health  department  as  well  as  the  appropri- 
ating body  to  interpret  progress  and  indicate  the  as  yet  unfilled  need. 
Honestly  and  thoughtfully  applied  by  the  health  officer  himself,  it  gives 
him  a  dispassionate  view  of  the  development  of  his  local  program  and 
indicates  those  places  where  attention  should  next  be  focused  if  he  is 
to  devote  uniform  attention  to  all  problems  and  clearly  set  forth  for 
his  staff  their  successes  and  failures  within  the  year. 

Points  X  =  Total 

assigned    Weighting    Per  cent      weighted 
SECTIONS  activities         factor        of  total  score 

I.    Vital  Statistics  100 

II.    Preventable  Disease  Activities 

A.  Acute  Communicable  Diseases  100 

B.  Venereal  Diseases  100 

C.  Tuberculosis  100 

D.  Other  Diseases  (no  score) 
III.    Activities   for  the   Promotion   of 

Hygiene  of  the  Individual 

A.  Maternal  Hygiene  100 

B.  Infant  Hygiene  100 

C.  Preschool  Hygiene  100 

D.  School  Hygiene  100 


.50 

5. 

50 

32.5 

1.70 

170 

.55 

55 

1.00 

41.0 

100 

.90 

90 

.90 

90 

.90 

90 

1.40 

140 

129 


SECTIONS 


Points  X 

assigned     Weighting 
activities         factor 


—  Total 

Per  cent       weighted 
of  total  score 


IV.    Sanitation  Activities 

A.  General  Sanitation,  includ- 
ing Water  Supply  and  Ex- 
creta Disposal 

B.  Activities  for  the  Protection 
of  Food  and  Milk 

Total 
Credit  allowed  for  balanced  program : 


16.5 


100 


100 


.90 


90 


.75 

75 

9.50 

5. 

950 

100.0 


If  each  activity  attains  a  rating  of  50  per  cent  or  better  of  the  points 
assigned  and  the  score  of  all  activities  is  900  or  more,  add  50  points  to 
total  weighted  score.   Grade  down  as  follows: 


Weighted  score 

Add  to  weighted 

all  activities 

score 

900     . 

50  points 

800     . 

40 

700     . 

30 

600     . 

20 

500     . 

10 

Less  than  500              . 

0 

MEDICAL  PRACTICE  IN  RURAL  AREAS 

Frank  H.  Washburn,  M.D.,  F.A.C.S.* 

Medicine  is  usually  defined  as  the  "science  which  relates  to  the  cure, 
prevention,  or  alleviation  of  disease." 

If  we  consider  science  exact  knowledge,  or  "ascertain  truth"  we  must 
admit  that  medicine  involves  much  that  is  not  strictly  scientific,  and  its 
practice  is  truly  an  art.  While  there  may  be  many  cults,  there  can  be  but 
one  true  medicine,  that  embracing  all  known  truth  regarding  disease. 

Rural  and  urban  practice  are  fundamentally  the  same.  The  medical 
needs  of  the  rural  populace  differ  in  no  essential  from  those  of  the  city. 

Recalling  the  old  order  of  society  in  our  New  England  countryside, 
one  can  but  miss  from  his  mental  picture,  the  old  family  practitioner  of 
protean  function.  Here  and  there  we  still  find  living  those  who  have  rid- 
den in  his  saddle  or  stanhope,  but  as  they,  one  by  one,  go  to  their  reward, 
there  seems  difficulty  in  replacing  them.  So  far  as  they  have  been  replaced 
in  the  past  few  decades,  it  has  been  by  a  transitional  type. 

The  country  practitioner  of  former  days  was  trusted  custodian  of  cur- 
rent knowledge  of  all  pertaining  to  health  and  disease.  Empirical  to  some 
extent,  his  therapeutics  were  favorably  enhanced  by  a  firm  faith  on  the 
part  of  both  doctor  and  patient.  He  was  the  hygienist  of  his  time  and 
usually  the  local  health  official,  directing  the  prophylactic  measures  then 
known,  or  believed,  to  be  effective. 

Accoucheur  at  birth,  trained  nurses  not  available,  he  did  many  things 
now  delegated  to  them.  He  resuscitated  the  baby  manually,  saw  it  through 
cholera  infantum  in  summer  and  croup  in  winter;  the  child  through  the 
long  gamut  of  infectious  diseases  then  prevalent;  and  the  youth  through 
typhoid  and  other  diseases.  He  diagnosed  fractures  by  noting  the  symp- 
toms of  pain,  disability,  abnormal  mobility,  and  crepitus  and  treated  them 
by  means  of  handmade  splints  and  common  sense.  He  was  friend  and  ad- 
visor to  his  clientele  through  life  and  his  counsel  was  often  sought  in 
family  problems  other  than  medical.    His  interest  touched  the  village 

*  Few  are  better  acquainted  with  the  present  day  problems  of  rural  practice  of  medicine  than 
is  Dr.  Washburn,  who  has  been  the  guiding  spirit  in  the  development  of  the  Holden  Clinic  at 
Holden,  Massachusetts.  Dr.  Washburn  thinks  of  the  rural  hospital  not  only  as  a  place  for  the 
care  of  the  .sick,  hut  as  the  health  center  for  the  community  which  it  serves. 


130 

church,  the  public  school,  and  the  town  government.  Not  infrequently 
matters  of  property,  including  the  drafting  of  wills,  were  referred  to  him. 
He  was  present  to  close  the  eyes  in  death.  In  his  community  he  was  an 
educated  man,  an  epitome  of  knowledge,  a  fount  of  wisdom.  He  was  an 
institution.  As  a  rule  he  was  honest,  devout,  just,  kindly,  charitable,  and 
ethical.  He  bore  the  prefix  to  his  name,  Doctor,  with  dignity  and  meaning. 

The  old  term  "old  country  doctor,"  so  often  used,  does  not  mean  he 
was  aged.  He  averaged  younger  than  the  practitioner  of  today.  A  com- 
mon school  education,  supplemented  by  one  or  two  years,  according  to  the 
period,  in  medical  school  and  a  clinical  year  under  a  preceptor  fitted  him 
to  practice,  often  before  twenty-one.  Thanks  to  modern  prevention  and 
practice,  the  span  of  life,  as  in  others,  is  greater  now  in  the  doctor  who 
begins  practice  ten  years  later  in  life  than  formerly. 

The  problem  of  restoring  the  country  practitioner  is  receiving  much 
thought.  Rural  communities,  viewing  the  economic  factor  as  paramount, 
are  offering  subsidy,  often  without  result.  It  is  obvious  that  some  other 
reason  contributes  to  deter  the  young  medical  man  from  rural  practice. 
Certain  schools  are  endeavoring  to  supply  the  demand  by  inculcating  in 
the  student  a  sense  of  service  and  usefulness  in  the  field;  by  registering, 
so  far  as  possible,  men  of  country  birth,  believing  that  they  will  thereby 
be  more  inclined  to  take  up  their  professional  work  in  such  communities ; 
and  as  in  the  case  of  at  least  one  school,  offering  the  attraction  of  scholar- 
ships to  country  bred  men  who  will  agree  to  begin  practice  in  the  less 
populated  areas.  Munificent  foundations  have  become  interested  in  the 
problem.   These  are  all  worthy  efforts  and  tend  toward  a  solution. 

Viewing  the  problem  analytically  one  may  well  consider  the  changes 
that  have  taken  place  in  medicine,  medical  education,  and  the  rural  public. 
The  advances  in  medicine  are  obvious.  Empiricism  has  been  largely  dis- 
placed by  rationalism,  the  use  of  scientific  knowledge;  specialism  has 
developed  to  a  superlative  degree.  It  is  largely  by  specialists  that  the 
medical  student  is  taught.  The  prospective  doctor  of  medicine  is  required 
to  be  an  educated  man  before  he  can  begin  his  professional  course.  A 
high  school  and  college  graduate,  he  spends  at  least  four  years  in  the 
medical  school  and  follows  this  by  two  years'  internship  in  a  hospital  and 
he  is  then  but  a  neophyte  at  the  threshold  of  a  life  of  study.  His  course 
has  involved  a  smattering  of  research,-  through  which  he  has  become 
imbued  with  a  desire  to  himself  contribute  to  discovery  and  the  advance- 
ment of  medical  knowledge.  He  has  learned  the  great  value  of  the  well 
equipped  laboratory  and  to  depend  a  great  deal  upon  its  assistance  in 
diagnosis.  He  has  learned  the  value  of  consultation  and  has  acquired  de- 
pendence upon  authority.  He  has  become  accustomed  to  the  use  of  instru- 
ments of  precision  and  has  learned  the  futility  of  attempting  fine  diag- 
noses without  their  aid.  He  has  been  taught  to  measure  the  basal  me- 
tabolism rate,  apply  electrocardiographic  studies  to  his  heart  cases,  to 
resuscitate  the  asphyxiated  newborn  by  means  of  the  electric  respira- 
tor, and  to  value  endoscopy,  especially  of  the  bronchial  tree  and  the  uri- 
nary tract.  He  knows  of  the  great  developments  in  skiagraphy,  fluoroscopy 
and  therapeutic  irradiation.  He  has  learned  to  realize  the  necessity  of 
keeping  abreast  of  advance  in  medicine,  in  touch  with  his  colleagues,  his 
medical  societies,  and  the  clinical  conventions.  The  current  medical  litera- 
ture he  requires  to  be  within  reach. 

While  our  people  deplore  the  passing  of  the  family  physician  of  the 
former  type,  it  is  doubtful  if  they  would  employ  him  if  he  could  be  re- 
turned to  them.  To  restore  him  in  his  simplicity  would  be  to  change  the 
spirit  of  the  age,  and  to  again  embody  in  the  individual  his  multiplicity 
of  function,  under  our  present  medical  standards,  would  be  equally  im- 
possible. The  attitude  of  the  public  has  changed,  for  the  veil  of  mystery 
has  been  dropped  from  the  art  and  the  why's  and  wherefore's  of  medicine 
are  public  knowledge.  Popular  medical  education,  through  lectures,  the 
press,  the  radio,  social  service,  and  other  means  is  responsible  for  this, 


131 

and  it  is  well.  The  day  of  one-man  surgery,  and  of  one-man  medicine 
has  passed,  and  the  people  themselves  realize  the  value  of  group  effort  in 
all  things. 

Better  schools  in  the  rural  areas,  the  telephone,  automobile,  good  roads, 
radio,  and  other  modern  conveniences  have  caused  intermingling  of  rural 
and  urban  people  until  they  do  not  differ  in  their  requirements  and  de- 
sires. The  rural  dweller  wishes  service  equivalent  to  that  of  his  city 
cousin,  whether  medical  or  other,  and  he  deserves  no  less. 

This  being  the  situation,  rf  the  medical  graduate  becomes  isolated  in  a 
remote  rural  community,  he  can  but  deteriorate  into  a  human  guide  post 
to  the  various  specialists  in  the  large  centers,  and  he  knows  this.  No 
self-respecting  physician  of  high  grade  training  wishes  to  deteriorate  in 
knowledge  and  usefulness.  He  abhors  the  thought  of  ever  becoming  a 
"fossil,"  a  back  number  in  his  profession.  On  the  contrary,  he  aspires  to 
grow  in  ability.  Whatever  value  he  may  place  on  the  medical  needs  of  the 
individual,  his  training,  observation,  and  conscience  have  combined  to- 
ward a  realization  of  the  infinitely  greater  importance  of  prophylaxis. 
When  those  under  his  care  come  to  operation,  whether  his  propensities 
may  be  toward  the  practice  of  surgery  or  internal  medicine,  he  desires 
the  privilege  of  viewing  the  "living  pathology"  and,  in  event  of  death  of 
a  patient,  to  see  his  judgment  and  error  revealed  at  autopsy. 

The  beginner  in  medical  practice  is  a  potential  husband  and  father,  if 
not  already  so,  and  in  his  choice  of  a  location,  obviously  must  consider 
supporting  a  family  and  educating  children. 

The  restoration  of  competent  medical  service  to  rural  areas  presents  a 
social  problem  of  several  factors,  the  paramount  of  which  has  its  solu- 
tion in  placing  at  the  disposal  of  the  country  doctor  modern  facilities  in 
order  that  he  may  serve  effectively.  That  this  may  be  done  through  the 
establishment  of  properly  equipped  and  located  community  hospitals,  by 
the  combined  effort  of  towns  grouped  into  districts,  each  having  repre- 
sentation upon  the  governing  boards,  is  already  past  the  experimental 
stage  in  Massachusetts  as  evidenced  by  several  instances. 

Of  course,  there  is  no  place  in  the  hospital  field  for  poorly  equipped, 
substandard  institutions.  It  is  conceded  that  the  small  hospital  of  less 
than  fifty  beds  is  handicapped  in  its  struggle  to  maintain  a  high  standard, 
but  that  it  can  successfully  do  so  is  proven  by  the  fact  that,  in  its  1931 
survey,  the  American  College  of  Surgeons  were  able  to  approve  18.9  per 
cent  of  hospitals  in  this  group,  which  is  not  a  poor  showing  considering 
the  short  time  attention  has  been  given  the  small  hospital.  Of  those  on 
the  list  many  are  located  in  rural  areas. 

While  its  primary,  or  direct  function,  that  of  making  available  to  the 
people  of  its  locality,  medical,  surgical,  obstetrical,  and  dental  facilities 
and  personnel  for  service,  is  important,  it  should  perform  many  other 
valuable  ones.  While  the  rural  community  hospital  becomes  recognized  as 
the  medical  center,  it  is  our  conviction  that,  with  its  medical  personnel, 
its  laboratories,  its  pathologist  and  technician,  its  visiting  nurse  or  social 
worker,  and  its  many  other  facilities,  it  should  logically  also  become  its 
health  center,  and  be  so  recognized.  By  cooperating  with  state  and  local 
health  authorities,  much  might  be  done  in  the  field  of  prophylaxis.  Diag- 
nosis in  "diseases  dangerous  to  the  public  health"  could  be  facilitated,  and 
the  rapidity  of  distribution  of  biological  products,  whose  prompt  use  is 
often  so  essential,  could  be  enhanced.  We  believe  that,  by  enlarging  its 
public  health  function,  the  rural  hospital  might  develop  a  field  of  far 
reaching  possibility. 

Great  institutions  of  proven  worthy  function  are  often  recipients  of 
ample  bequests,  and  this  is  as  it  should  be,  yet  rather  than  force  the 
lands  and  architecture  of  some  of  them  to  a  spaciousness  that  cannot  be 
occupied,  it  seems  to  the  essayist  that  a  bestowal  upon  an  effort  toward  the 
restoration  of  efficient  public  health  and  medical  treatment  facilities  to 
the  rural  communities  would  be  better  philanthropy. 


132 
The  "old  family  doctor"  of  former  days  is  passing  for  all  time.  He  can- 
not be  restored.  He  possessed  some  qualities  that  we  wish  might  char- 
acterize the  physician  of  today  and  which  we  have  to  admit  does  not  uni- 
versally obtain.  This  may  be  the  result  of  environment  or  perhaps  what 
we  think  of  as  the  "spirit  of  the  age."  While  we  cannot  bring  up  to  date, 
as  we  would  like  to  do,  all  the  traditions  of  the  former  rural  family  phy- 
sician, we  can,  by  effort,  bring  to  the  rural  communities  a  modern  scien- 
tific prophylaxis  and  practice  of  medicine  that  shall  be  productive  of  far 
greater  effect. 

SPECIAL  PROBLEMS  OF  COMMUNICABLE  DISEASE  IN  THE 
SMALL  COMMUNITY 

Gaylord  W.  Anderson,  M.D.* 

The  control  of  communicable  diseases  in  a  rural  area  or  the  small 
community  presents  problems  which  may  be  very  different  from  those 
of  a  large  city.  It  is  not  because  different  diseases  are  found  or  because 
the  diseases  are  different  in  their  manifestations,  but  rather  because  of 
the  character  of  the  environment  in  which  the  diseases  occur. 

A  large  city  means  the  crowding  together  of  a  large  number  of  per- 
sons within  a  relatively  small  area.  As  the  number  increases  the  con- 
tacts between  the  members  of  the  group  are  rapidly  multiplied,  yet  at 
the  same  time  the  degree  of  acquaintance  is  lessened.  Conversely,  the 
small  community  is  characterized  by  less  numerous  contacts,  but  a 
greater  degree  of  acquaintance  and  consequent  sense  of  unity.  Thus, 
public  opinion,  a  factor  which  cannot  be  ignored  in  disease  control,  is 
an  even  greater  factor  in  the  village  than  in  the  city. 

Owing  to  the  less  frequent  human  contacts  it  is  inevitable  that  epi- 
demic waves  of  communicable  disease  should  be  more  striking  in  the 
small  community.  Whereas  the  city  experiences  a  regular  cycle  of 
measles  with  a  wave  every  two  or  three  years,  the  village  may  escape 
for  a  longer  period  of  time.  This  can  only  mean,  however,  that  during 
the  interval  of  freedom  there  has  grown  up  a  greater  number  of  sus- 
ceptibles  with  the  result  that  when  the  infection  is  introduced  it  breaks 
out  more  dramatically.  The  height  of  the  epidemic  wave  is  thus  greater, 
just  as  may  be  the  distance  between  waves.  It  is  little  wonder  then 
that  when  such  an  epidemic  occurs  it  looms  large  on  the  horizon  and 
in  the  public  eye  often  assumes  unwarrantedly  large  proportions. 

This  characteristic  is  not  peculiar  to  measles  alone,  but  apparently 
to  all  other  diseases  spread  by  contact  and  entering  through  the  respira- 
tory tract.  Diphtheria  and  scarlet  fever  may  completely  disappear  from 
villages  and  several  years  pass  before  cases  reappear.  Too  often  this 
freedom  from  these  infections  has  lulled  the  community  into  a  satisfied 
state  of  complacence  leading  to  disregard  of  measures  for  protection 
from  future  storms.  Far  too  often  has  the  small  community  felt  that 
having  had  no  diphtheria  for  five  or  six  years  it  had  little  need  for 
diphtheria  immunization.  "Why  worry  about  a  disease  that  isn't 
around?"  Yet  it  is  this  same  absence  of  the  disease  that  makes  im- 
munization especially  important  for  this  community,  for  during  this 
period  there  has  grown  up  a  large  group  of  susceptible  children,  sus- 
ceptible because  they  have  never  been  exposed  to  the  disease  and  have 
therefore  built  up  no  resistance  to  it.  Immunization  of  children  in  this 
community  is  far  more  essential  than  in  a  city,  for  the  large  city  is 
never  free  of  diphtheria  and  even  though  the  individual  child  may  not 
have  had  the  disease  it  has  had  a  far  greater  opportunity  to  develop  a 

♦The  success  or  failure  of  the  health  officer  to  prevent  or  limit  the  spread  of  communicable 
diseases  often  determines  the  degree  of  confidence  with  which  he  is  regarded  by  the  public 
His  problems  are  frequently  magnified  by  a  public  demand  for  measures  which  his  judgment 
™nT.j«Kfr,n-Ce  show„to+bv,e  v,a'ueles?-  DJ-  Anderson,  who  is  Director  of  the  Division  of  Com- 
municable Diseases  for  the  Massachusetts  Department  of  Public  Health,  outlines  here  a  few 
of    the   difficulties    encountered    in    the    small    community,    together    with    certain    principles    of 


133 

resistance  through  frequent  exposure  to  unrecognized  carriers. 

The  small  town  that  finds  itself  the  victim  of  scarlet  fever  quite 
naturally  feels  that  the  number  of  cases  is  out  of  all  proportion  to  what 
it  should  be.  It  is  pointed  out  that  were  a  neighboring  city  to  have  as 
many  cases  in  proportion  to  its  population,  a  horrible  epidemic  would 
at  once  be  recognized.  What  is  too  often  overlooked  is  that  the  city  is 
never  free  from  scarlet  fever,  whereas  several  years,  perhaps  as  many 
as  ten  years,  have  passed  since  scarlet  fever  has  occurred  in  the  town. 
The  number  of  cases  per  population  that  occur  in  the  town  over  a  ten 
year  period  may  be  just  the  same  as  in  the  city,  but  if  the  town  has  all  its 
cases  concentrated  in  one  year,  and  the  city  scatters  its  cases  over  the 
years,  it  is  inevitable  that  the  town  outbreak  should  be  many  times 
worse  than  that  in  the  city. 

The  difference  in  age  of  the  cases  in  the  rural  area  is  but  another 
manifestation  of  the  same  phenomenon.  Because  of  the  more  constant 
presence  of  the  diseases  and  the  greater  frequence  of  contacts,  the  city 
child  is  inevitably  exposed  somewhat  earlier  in  life.  The  city  dweller 
that  reaches  adult  life  without  having  contracted  measles  is  rare,  yet 
in  the  country  this  is  frequently  found.  At  the  time  of  the  war,  the  con- 
centration camps  receiving  from  rural  areas  were  rather  severely 
affected  by  measles,  yet  those  recruiting  from  the  cities  were  relatively 
spared.  The  resistance  to  diphtheria  at  a  given  age,  as  shown  by  the 
Schick  test,  is  greater  in  the  city  than  the  country.  The  same  appears 
to  hold  for  all  other  contact  borne  diseases. 

In  view  of  the  greater  intensity  of  the  epidemic  waves  cf  communi- 
cable disease  in  a  small  community,  it  is  little  wonder  that  public  opinion 
with  respect  to  it  should  be  more  intense.  The  public  does  not  stop  to 
consider  why  the  disease  should  be  especially  prevalent.  Even  full  con- 
sideration and  understanding  would  do  little  to  satisfy  the  demand  for 
drastic  measures  for  control.  Being  more  of  a  unit  of  interests  and 
thought  than  is  a  city,  the  town  is  more  aware  of  the  presence  of  the 
disease  and  has  not  developed  the  somewhat  fatalistic  attitude  of  the 
metropolis.  It  is  little  wonder  then  that  measures  of  control  as  extreme 
and  dramatic  as  is  the  outbreak  should  be  demanded  by  the  public.  It 
is  unfortunate,  however,  that  the  measures  which  are  most  noisily  de- 
manded are  too  often  those  long  since  shown  to  be  ineffective. 

Terminal  fumigation  is  often  demanded,  yet  over  twenty  years  ago 
it  was  shown  to  be  completely  ineffective  except  against  insect  and 
rodent  borne  infections.  Cities  have  universally  dispensed  with  it  with- 
out ill  effect,  yet  it  is  still  too  often  found  in  the  small  community.  To 
be  sure  it  is  dramatic,  and  it  creates  an  odor  sufficiently  offensive  to 
the  human  nostrils  and  dangerous  to  human  life,  to  appeal  to  the  popu- 
lar imagination.  So  would  burning  of  the  house  or  school,  yet  none 
would  defend  such  an  outrage.  Concurrent  disinfection  with  proper 
disposal  of  all  discharges  and  thorough  cleaning  at  the  end  of  quaran- 
tine have  accomplished  more  than  fumigation. 

The  immediate  closure  of  schools  is  another  measure  of  great  popu- 
lar appeal.  It  is  apparent  that  the  children  are  contracting  the  disease 
from  contact  with  one  another  at  the  school,  so  it  therefore  seems  log- 
ical to  close  the  school  and  prevent  these  contacts.  The  theory  is  good 
as  far  as  it  goes,  but  it  presupposes  that  the  children  have  no  contacts 
outside  of  the  schoolroom.  In  the  extremely  rural  area  where  all  the 
children  live  on  farms  so  widely  scattered  that  they  are  never  brought 
together  except  in  school,  the  theory  is  still  good.  Under  any  other 
circumstances,  however,  the  theory  falls  down  because  of  the  frequent 
contacts  outside  of  the  schools.  A  certain  community  closed  schools  in 
the  hope  of  stopping  measles,  yet  the  closure  of  schools  was  but  a  sig- 
nal for  a  series  of  parties  which  brought  the  children  into  closer  con- 
tact than  existed  in  the  schoolrooms.  Another  closed  schools  because 
of  infantile  paralysis,  yet  every  afternoon  show  at  the  moving  picture 


i34 
theatre  crowded  several  hundred  together  in  the  same  room.    Experi- 
ence has  shown  that  it  is  rare  indeed  for  school  closure  to  lessen  human 
contacts. 

Another  fallacy  attendant  upon  the  closing  of  schools  to  control  com- 
municable disease  lies  in  the  period  of  closure.  Of  what  avail  to  close 
schools  for  a  week  because  of  measles  when  the  incubation  period  is 
usually  about  two  weeks.  One  week  closures  for  scarlet  fever  are  fre- 
quent. Those  with  mild  attacks  developing  during  the  period  and  never 
brought  to  medical  attention  will  be  reintroduced  at  the  height  of  their 
ability  to  pass  it  on  to  others.  Except  under  very  unusual  circumstances 
school  closure  accomplishes  so  little  that  it  cannot  be  justified. 

Almost  as  appealing  as  fumigation  and  school  closure  is  destruction 
of  school  books.  Many  dollars'  worth  of  valuable  books  may  be  thus 
sacrificed  on  the  altar  of  public  opinion  without  contributing  One  iota 
to  disease  control.  To  be  sure,  there  may  be  aesthetic  reasons  for 
destruction  of  books  grossly  soiled,  but  these  do  not  apply  to  all  that 
have  been  in  possession  of  a  child  infected  with  a  communicable  dis- 
ease. The  germs  do  not  lurk  around  inanimate  dry  objects.  Sunshine 
and  drying  are  so  powerful  in  their  germ  destroying  action  as  to  remove 
all  danger  from  these  books.  In  some  communities  public  opinion  has 
been  appeased  by  placing  them  in  a  chest  with  a  little  formalin.  It  is 
certainly  hard  to  conceive  that  they  might  ever  transmit  infection  if 
held  out  of  circulation  until  the  ensuing  school  year. 

Adequate  case  finding  is  the  key  to  communicable  disease  control. 
In  the  large  city,  owing  to  the  vastness  of  the  problem,  it  can  never  be 
completely  realized.  The  small  community  is,  however,  in  a  position  to 
protect  itself  through  such  measures.  More  than  one  community  has 
put  off  a  wave  of  measles  through  prompt  recognition  and  isolation  of 
initial  cases.  The  hazard  of  measles  and  whooping  cough  lying  in  the 
severity  of  the  disease  in  small  children,  delaying  an  attack  will  obvi- 
ously lessen  the  danger.  Such  is  possible  in  the  rural  area  to  a  degree 
never  attainable  under  urban  conditions. 

Coupled  with  adequate  case  finding  is  the  institution  of  such  active 
measures  as  have  been  found  effective  under  comparable  circumstances. 
Rigid  enforcement  of  vaccination  laws  is  our  best  protection  against 
smallpox.  Diphtheria  immunization  with  special  emphasis  on  the  pre- 
school child  accomplishes  far  more  than  mere  quarantine.  Active  case 
finding  in  scarlet  fever  and  educational  work  in  measles  and  whooping 
cough  stressing  particularly  the  problem  of  the  small  child,  are  still  our 
most  reliable  procedures.  Recognition  of  tuberculosis  in  its  early  stages 
and  careful  supervision  of  the  contacts,  likewise  to  detect  cases  while 
still  in  the  beginning  stages,  are  far  sounder  procedures  than  mere 
waiting  for  the  disease  to  have  progressed  so  far  that  nothing  more 
can  be  done  than  furnishing  care  during  the  last  few  months  of  life. 
Careful  supervision  of  water  supplies  and  sewage  disposal,  pasteur- 
ization of  milk  and  discovery  and  regulation  of  typhoid  carriers  have 
been  shown  to  reduce  typhoid  to  remarkably  low  levels. 

The  problem  of  communicable  disease  control  in  the  small  community 
thus  resolves  itself  into  application  of  the  same  measures  that  are  used 
in  other  places  so  modified  as  to  suit  the  problems  presented  by  the 
individual  situation.  There  is  no  magic  formula  which  spells  success. 
The  problem  is  one  which  requires  closest  attention  to  enable  one  to 
adapt  well  recognized  principles  to  local  circumstances.  The  value  to 
the  community  of  full-time  health  service  is  probably  evidenced  as  well 
in  this  phase  of  the  work  as  in  any  other  part  of  the  vast  field  of 
public  health. 


135 

THE  PROBLEM  OF  GONORRHEA  AND  SYPHILLIS 

IN  RURAL  AREAS 

N.  A.  Nelson,  M.D.* 

There  is  a  great  diversity  of  opinion  as  to  whether  or  not  gonorrhea 
and  syphilis  are  as  prevalent  in  rural  as  in  urban  communities.  Accord- 
ing to  the  United  States  Army  World  War  prevalence  rates,  syphilis 
was  less  common  in  rural  than  in  urban  districts  in  the  ratio  of  89  to 
100,  while  gonorrhea  was  more  common  in  the  rural  than  in  the  urban 
districts  in  the  ratio  of  109  to  100.1 

Various  one-day  prevalence  studies  which  have  been  made  in  a  num- 
ber of  large  cities,  counties,  portions  of  states,  and  whole  states  would, 
on  the  face  of  gross  analysis,  make  it  appear  that  the  urban  rate  for 
both  gonorrhea  and  syphilis  is  many  times  that  of  the  rural  rate.  The 
Army  statistics,  however,  being  based  on  the  actual  residence  of  the 
patient  and  not,  as  in  the  case  of  the  one-day  surveys,  on  the  place 
of  treatment,  more  rightly  represent  the  true  state  of  affairs. 

From  1925  to  1929,  inclusive,  reports  of  gonorrhea  and  syphilis  in 
Massachusetts  were  made  directly  to  local  boards  of  health.  These 
reports  were  made  to  the  local  board  of  health  of  the  treating  physician, 
clinic  or  institution,  rather  than  to  the  board  of  health  of  residence  of 
the  patient.  In  1929  it  appeared  that  only  98  of  the  355  communities  in 
Massachusetts  had  cases  of  gonorrhea  or  syphilis  since  reports  were 
received  only  by  that  number.  In  1931,  when  gonorrhea  and  syphilis 
were  made  reportable  directly  to  the  State  Department  of  Public  Health 
and  the  report  forms  required  a  statement  as  to  the  community  of  resi- 
dence of  the  patient,  it  was  discovered  that  the  cases  reported  came 
from  257  communities.  Thus  by  the  simple  expedient  of  revising  the 
reporting  system  nearly  200  communities,  most  of  them  small  towns 
hitherto  statistically  free  from  gonorrhea  and  syphilis,  became  officially 
conscious  for  the  first  time  of  the  existence  of  these  infections. 

In  spite  of  this  corrected  statistical  distribution  cf  cases,  however, 
there  still  exists  an  enormous  discrepancy  between  the  gross  reported 
rates  of  gonorrhea  and  syphilis  in  the  larger  cities  as  compared  to  the 
smaller  cities  and  towns,  as  shown  by  the  following : — 

Size  of  Community  Rate  per  100,000  Population 

Gonorrhea  Syphilis 

Boston  341.8  234.9 

150,000  and  over  184.8  119.3 

100,000  — 150,000  172.1  104.3 

50,000  —  100,000  120.9  77.3 

25,000  —  50,000  145.6  79.3 

10,000  —  25,000  102.7  53.8 

5,000  —  10,000  88.5  44.1 

Under  5,000  87.2  42.6 

Closer  scrutiny  of  these  rates,  however,  suggests  that  there  may  be 
a  number  of  factors  which  influence  the  reported  rates  to  such  an 
extent  that  they  may  be  -not  at  all  representative  of  actual  prevalence. 

In  a  study  of  the  migration  of  patients  with  gonorrhea  or  syphilis 
for  treatment2,  it  was  discovered  that  the  reported  rates  of  gonorrhea 

*  One  of  the  largest  and  at  the  same  time  most  difficult  problems  in  public  health  is  pre- 
sented by  gonorrhea  and  syphilis.  Although  certain  advances  have  been  made  in  large  cities 
through  clinic  service,  no  one  has  yet  offered  a  thoroughly  satisfactory  solution  for  the  rural 
area.  In  this  paper,  Dr.  Nelson  who,  as  Assistant  Director  of  the  Division  of  Communicable 
Diseases,  is  in  charge  of  the  work  for  the  Massachusetts  Department  of  Public  Health,  dis- 
cusses some  of  the  rural  problems.  It  is  hoped  that  the  article  may  help  arouse  serious  thought 
on  the  subject. 

1  Venereal  Disease  Prevalence  in  Tennessee.  L.  J.  Usilton  and  W.  D.  Riley.  Venereal  Disease 
Information,  Vol.  9,  No.  10,  October,   1928. 

2  The  Migration,  for  Treatment,  of  Patients  with  Gonorrhea  or  Syphilis.  N.  A.  Nelson,  M  D. 
and  H.  M.  DeWolfe,  M.D.,  Journ.  of  the  American  Medical  Association,  Vol.  98.  p.  794! 
March  6,  1932. 


136 

and  syphilis  for  even  the  smallest  cities  and  towns  near  (the  clinics  or 
in  the  Metropolitan  Boston  Area  very  nearly  approach  the  rates  for 
the  largest  cities  (excluding  Boston,  which  statistically  seems  to  be  in 
a  class  by  itself).  On  the  other  hand,  small  cities  and  towns  of  the 
same  size  but  distant  from  clinics  had  reported  rates  of  gonorrhea  and 
syphilis  of  about  half  the  rates  of  those  near  clinics.  This  might  lead 
to  the  conclusion  that  indigent  patients  in  rural  areas  distant  from  free 
medical  care  are  obliged  because  of  high  transportation  costs  to  go 
without  medical  attention  and  that  the  higher  reported  rates  in  clinic 
cities  and  in  communities  near  clinics  may  be  accounted  for  in  large 
measure  by  the  availability  of  free  treatment.  This  presumption  is  sup- 
ported apparently  by  the  marked  flattening  of  the  rate  curve  if  only 
those  cases  reported  by  private  physicians  are  considered,  as  follows : — 

Rate  per  100,000  Population 
Size  of  Community  As  Reported  by  Private  Physicians 

Gonorrhea  Syphilis 

Boston  121.8  41.9 

150,000  and  over  112.2  33.6 

100,000  —  150,000  82.2  22.3 

50,000  —  100,000  85.2  26.1 

25,000  —  50,000  88.3  20.9 

10,000  —  25,000  78.0  23.1 

5,000  —  10,000  65.2  15.8 

Under  5,000  67.3  18.9 

It  is  to  be  noted  that  there  are  98  communities  of  less  than  5,000  popu- 
lation which  have  no  resident  physician  so  far  as  can  be  determined, 
which  may  further  account  for  the  low  reported  rates  in  these  com- 
munities. Many  others  from  5,000  to  10,000  population  have  only  one 
or  two  resident  physicians.  Many  of  these  physicians  refuse  to  treat 
gonorrhea  or  syphilis. 

Of  course  it  must  not  be  forgotten  that  the  higher  rates  in  small 
communities  near  clinic  cities  or  in  the  Metropolitan  Boston  Area  may 
be  due  partly  to  the  greater  possibility  for  promiscuous  sexual  inter- 
course in  the  nearby  large  centers.  It  seems  safe  to  say,  however,  that 
both  gonorrhea  and  syphilis  are  much  more  prevalent  in  rural  or  semi- 
rural  areas  than  is  apparent  on  the  face  of  reports,  and  that  there  is 
much  less  discrepancy  between  the  rates  of  the  smaller  and  larger  com- 
munities than  appears  from  the  reports. 

The  provision  of  treatment  for  patients  in  small  cities  and  towns  is 
a  problem  regardless  of  the  patient's  ability  to  pay.  Desire  for  secrecy 
apparently  does  not  have  as  much  effect  on  migration  of  patients  from 
their  home  communities  for  treatment  as  has  been  presumed.  In  Massa- 
chusetts in  1930  and  1931  nearly  45  per  cent  of  the  patients  with  gonor- 
rhea were  treated  by  a  local  physician,  regardless  of  the  size  of  the 
community.  Migration  to  other  communities  for  treatment  seemed  to 
depend  almost  entirely  upon  the  availability  in  the  local  community  of 
physicians  willing  to  treat  or  the  availability  of  clinics  for  those  who 
were  unable  to  pay. 

About  22  per  cent  of  patients  with  syphilis  were  treated  by  local 
physicians  regardless  of  the  size  of  the  community,  the  greater  migra- 
tion for  treatment  of  this  disease  apparently  being  due  to  the  much 
higher  cost  of  treatment  with  consequent  migration  to  a  free  clinic, 
and  to  the  much  greater  inaccessibility  to  physicians  who  are  willing 
to  undertake  the  treatment  of  syphilis.  Fortunately  in  this  State  75  per 
cent  or  more  of  the  population  is  resident  in  communities  which  have 
clinics  or  which  are  immediately  adjacent  to  clinic  cities.  However 
there  remain  1,000,000  people  resident  in  communities  to  which  clinic 
service  is  not  available  and  in  which  it  is  frequently  impossible  either 
to  find  any  physician  or  one  willing  to  treat  syphilis.   Boards  of  health 


137 

frequently  are  obliged  to  pay  more  for  the  transportation  of  patients 
to  distant  communities  for  treatment  than  they  would  have  had  to  pay 
a  local  physician. 

Some  of  the  Southern  States  and  notably  Connecticut  and  New  Jersey 
among  the  Northern  States  are  experimenting  with  the  so-called  co- 
operating clinician  in  rural  areas.  This  physician,  usually  recom- 
mended by  the  county  or  district  medical  society,  is  appointed  by  the 
board  of  health  to  care  for  indigents.  In  some  cases  only  medication 
and  equipment  are  supplied,  and  in  some  the  physician  is  paid  by  the 
department  of  health  for  each  treatment  given.  There  seem  to  be  three 
objections  to  this  practice:  (1)  other  physicians  refuse  to  refer  even 
their  indigent  cases  to  the  cooperating  clinician  for  fear  of  thereby 
pointing  to  him  as  a  superior  practitioner;  (2)  the  physician  frequently 
is  disturbed  over  becoming  recognized  in  the  smaller  community  as 
treating  gonorrhea  or  syphilis  since  it  may  keep  patients  with  other 
conditions  from  coming  to  his  office;  and  (3)  unless  the  cooperating 
clinician  is  paid  for  his  services  it  puts  an  unfair  burden  upon  him 
as  compared  to  other  physicians  in  the  community  and  relieves  the 
local  board  of  health  of  assuming  a  financial  responsibility  which  be- 
longs to  it. 

The  problem  of  securing  the  return  to  treatment  of  delinquent  cases 
also  is  more  difficult  in  rural  than  in  urban  communities  since  there 
is  much  greater  opportunity  for  public  disgrace  resulting  from  "leaks" 
and  curiosity  in  the  small  community.  Further,  an  usually  difficult  task 
must  be  left  in  the  hands  of  health  workers  and  officials  who  frequently 
are  untrained.  On  the  whole,  therefore,  the  problem  of  controlling 
gonorrhea  and  syphilis  in  rural  areas  requires  even  more  thought  and 
greater  modification  of  procedure  than  that  of  controlling  these  two 
diseases  in  the  larger  communities,  difficult  as  that  may  be.  Evidently 
more  prevalent  in  rural  areas  than  hitherto  suspected,  they  offer  not 
only  the  usual  challenge  of  early  discovery  and  adequate  treatment, 
but  of  any  treatment  at  all.  This  difficulty,  coupled  with  the  damage 
that  may  be  done,  most  unfairly,  to  reputations,  especially  in  smaller 
communities,  through  curiosity  and  careless  wagging  of  tongues,  should 
give  the  health  workers  who  enjoy  tackling  a  problem  something  re- 
quiring their  best  efforts. 

A  PROGRAM  FOR  PUBLIC  HEALTH  NURSING  IN  A 
COUNTRY  COMMUNITY 

Marion  C.  Woodbury,  R.N.* 

The  picturesque  moors  of  Nantucket  Island  or  the  maze  of  diversions 
of  busy  cities  have  their  particular  and  subtle  attractions  but  the  country 
of  the  friendly  Berkshire  Hills  in  the  southern  part  of  the  "far  western" 
section  of  Massachusetts  has  something  more.  It  is,  perhaps,  magnetic. 
Even  as  we  think  of  public  health  nursing  here,  we  believe  that  the  coun- 
try's own  beauty,  its  impressiveness,  its  natural  physical  boundaries,  and 
its  traditions  have  had  a  particular  influence  upon  the  existence  and  de- 
velopment of  the  nursing  service. 

This  district  is  comprised  of  five  towns  with  Great  Barrington  as  the 
nucleus.  This  arrangement  is  a  very  logical  development  because  of 
social,  economic  and  natural  reasons.  It  is  the  largest  village  of  the 
group;  is  largely  residential;  has  the  largest  stores  where  the  people  of 
adjoining  towns  come  to  do  their  trading  and  especially  their  Saturday 

*  During  the  ten  years  that  Miss  Woodbury  has  directed  the  activities  of  the  Great  Bar- 
rington Visiting  Nursing  Association,  she  has  so  broadened  its  program  that  bedside  and  public 
health  nursing  have  been  offered  to  a  group  of  communities.  Through  her  description  of  what 
has  been  _  accomplished,  she  outlines  a  typical  program  for  nursing  service  in  rural  areas.  In 
this  particular  instance,  bedside  and  public  health  nursing  have  been  combined  successfully. 
As  their  separation  is  usually  preferable,  it  is  of  special  interest  to  see  some  of  the  details 
of  so  successful  a  grouping. 


138 
night  buying;  it  is  the  railroad  center;  has  the  best  moving  picture 
theatre  within  twenty  miles ;  is  at  the  crossroads  of  good  main  roads  in 
all  directions;  the  hospital  is  located  here  and  the  medical  service  centers 
here  for  a  wide  territory.  Thus  it  appears  that  Great  Barrington  natur- 
ally became  the  center  for  the  development  of  a  public  health  nursing  ser- 
vice which  was  dependent  upon  group  support  so  that  people  of  smaller 
communities  might  have  the  advantage  of  such  assistance. 

Characteristic  of  other  visiting  nurse  associations  formed  twenty-five 
years  ago,  this  started  as  a  philanthropy.  Public  spirited  citizens  caught 
the  spirit  of  the  times  in  1908  and  a  graduate  nurse  was  employed  to 
serve  the  people  of  just  one  village.  The  natural  development  was  to- 
ward expansion  and  soon  a  second  village  was  included,  then  two  nurses 
were  employed  and  then  an  automobile  was  purchased.  By  1918,  three 
nurses  with  two  cars  served  four  towns,  and  today  our  district  is  com- 
prised of  five  towns  with  a  population  of  approximately  8,500  people  and 
is  served  by  three  visiting  nurses  using  three  automobiles  and  all  work- 
ing in  definite  districts,  going  out  from  the  Center  each  day.  In  addition 
to  the  visiting  nurse  staff,  there  is  a  graduate  nurse  employed  by  the 
School  Department  of  Great  Barrington  for  school  nursing  in  that  town, 
one  graduate  nurse  for  industrial  nursing  in  one  mill  in  one  of  the 
villages,  and  the  staff  of  the  Southern  Berkshire  Health  Unit,  which  acts 
principally  as  assistant  to  the  Health  Officer  of  the  Unit  and  has  been 
effective  in  coordinating  the  public  health  work  of  the  whole  southern 
part  of  the  country. 

A  fairly  large  proportion  of  the  families  are  of  long  native  lineage 
but  there  is  a  variety  of  nationalities  represented.  The  occupations  are 
divided  among  farming,  paper  industry,  cotton  mills  and  other  industries 
and  catering  to  summer  resident  and  tourist  demands. 

In  the  practice  of  public  health  nursing  among  these  people,  we  are 
most  fortunate  in  having  a  delightful  headquarters  with  ample  room  for 
office,  clinic  room  and  board  room.  This  building,  Russell  House,  gives 
us  a  feeling  of  permanence  and  a  certain  dignity  which  naturally  influ- 
ences the  work.  The  plan  of  our  work  has  now  become  quite  definitely 
generalized.  Because  bedside  nursing  is  needed  and  wanted  and  because 
by  it  we  are  very  sure  we  do  some  of  our  best  health  teaching  we  consider 
morbidity  care  a  very  essential  part  of  a  public  health  nursing  program. 
We  go  to  any  part  of  this  district  to  give  that  care  and  while  it  might  be 
expected  that  much  of  it  would  be  for  the  chronic  invalid,  such  is  not 
the  case.  In  addition  to  this  type  of  nursing  we  carry  maternity  cases 
for  prenatal,  delivery  and  postnatal  care.  This  has  been  a  part  of  the 
program  for  the  past  sixteen  years  and  is  a  service  definitely  appreciated 
by  the  physicians,  as  well  as  families.  The  delivery  assistance  was  used 
in  forty-eight  cases  last  year  and  the  average  time  spent  at  the  home 
was  two  hours  and  forty-five  minutes.  It  cannot  be  considered  a  serious 
burden  to  maintain  this  department  here  even  though  many  places  have 
found  it  particularly  hard  to  handle.  When  any  of  these  calls  come  at 
night  the  physician  calls  for  the  nurse,  for  one  of  our  rules  is  that  the 
nurses  shall  not  be  expected  to  drive  their  cars  at  night.  The  nursing  vis- 
its of  these  two  branches  of  our  service,  as  a  rule,  comprise  less  than  one 
half  of  our  total  visits.  The  balance  is  for  instructive  purposes.  First,  we 
visit  the  homes  of  newborn  babies  before  they  are  a  month  old  and  see 
them  periodically  until  school  age.  The  two  weekly  well  child  conferences, 
while  presided  over  only  by  nurses,  are,  nevertheless,  of  quite  definite 
value.  There  is  a  real  personal  interest  often  shown  and  close  coopera- 
tion with  the  family  physician.  Time  is  given  for  discussion  of  many 
questions  and  problems  coming  up  from  week  to  week.  Next  we  carry 
on  school  nursing  in  four  of  these  five  towns.  Each  nurse  has  her  own 
district  and  knows  the  health  problems  of  the  whole  family  and  the  whole 
community. 

By  observing  special  precautions,  we  carry  the  nursing  care  and  super- 
vision of  communicable  disease  cases  and  tuberculosis  cases  in.  coopera,- 


139 

tion  with  the  Health  Unit.  For  one  industry  we  do  industrial  nursing,  in 
that  we  go  to  the  mill  at  a  specified  hour  five  days  a  week  for  attendance 
to  minor  ailments  and  health  advice. 

We  are,  of  course,  interested  in  the  preschool  examinations  and  yearly 
have  these  clinics  at  Russell  House  and  at  two  other  offices.  These  are 
planned  so  that  each  child  is  seen  by  his  own  physician  by  appointments 
made  by  the  nurses.  Nearly  all  of  these  first  graders  are  known  to  us 
but  a  list  of  prospective  beginners  is  received  from  the  office  of  the  su- 
perintendent of  schools  and  home  visits  made.  Each  physician  has  a 
certain  day  and  hour  for  his  clinic  at  which  he  gives  a  careful  physical 
examination  and  vaccinates  the  child.  The  permanent  physical  examina- 
tion records  are  made  out  by  the  nurses  assisting,  and  follow-up  is  done 
during  the  summer.  A  dental  check-up  is  always  urged,  and  usually  at- 
tended to.  If  parents  prefer,  they  take  their  children  to  the  doctors' 
offices  and  are  urged  to  ask  for  the  check-up  to  be  recorded  on  the  school 
physical  records  furnished  to  the  doctors.  The  physicians  charge  their 
regular  office  fee  whether  they  see  these  children  at  the  office  or  at  the 
special  clinic.  This  has  developed  from  the  demonstration  of  preschool 
physical  examinations  by  the  State  Department  of  Public  Health  and 
promises  to  be  an  annual  procedure  as  this  is  the  third  year  of  the 
family  physician's  service. 

In  order  to  carry  out  the  above  full  program,  organization  and  stand- 
ardization are  quite  essential.  In  the  first  place,  we  have  a  voluntary 
organization  of  women,  representative  of  the  five  towns,  meeting  monthly 
to  hear  reports  and  transact  routine  business.  This  organization  is  in- 
corporated and  takes  its  responsibility  seriously.  Local  support  is  very 
loyal  and  the  point  always  most  important  is  to  ever  keep  each  town  re- 
sponsible for  its  share  of  the  support  of  the  work.  Lacking  that,  it  is 
doomed  to  failure. 

Likewise,  our  plan  of  work  must  be  well  organized  and  carried  on  ac- 
cording to  best  known  standards.  First  of  all,  the  nurses  are  public 
health  graduates  and  are,  in  addition,  selected  for  their  interest  in 
country  public  health  nursing.  We  have  standing  orders  from  the  Medi- 
cal Committee,  and  rules  and  regulations  according  to  the  best  principles 
of  the  work  as  recommended  by  the  National  Organization  for  Public 
Health  Nursing. 

Efforts  are  made  to  carry  on  staff  education  and  to  attend  conferences 
so  as  to  keep  informed  of  interested  health  activities  and  advances. 

While  we  thus  attempt  to  carry  on  a  generalized  service,  we  see  two 
very  definite  lapses.  We  are  unable  to  give  much  time  to,  and  are  not 
equipped  to  handle  scientifically  the  many  serious  social  problems.  We 
are  grateful  for  the  consultation  service  available  to  us  but  even  these 
splendid  county  and  district  agents  are  over-burdened  and,  as  I  see  it, 
what  is  really  needed  is  a  family  case-worker  or  a  case-consultant  for 
us.  Perhaps  if  we  solved  our  mental  hygiene  problems  by  having  a  part- 
time  psychiatric  consultant,  many  of  our  social  problems  would  be  ad- 
justed to  a  solution. 

The  financial  support  of  this  service  comes  about  equally  from  two 
sources:  one,  earnings;  and  two,  contributions.  In  the  earnings  are  in- 
cluded fees  from  patients  and  insurance  companies,  fees  from  towns  for 
school  narsing  services  and  fees  from  towns  as  appropriations  for  public 
health  nursing,  as  our  instructive  work  is  thus  interpreted.  In  the  con- 
tributions are  included  the  receipts  from  our  annual  house-to-house 
campaign  for  funds,  frequent  donations  from  individuals  at  other  times, 
and  the  interest  from  the  invested  funds  of  an  endowment. 

This  Association  has  developed  a  service  which  appears  to  be  as  per- 
manent as  the  Hills  and  it  must  be  said  that  its  seeming  success  is  due 
to  the  inspiration  of  its  early  promoters  and  to  the  interested  support 
of  the  lay  and  professional  citizens. 


140 
RURAL  CHILD  HYGIENE  IN  MASSACHUSETTS 

Susan  M.  Coffin,  M.D.* 

The  rural  child  is  one  of  the  great  army  of  children  the  world  over 
and,  like  each  individual  child  in  a  large  family,  special  problems  arise 
in  connection  with  his  growth  and  development  and  his  protection  from 
disease  and  defects.  The  child  is  the  key  to  most  preventive  work,  the 
never-failing  approach.  A  family  or  town  that  has  no  interest  in  its 
children's  welfare  would  be  hard  to  find,  but  often  this  interest  needs 
guidance. 

Health  teaching  in  country  schools  should  be  even  more  inclusive  than 
in  the  city  because  of  the  smaller  number  of  opportunities  to  receive 
such  teaching  elsewhere.  The  little  Polish  girl  who  taught  her  family 
to  sleep  with  open  windows — to  start,  she  had  to  open  them  after  the 
family  was  sound  asleep! — is  one  small  example  of  the  value  of  school 
health  training  to  the  whole  family. 

Our  first  concern  is,  of  course,  with  the  child's  immediate  inheritance 
and  environment.  Are  his  father  and  mother  healthy  and  of  normal  in- 
telligence; do  his  home  and  community  come  up  to  at  least  minimum 
standards  of  cleanliness  and  health? 

Clean  water  and  milk  and  safe  sanitary  arrangements  remain  essen- 
tials. We  find  unpasteurized  milk,  untested  caws  and  the  old-fashioned 
pump  pretty  common  still.  Open  privies  and  stables  and  unscreened  win- 
dows are  by  no  means  rare.  Until  these  things  are  corrected  it  is  neces- 
sary to  urge  boiled  milk  and  water  for  all  babies,  and  to  take  time  to 
teach  the  mother  who  has  no  ice  how  to  keep  milk  and  food  safely,  with 
what  conveniences  she  may  possess. 

Country  mothers  are  often  quite  astonished  that  we  want  them  to 
know  if  the  cows  are  tested,  what  they  are  fed  and  from  what  breeds  the 
milk  that  they  are  feeding  their  babies  comes.  Many  feel  that  it  is  a 
privilege  to  have  milk  from  the  neighbor's  "best"  cow  rather  than  from 
a  herd  and  also  they  are  surprised  to  learn  that  babies  do  not  always  di- 
gest easily  the  richest  Jersey  or  Guernsey  product.  Boiled  milk  is  still 
held  to  be  "very  constipating,"  while  sweetened  condensed  milk  remains 
unduly  popular  and  there  is  considerable  prejudice  against  the  really 
valuable  unsweetened  evaporated  milk.  We  would  be  willing  to  wager, 
too,  that  country  babies  are  fed  ice  cream  and  lollypops  just  as  early  and 
just  as  often  as  their  city  cousins,  now  that  nearly  every  gas  station 
specializes  in  these  articles. 

One  step  forward  is  the  almost  universal  use  of  orange  and  tomato 
juice  for  infants  and  the  increasing  use  of  cod  liver  oil,  all  of  which  are 
extremely  important  because  of  our  large  number  of  babies  who  have 
little  or  no  breast  milk  and  do  not  get  regular  sun  baths. 

The  sun  suit  is  gaining  ground — it  is  "stylish"  to  have  your  baby  or 
young  child  tanned  and  it  saves  lots  of  washing  for  the  busy  mother  of 
three  or  four  under  school  age.  But  it  took  time  in  the  county,  far  from 
the  beach.  Only  three  years  ago  one  indignant  father  told  us  his  children 
had  "always  been  brought  up  respectable"  and  he  wasn't  going  to  have 
them  running  around  "with  anything  like  that  on"!  We  granted  that 
sun  suits,  like  most  things,  should  be  used  with  discrimination,  and 
finally  extracted  a  promise  that  young  Bill  might  wear  a  bathing  suit 
to  play  in  an  hour  or  two  a  day — the  bathing  suit  at  least  had  "some 
back  to  it,"  though  today  poor  father  would  not  have  even  that  comfort 
as  a  bathing  suit  with  a  back  would  be  hard  to  find ! 

In  the  five-year  demonstration  of  Well  Child  Conferences  just  completed 

*  Doctor  Coffin,  during  the  past  few  years  one  of  the  pediatricians  on  the  staff  of  the 
Division  of  Child  Hygiene,  has  done  much  work  with  the  infant  and  preschool  child  in  the 
rural  communities  of  the  State  in  conducting  the  demonstration  well  child  conferences  of  the 
Department.  For  the  past  five  years,  she  has  been  carrying  on  a  special  study  in  Franklin 
County,  holding  conferences  in  the  several  towns,  and  frequently  reexamining  the  same  children 
yearly  until  they  enter  school.  This  paper  gives  some  of  her  conclusions,  based  on  this  study 
which  will  be  completed  this  summer. 


141 

in  Franklin  County  (population  49,361)  by  the  Massachusetts  Depart- 
ment of  Public  Health,  constant  effort  was  made  to  show  the  value  of 
regular  medical  and  dental  examination  of  infants  and  preschool  children 
and  prompt  correction  of  all  remediable  defects  found.  We  believe  that 
genuine  progress  was  made  along  this  line  during  the  five  years.  At 
first  a  common  response  on  the  part  of  a  large  number  of  the  parents 
was,  "My  children  are  all  well,  I  dcn't  see  why  they  should  be  examined." 
The  local  nurses  working  in  the  homes  and  the  conference  workers  were, 
however,  able  to  demonstrate  so  often — too  often,  alas! — the  presence 
of  handicapping  defects  in  well  children  that  gradually  fewer  and  fewer 
parents  felt  this  way.  Particularly  in  the  group  of  families  who  have 
faithfully  returned  year  after  year  to  the  conferences  has  change  in  at- 
titude been  most  interesting.  In  fact,  it  has  sometimes  been  difficult  to 
restrict  the  children  admitted  to  the  conference  to  a  number  possible  to 
handle  satisfactorily.  Conference  work  in  rural  sections,  where  so  many 
questions  arise  for  discussion,  should  never  be  hurried. 

Incidentally,  the  value  of  a  yearly  physical  examination  for  every  mem- 
ber of  the  family,  old,  young  and  middle-aged,  is  urged.  With  heart 
disease  and  cancer  the  leading  causes  of  death  today  it  is  not  difficult  to 
explain  the  importance  of  early  diagnosis  and  prompt  treatment  for 
adults  as  well  as  children.  The  great  need  of  examination  of  the  mother 
after  she  recovers  from  childbirth  is  also  emphasized.  Ill  health  from 
neglected  conditions  following  confinement  is  painfully  common.  Many  a 
young  mother,  especially,  says  to  us,  "I've  never  felt  well  since  the  baby 
came." 

Three  things  interfere  with  smallpox  and  diphtheria  protection  for 
the  country  child — fear,  over-confidence  and  expense.  There  is  fear  of 
harmful  results — so-and-so's  child  was  very  sick  after  vaccination,  though 
it  may  have  been  a  year  or  more  afterwards ;  or  there  has  been  no  case 
of  diphtheria  in  a  town  for  so  long  that  many  parents  cannot  feel  there 
ever  will  be  another.  The  matter  of  expense  looms  large  among  poorer 
families  in  towns  where  there  is  no  vaccination  or  toxin  antitoxin  clinic 
service.  Surely  such  protection  should  be  available  in  every  community 
regardless  of  expense. 

One  physician  tells  us  that  in  his  twelve  years'  practice  in  one  rural 
area  mothers  are  coming  more  often  and  earlier  in  pregnancy  for  pre- 
natal care.  This  appears  to  be  true  wherever  we  have  made  inquiry,  but 
we  still  find  many  mothers  having  little  or  no  prenatal  care.  We  see 
many  mothers  suffering  from  dental  defects  and  gynecological  com- 
plaints that  could  have  been  avoided  had  they  had  adequate  continuous 
prenatal  and  postnatal  care.  Many  nutritional  defects  in  infants  and 
preschool  children  as  shown  by  bone  and  teeth  defects  also  point  to  lack 
of  correct  maternal  diet  during  pregnancy  and  lactation.  Severe  rickets 
is  rare  in  the  country  and  only  one  or  two  cases  of  scurvy  have  been  ob- 
served in  the  last  five  years  at  the  State  Well  Child  Conferences,  but 
mild  rickets,  decaying  teeth  and  "poor"  or  "only  fair"  nutrition  are  ex- 
tremely common. 

In  the  matter  of  breast  feeding,  we  are  finding  the  same  difficulties 
with  country  mothers  as  elsewhere — lack  of  teaching  during  pregnancy 
and  lactation  of  the  correct  diet  and  proper  methods  of  keeping  up  breast 
milk,  failure  of  physicians  and  nurses  in  both  hospital  and  home  de- 
liveries to  persist  in  the  effort  to  establish  breast  feeding,  too  frequent 
pregnancies,  and  lack  of  adequate  care  of  the  mother's  own  health  dur- 
ing the  child-bearing  period. 

Mothers'  Classes  can  be  an  enormous  help  along  this  line  and  we  hope 
every  year  will  see  more  of  them  started  as  a  part  of  rural  community 
health  programs.  Such  service  is  an  important  measure  in  preventive 
work,  but  as  its  results  cannot  be  translated  in  small  towns  into  definite 
statistical  gains  it  gets  neglected. 

Infant  care  has  been  so  widely  taught  in  the  last  twenty  years  that 


142 
great  improvement  has  taken  place  in  the  country  as  well  as  in  cities. 
In  Franklin  County  for  example  the  infant  death  rate  has  dropped  from 
90  in  1920  to  71  in  1930.  The  health  of  the  preschool  child  has  also  re- 
ceived increased  attention  but  not  for  so  long  a  period  nor  has  it  had 
as  much  intensive  study.  We  find  the  percent  of  physical  defects  in  any 
group  of  preschool  children,  both  rural  and  urban,  increasing  with  age, 
even  if  we  omit  dental  defects.  The  Summer  Round-Up  conferences  alone 
certainly  convinced  us  of  the  large  percent  of  defects  prevalent  among 
well  children  at  school  entrance  age.  A  great  number  of  these  defects 
have  their  causes  in  nutritional  deficiencies  in  the  early  years.  To  these 
we  must  add  congenital  defects,  those  defects  due  to  injuries  and  com- 
municable disease,  and  abnormal  tonsils,  adenoids  and  glands.  Correc- 
tion or,  at  least,  improvement  is  possible  in  most  cases. 

The  need  of  proper  diet,  sufficient  rest  and  sleep,  normal  elimination, 
fresh  air,  direct  sunlight  and  cleanliness  are  daily  topics  at  our  rural 
well  child  conferences.  We  would  like  to  spend  more  time  on  mental 
hygiene  but  so  far  physical  essentials  have  claimed  our  first  attention. 
Perhaps  some  day  we  will  learn  how  to  create  mental  attitudes  which 
will  lay  a  better  foundation  for  the  health  and  happiness  of  parents  and 
children. 

Every  child  should  have  a  fair  chance  to  develop  to  the  limit  of  his 
individual  capacity  and  there  is  a  growing  interest  and  effort  in  our 
communities  towards  helping  to  provide  this  chance  by  means  of  im- 
proved conditions  in  home  and  school.  Progress  may  seem  slow  but  care- 
ful scrutiny  shows  improvement  year  by  year.  Better  feeding,  freer 
clothing,  more  "well"  children  having  regular  medical  and  dental  ex- 
amination, earlier  correction  of  defects,  more  and  better  nursing  and 
dental  service,  more  protection  from  disease,  all  these  are  concrete  ex- 
amples that  become  incentives  for  furthr  effort  toward  our  goal  in  child 
hygiene. 

At  each  Well  Child  Conference  we  ask  the  father  or  mother,  "Is  your 
child  well?  Is  he  happy?"  To  enable  more  fathers  and  mothers  to  an- 
swer "yes" — that  is  our  goal. 

PRIVATE  WATER  SUPPLY  AND  SEWAGE  DISPOSAL  PROBLEMS 

Francis  H.  Kingsbury* 

Rural  sanitation  affects  not  only  the  health  of  those  who  live  in  the 
country  districts  but  also  the  inhabitants  of  urban  communities  who 
visit  the  rural  sections.  Although  over  97  per  cent  of  the  population  of 
this  State  is  in  cities  and  towns  which  are  provided  with  a  public  water 
supply  and  87  per  cent  of  the  population  is  in  municipalities  provided 
with  sewerage  facilities,  there  remain  127,000  people  in  Massachusetts 
dependent  upon  private  sources  of  supply  and  over  465,000  people  who 
are  living  in  communities  not  provided  with  public  sewerage  systems. 

Since  the  advent  of  the  automobile  there  has  been  a  considerable 
movement  of  the  population  from  the  city  to  the  country  during  the 
summer  vacation  season.  It  is  estimated  at  the  present  time,  with  over 
600,000  passenger  automobiles  registered  in  Massachusetts  and  the 
large  number  which  come  to  this  State  from  other  states,  that  on  a 
pleasant  Sunday  during  the  months  of  June,  July  and  August,  as  many 
as  2,000,000  people  leave  their  urban  homes  to  journey  through  the 
country.  While  many  of  them  stop  for  refreshments  at  local  drug  stores 
or  other  places  provided  with  public  water  supplies,  there  are  118  towns 
in  the  State  without  public  water  supplies  and  places  of  refreshment 
in  such  communities  are  supplied  from  private  wells  or  springs.    In 

*  Few  health  problems  are  more  perplexing  to  the  board  of  health  or  the  householder  in  a 
small  community  than  those  presented  in  securing  safe  water  supply  and  adequate  disposal  of 
sewage.  Mr.  Kingsbury,  who  is  Senior  Sanitary  Engineer  in  the  Massachusetts  Department 
of  Public  Health  discusses  here  many  of  the  problems  and  the  relative  merits  of  various  sources 
of  water  supply  and  modes  of  sewage  disposal. 


143 

addition  to  these  long-established  places  of  refreshment  there  have 
sprung  up  along  the  highways  many  wayside  stands  also  supplied  with 
water  from  private  wells  or  springs.  Even  in  this  day  when  we  con- 
sider ourselves  to  be  more  or  less  enlightened  on  subjects  of  sanitation, 
the  wayside  well  or  spring  has  a  peculiar  appeal. 

Adequate  sewerage  facilities  to  care  for  this  large  transient  popula- 
tion at  comfort  stations,  at  wayside  stands  and  rest  rooms  must  also 
be  given  due  consideration.  The  magnitude  of  the  rural  health  problem 
and  the  responsibility  which  rests  upon  these  communities  in  the  care 
of  uninvited  though  welcome  guests  may  perhaps  best  be  visualized  by 
considering  that  this  mobile  population  on  Sundays  and  holidays  is 
larger  at  times  than  the  whole  population  of  the  Metropolitan  Water 
District. 

The  country  boarding  house  and  the  summer  hotel  are  also  vitally 
interested  from  the  commercial  standpoint  in  measures  to  diminish  the 
prevalence  of  flies,  vermin  and  mosquitoes  and  in  the  prevention  of 
nuisances  such  as  odors  arising  from  dumps,  piggeries,  overflowing  of 
cesspools  and  other  similar  conditions.  Because  rural  health  boards 
are,  with  few  exceptions,  part-time  officials,  meeting  possibly  two  or 
three  times  a  month  at  the  most,  and  who  work  for  a  very  small  re- 
muneration with  the  increasing  amount  of  time  demanded  of  them,  co- 
operative health  districts  are  being  established  for  the  purpose  of 
employing  full-time  health  officers  to  carry  on  the  executive  work  for 
groups  of  several  towns.  In  Massachusetts  three  of  these  organizations 
have  thus  far  been  organized:  the  Southern  Berkshire  District  com- 
prising the  southern  half  of  Berkshire  County  with  16  towns,  the  Nash- 
oba  Health  District  comprising  14  towns  in  the  vicinity  of  Ayer,  and 
the  Barnstable  County  Health  Unit  consisting  of  15  towns  on  Cape  Cod 
south  of  the  Cape  Cod  Canal.  The  towns  of  Weston  and  Wellesley  also 
share  in  the  employment  of  a  health  offjcer.  These  organizations  pro- 
vide the  machinery  for  the  active  enforcement  of  rural  health  regula- 
tions and  for  much  educational  and  clinical  health  work  by  full-time 
personnel  properly  trained.  They  receive  the  cooperation  of  the  Depart- 
ment of  Public  Health,  through  its  various  divisions.  The  Engineer- 
ing Division  investigates  matters  of  water  supply  and  sewage  disposal 
and  occasionally  swimming  pools  and  other  matters  of  an  engineering 
nature  upon  which  advice  is  requested. 

Private  Water  Supplies 

At  the  request  of  local  boards  of  health  or  their  agents,  the  Depart- 
ment, through  its  Engineering  Division,  examines  and  reports  upon 
private  water  supplies  whenever  in  the  opinion  of  the  local  board  of 
health  the  public  health  may  be  involved  or  for  the  assistance  of  local 
boards  of  health  in  the  investigation  of  epidemics  or  sources  of  sickness. 

Private  water  supplies  in  this  State  are  derived  for  the  most  part 
from  dug  wells  and  shallow  tubular  wells,  springs,  tubular  wells  in  rock 
and  occasionally  from  an  open  reservoir  or  brook.  Many  of  the  diffi- 
culties which  arise  from  the  pollution  of  private  sources  of  supply  may 
be  avoided  if  persons  responsible  for  their  construction  and  use  will 
observe  a  few  of  the  fundamental  principles  of  sanitation  which  in 
general  are  becoming  more  and  more  familiar.  Undoubtedly  the  fact 
that  many  of  these  wells  and  springs  have  been  used  for  generations 
without  any  recognizable  ill  effects  has  been  responsible  for  the  con- 
tinued use  of  many  supplies  of  questionable  quality. 

The  most  common  type  of  private  water  supplies  in  earlier  days  was 
the  dug  well,  which,  as  the  name  implies,  was  constructed  by  digging 
a  hole  in  the  ground  down  to  and  below  the  ground  water  level  and  con- 
structing in  this  excavation  a  wall  of  stone  or  other  material  not  readily 
attacked  by  the  water  and  of  sufficient  strength  to  withhold  the  pres- 
sure of  the  surrounding  earth.   It  was  not  customary  in  the  older  wells 


144 
to  use  cement  or  mortar  between  the  stones  and  although  a  curb  was 
sometimes  built  above  the  surface  of  the  ground  to  prevent  persons  or 
larger  animals  from  falling  into  the  well,  no  attempt  was  made  to  pre- 
vent the  entrance  of  surface  drainage  through  the  crevices  between  the 
stones.  Instances  were  numerous  where  small  animals,  snakes,  etc. 
crawled  or  fell  into  the  wells.  It  was  the  custom  with  earlier  forms  of 
wells  to  draw  the  water  by  means  of  a  bucket  or  pail  attached  to  a  rope 
or  possibly  by  a  pump  located  directly  over  the  well.  It  was  possible 
for  the  waste  water  from  the  pump  or  bucket  to  run  back  into  the  well 
carrying  with  it  any  contamination  that  may  have  taken  place  from 
the  hands  of  the  individual  drawing  water  or  which  may  have  been 
tracked  onto  the  well  cover.  A  later  type  of  well  was  that  lined  with 
brick  laid  in  cement  mortar  or  lined  with  vitrified  clay  pipe  or  precast 
cement  pipe. 

In  the  eastern  part  of  the  State  where  there  are  considerable  depths 
of  sand  and  gravel  a  newer  type  of  well,  known  as  the  driven  or  tubular 
well,  has  found  favor.  The  tubular  well  usually  consists  of  wrought 
iron  pipe  from  1%  to  21/2  inches  in  diameter  driven  into  the  soil  to 
depths  generally  ranging  from  20  to  50  feet.  The  bottom  length  of  pipe 
is  frequently  drilled  with  holes  about  %-inch  in  diameter  to  allow  the 
water  to  enter  the  pipe  and  where  the  well  terminates  in  fine  material 
it  may  be  provided  with  a  metallic  gauze  screen  or  strainer  to  prevent 
fine  sand  from  entering.  Such  a  driven  well  may  extend  to  the  surface 
where  a  hand  pump  is  attached  to  the  top  or  the  pipe  may  be  cut  off 
below  the  surface  and  connected  underground  to  a  pump  located  in  the 
house. 

The  drilled  well,  so  called,  usually  penetrates  several  feet  of  soil  and 
then  for  the  remainder  of  its  depth  is  drilled  in  the  underlying  rock. 
In  certain  sections  of  the  country,  where  this  rock  consists  of  sand- 
stone, such  wells  often  yield  a  considerable  quantity  of  water  from  the 
pores  of  the  rock  surrounding  the  well.  In  Massachusetts,  however, 
where  the  underlying  ledge  consists  for  the  most  part  of  granite  or 
other  similar  rocks,  wells  of  this  type  depend  upon  water  which  is 
drawn  through  cracks  in  the  rock,  oftentimes  from  a  considerable  dis- 
tance. In  penetrating  the  top  soil,  which  overlies  the  ledge,  it  is  the 
practice  to  drive  a  steel  or  wrought  iron  pipe  to  the  ledge,  excavating 
the  material  from  inside  this  casing.  When  ledge  is  reached  the  drill- 
ing in  rock  is  begun. 

Some  well  drillers  attempt  to  seal  the  joint  between  this  casing  and 
the  surface  of  the  ledge  with  concrete  in  order  to  prevent  surface 
drainage  from  the  top  soil  from  entering  the  well.  This  may  or  may  not 
be  successful  depending  upon  the  size  and  frequency  of  cracks  in  the 
ledge.  It  is  obvious  that  the  careful  sealing  of  the  connection  between 
the  casing  and  the  top  of  the  ledge  will  be  futile  if  there  are  cracks  in 
the  ledge  which  enter  the  well  a  few  feet  below  this  seal. 

Little,  if  anything,  is  known  concerning  the  degree  of  purification 
which  may  take  place  in  polluted  water  as  it  passes  through  seams  in 
ledge,  and  a  well  drilled  in  rock  must  be  viewed  with  suspicion  until  it  is 
definitely  known  that  pollution  does  not  exist  since  the  cracks  in  the 
rock  may  offer  a  direct  channel  between  sources  of  pollution  and  the 
well. 

In  drawing  water  from  wells  it  is  now  common  practice  to  locate  a 
gasoline  driven  engine  or  electric  pump  at  some  point  remote  from  the 
well  and  to  connect  this  with  the  well  by  a  suction  pipe  laid  under- 
ground. It  is  also  common  practice  for  such  pumps  to  discharge  into  a 
galvanized  iron  or  wrought  iron  pressure  tank  whereby  water  is  made 
available  under  pressure  throughout  the  premises. 

All  soil  is  more  or  less  porous,  including  ledge  which  contains  many 
cracks,  and  underneath  the  surface  of  the  ground  there  exists  what  is 
known  as  ground  water.  Everyone  is  familiar  with  the  fact  that  if  you 


145 

dig  deep  enough  in  ordinary  cases  you  will  come  upon  soil  saturated 
with  water  and  after  a  little  while  a  pool  will  form  in  the  bottom  of 
the  hole  remaining  at  a  more  or  less  constant  level.  This  ground  water 
by  capillary  action,  similar  to  that  which  draws  the  oil  through  the 
wick  of  a  lamp,  follows  in  a  general  way  the  contour  of  the  ground  but 
does  not  come  as  near  the  surface  on  the  hills.  In  the  lowlands  it  often 
rises  above  the  natural  surface  of  the  ground  to  form  lakes  and  ponds 
which  may  have  no  visible  inlet.  Under  certain  conditions  the  ground 
water  in  flowing  downhill  through  the  soil  is  prevented  from  seeking 
its  natural  level  by  reason  of  some  impervious  stratum,  such  as  clay  or 
hardpan,  and  where  such  an  impervious  formation  outcrops  on  the  sur- 
face the  ground  water  appears  in  the  form  of  a  spring.  Sometimes  the 
flow  is  sufficient  to  wash  out  a  certain  amount  of  the  surface  material 
to  form  a  depression  filled  with  water  which  continues  to  overflow  dur- 
ing most  of  the  year.  It  is  often  possible  by  careful  observation  of  the 
character  of  the  vegetation,  unusually  green  grass  or  soggy  nature  of 
the  soil,  to  discover  a  spring  which  may  later  be  developed  by  digging 
out  a  hole  in  the  ground  and  suitably  lining  it  with  concrete  or  tile  in 
the  same  manner  that  a  well  would  be  lined.  Whenever  it  is  necessary 
to  install  an  overflow  pipe  in  a  spring  this  pipe  should  be  so  located 
that  surface  water  cannot  back-flood  into  the  spring  from  adjoining 
land  or  water  course  at  any  time.  This  overflow  pipe  also  should  be 
protected  by  a  screen  to  prevent  the  entrance  of  small  animals  into  the 
spring. 

Wells  or  springs  should  be  protected  against  the  entrance  of  surface 
drainage  and  foreign  matter.  A  dug  well,  if  constructed  of  stone, 
should  be  cemented  water-tight  from  a  point  4  or  5  feet  below  the 
ground  and  should  have  a  water-tight  curb  extending  from  1  to  1% 
feet  above  the  surface.  Wells  and  springs  should  be  provided  with 
water-tight  covers  of  concrete  on  plank  covered  with  roofing  paper  and 
if  it  is  necessary  to  mount  the  pump  directly  over  the  well  care  should 
be  taken  that  the  joint  where  the  draw  pipe  passes  through  the  cover 
is  water-tight  and  sealed  with  roofing  cement  or  other  similar  com- 
pound. It  is  often  advantageous  to  construct  a  concrete  apron  around 
the  well  ©r  to  construct  a  small  embankment  or  ditch  around  the  well 
to  prevent  surface  drainage  from  standing  in  its  vicinity.  Great  care 
should  be  taken  to  prevent  pollution  by  surface  drainage  since  if 
polluted  water  is  allowed  to  enter  the  well  directly  without  having 
been  purified  in  its  passage  through  the  ground  the  water  of  the  well 
may  become  polluted.  Surface  water  may  be  polluted  by  sink  drainage 
or  from  cattle  or  other  animals  or  other  sources.  It  also  may  be  polluted 
from  shoes  of  human  beings  who  may  come  to  the  well. 

The  ground  in  the  vicinity  of  the  well  at  all  times  should  be  free 
from  pollution  by  the  seepage  of  sewage  from  cesspools,  subsurface 
drains  connected  with  septic  tanks,  earth  vault  privies  and  barnyard 
drainage  or  other  polluted  matter  which  may  percolate  through  the  soil 
into  the  well.  No  definite  statement  can  be  made  as  to  the  safe  distance 
that  pollution  should  be  kept  from  a  well  since  the  character  of  the 
soil  determines  to  a  large  extent  its  ability  to  purify  organic  matter 
and  remove  objectionable  bacteria.  In  fine  sand  the  greatest  purifica- 
tion may  be  expected,  while  with  coarse  gravel  a  lesser  amount  of  pro- 
tection is  afforded  since  pollution  may  flow  more  freely  and  therefore 
in  a  shorter  period  of  time  to  the  well.  Should  the  well  be  constructed 
in  part  through  rock,  pollution  may  travel  rapidly  from  long  distances 
through  cracks  in  the  ledge.  It  is,  of  course,  of  paramount  importance 
that  pollution  from  cesspools  or  other  containers  for  the  disposal  of 
sewage  of  human  origin  should  not  be  allowed  to  pollute  a  water  supply 
since  all  water-borne  diseases  have  their  origin  in  the  disease  germs 
contained  in  the  feces  of  patients  suffering  from  such  diseases.  Barn 
drainage,  sink  drainage  and  other  objectionable  organic  matter  which 
may  result  in  a  disagreeable  taste  and  odor  in  the  water  is  repugnant 


146 

in  any  case  and  should  not  be  allowed  to  pollute  the  water  supply. 

Wells  or  springs  may  sometimes  be  polluted  by  the  cultivation  of 
land  in  their  vicinity,  especially  where  manure  is  used  in  fertilizing 
the  soil,  and  such  pollution  may  become  particularly  dangerous  if  the 
unsanitary  practice  is  followed  of  disposing  of  the  night  soil  from 
privies  together  with  the  manure  from  the  stables.  In  this  connection 
it  may  be  noted  that  it  is  advisable  that  each  barn  should  be  provided 
with  a  suitable  privy  or  other  toilet  in  order  that  the  barn  drainage 
may  not  become  polluted  with  sewage  by  the  farm  hands  and  then 
spread  upon  the  land  for  the  fertilization  of  crops,  especially  the  kind 
which  are  consumed  without  cooking,  such  as  strawberries,  lettuce,  etc. 

In  earlier  days  the  only  suitable  form  of  pipe  which  was  available 
was  constructed  of  lead  and  many  of  the  older  springs  and  wells  are 
connected  to  houses  by  lead  pipe  through  which  the  water  must  pass 
before  it  is  available  for  drinking.  Certain  waters  dissolve  metals  more 
readily  than  others  and  the  ability  of  a  water  to  attack  lead  pipe  may 
vary  from  time  to  time  due  to  the  particular  conditions  of  the  soil 
through  which  the  water  passes  on  its  way  to  the  well  or  spring.  It  is, 
therefore,  important  that  if  lead  pipe  is  used  that  the  owner  make  sure 
that  the  particular  water  with  which  he  is  supplied  does  not  dissolve 
lead  and  thus  lead  to  lead  poisoning.  This  applies  particularly  to  the 
older  wells  and  springs  since  very  few  people  at  the  present  time  use 
lead  pipe,  generally  turning  to  galvanized  iron  pipe  or  iron  pipe  lined 
with  cement  or  bitumastic  compound. 

The  owner  of  a  private  water  supply  should  make  certain  that  the 
water  is  not  contaminated  after  it  leaves  the  well  or  other  source  of 
supply.  This  is  especially  true  where  the  pump  is  remote  from  the  well 
as  pollution  in  the  ground  between  the  well  and  the  pump  may  in  such 
cases  enter  the  suction  pipe.  In  some  cases  water  is  pumped  into  a 
storage  tank,  which  may  be  located  in  the  loft  of  a  barn  or  attic  of  a 
house  and  often  these  tanks  are  open  at  the  top  and  accessible  to  small 
animals  and  birds  and  the  water  may  become  polluted  by  their  presence. 
The  same  care  should  be  exercised  in  regard  to  such  tanks  as  would  be 
given  to  the  source  of  supply.  These  tanks  also  should  be  adequately 
covered  to  prevent  the  growth  of  certain  microscopic  organisms  which 
may  take  place  in  an  open  tank  if  the  water  is  exposed  to  the  light  for 
any  considerable  length  of  time. 

We  have  so  far  discussed  only  those  methods  of  obtaining  a  water 
supply  from  the  ground  protected  to  a  certain  extent  by  natural  filtra- 
tion. In  certain  cases,  however,  private  water  supplies  have  been  ob- 
tained directly  from  a  brook  or  pond  or  other  open  water  but  such  sources 
are  not  desirable  for  private  supplies.  Usually  in  such  cases  there  is  a  very 
short  period  of  storage  in  a  pond  or  small  intake  reservoir  which  re- 
ceives the  drainage  from  considerable  areas  and  during  times  of  spring 
freshets  or  sudden  runoffs  resulting  from  thunder  showers  polluted 
material  on  the  surface  of  the  ground  must  of  necessity  find  its  way 
into  such  water  supplies  in  a  very  short  time.  Pollution  may  result  be- 
cause of  the  presence  of  hunters  and  others  going  to  and  fro  upon  the 
drainage  area.  Surface  water  supplies  for  private  individuals  are  not 
considered  desirable  or  safe  without  treatment  unless  considerably 
longer  periods  of  storage  are  available  than  is  usually  the  case  and  the 
watershed  is  adequately  protected  from  pollution.  A  suitable  supply 
for  drinking  and  other  domestic  purposes  may  almost  always  be  ob- 
tained from  the  ground  in  the  vicinity. 

In  communities  where  there  are  no  public  water  supplies  local  officials 
are  often  faced  with  the  problem  of  providing  a  semi-public  supply 
from  suitable  sources  for  schoolhouses  or  other  buildings  where  public 
gatherings  are  held.  Their  responsibility  for  a  safe  water  supply 
should  be  thoroughly  appreciated  and  the  same  principles  should  govern 
the  protection  of  such  a  supply  as  for  private  individuals.    Since  the 


147 
works  for  such  a  large  supply  must  be  of  necessity  considerably  more 
extensive  it  is  advisable  that  the  services  of  an  engineer  experienced 
in  these  matters  be  secured.  The  Department  of  Public  Health  will  be 
pleased  to  cooperate  with  its  advice  and  by  the  analysis  of  samples  of 
water  from  such  supplies  if  requested. 

Private  Sewage  Disposal  Works 

It  is  important  to  dispose  of  sewage  at  some  point  where  it  will  not 
create  a  nuisance  or  endanger  the  safety  of  a  water  or  food  supply.  It 
has  become  instinctive  with  man  and  animals  to  avoid  locations  selected 
for  disposal  of  their  wastes  and  the  early  Nomadic  tribes  accomplished 
this  by  changing  camp  from  place  to  place  whenever  the  surroundings 
became  sufficiently  contaminated  to  cause  a  nuisance  by  reason  of 
odors,  insects  and  vermin.  They  habitually  kept  as  far  away  from  other 
tribes  as  possible  because  of  the  instinctive  knowledge  that  contact 
might  result  in  disease  and  death.  It  is  no  longer  possible  to  avoid  the 
responsibility  for  taking  care  of  our  wastes  and  where  public  sewerage 
systems  are  not  available  the  individual  family  must  provide  some 
means  of  sewage  disposal.  It  is  often  a  problem  to  provide  such  means 
on  a  relatively  small  area  where  it  is  difficult  to  construct  suitable 
works  and  adequately  protect  the  water  supply. 

The  most  common  methods  of  sewage  disposal  for  private  dwellings 
in  rural  communities  are  the  common  privy  and  cesspool.  A  privy 
properly  constructed  with  tight  removable  vaults  will  prevent  the  pollu- 
tion of  the  ground  but  the  contents  should  be  carted  away  for  disposal 
by  burying  in  the  ground  at  some  point  remote  from  any  source  of 
water  supply. 

When  it  became  feasible  to  install  running  water  either  by  piping 
water  from  a  spring  on  a  hillside  or  by  installing  a  ram  or  other 
means  of  pumping,  the  installation  of  bath  tubs  and  toilets  in  rural 
communities  became  more  frequent  and  more  adequate  means  of  dis- 
posal of  sewage  than  the  common  privy  became  necessary.  This  has 
led  to  the  construction  of  cesspools  which  are  really  large  holes  in  the 
ground  lined  with  stone,  brick  or  cement  blocks  or  other  material  laid 
below  the  water  line  without  mortar  and  with  open  spaces  leading  to 
the  soil  surrounding  this  wall.  It  is  common  practice  to  construct  the 
wall  of  smaller  diameter  as  it  approaches  the  surface  of  the  ground 
and  to  provide  the  top  with  a  suitable  cover  of  plank,  stone  slab,  con- 
crete or  iron  manhole  cover.  The  successful  operation  of  the  cesspool 
depends  to  a  very  large  extent  upon  the  character  of  the  soil.  Sand  and 
gravel  absorb  the  liquid  portions  of  the  sewage  much  more  rapidly 
than  clay  or  loam.  In  a  cesspool  which  retains  much  liquid  the  more 
solid  portions  of  the  sewage  undergo  a  liquefying  action  with  the  assist- 
ance of  bacteria  and  whatever  material  is  not  liquefied  settles  to  the 
bottom.  This  material  must  be  removed  occasionally  although  in  open 
soil  a  cesspool  may  be  satisfactory  for  many  years.  One  of  the  prin- 
cipal difficulties  is  caused  by  the  clogging  of  the  soil  with  grease  which 
prevents  the  liquid  contents  of  the  cesspool  from  leeching  out  through 
the  crevices  in  the  wall  into  the  surrounding  soil  which  may  thus  be- 
come clogged.  It  is  advantageous  to  pass  the  sewage,  especially  the 
drainage  fom  kitchen  sinks,  through  a  small  tank  known  as  a  grease 
trap,  constructed  of  a  sufficient  size  to  allow  the  grease  to  separate 
from  the  liquid  and  rise  to  the  surface  where  it  may  be  skimmed  off 
and  buried  or  burned  when  necessary. 

Where  the  soil  is  not  particularly  well  adapted  to  the  absorption  of 
the  liquid  portion  of  the  sewage,  it  may  be  necessary  to  construct  more 
than  one  cesspool  and  the  discharge  may  be  led  from  one  to  the  other. 
If  the  ground  water  is  close  to  the  surface  of  the  ground  the  liquid 
portion  of  the  sewage  may  be  discharged  through  blind  drains  varying 
from  V-/2  feet  to  2  feet  in  depth  consisting  of  covered  trenches  filled 
with  stone  or  provided  with  tile  pipes  to  conduct  the  sewage  along  the 


148 
trench  above  the  ground  water  table.  The  pipes  should  be  laid  without 
mortar  with  the  joints  left  open  in  order  that  the  liquid  may  escape 
at  several  points  along  the  trench.  It  is  often  advantageous  to  surround 
these  pipes  with  crushed  stone  or  gravel  to  facilitate  the  movement  of 
the  liquid  into  the  surrounding  soil.  In  this  connection  certain  tight 
cesspools  known  as  septic  tanks  have  been  developed  having  the  ad- 
vantage particularly  in  regard  to  the  ease  of  installation.  These  septic 
tanks,  so  called,  act  as  chambers  wherein  the  more  solid  portions  of 
the  sewage  are  liquefied  and  they  require  the  installation  of  cesspools 
or  blind  drains  to  enable  the  settled  sewage  to  be  discharged  into  the 
ground.  Contrary  to  common  belief,  these  septic  tanks  should  not  be 
depended  upon  to  remove  disease  bacteria. 

In  connection  with  rural  hotels  or  schools,  it  will  be  necessary  to 
construct  more  extensive  works  for  the  treatment  of  sewage  and  in  such 
cases  it  is  desirable  that  the  local  officials  secure  the  services  of  en- 
gineers experienced  in  such  matters  to  design  a  sewage  collection 
system  laid  at  proper  grades  and  a  disposal  system  consisting  of  a 
properly  balanced  design  of  settling  tanks,  dosing  tanks  and  filters 
preferably  of  the  subsurface  type.  In  such  instances  the  Department 
of  Public  Health  is  pleased  to  advise  local  officials  or  their  repre- 
sentatives. 

It  must  be  remembered  that  in  the  proper  treatment  of  sewage  it  is 
necessary  to  dispose  of  the  material  so  that  it  will  not  create  a  nuisance 
and  since  a  large  portion  is  of  a  liquid  nature  it  must  eventually  be 
absorbed  to  a  large  extent  by  the  soil.  The  point  where  this  discharge 
into  the  soil  takes  place  should  be  remote  from  any  source  of  water 
supply  and  the  disposal  works  so  maintained  that  there  will  be  no 
offense  to  the  senses  and  that  the  works  will  not  be  accessible  to  ani- 
mals, flies  or  vermin  which  might  carry  the  germs  of  disease  to  a  point 
where  they  might  contaminate  a  food  supply.  If  ledge  is  encountered 
in  digging  a  cesspool  or  in  the  construction  of  a  sewer  leading  to  a 
cesspool,  particular  attention  should  be  given  to  make  absolutely  cer- 
tain that  the  water  of  any  well  may  not  be  contaminated  directly  from 
the  cesspool  or  sewer  through  a  crack  in  the  ledge.  A  sewer  leading  to 
a  cesspool  should  not  pass  in  close  proximity  to  the  well  since  several 
instances  have  been  known  where  the  water  of  wells  has  been  danger- 
ously polluted  by  the  discharge  of  sewage  into  the  ground  through  a 
broken  sewer. 

Rural  sanitation  resolves  itself  largely  into  the  problem  of  the  dis- 
posal of  human  and  animal  wastes  in  such  a  manner  that  they  will  not 
pollute  the  air,  food  or  water  supply  and  thus  endanger  the  health  and 
comfort  not  only  of  the  considerable  population  residing  in  rural  com- 
munities but  also  of  the  large  number  of  persons  who  travel  about  the 
State  for  business  or  recreation. 

RURAL  NUISANCES  AND  THEIR  CONTROL 

Willard  S.  Little  * 

Since  the  first  formation  of  society,  nuisances  have  been  associated 
with  the  health  of  the  community.  So  it  was  that  our  forefathers  placed 
the  control  of  nuisances  on  the  shoulders  of  the  local  boards  of  health. 
The  belief  in  early  days  was  that  the  source  and  spread  of  practically  all 
diseases  lay  in  filth  and  the  environment  of  the  individual.  This  idea  is 
shown  in  the  phrase  "source  of  filth  and  causes  of  sickness  which  may 
be  injurious  to  the  public  health"  which  is  part  of  the  law  enacted  in 
Massachusetts  in  1797. 


*  Probably  the  most  troublesome  problem  with  which  a  board  of  health  may  be  faced  is  that 
of  control  of  nuisances.  Though  often  without  direct  public  health  significance  the  nuisance 
may  assume  major  importance  in  the  community.  Mr.  Little,  who  is  Assistant  Engineer  in 
the  Massachusetts  Department  of  Public  Health,  has  had  wide  experience  in  this  problem  both 
as  a  health  officer  of  a  small  community  and  in  connection  with  his  present  duties. 


149 

The  present  general  feeling  of  health  officials  is  that  nuisances  are  only 
distantly  related  to  public  health,  and  with  the  development  of  bacteri- 
ology it  has  been  proved  that  it  is  the  individual  who  must  be  controlled 
and  not  his  environment  to  check  the  spread  of  communicable  disease, 
but  of  course  an  environment  which  causes  discomfort  may  indirectly 
cause  sickness  in  individuals  because  of  loss  of  sleep,  nervous  irritation, 
nausea  and  other  enervating  disorders. 

Consequently  the  Supreme  Court  of  Massachusetts  has  ruled  that  "in 
order  to  amount  to  a  nuisance  it  is  not  necessary  that  the  corruption  of 
the  atmosphere  should  be  such  as  to  be  dangerous  to  health ;  it  is  sufficient 
that  the  effluvia  are  offensive  to  senses,  and  render  habitation  uncomfort- 
able." Within  this  ruling  come  the  ordinary  nuisances,  which  consume  a 
considerable  amount  of  the  time  and  patience  of  local  boards  of  health. 
These  may  include  cesspools,  privies,  sink  drains,  dumps,  piggeries,  gar- 
bage, poultry  yards,  stables  and  dead  animals.  There  is  also  a  group 
which  may  be  styled  unusual  nuisances,  including  wet  and  spongy  lands, 
dwellings  unfit  for  habitation,  defective  plumbing,  offensive  trades  and 
smoke.  This  latter  group  seldom  bothers  rural  boards  of  health  and  is 
regulated  by  certain  specific  laws. 

The  General  Laws  of  Massachusetts  are  very  definite  in  regard  to  nuis- 
ances. They  specifically  state  in  Chapter  41  that  all  cities  and  towns 
shall  have  a  board  of  health  and  definitely  assign  the  abatement  of  nuis- 
ances to  that  board  in  Chapter  111,  Section  122,  which  is  as  follows: 

"Section  122.    Regulations  relative  to  nuisances,  etc.    The  board 
of  health  shall  examine  into  all  nuisances,  sources  of  filth  and  causes 
of  sickness  within  its  town,  or  on  board  of  vessels  within  the  har- 
bor of  such  towns,  which  may,  in  its  opinion,  be  injurious  to  the 
public  health,  shall  destroy,  remove  or  prevent  the  same  as  the  case 
may  require,  and  shall  make  regulations  for  the  public  health  and 
safety  relative  thereto  and  to  articles  capable  of  containing  or  convey- 
ing infection  or  contagion  or  of  creating  sickness  brought  into  or  con- 
veyed from  the  town  or  into  or  from  any  vessel.    Whoever  violates 
any  such  regulation  shall  forfeit  not  more  than  one  hundred  dollars." 
This  is  a  very  broad  statute  and  confers  full  powers  upon  health  officers 
and  not  only  gives  them  the  right  specifically  mentioned  in  the  statute 
but  all  other  rights  that  are  reasonably  necessary  and  incidental  to  carry- 
ing out  the  purpose  of  the  act. 

The  procedure  under  the  statute  as  described  in  Sections  123-125,  in- 
clusive, of  Chapter  111  is  simple  and  is  intended  to  provide  a  summary 
and  speedy  remedy  for  the  ordinary  class  of  local  nuisances  caused  by  the 
neglect  of  an  individual  which  could  be  abated  by  him  personally.  The 
board  may  proceed  after  receiving  a  complaint  by  making  an  investiga- 
tion and,  if  a  nuisance  is  deemed  to  exist,  sending  a  written  order  to  the 
owner  or  occupant  to  remove  the  nuisance,  source  of  filth  or  cause  of  dis- 
ease within  the  time  specified  in  the  order.  If  the  order  is  not  complied 
with,  the  board  may  cause  the  nuisance  to  be  removed  and  the  expense 
therefor  to  be  paid  by  the  person  who  caused  or  permitted  the  same. 
The  decision  of  a  board  of  health  that  a  nuisance  exists  is  sufficient  for 
issuance  of  an  order.  It  is  well  however,  for  the  board  to  understand 
thoroughly  its  powers  before  proceeding  to  the  investigation  of  a  com- 
plaint and  issuance  of  an  order.  The  board  should  fully  comply  with  the 
statute  by  taking  steps  above  outlined  so  that  if  there  is  any  claim  by 
the  property  owner  the  board  may  seek  full  justification  under  the  law. 
It  is  well  to  seek  the  advice  of  the  town  counsel. 

The  Supreme  Court  of  Massachusetts  has  decided  that  a  board  cannot 
order  the  owner  or  occupant  of  private  premises  to  abate  a  nuisance  in 
a  specific  way  but  that  the  owner  may  abate  it  in  any  proper  manner. 
(See  Belmont  v.  N.  E.  Brick  Co.  190  Mass.  442)  That  is  to  say,  if  a 
board  of  health  orders  the  abatement  of  a  nuisance  by  any  specific  way, 
the  owner  or  occupant  is  not  restricted  to  that  mode.  Neither  is  the  order 
void  if  it  purports  to  direct  the  manner  in  which  the  nuisance  shall  be 


150 
abated.    (See  Commonwealth  v.  Alden  143  Mass.  113) 

Although  the  sections  pertaining  to  nuisances  and  their  abatement 
have  been  held  constitutional  by  the  courts  of  Massachusetts  and  the  law 
is  mandatory  that  the  local  boards  of  health  control  nuisances,  consider- 
able tact  and  judgment  are  necessary  on  the  part  of  the  board  in  deter- 
mining whether  a  nuisance  exists  and  in  its  method  of  procedure  of 
abatement.  Many  complaints  received  by  the  board  are  trivial  and  an 
agreement  may  be  reached  if  the  investigator  will  handle  it  in  the  right 
spirit.  Neighborhood  quarrels  are  the  cause  of  many  complaints,  and 
with  no  attempt  to  settle  the  matter  amicably  the  local  board  of  health  is 
called  in  and  threatened  in  no  uncertain  words  that  if  the  matter  is  not 
attended  to  at  once  the  complainant  will  take  the  matter  up  with  the  State 
Department  of  Public  Health.  This  practice  is  very  common  and  the 
State  Department  annually  receives  many  complaints  requesting  the 
abatement  of  nuisances.  The  laws  are  very  definite  in  this  matter  and 
grant  no  authority  to  the  State  Department,  which  explains  to  the  com- 
plainant the  provisions  of  the  General  Laws,  Chapter  111,  Sections  140- 
141.  In  these  it  is  stated  that  if  the  local  board  fails  to  act  on  a  com- 
plaint or  petition,  the  appeal  is  to  the  county  commissioners  or  superior 
court  and  not  to  the  State  Department  of  Public  Health.  The  Depart- 
ment will,  however,  advise  the  local  board  of  health  upon  request  if  an 
engineering  investigation  seems  advisable. 

From  the  large  list  of  wrongs  which  are  popularly  called  nuisances,  this 
paper  is  limited  to  those  which  are  more  common  and  perplexing  to  the 
rural  boards  of  health,  including  dumps,  privies,  piggeries,  and  garbage. 

Dumps 

Dumps  are  included  in  the  class  of  nuisances  which  have  much  less 
bearing  on  the  public  health  than  many  others  but  which  consume  much 
of  the  routine  attention  of  health  boards.  Dumps  relate  chiefly  to  the 
promotion  of  general  municipal  cleanliness,  the  influence  of  which  on 
general  public  health  is  indirect  but  which  without  regulation  and  con- 
A  dump  without  restrictions  will  be  the  disposal  station  for  all  munic- 
ipal refuse  including  garbage,  dead  animals,  night  soil,  manure,  ashes, 
rubbish  and  street  sweepings.  A  dump  of  this  type  may  be  a  nuisance 
trol  by  the  health  departments  rapidly  becomes  a  nuisance, 
from  the  offensive  odors  arising  from  the  decaying  organic  matter.  The 
wind,  which  is  a  strong  ally  of  nuisances,  may  carry  the  odors  to  the 
residential  sections  of  the  town  and  complaints  will  immediately  arise. 
Uncontrolled  dumps  also  make  breeding  places  for  rats,  flies  and  other 
vermin,  and  cause  innumerable  fires  accompanied  by  offensive  odors. 

Although  other  methods  are  employed  for  the  disposal  of  municipal 
wastes,  it  is  not  necessary  for  the  small  communities  to  install  expensive 
works  for  modern  methods  of  incineration  if  the  necessary  rules  and  regu- 
lations are  adopted  and  enforced  by  the  boards  of  health.  The  following 
is  a  suggested  rule  governing  dumps: 

"The  owner,  agent  or  lessee  of  any  land  or  enclosure,  used  as  a 
dump,  either  public  or  private,  shall  cause  all  offensive  matter  , 
dumped  thereon  to  be  immediately  covered,  and  all  other  refuse 
matter  dumped  thereon  to  be  kept  leveled,  and  the  premises  kept  in 
such  a  manner  as  to  cause  no  nuisance  during  the  process  of  filling. 
No  person  shall  dump  any  offensive  material  upon  any  dump  unless 
permitted  to  do  so  by  the  Board  of  Health,  and  all  such  offensive 
materials  shall  be  properly  buried  or  otherwise  disposed  of  to  the 
approval  of  the  Board  of  Health.  All  possible  care  shall  be  used  in 
preventing  the  escape  of  dust  and  papers  from  the  dump  and  from 
the  vehicles  used  in  conveying  waste  materials  to  the  dump." 
An  inexpensive  incinerator  of  the  cage  type  is  of  considerable  assist- 
ance for  the  disposal  of  papers  at  a  dump. 


151 
Privies 

By  far  the  most  important  class  of  nuisances  from  the  public  health 
standpoint  is  that  involved  in  the  disposal  of  human  wastes.  It  is  the 
first  duty  of  every  board  of  health  to  insist  upon  the  disposal  of  such 
matter  in  a  way  which  will  safeguard  the  public  health.  Excreta  should 
always  be  regarded  as  potentially  infected.  Proper  disposal  means  prompt 
removal.  Where  sewers  do  not  exist,  as  in  rural  districts,  the  methods 
of  excreta  disposal  should  be  strictly  regulated.  The  spread  of  infection 
from  insanitary  privies  through  domestic  animals,  flies  and  the  pollution 
of  surface  and  ground  waters  is  inexcusable  in  any  community.  The 
danger  of  pollution  and  contamination  of  wells  and  springs  from  privies 
and  cesspools  and  disposal  of  night  soil  cannot  be  impressed  too  strongly 
upon  the  minds  of  the  people.  In  cities  and  towns  having  a  partial  system 
of  sanitary  sewers,  night  soil  may  be  disposed  of  satisfactorily  by  pro- 
viding suitable  means  for  dumping  it  into  the  sewerage  system;  the  city 
of  Lynn  has  used  this  method  with  satisfactory  results.  It  may  be  possi- 
ble for  rural  communities  adjacent  to  sewered  communities  to  arrange 
for  the  disposal  of  night  soil  by  this  method. 

General  Laws,  Chapter  111,  Sections  126  and  127  deal  with  privy 
vaults  and  state  that  no  privy  vault  shall  be  constructed  on  premises 
where  connections  to  a  sewer  can  be  made,  without  permission  in  writing 
from  the  board  of  health.  The  board  is  also  given  power  to  declare  a 
privy  a  nuisance  and  forbid  its  use.  Section  127  grants  the  board  author- 
ity to  make  and  enforce  regulations  for  the  connection  of  house  drain- 
age to  a  common  sewer  if  one  abuts  the  estate  to  be  drained. 

In  rural  communities  the  proper  disposal  of  fecal  matter  is  a  difficult 
problem.  Privies,  which  are  essentially  simple  structures  are  often 
thoughtlessly  constructed  and  located  and  then  are  not  given  adequate 
care,  chiefly  because  the  inherent  dangers  have  not  been  understood. 

What  are  the  dangers  and  objections  of  the  unprotected  privy? 

1.  Human    excreta    may    contain    the    causative    agents    of    typhoid, 

cholera,  dysentery  and  other  dangerous  diseases. 

2.  Open  and  unprotected  privies  may  make  it  possible  for  flies,  ani- 

mals and  other  vermin  to  carry  disease. 

3.  Proximity  to  wells  and   springs  fed  by  ground  water,   which   is 

merely  natural  drainage,  may  result  in  dangerous  pollution  of 
the  water. 

4.  Neglected  privies  produce  offensive  odors. 

5.  They  require  more  personal  attention  and  care  than  people  gen- 

erally are  willing  to  give. 
What  are  the  remedies  of  privy  nuisances? 

1.  Locate  privy  inconspicuously,  detached  and  at  least  20  feet  from 

dwelling. 

2.  Make  receptable  or  vault   small,  easy  of  access  and  water-tight, 

and  removable  as  a  whole  so  that  cleaning  is  not  necessary  near 
a  dwelling. 

3.  Clean  out  vault  often  to  prevent  decomposition  which  causes  odors. 

4.  Sprinkle  daily  into  the  vault  loose,  dry  soil,  ashes,  lime  or  sawdust 

to  absorb  liquid  and  odors. 

5.  Make  privy  rain-proof,  rat-proof,  fly-proof  and  ventilated. 

6.  Do  not  locate  above  or  near  water  supply. 

7.  Final  disposal  of  contents  should  not  be  near  or  above  wells  or 

springs,  should  not  be  used  as  a  fertilizer  on  crops  which  are 
eaten  uncooked,  and  preferably  should  be  burned  or  buried  with 
chloride  of  lime. 
As  with  other  nuisances  the  general  laws  are  very  definite  as  to  regula- 
tions of  privies,  and  local  boards  should  incorporate  and  enforce  rules 
governing  them. 


152 
Piggeries 

Piggeries  constitute  one  of  the  most  annoying  and  difficult  problems 
with  which  boards  of  health  have  to  contend.  Piggeries  are  a  means 
for  garbage  disposal,  particularly  in  smaller  communities.  Under 
proper  supervision  this  method  of  garbage  disposal  may  be  made  both 
inoffensive  and  financially  profitable.  Proper  methods  of  operation, 
however,  are  not  always  followed  and  complaints  due  to  offensive  odors 
may  result. 

Referring  again  to  General  Laws,  Chapter  111,  piggeries  have  been 
ruled  a  nuisance  by  the  courts.  A  piggery,  in  which  swine  are  kept  in 
such  numbers  that  their  odors  make  the  occupancy  of  neighboring 
houses  and  passage  over  the  adjacent  highways  disagreeable,  is  a 
nuisance.  (See  Commonwealth  v.  Perry  139  Mass.  198,  Commonwealth 
v.  Young  135  Mass.  526,  Fay  v.  Whitman  100  Mass.  76,  also  Common- 
wealth v.  Surrney  131  Mass.  579). 

The  keeping  of  swine  is  an  employment  within  the  meaning  of  Chap- 
ter 111,  Section  143,  and  a  board  of  health  has  authority  to  prohibit  it. 
(See  Commonwealth  v.  Young  135  Mass.  526,  Commonwealth  v.  Patch 
97  Mass.  233,  also  Commonwealth  v.  Rawson  183  Mass.  491). 

There  are  many  factors  which  cause  a  nuisance  from  a  piggery,  in- 
cluding the  following: 

1.  Unsuitable  location  in  respect  to  dwellings, 

2.  Swampy  land, 

3.  Cheap  and  poorly  ventilated  buildings, 

4.  Garbage  dumped  on  ground  for  feeding, 

5.  Lack  of  running  water  for  cleaning  purposes,  and 
-  6.    No  disposal  of  piggery  refuse. 

Suggestions  for  a  piggery  that  will  not  cause  a  nuisance  are  as 
follows: 

1.  Selection  of  a  suitable  site,  preferably  with  a  southerly  exposure, 

2.  Soil  should  be  preferably  sand  or  gravel,  thus  insuring  proper 

drainage, 

3.  Adequate  water  supply  for  cleaning, 

4.  Well  lighted,  ventilated  buildings  of  substantial  construction, 

5.  Feeding  platforms  which  can  be  readily  and  thoroughly  washed, 

6.  Sufficient  number  of  hogs  to  consume  all  the  garbage, 

7.  Satisfactory  disposal  of  piggery  waste, 

8.  Sterilizing  of  garbage  cans  and  wagons  or  trucks,  and 

9.  Suitable  covering  for  garbage  pending  feeding. 

The  application  of  the  above  suggestions  can  best  be  effected  through 
such  rules  and  regulations  adopted  and  enforced  by  the  local  board  of 
health. 

Frequently  the  question  of  pollution  of  water  supplies  from  piggeries 
has  been  brought  to  the  attention  of  local  boards  and  the  State  Depart- 
ment of  Public  Health.  General  Laws,  Chapter  111,  Section  160  grants 
the  State  Department  authority  to  make  rules  and  regulations  to  pre- 
vent the  pollution  and  secure  the  sanitary  protection  of  all  sources  of 
water  supply. 

With  proper  location,  construction,  and  management,  and  with  careful 
supervision  and  inspection  by  the  board  of  health,  there  is  no  sanitary 
objection  to  the  piggery  business  and  no  cause  for  a  nuisance. 

Garbage 

From  a  sanitary  standpoint  and  even  from  the  standpoint  of  a 
nuisance,  the  problem  of  garbage  collection  and  disposal  is  a  perplex- 
ing one.  Although  only  indirectly  a  health  problem,  the  collection  of 
garbage  in  many  communities  is  a  duty  of  the  board  of  health  by 
ordinance. 

From  the  sanitary  point  of  view  it  is  desirable  to  dispose  of  garbage 
promptly  and  effectively.   Various  systems  of  collection  and  methods  of 


153 

disposal  are  employed  and  all  have  their  merits,  the  choice  depends  on 
local  conditions. 

General  Laws,  Chapter  111,  Section  31A  provides  that  any  person 
may  remove  garbage  through  the  streets  providing  he  registers  with 
the  board  of  health  and  pays  a  fee  of  two  dollars  and  providing  further 
that  he  must  comply  with  such  rules  and  regulations  as  may  be  estab- 
lished by  the  board.  The  usual  rules  and  regulations  provide  for  suit- 
able covered  vehicles  and  proper  containers. 

The  nuisance  problem  of  garbage  arises  mainly  from  a  poor  collec- 
tion system,  unsuitable  vehicles  for  transportation,  unrestricted  dis- 
posal by  householders,  and  dumping  with  refuse.  The  problem  may  be 
handled  by  strict  enforcement  of  rules  and  regulations  and  efficient 
supervision  by  the  health  officials. 

In  theory  the  local  department  of  public  works  rather  than  the  board 
of  health  should  have  control  of  garbage  collection  and  disposal.  The 
supporting  rules  and  regulations,  however,  should  be  approved  by  the 
board  of  health.  The  inclusion  of  garbage  disposal  among  the  duties  of 
the  health  department  is  one  of  those  peculiar  traditions  sanctioned  by 
custom  rather  than  by  good  judgment.  Water  supply  and  sewerage, 
which  have  a  vital  relation  to  public  health,  are  never  operated  by  a 
health  department. 

Conclusion 

When  boards  of  health  are  in  doubt  as  to  their  duties  and  powers  and 
proper  methods  of  procedure  they  may  request  the  assistance  of  their 
District  Health  Officer,  who,  in  turn,  if  necessary,  calls  in  the  Sanitary 
Engineering  Division  of  the  State  Department  for  advice.  The  usual 
procedure  is  an  examination  of  the  locality  by  an  engineer  which  is  fol- 
lowed by  a  report  advising  the  board  of  the  proper  method  of  pro- 
cedure. It  should  be  remembered,  however,  that  the  State  Department 
is  given  no  authority  in  the  abatement  of  ordinary  nuisances.  Under 
Section  152  of  Chapter  111  of  General  Laws  relative  to  offensive  trades 
the  State  Department  is  given  the  same  authority  and  powers  of  local 
boards  of  health  under  Section  143  of  the  same  chapter.  The  only 
difference  is  that  the  State  Department  is  required  to  give  notice  to  the 
party  and  allow  him  a  hearing  before  it  can  pass  an  order  of  prohibi- 
tion.  The  order  is  subjected  to  appeal  and  trial  by  jury. 

In  general  two  methods  are  followed  for  the  control  of  nuisances; 
namely,  prevention  and  abatement.  The  first  is  the  wiser  and  aims  to 
regulate  by  ordinances  the  different  conditions  likely  to  cause  nui- 
sances. The  second  method  merely  provides  legal  steps  for  the  abate- 
ment of  nuisances  already  in  existence. 

The  Department  of  Public  Health  has  issued  a  bulletin  entitled  "Sug- 
gestions for  the  Guidance  of  Boards  of  Health  in  Preparing  Regulations 
including  Minimum  Quarantine  Requirements"  which  might  assist  ru- 
ral communities  in  the  formulation  of  health  regulations.  When  formu- 
lating rules  and  regulations,  boards  of  health  should  exercise  care  and 
should  seek  legal  advice  to  guard  against  the  danger  of  unreasonable 
rules  and  regulations. 


154 

THE  HOME  ECONOMICS  EXTENSION  SERVICE  PROGRAM 

IN  RURAL  DISTRICTS  OF  MASSACHUSETTS 

Annette  T.  Herr,  B.S.,  A.M.* 
Organization 

Representatives  "from  existing  organizations  are  called  together  by 
the  local  Extension  Committee  to  discuss  the  needs  of  the  homemakers 
of  that  particular  community. 

Such  facts  as  the  following  are  brought  out  for  discussion. 

1.  No  whole  grain  bread  is  sold  at  the  stores. 

2.  There  is  not  sufficient  amount  of  milk  used. 
Several  reasons  are  given  for  this : 

Lack  of  money 

Lack  of  knowledge  regarding  value  of  milk  in  diet 
Lack  of  information  relative  to  ways  to  use  milk  to  give 
variety  to  the  diet. 

3.  Too  few  people  have  vegetable  gardens. 

4.  There  is  too  little  canning  and  storing  of  vegetables. 

5.  There  is  no  hot  lunch  for  school  children. 

6.  School  ground  has  never  been  drained  and  graded,  no  place  for 

children  to  play. 

7.  Drinking  facilities  are  too  limited  in  schools. 

Note:  When  possible,  a  member  of  the  Department  of  Health  assists  in 
checking  on  the  lack  of  other  health  facilities  or  the  lack  of  use 
of  existing  health  agencies. 

Program  to  Help  Meet  These  Needs 

A  plan  of  work  and  a  program  are  formulated  as  a  result  of  the  dis- 
cussion of  the  needs  which  may  include  the  following: 

1.  List  of  names  of  those  interested  in  gardens  is  secured  and  ar- 

rangements made  for  a  series  of  meetings,  a  series  of  letters, 
and  any  other  help  which  seems  desirable. 

2.  Arrangements  are  made  to  train   several   leaders   in   canning 

fruits  and  vegetables.  These  in  turn  will  teach  other  neighbors. 

3.  Information  on  storage  of  surplus  vegetables  and  fruits  will  be 

sent  to  those  interested. 

4.  Information  on  packed  lunches  and  hot  school  lunches  will  be 

given  to  mothers,  teachers,  and  others  having  this  problem. 
This  may  be  accomplished  through  meetings  with  the  state 
nutritionist,  or  the  home  demonstration  agent  or  through 
trained  lay  leaders. 

5.  Rural  engineer  and  home  grounds  improvement  specialists  will 

assist  in  improvement  of  school  grounds  and  playgrounds, 
and  the  installation  of  running  water. 

Procedure  for  Carrying  Out  the  Program 

1.  Leader  training  conferences  planned  to  train  lay  leaders. 

2.  Community  group  meetings  led  by  specialist,  and  home  demon- 

stration agent  or  lay  leader  depending  upon  nature  of  work 
to  be  done. 

3.  Other  methods 

News  items 
Feature  articles 
Circular  letters 
Broadcasting 
Exhibits 


Mrs-  Herr,  who  has  for  six  years  been  State  Leader  of  the  Home  Demonstration  Work  in 
Massachusetts  has  her  office  at  the  State  College,  Amherst.  Before  coming  to  Massachusetts 
she  did  health  education  work  in  the  public  schools  and  settlements  of  New  York  City  and  for 
5!£ ht  years  previous  was  on  Columbia  University  staff  working  closely  with  Professors  Cora 
Winchell  and  Mary  Swartz  Rose. 


155 

Home  visits 

Meal  planning 

Buying  of  food 

Food  preparation 

Short  cuts  in  preparation. 
In  teaching  nutrition  and  meal  planning  to  foreign  homemakers,  a 
study  of  their  good  habits  is  made  and  suggestions  given  for  balancing 
the  diet  where  necessary. 

Coordination  and  Correlation  with  Existing  Agencies 

A  definite  effort  was  made  in  June  1931  to  hold  a  joint  conference  of 
the  state  and  local  officers  of  the  various  organizations  and  the  state 
and  county  workers  of  the  Massachusetts  Home  Economics  Extension 
Service.   The  purpose  of  the  conference  was  : 

1.  To  establish  a  mutual  understanding  of  the  aim  of  the  different 

organizations  at  work  in  a  given  community. 

2.  To  find  ways  of  working  together  in  the  community  in  order  to 

make   permanent   the    desirable    practices    recommended   by 
these  organizations. 

3.  To  decide  on  a  few  "things  to  do"  together  during  the  coming 

year  as  well  as  to  work  out  a  procedure  for  accomplishing 
these  plans. 
Some  definite  results  in  our  nutrition  program  definitely  traceable  to 
the  cooperative  work  are  included  in  the  following: 

1.  Groups  of  mothers  whose  children  attended  the  health  camp 

were  taught  by  the  nutrition  specialist.    These  groups  were 
organized  by  the  public  health  nurses. 

2.  Public  health  and  school  nurses  attended  nutrition  meetings  on 

"Good  School  Lunches." 

3.  Nutrition  specialist  conducted  meetings  with  Franklin  County 

public    health   nurses    on    new   nutrition    facts    and   budget 
making. 

4.  Specialist  taught  classes  of  Polish  mothers.   These  groups  were 

organized  by  public  health  nurses. 

5.  The  home  demonstration  agents  have  assisted  in  the  well  child 

conferences  conducted  by  the  Department  of  Public  Health. 

6.  Nutrition  specialist  taught  a  group  of  adolescent  girls  at  a 
county  health  camp  and  assisted  in  meal  planning  for  this 
health  camp. 

Checking  Results  in  Order  to  Build  New  Program 

Through  cooperative  work  on  the  part  of  the  State  Department  of 
Public  Health  and  the  Extension  Service,  several  preschool  clinics  and 
dental  clinics  have  been  held  in  communities  in  western  Massachusetts 
where  there  was  great  need  for  this  service. 

An  effort  is  made  to  interpret  to  the  homemakers  of  the  rural  districts 
the  importance  of  child  health  and  nutrition  and  to  interest  parents  in 
assuming  their  responsibility  for  adequate  health  facilities  for  all 
communities. 

During  the  coming  year  special  emphasis  will  be  put  on  having  the 
leaders  in  each  community,  guided  by  trained  nutritionists,  study  the 
nutritional  needs  in  order  to  marshal  the  forces  of  all  organizations  in 
the  community  to  stand  back  of  all  sound  programs  for  improving  the 
health  of  the  children. 

During  the  past  year  3,626  visits  were  made  by  the  specialist  and 
home  demonstration  agent  to  homes  in  the  rural  sections  of  the  State. 
This  report  deals  primarily  with  the  program  in  nutrition,  but  it  is 
impossible  to  think  of  this  phase  of  homemaking  without  including  the 
(managerial  phases  of  food  selection  and  food  preparation,  the  psychol- 
ogy of  child  feeding,  household  finance,  gardening,  food  preservation, 
and  many  other  allied  subjects. 


156 

THE  MASSACHUSETTS  PARENT-TEACHER  ASSOCIATION 

AND  THE  RURAL  SCHOOL 

Mrs.  George  Hoague* 

Previous  to  the  White  House  Conference  on  Child  Health  and  Protec- 
tion, the  Massachusetts  Parent-Teacher  Association,  through  its  ex- 
tension service,  had  begun  to  realize  the  poor  conditions  for  children  in 
many  of  the  rural  communities  in  Massachusetts,  which  arose  mainly 
from  lack  of  interest  on  the  part  of  parents  and  cooperation  between  the 
home  and  the  school. 

Point  seventeen  of  the  Children's  Charter,  which  reads,  "For  every 
rural  child  as  satisfactory  schooling  and  health  services  as  for  the  city 
child  and  an  extension  to  rural  families  of  social,  recreational  and  cul- 
tural facilities,"  was  the  starting  point  for  our  special  work  for  the  rural 
one-teacher  schools  by  the  Massachusetts  Parent-Teacher  Association. 

In  order  to  understand  the  rural  problem  in  Massachusetts  as  thorough- 
ly as  possible,  the  State  Department  of  Education  was  consulted  for 
up-to-date  information.  Mr.  Burr  F.  Jones  of  that  department  initiated 
a  new  rural  survey  by  means  of  questionnaires  sent  to  all  superintend- 
ents of  one-teacher  schools  in  the  State  and  presented  that  survey  at 
our  State  Convention  in  1931. 

The  survey  showed  among  other  things  that  there  are  382  one-teacher 
schools  left  in  Massachusetts  and  that  not  more  than  one-fifth  of  these 
buildings  met  modern  standards  so  far  as  lighting,  heating,  ventilation 
and  sanitation  are  concerned.  In  addition  to  the  facts  shown  by  the 
survey,  further  information  was  sought  from  the  State  Department  of 
Public  Health  and  from  rural  supervisors  of  three  other  states.  "Screen 
your  schools,"  said  one  of  these  supervisors;  "the  city  child  does  not 
start  school  each  fall  in  a  welter  of  flies."  "Visit  the  nearest  consolidated 
school,"  said  another;  "nothing  like  seeing  a  plan  in  working  order." 
"Make  the  rural  school  more  interesting,"  said  a  third,  "through  the  use 
of  the  state  library  service  and  the  special  offer  to  rural  schools  from 
the  National  Geographic  Society,  and  think  in  terms  of  better  recrea- 
tion for  the  country  child." 

Also,  in  reply  to  our  inquiry,  Mr.  Owen  D.  Young  gave  us  the  complete 
story  of  the  Van  Hornesville  School,  New  York,  where,  by  his  gift  of  a 
new  schoolhouse,  when  the  little  district  school  of  Van  Hornesville 
burned,  and  because  of  the  willingness  of  eighteen  districts  to  consoli- 
date, four  hundred  children  now  have  the  advantages  of  a  really  first 
class  school,  as  good  as  any  in  the  State,  without  any  increase  of  the  tax 
levy. 

Recently  in  our  own  State  a  new  school  has  been  given  to  Townsend 
by  Mr.  Huntley  N.  Spaulding  and  Mr.  Roland  H.  Spaulding  of  Rochester, 
N.  H. ;  and  also  the  late  Mrs.  Henry  T.  Wing  of  Sandwich  made  a  similar 
gift  to  that  town. 

With  this  information  at  hand  the  Massachusetts  Parent-Teacher  As- 
sociation had  two  avenues  through  which  it  has  tried  to  serve  the  rural 
schools : 

1.  By  influencing  successful  men  born  in  Massachusetts  to  take  a 
loving  look  back  to  the  scene  of  their  childhood  and  in  that  memory 
and  out  of  their  good  fortune,  replace  the  poorly  lighted,  unsani- 
tary, uninteresting  school  with  a  new  school,  large  enough  so  that 
neighboring  towns  by  consolidation  could  pool  their  taxes  and 
transport  the  children  to  one  real  center  of  light  and  life. 

2.  By  means  of  a  Massachusetts  Parent-Teacher  Report  Card  for 
Rural  School  Improvement,  carrying  twelve  points  to  be  accom- 
plished by  the  local  rural  parent-teacher  associations,  we  have  given 


*  Mrs.  Hoague,  the  President  of  the  Massachusetts  Parent-Teacher  Association,  describes  one 
of  the  many  worth-while  activities  of  her  Association.  The  rural  school  Parent-Teacher  report 
card  should  indeed  be  a  great  influence  for  rural  school  improvement. 


157 

parents  and  teachers  of  the  rural  schools  a  definite  purpose — school 
improvement. 

One  point  hampers  this  work  very  much.  We  can  only  offer  to  stimu- 
late this  interest  where  the  superintendent  is  willing  to  have  a  parent- 
teacher  association.  Many  superintendents  still  think  that  they  prefer  to 
carry  the  responsibility  alone.  The  rural  schools  testify  to  the  wrongness 
of  this  thinking. 

Where  the  parents  and  teachers  have  learned  to  cooperate,  comes  this 
kind  of  a  report: 

"The  town  of  New  Marlboro  has  voted  to  erect  a  new  school  in  Mill 
River.  When  the  P.  T.  A.  started  three  years  ago  no  one  was  interested 
in  the  school  children.  Everything  seemed  wrong;  a  very  discouraging 
place.  The  parents  and  teachers  finally  decided  to  build  some  plain  wood 
benches  in  the  yard,  so  that  the  children  could  eat  their  lunch  out  of  the 
dismal  schoolroom  in  pleasant  weather.  Even  that  seemed  almost  too 
much  for  them  at  the  time  but  a  few  persisted  and  interest  grew.  Today, 
Mr.  Jones  (of  the  State  Department  of  Education)  reports  that  they  have 
developed  the  finest  rural  playground  he  has  seen  and  spoke  of  their 
work  in  the  highest  terms.  Now  that  the  parents  have  seen  how  poor  the 
equipment  is,  a  new  school  has  been  voted;  and  also  Southfield,  a  nearby 
town,  will  send  its  children  to  the  school  in  Mill  River.  The  P.  T.  A. 
have  also  earned  money  for  a  dental  clinic." 

In  reply  to  the  questions  asked  on  the  report  card,  "What  will  you  do 
to  make  a  better  school  for  your  children?"  and  "Will  you  do  your  share 
now?"  come  the  report  cards  checked  as  to  points  accomplished,  signed 
and  returned  to  our  state  office.  As  yet  only  a  beginning  has  been  made, 
but  those  that  have  come  can  be  viewed  with  complete  respect. 

The  rural  parent-teacher  associations  are  learning,  by  working  to- 
gether over  these  rural  school  improvements,  to  help  themselves.  The 
next  step  for  them  will  be  to  work  together  to  conquer  bad  health  condi- 
tions and  to  use  their  native  wit  for  home  fun  and  a  richer  life. 

(We  should  be  glad  to  send  a  copy  of  the  Rural  Report  Card  to  any 
interested  person  upon  application  to  the  state  office,  80  Boylston  St., 
Boston,  Mass.) 

4  -  H  CLUB  WORK 

George  L.  Farley,  M.S.* 

Four  H's — Head,  Heart,  Hand,  Health — and  far  from  the  least  of  these 
is  health. 

A  unique  organization  with  a  unique  name.  An  organization  that  knows 
no  distinction  of  race,  color  or  creed. 

Its  one  object  is  to  build  citizenship,  citizenship  based  upon  the  develop- 
ment and  training  of  these  four  H's — Head,  Heart,  Hand,  Health — and 
as  the  member  obtains  this  training  the  call  is  to  pass  it  on  to  others  and 
thus  render  service,  the  highest  expression  of  citizenship. 

Visit  with  me  some  community  where  an  adult,  having  caught  the 
vision  of  the  work,  has  gathered  together  a  group  of  boys  or  girls  or 
perhaps  a  group  made  up  of  both. 

The  group  has  been  organized  as  a  club,  has  chosen  a  name  and  has 
decided  to  hold  a  meeting  perhaps  once  a  week  or  once  in  two  weeks.  We 
will  attend  one  of  these  meetings.  We  will  find  it  conducted  upon  the  rules 
of  simple  parliamentary  procedure. 

A  program  has  been  arranged  by  a  committee  of  club  members  and 
usually  consists  of  three  parts:  first,  the  business  meeting;  second,  the 
study  of  the  subject  matter  along  the  line  of  agriculture  or  home  eco- 
nomics in  which  the  club  is  interested;  and  third,  some  form  of  enter- 
tainment. 


*  George  L.  Farley,  M.S.,  is  the  leader  of  4-H  clubs  here  in  Massachusetts  Extension  Service. 
He  has  most  ably  filled  this  position  for  the  past  sixteen  years  and  is  well  known  in  many  other 
states.  Before  entering  Extension  Service  Mr.  Farley  was  Superintendent  of  Schools  in 
Brockton.  Sixteen  thousand  Massachusetts  4-H  Club  boys  and  girls  affectionately  know  him  as 
their  "Uncle  George." 


158 

All  this  is  in  the  hands  of  the  young  people  themselves,  the  local  leader 
acting  simply  as  an  advisor,  helping  the  young  people  to  help  themselves. 

In  the  early  days  of  the  work  the  training  of  the  head  and  hands  got 
most  excellent  attention  and  it  slowly  grew  into  the  minds  of  the  people 
responsible  that  the  heart  and  health  H's  were  so  far  neglected  that  the 
organization  could  hardly  lay  claim  to  its  name. 

Not  discouraged,  however,  ways  and  means  were  sought  to  make  good 
its  name  and  live  up  to  its  ideals,  and  study  was  made  of  how  best  to  do 
this. 

When  it  came  to  health  work  it  was  decided  to  cooperate  in  every  way 
possible  with  existing  agencies.  Why  attempt  to  do  only  in  small  measure 
something  which  an  existing  agency  is  fully  equipped  to  do  and  to  which 
it  can  give  its  entire  attention,  was  the  attitude  assumed  from  the  first 
and  as  a  result  today  we  are  working  with  the  State  Department  of 
Public  Health  and  have  outlined  a  program  which  it  is  hoped  will  even- 
tually be  so  worked  out  that  every  boy  and  girl  may  become  interested 
in  good  health  habits.  All  this  has  been  brought  about  through  the  co- 
operation of  Mrs.  Albertine  McKellar  and  the  members  of  the  Junior 
Extension  Department  of  the  Massachusetts  State  College.  How  can 
we  hope  to  do  this  and  reach  the  more  than  sixteen  thousand  boys  and 
girls  who  are  enrolled  in  the  work  today?   By  building  a  Health  Program. 

As  good  or  poor  health  is  a  part  of  us  at  all  times,  the  4-H  health  pro- 
gram in  Massachusetts  is  carried  along  with  the  project  work  and  not 
as  a  separate  program.  Several  means  are  used  to  help  the  club  member 
to  be  health  conscious.  One  way  of  doing  this  is  the  keeping  of  a  health 
score,  each  member  being  scored  at  the  beginning  of  the  club  season 
on  health  and  food  habits,  and  a  check-up  taken  on  height  and  weight, 
teeth,  etc.  During  the  club  season  the  boy  or  girl  works  toward  improv- 
ing some  of  his  or  her  defects.  Another  scoring  is  done  at  the  end  of  the 
club  season  which  shows  the  amount  of  improvement  made.  Emphasis 
is  placed  on  improvement  made  rather  than  on  a  high  score. 

Another  means  of  stressing  the  importance  of  good  health  is  through 
an  annual  state-wide  health  contest  which  is  held  in  June  or  July.  Each 
club  member  wishing  to  enter  this  contest  has  a  physical  examination  at 
the  starting  of  the  club  season  and  again  at  the  end.  The  member  stand- 
ing highest  and  making  the  most  improvement  enters  a  county  contest 
and  the  winners  picked  there  are  eligible  to  enter  the  state  contest.  The 
State  Department  of  Public  Health  and  also  the  State  Department  of 
Education  give  valuable  help  at  these  contests.  Posture  is  taught  through 
games,  songs  and  health  talks.  This  past  year  charm  schools  were  held 
in  several  counties  for  groups  of  older  girls.  At  the  charm  schools  each 
girl  was  scored  individually  in  posture,  food,  health  habits,  and  general 
charm,  which  included  appropriate  clothing  and  grooming.  Suggestions 
were  given  each  girl  as  to  how  she  might  improve  herself.  About  six 
weeks  later  a  follow-up  meeting  was  held  for  these  same  girls  and  it  was 
gratifying  to  see  the  improvements  made.  At  this  second  meeting  a 
little  help  was  given  on  voice  culture. 

4-H  camps  are  helping  to  develop  the  health  H.  Every  county  in  the 
state  had  a  camp  available  for  its  4-H  members  for  a  week  this  past 
summer.  A  state  camp  of  two  weeks  duration  was  held  on  the  campus 
of  the  Massachusetts  State  College  in  July  for  boys  and  girls  sixteen 
years  of  age  and  over.  A  physical  examination  by  a  doctor  was  re- 
quired of  each  member  before  enrolling  in  the  camps.  At  the  State 
Camp  this  year,  special  training  was  given  to  the  boys  and  girls  on  the 
teaching  of  health  work  in  the  local  clubs.  Mrs.  Albertine  McKellar  gave 
the  instruction  in  this  work.  The  camp  program  also  included  taking  a 
group  out  in  the  woods  each  night  to  learn  the  fun  found  in  out-door 
cookery. 

4-H  workers  are  new  putting  as  much  emphasis  on  the  health  H  as 
on  the  other  three,  realizing  that  without  health  the  development  of  the 
head,  heart  and  hand  is  retarded. 


159 
THE  VEGETABLE  CUPBOARD  FOR  THE  COUNTRY  SCHOOL 

Mary  Spalding,  M.A.,  B.S.* 
Need 

Dr.  Davies,  formerly  of  the  Amherst  State  Experiment  Station,  in 
studying  food  habits  of  Massachusetts  children,  found  that  even  country 
children  do  not  eat  enough  vegetables — those  foods  that  the  White  House 
Conference  says  exert  such  a  profound  influence  on  growth  and  well-being. 

Cause 

Why  this  poverty  in  the  supply  of  vegetables?  Vegetables  have 
rather  decided  flavors.  It  is  a  little  harder  to  interest  children  in  them, 
but  who  has  not  seen  a  boy  or  a  girl  pull  a  carrot  from  the  garden  or  eat 
a  tomato  with  relish?  A  little  boy  in  the  Well  Child  Conference,  the 
other  day,  said  that  he  ate  all  his  cabbage  but  the  bones.  Boys  and  girls 
do  learn  to  like  vegetables. 

Is  it  because  vegetables  have  no  special  "backers"  ?  Milk  has  the  Dairy 
Council,  fruits  have  the  big  fruit  companies.  Cereal  companies  have  sent 
out  stories  written  by  real  writers  for  children.  These  organizations 
supply  posters  and  graded  material  for  teachers  so  that  the  children  al- 
ways have  interesting  matter  to  remind  them  to  eat  these  foods.  Vegeta- 
bles do  not  have  such  strong  supporters. 

These  may  be  the  reasons.  Have  you  studied  the  Boston  food  supply 
for  1931?  This  shows  a  promising  increase  in  vegetables  sold  in  this 
city  market,  but  only  17  per  cent  of  the  total  vegetables  and  fruits  were 
trucked  into  Boston  from  Masachusetts  farms.  Even  July  peas  came  in 
large  quantities  from  Idaho  and  Washington,  carrots  in  large  amounts 
from  California  and  Texas  and  a  large  supply  of  cabbage,  the  first 
of  the  year  from  Texas.  Farmers  do  not  feel  like  buying  products 
that  they  can  raise  themselves.  Yet,  in  many  cases  they  have  not  pro- 
duced enough  for  their  families.  The  Extension  Service  is  doing  an 
astonishing  amount  to  encourage  the  canning  and  storage  of  vegetables. 
More  parent  and  school  education  is  needed. 

Value 

Food  economists  recommend  even  in  the  very  low  cost  food  budgets 
that  children  should  have  every  day,  tomatoes,  a  green  or  yellow  vegeta- 
ble, a  fruit  or  an  additional  vegetable  (raw).  The  White  House  Confer- 
ence reports  that  green  vegetables  generally  should  make  up  15  to  20  per 
cent  of  the  day's  calories.  They  should  be  a  regular  part  of  each  day's 
diet,  beginning  with  one  tablespoon  of  sifted  pulp  for  the  child  under  a 
year,  and  increasing  gradually  to  one-half  cup,  then  to  two  cups. 

In  all  diets,  especially  in  the  low  cost  diets,  vegetables  must  be  counted 
on  to  supply  the  iron  and  copper  which  are  too  often  lacking  in  children's 
foods.  Immature  seeds  of  plants  such  as  lima  beans  and  peas  and  thin, 
green  leaves,  such  as  beet  tops  and  spinach,  are  excellent  sources.  To- 
matoes are  invaluable  for  Vitamin  C,  deficiency  of  which  is  shown  too 
quickly  in  the  condition  of  gums  and  teeth.  Dr.  Sherman  warns  us  that 
this  vitamin  is  one  that  must  not  be  forgotten  this  year.  In  our  Well 
Child  Conferences  the  effect  of  Vitamin  C  deficiency  is  already  too  evi- 
dent. Raw  vegetables  such  as  cabbage  and  raw  spinach,  so  good  in  salads 
and  sandwiches,  give  some  of  this  important  vitamin  and  also  are  rich 
in  Vitamin  A  and  Vitamin  B. 

Cooking  has  much  to  do  with  the  value  of  the  vegetable.  Much  Vitamin 
C  may  be  destroyed  by  cooking  or  by  the  addition  of  soda.  Tomato 
bisque,  for  instance,  does  not  need  soda;  it  can  be  made  without  curdling 

*  Mary  Spalding,  M.A.,  B.S.,  is  the  Consultant  in  Nutrition  of  the  Massachusetts  Depart- 
ment of  Public  Health.  Miss  Spalding  supervises  the  work  of  five  nutritionists,  and  is  respon- 
sible for  the  preparation  of  all  the  Department  nutrition  material.  She  has  during  the  past 
months  given  particular  attention  to  the  emergency  nutrition  problem.  A  vegetable  cupboard 
for  each  rural  school  is  a  splendid  idea,  and  Miss  Spalding  gives  some  very  practical  suggestions. 


160 

by  combining  the  milk  and  tomato  at  the  same  temperature.  Vegetables 
put  in  boiling  water  retain  more  of  their  mineral  and  vitamin  content 
than  those  put  in  cold  water.  Some  of  our  scientists  are  working,  at 
the  present  time,  on  the  seemingly  simple  problem  of  better  cooking  of 
vegetables. 

The  Vegetable  Cupboard 

This  year  of  much  scarcity,  cannot  home-makers  who  have  been  look- 
ing ahead,  share  some  of  their  shelf  of  canned  vegetables  for  that  "noon 
hot  dish"?  Country  children  who  are  growing  and  active  need  three 
square  meals,  one  of  which  should  be  the  school  lunch.  How  well  a  good, 
hot,  tomato  bisque  goes  with  a  cold,  concentrated  sandwich  brought  from 
home!  Each  week  some  parent  might  send  to  the  school  raw  carrots,  to- 
matoes or  cabbage  so  that  these,  too,  could  help  out  the  daily  raw  vegeta- 
ble supply.  This  would  not  mean  much  in  money,  but  would  mean  a  tre- 
mendous amount  in  protecting  the  children  within  your  neighborhood 
from  anemia,  constipation,  and  tooth  and  gum  troubles.  Is  not  the  vege- 
table hunger  of  the  children  a  need  that  country  men  and  women  may 
undertake  to  fill  by  taking  pride  in  stocking  a  school  cupboard  with  vege- 
tables ? 

Moreover,  the  children  will  not  only  have  a  wholesome  lunch,  but  will 
learn  a  life-long  lesson  in  the  importance  of  eating  vegetables  each  day. 
It  may  well  be  that  Massachusetts  boys  and  girls  may  be  stronger  for 
this  forethought  of  their  parents. 

Dr.  Ray  Lyman  Wilbur  thinks  that  one  of  the  reasons  Pacific  Coast 
athletes  seem  to  excel  over  those  in  the  East  may  be  because  they  have 
fresh  foods  each  day  of  the  year. 


161 

Book  Notes 

The  School  Health  Program — a  publication  of  the  White  House  Con- 
ference on  Child  Health  and  Protection.  Published  by  the  Century 
Company,  1932.   $2.75. 

"The  book  investigates  the  major  health  and  health  education  problems 
confronting  the  schools,  and  by  throwing  light  on  the  many  facets  of 
the  school's  task  of  helping  to  keep  children  well  and  training  them  to 
make  the  most  of  their  physical  endowment,  it  gives  a  comprehensive 
picture  of  the  national  school  health  program. 

"The  summarized  reports  deal  with  medical,  dental,  nursing,  and 
nutrition  services  in  the  schools;  mental  and  social  hygiene  in  schools; 
the  school  plant  in  its  relation  to  the  well-being  of  the  children;  health 
education  in  elementary  and  secondary  schools;  health  problems  in  the 
kindergarten,  in  rural  schools,  private  and  parochial  schools,  and  in 
schools  for  Negro  and  for  Indian  children.  Physical  education  in  schools, 
the  administration  of  the  school  health  program,  home  and  school  co- 
operation, safety  education,  summer  vacation  activities  of  the  school 
child,  and  the  education  of  teachers  and  leaders  in  health  work  are  other 
matters  taken  up  in  this  careful  study  of  health  services  and  health  train- 
ing in  our  schools." 

Milk  Production  and  Control — a  publication  of  the  White  House  Con- 
ference on  Child  Health  and  Protection.  Published  by  the  Century 
Company,  1932.   $3.00. 

This  volume  contains  a  large  amount  of  up-to-date  information  upon 
various  aspects  of  milk  and  its  relation  to  life  and  health.  The  section  on 
diseases  transmitted  through  milk  is  brief  but  comprehensive.  It  might 
well  have  been  given  more  space.  The  section  on  public  health  supervision 
of  milk  contains  most  of  the  essential  facts  but  is  likewise  quite  abbre- 
viated. 

On  the  other  hand,  the  section  on  the  nutritional  aspects  of  milk  is 
quite  voluminous  and  covers  the  field  with  considerable  detail.  The  vari- 
ous constituents  of  milk  are  taken  up  separately  and  the  role  of  each  in 
the  development  and  maintenance  of  the  body  is  discussed.  Evaporated 
and  condensed  milk,  as  well  as  other  milk  products,  also  come  up  for 
discussion. 

The  section  on  the  economic  aspects  of  milk  gives  a  good  summary  of 
production  and  consumption  during  recent  years  and  takes  up  a  number 
of  the  problems  which  arise  in  connection  with  production,  transportation 
and  distribution.  Bibliographies  at  the  end  of  each  chapter  make  it  pos- 
sible to  follow  up  the  subject  in  greater  detail  when  desired. 


News  Note 


AMERICAN  RED  CROSS 

The  Annual  Roll  Call  of  the  American  Red  Cross  to  enroll  members  for 
1933,  will  be  held  from  Armistice  Day  to  Thanksgiving,  November  11 
to  24. 


162 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS 

During  the  months  of  April,  May  and  June  1932,  samples  were  col- 
lected in  255  cities  and  towns. 

There  were  2,180  samples  of  milk  examined,  of  which  398  were  below 
standard;  from  28  samples  the  cream  had  been  in  part  removed,  and  24 
samples  contained  added  water.  There  were  57  samples  of  Grade  A 
milk  examined,  53  samples  of  which  were  above  the  legal  standard  of 
4.00%  fat,  and  4  samples  were  below  the  legal  standard.  There  were 
1,091  bacteriological  examinations  made  of  milk.  There  were  135  samples 
examined  for  hemolytic  bacteria,  8  of  which  were  positive,  and  127  sam- 
ples were  negative. 

There  were  272  samples  of  food  examined,  of  which  29  were  adulter- 
ated or  misbranded.  These  consisted  of  2  samples  of  butter  which  were 
below  the  standard  in  milk  fat;  6  samples  of  eggs,  4  samples  of  which 
were  sold  as  fresh  eggs  but  were  not  fresh,  and  2  samples  were  decom- 
posed; 15  samples  of  hamburg  steak,  1  sample  of  which  was  decomposed, 
and  14  samples  contained  a  compound  of  sulphur  dioxide  not  properly 
labeled;  1  sample  of  sausage  which  contained  a  compound  of  sulphur  di- 
oxide not  properly  labeled;  1  sample  of  diabetic  flour  which  contained  too 
much  starch ;  1  sample  of  cream  which  was  not  labeled  in  accordance  with 
the  law;  1  sample  of  mayonnaise  adulterated  with  mineral  oil;  and  2 
samples  of  vinegar  which  were  low  in  acid,  1  sample  of  which  was  mis- 
branded. 

There  were  160  samples  of  drugs  examined,  of  which  45  were  adulter- 
ated or  misbranded.  These  consisted  of  32  samples  of  argyrol  solution  not 
corresponding  to  the  professed  standard  under  which  it  was  sold;  4 
samples  of  elixir  potassium  bromide  which  were  not  up  to  the  required 
National  Formulary  strength;  1  sample  of  magnesium  citrate,  and  8 
samples  of  spirit  of  nitrous  ether,  all  of  which  did  not  conform  to  the 
requirements  of  the  U.  S.  Pharmacopoeia. 

The  police  departments  submitted  1,268  samples  of  liquor  for  examina- 
tion, 1,237  of  which  were  above  0.5%  in  alcohol.  The  police  departments 
also  submitted  17  samples  of  narcotics,  etc.,  for  examination,  2  of  which 
contained  morphine;  1  sample  contained  a  morphine  derivative,  which 
was  probably  heroin;  7  samples  contained  heroin;  2  samples  contained 
opium;  1  sample  of  colorless  liquid  which  contained  ethyl  alcohol;  1  sam- 
ple of  capsules  contained  apiol,  oil  of  savin,  ergotin  and  aloes;  1  sample 
of  capsules  contained  ergot,  aloes,  oil  of  savin  and  oil  of  parsley  seed;  a 
sample  of  pills  was  tested  for  narcotics  with  negative  results;  and  1 
sample  of  earth  was  found  to  contain  ethyl  alcohol. 

One  sample  submitted  from  the  Division  of  Fisheries  and  Game  was 
examined  for  the  presence  of  poisons  with  negative  results. 

There  were  116  cities  and  towns  visited  for  the  inspection  of  pasteur- 
izing plants,  and  319  plants  were  inspected. 

There  were  96  hearings  held  pertaining  to  violations  of  the  laws. 

There  were  47  convictions  for  violations  of  the  law,  $850  in  fines  be- 
ing imposed.  * 

Eugene  Hamel  of  Attleboro;  John  Joubert  of  Lawrence;  Frank  Mol  of 
South  Hadley;  Maynard  S.  Harriman  and  Abraham  Prentiss  of  West 
Acton ;  Stephen  Tsoutsanis  of  Manchester ;  John  Georgian  of  Cambridge ; 
Clinton  A.  Harris  of  Shirley,  and  Peter  B.  Trombly  of  Grafton,  were  all 
convicted  for  violations  of  the  milk  laws.  Clinton  A.  Harris  of  Shirley, 
and  Peter  B.  Trombly  of  Grafton  appealed  their  cases. 

Max  Robinovitz,  Samuel  Tuvman,  Louis  Bernstein,  Samuel  Kutzenko, 
and  Morris  Levine,  all  of  Springfield ;  Peter  Panos  of  Watertown ;  Nestor 
Pialtos  of  Worcester;  Armand  Lussier  of  Fall  River;  Boleslaw  Kocot  of 
Northampton;  and  Bernard  Ladow  of  Providence,  Rhode  Island,  were 
all  convicted  for  violations  of  the  food  laws.  Nestor  Pialtos  of  Worcester 
appealed  his  case. 


163 

Growers  Outlet,  Incorporated,  of  Holyoke  was  convicted  for  false  ad- 
vertising. 

Flaherty's  Drug  Store,  Incorporated,  of  Arlington;  Hebbard  Drug 
Company  and  Leonel  Savoie  of  Lynn;  Lincoln  Square  Drug  Company,  In- 
corporated, of  Worcester;  Peter  J.  Sullivan  of  Greenfield;  Louis  B.  Terney 
of  Springfield;  James  0.  Case,  Joseph  De  Pietro,  and  Leo  Cincotti  of 
East  Boston;  Aram  Davidson  and  Kevork  Gostanian  of  Allston;  and 
Robert  McKeogh,  2  cases,  of  Gardner,  were  all  convicted  for  violations 
of  the  drug  laws. 

Michael  Brooks  of  Worcester;  Chester  J.  Burkinshaw,  John  B.  Hen- 
shaw,  and  Wallace  L.  Henshaw,  2  cases,  all  of  Salem;  Joseph  Zala  of 
North  Dartmouth;  Holyoke  Producers'  Dairy  Company  of  Holyoke; 
Dwight  Ware  of  Abington;  Foster  S.  Barstow,  4  cases,  of  Wakefield; 
and  Howard  H.  Tochach  of  Atkinson,  New  Hampshire,  were  all  convicted 
for  violations  of  the  pasteurization  law  and  regulations. 

National  Mattress  Company  of  Boston  was  convicted  for  violation  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: 

One  sample  of  milk  from  which  a  portion  of  the  cream  had  been  re- 
moved was  produced  by  Clinton  A.  Harris  of  Shirley. 

Butter  which  was  below  the  standard  in  milk  fat  was  obtained  as  fol- 
lows: 

One  sample  each,  from  Dutchland  Farms  of  Newtonville,  and  Spring- 
field Butter  Company  of  Springfield. 

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

One  sample  each,  from  The  Great  Atlantic  and  Pacific  Tea  Company  of 
Newton,  Concord,  Wollaston,  and  Roxbury;  Boleslaw  Kocut  of  Northamp- 
ton; F.  Kastan,  P.  Schwachman,  S.  Gammonnan,  all  of  Boston;  Folsom 
Market,  Incorporated,  and  Benjamin  Gross  of  Roxbury;  Rood  and  Wood- 
bury of  Springfield;  and  Sam  Lipsky  of  Brookline. 

Two  samples  were  obtained  from  American  Beef  Company  of  Boston. 

One  sample  of  sausage  which  contained  a  compound  of  sulphur  dioxide 
not  properly  labeled  was  obtained  from  Hager  and  Houghton  of  Gardner. 

One  sample  of  salad  dressing  adulterated  with  mineral  oil  was  obtained 
from  United  Markets  Incorporated  of  Quincy. 

One  sample  of  vinegar  which  was  low  in  acid  was  obtained  from  Grow- 
ers Outlet,  Incorporated,  of  Springfield. 

One  sample  of  vinegar  which  was  misbranded  was  obtained  from  Reid- 
Murdick  Company  of  Chicago,  Illinois. 

There  were  six  confiscations,  consisting  of  400  pounds  of  beef  affected 
with  septicaemia;  521  pounds  of  decomposed  boneless  beef;  132  pounds 
of  decomposed  lamb  fores;  30  pounds  of  immature  and  unstamped  veal; 
and  125  pounds  of  decomposed  ducks. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  March,  1932: —  631,620  dozens  of  case 
eggs;  460,702  pounds  of  broken  out  eggs;  337,765  pounds  of  butter; 
1,005,074  pounds  of  poultry;  3,218,773%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  2,280,285  pounds  of  fresh  food  fish. 

There  was  on  hand  April  1,  1932: —  559,830  dozens  of  case  eggs; 
1,142,814  pounds  of  broken  out  eggs;  590,677  pounds  of  butter;  5,621,- 
leS1/^  pounds  of  poultry;  10,099,494%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  5,141,752  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts  of 
food  placed  in  storage  during  April,  1932: —  2,418,210  dozens  of  case 
eggs:  941,650  pounds  of  broken  out  eggs;  446,500  pounds  of  butter; 
669,672  pounds  of  poultry;  2,214,511  pounds  of  fresh  meat  and  fresh  meat 
products;  and  4,687,425  pounds  of  fresh  food  fish. 

There  was  on  hand  May  1,  1932:—  2,830,680  dozens  of  case  eggs; 


164 
1,575,796  pounds  of  broken  out  eggs;  544,256  pounds  of  butter;  4,358,- 
701%  pounds  of  poultry;   8,514,3491/^  pounds  of  fresh  meat  and  fresh 
meat  products;  and  7,371,472  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  May,  1932: — 2,961,840  dozens  of  case 
eggs;  1,137,510  pounds  of  broken  out  eggs;  1,827,335  pounds  of  butter; 
1,183,694  pounds  of  poultry;  1,723,389%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  7,486,402  pounds  of  fresh  food  fish. 

There  was  on  hand  June  1,  1932: —  5,574,570  dozens  of  case  eggs; 
2,032,193  pounds  of  broken  out  eggs;  2,004,258  pounds  of  butter;  3,977,- 
184  pounds  of  poultry;  6,447,106%  pounds  of  fresh  meat  and  fresh  meat 
products;  and  12,593,091  pounds  of  fresh  food  fish. 


165 
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  Child  Hygiene 
Division   of  Tuberculosis 
Division  of  Adult  Hygiene 


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Director, 

Gaylord  W.  Anderson,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  Pittsfield. 


Publication  of  this  Document  Approved  by  the  Commission  on  Administration  and  Finance. 
6M.    8-'32.    Order  6093. 


BTiTELIBKM         .^^iwtiw 


V  /      ^~    ^*Y    "^— * 


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THE 
COMMONHEALTH 


Volume  19 

No.  4 


OCT.-NOV.-DEC. 
1932 


The  Child 


MASSACHUSETTS 
DEPARTMENT  OF  PUBLIC  HEALTH 


THE  COMMONHEALTH 

Quarterly  Bulletin  of  the  Massachusetts  Department  op 
Public  Health 

Sent  Free  to  any  Citizen  of  the  State 

Entered  as  second  class  matter  at  Boston   Postoffice. 

M.  Luise  Diez,  M.D.,  Director  of  Division  of  Child  Hygiene,  Editor. 
Room  545  State  House,  Boston,  Mass. 


CONTENTS 

PAGE 

The  Trend  Toward  Parent  Education,  by  Clifford  K.  Brown  .          .  169 

Maternal  Mortality,  by  John  Rock,  M.  D 171 

Body  Mechanics,  By  Lloyd  T.  Brown,  M.  D 176 

Summary  of  Round  Table  on  the  Handicapped  Child,  by  Alfred  F. 

Whitman                 178 

How  the  Massachusetts  Child  Council  Came  into  Being,  by  Mary  R. 

Lakeman,  M.  D 181 

The  Purpose,  Plans  and  Possibilities  of  the  Massachusetts  Child 

Council,  by  Herbert  C.  Parsons       .....  184 
The  Importance  of  Guarding  Infants  against  Infections,  by  Gaylord 

W.  Anderson,  M.  D 187 

Play  —  A  Necessary  Factor  in  the  Life  of  Every  Child,  by  Elizabeth 

M.  Laurie 188 

Mental  Hygiene  for  Cardiac  Children,  by  Mrs.  T.  Grafton  Abbott  .  191 

Home  Visits  in  Rural  Schools,  by  Ruth  E.  Barnum,  R.  N.       .          .  193 

Milk 195 

An  Island  Visit,  by  Susan  M.  Coffin,  M.  D 196 

Exercise  as  an  Aid  to  Health  in  Women,  by  Alice  E.  Sanderson 

Clow,  B.Sc,  B.S.,  M.D 199 

To  the  Memory  of 

Dr.  Henry  P.  Walcott 202 

Dr.  William  E.  Rice 203 

Book  Notes : 

Your  Hearing       .........  204 

Community  Health  Organization   ......'  204 

Youngest  of  the  Family        .          .          .                    .          .          .  204 

Food  and  Your  Body  ........  205 

Hospitals  and  Child  Health  .......  205 

News  from  the  N.  O.  P.  H.  N 206 

Report  of  the  Division  of  Food  and  Drugs,  July-August-September 

1932 207 


THE  TREND  TOWARD  PARENT  EDUCATION* 

Clifford  K.  Brown 
Chairman  of  the  Boston  Parents  Council 

For  some  unexplainable  reason  a  deep  interest  in  our  children  is  a 
rather  recent  experience  in  America.  Dorothy  Canfield  Fisher  has 
pointed  out  that  in  all  ancient  literature,  Shakespeare  included,  there 
is  practically  no  reference  to  children.  There  is  not  a  normal,  healthy 
child  romping  through  the  pages  of  any  book,  other  than  those  children 
who  are  destined  to  become  kings  or  queens.  So  far  as  ancient  litera- 
ture is  concerned,  one  might  assume  there  was  no  interest  in  children 
or  that  they  did  not  become  interesting  to  adults  until  they  were  old 
enough  to  make  love. 

It  was  the  middle  of  the  nineteenth  century  before  doctors  entered 
the  field  of  maternity  work,  though  midwives  still  ply  their  trade  in 
the  large  cities.  It  was  as  late  as  1874  that  the  first  society  for  the  pre- 
vention of  cruelty  to  children  was  organized  in  America;  namely,  The 
Gerry  Society.  From  the  standpoint  of  organized  effort,  interest  in 
childhood  has  developed,  especially  in  the  present  century. 

The  White  House  Conference  has  given  us  a  close-up  of  the  child. 
We  must  never  forget,  however,  that  the  child  always  should  be  viewed 
in  the  setting  of  the  family  and  never  apart  from  it.  The  family  is  the 
basic  and  primary  group  in  society.  It  is  established  by  society  to  care 
for  the  deepest  needs  and  cravings  of  the  individual.  In  the  family  the 
child  is  born  and  nurtured.  Social  workers  and  educators  now  realize 
that  the  family  is  the  only  satisfactory  place  for  the  rearing  of  children. 
The  child  is  the  objective  of  the  family. 

The  family,  although  the  primary  group  in  society,  we  believe  has 
not  had  its  due  consideration.  We,  as  social  workers,  teachers  and 
business  men,  have  not  thought  enough  in  terms  of  the  family  as  a  unit. 
We  have  taken  the  family  for  granted  and  the  result  is  not  good. 

Had  educators,  social  workers  and  others  given  sufficient  considera- 
tion to  this  basic  group  we  probably  would  have  had  a  better  distri- 
bution of  family  income  by  now.  According  to  Government  figures,  in 
1927  there  were  eighty-eight  billions  of  dollars  earned  in  the  United 
States.  Fifty-eight  per  cent  only  of  this  amount  was  distributed  in 
salaries  and  wages;  nine  per  cent  went  to  land  owners  through  rents, 
etc.;  eight  per  cent  went  to  capitalists  in  interest  and  dividends;  twen- 
ty-five per  cent  went  as  additional  profits  of  business  enterprises.  One- 
half  of  this  additional  profit  of  twenty-two  billion  would  have  given 
every  family  in  America  receiving  $2,000  or  less  annually  $500  addi- 
tional income. 

There  are  in  America  twenty-six  million  one  hundred  thousand  fam- 
ilies or  households.  Twenty  million  families  or  households  in  America, 
at  the  peak  of  our  national  prosperity,  received  $2,000  or  less  per  year. 
During  this  period  our  Government,  after  careful  study,  decided  that 
a  normal  family  (two  adults  and  three  children)  should  have  between 
$1,900  and  $2,000  annually  for  a  decent  living.  Therefore,  at  the  height 
of  our  American  prosperity  twenty  million  (or  75  per  cent)  of  the  twenty- 
six  million  families  received  as  much  or  less  only  as  our  Government 
indicates  to  be  essential  to  good  living.  Eleven  million  (or  42  per  cent) 
of  these  families  received  $1,500  or  less  annually. 

Professor  Groves,  in  one  of  his  recent  books,  makes  the  statement 
that  "the  role  of  the  parent  is  as  difficult  and  as  important  as  the  role 
of  the  teacher.  Each  decision  adds  something  to  the  making  of  the 
child's  personality."  If  this  be  true,  preparation  for  parenthood  would 
seem  to  be  an  important  step  and  an  essential  aim  of  education.  This 
preparation  at  the  present  time  has  been  largely  lacking  and  the  family 
is  in  difficulty.    There  are  lots  of  bad  families. 

*  Presented  at  the  meeting  of  the  Massachusetts  Committee  for  the  White  House  Conference 
on  Child  Health  and  Protection,  Worcester,  Mass.,  May,   1932. 


170 

The  family  is  changing  at  a  greater  rate  than  at  any  time  in  the 
records  of  American  family  life.  Apparently  neither  religion  nor  any 
other  force  is  capable  of  holding  back  this  change.  The  greatest  ele- 
ment of  change  in  the  family  perhaps  is  the  status  of  women,  who, 
largely  through  education,  have  taken  a  new  place  in  society.  Mar- 
riage, for  economic  reasons  only,  is  rapidly  diminishing  with  thousands 
of  women.  Fewer  children  indicates  a  world  trend  as  well  as  a  national 
trend.  (In  Boston,  in  1931,  the  birth  rate  dropped  22  per  cent).  Woman 
has  demonstrated  her  ability  to  enter  the  field  successfully  of  any  ac- 
tivities which  man  has  pioneered.  Science  has  remade  the  house  and 
its  appliances,  which  has  greatly  decreased  the  labor  formerly  required 
by  women  in  the  home.  Woman  has  overthrown  the  subordinate  posi- 
tion which  she  occupied  only  a  short  time  ago  and  has  now  taken  her 
place  as  a  partner  rather  than  as  the  servant  of  man  in  the  home. 

In  spite  of  all  the  changes  in  American  family  life  the  parent  is  still 
the  educator  and  the  greatest  influence  in  the  life  of  the  child.  The 
child  is  trained  by  the  parent  in  ideals.  From  the  parent  he  learns  his 
native  speech.  He  learns  the  care  of  his  person.  He  shapes  his  atti- 
tudes and  no  one  yet  knows  to  what  extent  the  first  six  years  before 
the  child  goes  to  school  may  determine  the  development  of  his  whole 
personality.  Perhaps  the  great  unconquered  area  of  child  life  which 
the  parent  must  satisfactorily  control  is  the  period  from  fifteen  to  twenty 
years  of  age. 

Professor  Finney  gives  as  his  opinion  that  the  task  of  guiding  youth 
from  birth  to  fifteen  years  of  age  is  simple  as  compared  with  the  task 
of  successfully  guiding  youth  from  fifteen  to  twenty. 

From  the  title  page  of  a  recent  book  on  education  by  Professor 
Counts,  we  quote  the  following: 

"Greeting  his  pupils  the  master  asked: 

What  would  you  learn  of  me,  and  the  reply  came — 

How  shall  we  care  for  our  bodies 

How  shall  we  rear  our  children 

How  shall  we  work  together 

How  shall  we  live  with  our  fellowmen 

How  shall  we  play 

For  what  end  shall  we  live 
and  the  teacher  pondered  these  words  and  sorrow  was  in  his  heart 
for  his  learning  touched  not  these  things." 

It  would  seem  that  the  mother  has  the  opportunity  and  the  necessity 
to  teach  the  child  what  the  school  does  not.  All  the  resources  of  the  arts 
and  sciences  are  hers.  The  cultured  home  will  find  the  parent  drawing 
heavily  from  the  field  of  literature,  dietetics,  music  and  other  arts  and 
also  the  choice  of  vocations.  The  conversation  at  the  dinner  table  will 
demonstrate  the  extent  to  which  the  parent  has  used  the  arts  and  sci- 
ences in  preparing  the  children  for  life's  voyage  and  enrichment. 

The  parent  shoud  be  the  interpreter  and  the  guide  for  all  the  conflict- 
ing opinions  and  attitudes  of  the  child's  outside  world.  In  the  home 
the  parent  should  be  able  to  adjust  the  conflicts  which  are  bound  to 
come  from  the  many  contacts  which  a  normal  child  has  in  our  present 
civilization.  The  parent  is  the  judge,  and  the  guide,  a  function  requir- 
ing great  skill  and  knowledge. 

Finally,  we  would  indicate  that  parent  education  at  the  present 
time  might  be  divided  into  three  groups.  There  is  first  the  general  prop- 
aganda to  awaken  parents  and  educators  to  the  needs  of  better  family 
life.  Then  too  there  must  be  premarriage  education  for  youth  about  to 
be  married.  The  philosophy  of  happiness  is  not  sufficient  at  this  point. 
The  fruits  of  good  family  life  come  as  the  fruits  of  any  other  phase  of 
life;  namely,  by  purposeful  effort  and  not  as  a  gift.  Perhaps  most  im- 
portant of  all,  parent  education  is  attempting  to  help  parents  with  the 


171 
problems  growing  out  of  their  experience  in  child  rearing,  and  at  this 
point  the  greatest  need  is  felt. 

Summarizing — social  workers,  educators  and  all  professional  people 
should  constantly  think  in  terms  of  the  family  as  the  basic  unit  of 
society  and  particularly  as  they  deal  with  the  individuals  still  under 
the  influence  of  the  family.  Furthermore,  they  should  use  their  in- 
fluence to  encourage  school  committees  and  boards  to  include  in  the 
curriculum  basic  courses  in  preparation  for  family  life. 

MATERNAL  MORTALITY* 

John  Rock,  M.D. 
Obstetrician 

That  maternal  mortality  in  the  United  States  is  very  high  is  well 
recognized  fact;  that  it  is  actually  highest  among  the  leading  countries 
of  the  world  has  been  questioned.  It  is  probably  so.  Whether  more  par- 
turient women  of  each  ten  thousand  in  the  United  States  of  America 
lose  their  lives  than  in  the  divided  states  of  Europe,  however,  is  a  mat- 
ter of  merely  forensic  value  to  us  here.  The  critical  fact  for  us  who 
profess  medicine  to  realize  is  that  maternal  mortality  is  higher  here 
than  the  public  conscience  can  or  will  tolerate. 

Like  a  child,  when  our  country  was  very  young,  its  people  were  con- 
cerned with  food  and  shelter;  when  they  were  established  here  in  vigor- 
ous youth  political  autonomy  was  striven  for  and  achieved;  as  manhood 
came  with  physical  growth,  the  young  man's  urge  to  economic  inde- 
pendence and  stability  engrossed  the  country's  activities.  Like  a  man 
of  fifty,  the  country  now,  in  its  maturity,  pays  attention  to  health.  This 
universal  awareness  of  health  matters  is  manifested  everywhere.  Were 
one  to  doubt  it  let  him  consider  the  targets  at  which  every  astute  ad- 
vertiser of  every  conceivable  product  aims  his  attack.  Every  advertiser 
appeals  to  health.  The  public  is  health  conscious,  and  every  political 
unit,  city,  state,  and  country,  is  actively  engaged  in  health  matters. 
Obviously  this  is  of  profound  interest  to  us  doctors  who  deal  with  the 
physical  and  mental  welfare  of  the  individual. 

Until  just  recently  our  people  were  content  to  safeguard  themselves 
with  medical  practice  acts  which  give  the  privilege  of  ministering  to 
the  health  of  individuals  into  only  presumably  competent  hands;  and 
with  using  the  police  power  of  each  governmental  unit,  after  the  man- 
ner of  boards  of  health,  to  enforce  basic  principles  of  sanitation  and 
epidemiology.  For  the  last  twenty  years,  however,  there  has  been  a 
definite  expansion  in  the  people's  activities.  Not  unconscious  of  the 
amazing  advances  made  in  the  medical  sciences,  the  people  have  asked 
whether  they  were  being  as  well  cared  for  as  the  extent  of  science  war- 
ranted. There  is  no  implication  of  distrust  of  the  medical  profession 
in  this  question.  There  is  rather  the  realization  that  so  busy  is  the 
good  doctor  practicing  medicine  on  the  individual  that  he  has  little 
time  to  devote  to  large  public  health  affairs.  And  so  the  people  have 
looked  to  the  appropriate  paid  departments  of  the  government  to  do 
more  than  write  cesspool  permits  or  placard  a  house  for  scarlet  fever. 
The  taxpaying  citizen  now  expects  his  department  of  health  to  deter- 
mine how  well  he  can  be  cared  for,  and  then  through  the  existing  med- 
ical profession  to  devise  means  by  which  his  health  is  safeguarded  to 
every  possible  extent. 

The  White  House  Conference  on  Child  Health  and  Protection  was  one 
of  the  responses  made  by  the  Federal  Government  to  this  normal  de- 
mand of  the  public  for  the  best  in  individual  service.  It  took  count  of 
stock  and  then  made  plans  for  the  more  effective  administration  of 
the  business  of  safeguarding  mothers  and  babies.  Detailed  surveys 
were  made  to  learn  what  was   actually  happening,   and  plans  were 

*  Presented  at  the  meeting  of  the  Massachusetts  Committee  for  the  White  House  Conference 
on  Child  Health  and  Protection,  Worcester.  Mass.,  May,  1932. 


172 
evolved  from  these  findings  to  improve  matters.  I  wish  to  consider  with 
you  the  maternity  phase  of  this  work. 

Each  one  of  us  ardently  wants  each  mother  to  have  her  baby  safely. 
We  are  each  shocked  and  hurt  when  we  learn  of  a  maternal  death. 
Somewhere  along  the  course  of  that  woman's  life  medicine  failed — in 
prophylaxis;  perhaps  years  ago  in  puberty;  perhaps  last  month  in  not 
directing  her  diet  to  relieve  deficient  kidneys;  in  diagnosis,  perhaps 
long  ago,  in  missing  a  rheumatic  heart;  perhaps  yesterday  in  not  dis- 
covering a  placenta  praevia;  or  in  treatment,  sometime,  somehow. 
Closely  must  we  weave  our  net  of  prenatal  care,  delivery,  and  post- 
partum care,  that  not  a  single  woman  may  lose  her  life  or  health 
through  a  defect  in  the  mesh  of  prophylaxis,  diagnosis  or  treatment. 

In  the  United  States  6.9  die  per  every  1,000  live  births ;  in  Massachu- 
setts 5.9;  in  Boston  7;  in  Worcester  8.2.  Among  the  clinic  patients  of 
the  Boston  Lying-in  Hospital  delivered  at  home  or  in  the  hospital,  4.2 
die  per  1,000  live  births.  Obstetrics  can  be  practiced  in  these  parts  that 
well :  how  much  better  I  have  not  had  the  time  to  ascertain,  but  mani- 
festly both  in  Boston  and  in  Worcester  it  can  be  and  must  be  practiced 
at  least  that  well.  No  doubt  the  figures  from  your  local  specialty  mater- 
nity services  are  as  good,  perhaps  better,  than  those  I  quote  from  the 
Boston  Hospital.  The  point  I  wish  to  make  is  that  given  the  kind  of 
woman  who  has  babies  in  Worcester  and  Boston,  if  more  than  4.2  die 
per  1,000  live  births,  some  safeguard  known  and  used  among  a  cer- 
tain group  of  patients  has  not  been  used  here  nor  there.  To  obviate 
such  a  possibility  is  one  aim  of  the  White  House  Conference  Committee 
of  the  Massachusetts  Department  of  Public  Health,  and  surely  must 
be  of  every  one  of  us  however  related  we  are  to  maternity  work. 

The  factors  affecting  the  mother's  life  and  health  during  pregnancy, 
delivery,  and  the  postpartum  period  may  be  roughly  separated  into 
those  pertaining  to  the  individual  herself,  those  pertaining  to  personal 
services  rendered  her  by  doctor  and  nurse,  and  those  pertaining  to 
the  facilities  for  care  and  delivery  which  the  house  or  the  hospital  afford. 

If  a  woman  of  twenty  appears  normal  and  considers  herself  healthy 
and  well,  she  is  probably  healthy  and  well  enough  to  withstand  the 
trial  of  childbirth  provided  all  the  doctor  factors  and  all  the  facility 
factors  are  present  and  utilized.  If,  on  the  other  hand,  a  woman  is 
known  to  have  a  serious  defect  of  structure  or  function,  careful  con- 
sideration by  capable  judges  must  determine  whether  the  science  and 
the  art  of  obstetrics  are  adequate  to  compensate  for  the  given  defects. 
If  unprejudiced  medical  intelligence  becomes  aware  that  the  defect 
of  lungs,  heart,  kidney,  blood,  or  what-not  cannot  be  offset  by  the  best 
available  obstetrical  care,  then  honesty,  and  charity,  and  faithful  al- 
legiance to  his  professional  responsibilities  force  the  conscientious 
doctor  to  do  all  that  he  can  to  protect  that  woman  from  the  fatality  of 
childbirth,  until  time  and  science  can  improve  her  or  the  art  of  obstet- 
rics to  a  point  of  safety  for  her.  It  is  an  incontrovertible  fact  that  cer- 
tain discoverable  functional  defects  render  a  woman  unfit  for  preg- 
nancy or  delivery,  by  which  I  mean  that  present  obstetrical  knowledge 
and  skill  in  all  probability  will  be  incapable  of  saving  her  life  or  health 
if  she  is  allowed  to  reach  the  seventh  month  of  pregnancy.  To  expect  a 
miracle  to  intervene  is  unwarranted  by  the  frequency  of  such  occur- 
rences; to  deny  the  fact  of  her  danger  denotes  either  ignorance  or 
deceit;  to  know  the  danger  and  to  refuse  to  protect  her  from  it  is  to 
practice  not  enlightened  medicine,  but  ancient  or  medieval  philosophy, 
on  the  altars  of  which  every  year  certain  women  of  our  4.2  and  your 
8.2  are  sacrificed. 

The  other  factors  in  maternal  health  pertaining  to  the  individual  are 
of  a  more  general  nature  than  those  mentioned;  namely,  her  immediate 
fitness  for  parturition.  Her  economic,  her  domestic,  her  hygienic  situa- 
tion are  important  factors,  which  will  concern  the  social  welfare  worker 
rather  than  the  doctor.  They  must  concern  someone  if  fewer  mothers 
are  to  be  lost. 


173 

The  factors  in  maternal  welfare  pertaining  to  the  doctor  are  per- 
haps the  most  important  of  all,  and  paramount  among  these  are  his 
obstetrical  ability,  his  knowledge  of  the  science  of  midwifery,  his  cap- 
ability to  practice  it  and  to  the  deficiency  of  this  factor  most  of  the 
avoidable  mortality  is  directly  attributable.  When  every  pregnant  wom- 
an is  cared  for  as  well  as  the  obstetrical  knowledge  of  her  day  war- 
rants, fewer  mothers  will  die  or  be  incapacitated  by  childbirth.  Some 
causes  of  death  are  apparently  unavoidable;  such  as  embolism,  or  in- 
tercurrent infections  like  pneumonia;  by  far  the  greater  number  of 
causes  can  be  eliminated  if  the  patient  will  submit  herself  to  medical 
care  early,  and  if  the  doctor  knows  enough  about  obstetrics  to  recog- 
nize the  sign  of  approaching  danger  and  has  the  knowledge  and  the 
will  and  the  facilities  to  avoid  it.  This  does  not  mean  that  all  doctors 
doing  confinement  work  need  as  complete  a  knowledge  of  obstetrics 
as  that  which  is  demanded  of  the  specialist  in  midwifery,  for  only  about 
five  per  cent  of  pregnant  women  will  need  that  much  science,  but  no 
doctor  should  be  asked  to  care  for  a  women  if  his  obstetrical  knowl- 
edge is  not  sufficient  to  recognize  those  complications  with  which  he 
is  not  equipped  to  deal  or  who  is  not  conscientious  enough  to  obtain 
for  his  patient  adequate  care  when  he  does  see  the  need  for  more  than 
he  can  effectively  supply.  The  Committees  of  the  Conference  were  not 
unaware  of  the  many  difficulties  besetting  the  medical  graduate  of  per- 
haps thirty  or  more  years  ago  and  now  in  general  practice,  who  would 
wish  to  apply  what  they  have  suggested.  Neither  is  the  public  unaware 
of  these  difficulties.  Nor  is  the  public  unaware  of  the  fact  that  more 
mothers  are  dying  in  childbirth  than  need  die ;  and  you  will  agree  with 
me  that  knowing  this,  the  public  is  not  going  to  tolerate  it.  If  we  of 
the  profession,  in  spite  of  the  difficulties  in  our  path  do  not  move  to 
remedy  the  situation,  we  shall  find  other  agents  doing  it  in  spite  of  us. 

But  the  public,  even  were  it  willing,  cannot  afford  to  be  ruthless  in 
its  solution  of  this  problem.  Its  answer,  through  its  constituted  agen- 
cies, the  departments  of  health  of  city,  state,  and  country,  is  a  better 
organization  of  the  work,  so  that  the  real  useful  goods  that  each  in- 
dividual physician  has  to  offer  will  be  bought  and  paid  for  by  the  pa- 
tient who  needs  it  and  can  afford  to  pay,  and  whatever  else  is  needed 
shall  be  obtained  from  some  other  source  for  whatever  the  patient  can 
pay.  The  various  maternity  welfare  activities  of  our  own  Department 
of  Health  in  Massachusetts  are  all  directed  to  this  end.  This  is  the 
factor  pertaining  to  organization.  Fewer  mothers  will  die  if  all  the 
possible  resources  of  their  community  are  developed  and  properly  used. 

So  complex  has  obstetrical  practice  become  that  it  requires  an  in- 
stitution comprehensively  equipped,  for  the  proper  care  of  the  abnormal 
case.  This  is  the  factor  in  maternal  welfare  pertaining  to  facilities. 
Not  only  must  every  community  have  an  adequately  equipped  hospital 
with  sufficient  beds,  but  all  parts  of  the  community  must  have  easy  and 
quick  access  to  it  by  telephone,  ambulance  and  good  traffic  roads  and 
regulations.  A  good  hospital  requires  endowment,  preferably  from  pri- 
vate funds.  Where  the  need  for  such  has  been  realized  and  the  com- 
munity awakened  and  led  by  the  medical  group,  the  money  has  been 
found.  It  always  can  be. 

The  White  House  Conference  in  last  analysis  must  be  recognized 
as  an  expression  through  well-trained  spokesmen  of  interest  in  child 
and  maternal  welfare  from  the  country  at  large.  These  spokesmen  were 
not  elected  by  the  communities  which  they  represented,  but  they  were 
accredited  nevertheless,  for  they  were  chosen  by  legal  officers  of  the 
Federal  Government  because  they  were  intimately  concerned  and  con- 
versant with  the  subject  at  hand.  The  findings  of  the  committees  are 
accurate ;  their  recommendations  dependable.  It  remains  for  us  citizens 
of  Massachusetts  to  apply  those  pertinent  to  our  particular  conditions. 

Obviously  the  doctor  is  the  keystone  in  the  arch  of  maternity  ser- 
vice whether  from  the  individual  point  of  view  or  the  community  point 


174 
of  view.  Concerning  the  obstetrical  qualifications  of  the  doctors  in 
the  United  States,  the  Committee  on  Medical  Service  reached  some  very 
uncomplimentary  conclusions.  There  is  no  reason  in  the  maternal  mor- 
tality statistics  in  Worcester  and  Boston  to  assume  that  their  conclu- 
sions do  not  apply  to  us.  By  far  the  greater  number  of  doctors  who  are 
licensed  to  practice  in  Massachusetts  and  who  accept  responsibility  for 
obstetrical  cases  have  received  but  little  instruction  in  obstetrics  and 
as  little  or  no  training.  Most  of  those  practicing  passably  now  have  ac- 
quired knowledge  and  skill  in  the  only  school  open  to  them,  experience 
among  their  patients,  and  have  contributed  largely  to  the  high  mater- 
nal mortality  of  those  years  spent  in  doing  so.  Careful  investigations 
of  maternal  deaths  reveal  their  successors  doing  the  same  thing  today. 
Most  mothers  are  lost  by  ill-advised  or  badly  executed  operative  de- 
livery and  by  neglect  of  the  prenatal  danger  signals.  This  might  have 
been  necessary  when  the  absence  of  an  adequately  trained  physician 
meant  no  doctor  at  all,  and  a  poor  one  was  safer  than  the  ignorant  or 
meddlesome  neighbor-midwife.  It  is  not  necessary  today  in  Massachu- 
setts. If  only  those  qualified  were  allowed  or  willing  to  assume  the  care 
and  delivery  of  pregnant  women,  and  lines  of  communication  among 
patient,  doctor,  and  hospital  constantly  maintained,  that  devastating 
family  catastrophe,  the  death  of  the  mother,  would  be  less  frequent. 
Again  I  must  say  this  does  not  mean  that  only  specialists  in  obstetrics 
should  do  maternity  work,  but  merely  that  all  those  who  do  do  it  shall 
be  qualified  for  all  that  they  undertake. 

Censure  for  the  present  situation  is  rarely  deserved  by  the  individual 
doctor.  Even  few  cultists  are  charlatans.  Most  osteopaths,  science 
healers,  antivivisectionists  and  antivaccinationists  are  quite  unaware 
of  their  pitiful  ignorance.  The  well-deserved  denunciation  of  all  such 
is  made,  not  because  of  their  ignorance,  but  because  of  their  unwilling- 
ness to  learn,  and  the  damage  they  do  by  their  selfish  stubbornness. 
Let  not  this  be  said  of  the  medical  profession. 

Subcommittee  IA  on  Prenatal  and  Maternal  Care  of  the  Medical  Ser- 
vice Section  of  the  White  House  Conference,  realizing  the  danger  to 
which  our  pregnant  women  are  exposed,  but  also  appreciating  the  social 
and  economic  factors  in  the  practice  of  private  medicine,  have,  in  de- 
tail, shown  us  the  way  out  of  the  present  intolerable  situation.  They 
choose  three  avenues,  all  interrelated:  via  the  doctor,  the  patient,  and 
the  community.  Nothing  can  be  done  without  the  doctor's  help;  but 
this,  as  always,  will  be  forthcoming.  Medicine  like  ministry  in  the 
church,  from  which  it  was  indissoluble  for  centuries,  from  which  even 
now  it  still  is  inseparable  in  more  primitive  cultures  and  to  which  it 
is  closely  related  even  in  ours,  is  among  the  highest  of  the  humanities. 
The  welfare  of  man  is  its  intrinsic  purpose,  not  a  by-product  as  it  is 
with  most  other  professions.  We  merely  need  to  know  how  men  and 
women  can  be  helped.  We  will  then  help,  realizing  that  those  who  help 
the  most  are  the  most  nearly  perfect  physicians.  If  we  are  not  per- 
sonally equipped  to  give  the  immediate  help  which  is  needed,  we  can 
at  least  lend  ourselves  to  supplying  it  through  others.  It  is  in  such 
division  of  labor  that  maternal  welfare  will  be  accomplished. 

Admitting  that  safe  obstetrics  should  be  practiced  only  by  those  who 
are  adequately  educated  and  trained,  we  will  agree  with  the  committee 
of  the  White  House  Conference  that  the  course  in  obstetrics  in  most 
medical  schools  must  be  improved  enormously,  that  courses  must  be 
offered  for  graduates,  and  further  we  will  agree  with  them  that  even 
graduates  of  these  schools  must  have  sufficient  supervised  hospital  or 
clinic  practice  in  obstetrics  before  they  offer  themselves  to  the  people 
as  capable  obstetricians.  Our  legislature,  for  no  good  reason,  other 
than  political  expendiency  if  that  be  one,  (I  heard  the  reasons  uncriti- 
cally itemized  by  the  President  of  the  Senate  only  a  few  days  ago)  — 
our  legislature,  I  repeat,  is  unwilling  to  insure  this  safety  to  Massachu- 
setts by  refusal  of  its  license  to  the  unqualified.    It  must  remain  then 


175 

for  the  organized  profession,  by  its  prestige  and  influence  in  the  com- 
munity to  do  this.  When  new  doctors  who  have  had  insufficient  educa- 
tion and  training  in  obstetrics,  yet  attempt  maternity  work,  find  that 
they  are  not  recognized  by  their  colleagues  as  ethical,  and  are  not 
admitted  to  practice  in  good  hospitals,  just  as  they  would  be  condemned 
were  they  to  do  major  surgery  without  a  good  hospital  internship,  they 
will  either  limit  their  practice  to  the  things  they  can  do  well,  or  they 
will  obtain  better  obstetrical  training.  When  medical  schools  realize 
that  doctors,  to  practice  midwifery,  will  be  required  to  have  had  suffi- 
cient education  and  training,  they  will  give  it.  This  will  be  done  even- 
tually; but  what  shall  we  do  in  the  meantime? 

The  solution  is  not  difficult  in  theory — it  does  require,  however,  what 
may  seem  like  personal  sacrifice  in  practice.  It  lies  essentially  in  what 
I  have  called  a  division  of  labor  (and  no  pun  is  intended).  What  work 
does  the  maternity  case  include?  As  with  every  other  condition  which 
may  prove  fatal  or  incapacitating,  there  must  be  prophylaxis  or  pre- 
ventive medicine.  So  essential  are  the  fruits  of  pregnancy,  however,  to 
the  happiness  of  most  individuals  and  to  humanity  that  it  should  be 
encouraged  and  social  and  economic  conditions  arranged  for  its  safe 
accomplishment  by  the  proper  individuals.  But  for  those  to  whom  it 
is  practically  certain  to  mean  death  or  complete  disability,  and  as  I  said 
before,  there  are  such  unavoidably  exposed  to  it,  some  adequate  protec- 
tion must  be  given.  The  doctor  who  because  he  knows  not  the  physio- 
logical principles  and  treatment  involved  in  such  protection,  or  whose 
religious  convictions  forbid  his  offering  it  in  the  interest  of  saving  a 
life,  is  bound  by  the  ethics  of  the  profession  he  practices  to  refer  his 
patient  to  some  other  doctor  who  can  and  will  protect  her.  Failing 
this,  to  offer  her  as  a  substitute  for  the  medical  attention  she  needs, 
the  advice  to  remain  continent  when  it  is  probable  she  cannot,  will 
not,  or  will  not  be  allowed  to  remain  continent,  is  not  practicing  medi- 
cine but  religion  under  the  guise  of  medicine,  which  is  unfair,  perhaps 
to  both — religion  and  medicine. 

Prenatal  care  is  the  next  essential  to  the  practice  of  good  obstetrics. 
We  did  not  need  the  White  House  Conference  to  tell  us  this  again.  Why, 
then,  is  it  not  the  rule  among  pregnant  women  to  seek  the  doctor  early 
and  visit  him  often?  There  are  two  major  reasons:  The  first,  because 
they  do  not  realize  the  necessity  for  such  attention;  the  second,  because 
they  cannot  afford  to  pay  for  it.  To  teach  men  and  women  the  value 
of  prenatal  care  promising  work  is  now  carried  on  through  mothers' 
clubs,  health  magazines,  radio  addresses,  insurance  company  propa- 
ganda, commerical  house  advertisements,  and  other  such  lay  activities ; 
through  state  and  city  health  agencies,  and  by  the  various  nursing  or- 
ganizations. Continually  the  young  men  and  women  especially  of  the 
foreign  element  and  the  poorer  classes,  for  their  deaths  count  heavily 
against  us,  are  being  impressed  by  every  available  means  with  the 
value  of  early  and  frequent  medical  attention  during  pregnancy. 

Unfortunately  large  numbers  cannot  afford  to  pay  for  it.  Here  is 
where  the  doctor's  apparent  sacrifice  is  called  for.  For  the  welfare  of 
society,  to  which  the  whole  profession  is  dedicated,  he  must  not  only 
give  his  services  when  they  are  required,  but  he  must  give  over  as  much 
of  the  supervisory  work  as  other  agencies  are  qualified  to  do.  The 
State  Department  of  Health  is  ready  and  able  to  help  by  teaching  preg- 
nant women  the  fundamentals  of  maternity  hygiene  and  diet.  This  is 
free  service  to  the  individual,  paid  for  by  the  group  at  large.  The  prac- 
ticing physician  can  save  hours  of  his  time  which  the  patients  will  not, 
will  not,  because  she  cannot,  pay  for,  by  advising  his  practice  to  take 
advantage  of  this  service.  The  District  Nursing  Association  is  ready  and 
able  to  help  by  sending  efficiently  trained  nurses  from  house  to  house 
to  explain  important  details  of  hygiene  and  diet  to  the  pregnant  women 
and  to  help  even  more,  by  ascertaining  the  blood  pressure  and  testing 
the  urine  of  those  women  who  cannot  afford  to  visit  the  doctor  often 


176 

enough  and  by  sending  the  reports  to  the  patient's  doctor.  The  prac- 
ticing physician  can  save  hours  of  his  time  which  the  patients  will  not, 
because  they  cannot,  pay  for  by  advising  his  practice  to  take  advantage 
of  this  service,  too.  Assuredly  he  loses  nothing  in  prestige  or  practice 
by  having  these  details  executed  by  others  who  can  do  them  well.  Rather 
will  his  reputation  as  a  good  doctor,  whose  patients  are  thoroughly  cared 
for,  be  enhanced  and  his  tangible  perquisites  as  well.  In  every  com- 
munity where  there  is  no  such  nursing  work  organized,  the  medical  fra- 
ternity with  the  help  of  the  womens'  clubs  and  the  State  Board  of 
Health  should  organize  it.  - 

In  every  city  there  will  be  many  pregnant  women  who  cannot  even 
afford  to  pay  the  two  or  three  dollars  which  is  the  least  the  physician 
must  get  for  the  monthly  or  bi-weekly  prenatal  visit.  The  doctors  are 
advised  to  organize  clinics  where  such  women  can  receive  the  necessary 
supervision.  Again  the  practicing  physician  must  make  an  apparent 
sacrifice  by  sending  his  patient  to  a  clinic  in  charge  of  some  other  doc- 
tor in  order  to  save  time,  money  and  probably  lives.  The  work  of  the 
clinic  should  be  divided  among  those  of  the  local  fraternity  most  in- 
terested and  best  qualified  in  maternity  work.  The  reports  of  her 
visits  will  be  sent  to  the  patient's  private  physician,  back  to  whose  care 
she,  too,  will  be  sent  when  she  has  been  seen  safely  to  term.  But  should 
ante  partum  complications  arise  which  the  private  physician  is  not 
fully  qualified  to  deal  with,  he  will  gladly  ask  for  help — not  after  the 
patient  has  been  neglected,  and  her  condition  has  become  serious,  but 
before  this  occurs. 

In  the  presence  of  obstetrical  abnormalities  the  able  physician  is 
powerless  without  the  facilities  to  apply  his  science.  The  need  for  a 
well-equipped  maternity  hospital  within  the  speedy  reach  of  all  patients 
is  too  apparent  to  dwell  upon.  An  essential  to  good  service  here  too, 
may  require  an  apparent  sacrifice  from  the  individual  physician.  We 
must  cooperate  with  each  other  to  the  end  that  this  maternity  hospital 
which  is  to  assure  safe  care  to  those  pathological  cases  needing  it 
most  will  be  administered  again  by  those  most  interested  and  best 
equipped  in  the  science  of  obstetrics. 

All  this  division  of  labor  is  not  difficult  to  visualize  for  the  poorer 
class  of  patients.  The  greatest  apparent  sacrifice  by  the  physician  is 
demanded  when  the  patient  who  needs  supervision  or  treatment  which 
he  cannot  give,  is  one  who  pays  for  medical  attention.  As  was  the  case 
with  child  welfare  work,  when  the  less  fortunate  people  were  obtaining 
good  care,  the  more  fortunate  came  for  it  also.  When  the  poorer  wives 
are  profiting  by  adequate  obstetrical  supervision,  the  whole  salaried 
class  will  demand  it  is  well.  Let  us  not  forget  that  no  physician  ever 
suffered  from  the  reputation  of  taking  good  care  of  his  patients.  No 
patient  expects  her  physician  to  know  everything.  She  merely  expects 
him  to  watch  well  over  her — to  protect  her  from  threatened  dangers, 
and  to  extricate  her  from  those  which  overtake  her.  She,  as  well  as 
his  professional  colleagues  will  but  honor  him  for  seeking  help  to  this 
end  when  he  needs  it. 

BODY  MECHANICS* 

Lloyd  T.  Brown,  M.D. 

Instructor  in  Orthopedics,  Harvard  Medical  School 

It  was  my  privilege  at  the  White  House  Conference  to  be  a  member  of 
the  Subcommittee  on  Orthopedics  and  Body  Mechanics  and  thus  to  be  able 
to  sit  in  not  only  at  some  of  the  meetings  of  the  Committee  on  Growth 
and  Development  but  also  of  the  Committee  on  Medical  Care  of  Children. 
This  was  a  privilege  which  made  one  realize  what  a  tremendous  under- 
taking was  being  carried  on  and  it  certainly  made  one  wish  that  the  find- 

*  Presented  at  the  Meeting  of  the  Massachusetts  Committee  for  the  White  House  Conference 
on  Child  Health  and  Protection,  Worcester,  Mass.,  May  6,  1932. 


177 
ings  could  be  given  to  the  medical  profession,  and  to  the  people  of  this 
country.  It  must  be  a  great  satisfaction  to  those  who  instigated  and  car- 
ried out  the  work  of  the  Conference  to  know  that  meetings  such  as  this 
are  being  held  all  over  the  country  at  the  present  time. 

The  findings  of  the  Subcommittee  on  Orthopedics  have  recently  been 
published  fey  the  Century  Company  in  a  book  entitled  "Body  Mechanics — 
Education  and  Practice."  Therefore,  I  shall  not  attempt  to  tell  you  what 
can  easily  be  read  in  this  book  about  the  data  that  was  collected  and  the 
details  of  working  out  the  results.  What  I  shall  do  is  to  answer  the  fol- 
lowing questions:  What  is  meant  by  body  mechanics?  Is  bad  body  me- 
chanics prevalent  and  can  we  associate  good  body  mechanics  with  good 
health  and  bad  body  mechanics  with  poor  health? 

The  White  House  Conference  adopted  the  following  as  the  definition  of 
body  mechanics:  "Body  mechanics  may  be  denned  as  the  mechanical  cor- 
relation of  the  various  systems  of  the  body,  with  special  reference  to  the 
skeletal,  muscular  and  visceral  systems  and  their  neurological  associa- 
tions. Normal  body  mechanics  may  be  said  to  obtain  when  this  mechan- 
ical correlation  is  most  favorable  to  the  function  of  these  systems." 

The  question  of  the  prevalence  of  bad  body  mechanics  was  answered 
from  statistics  gathered  from  many  sources,  such,  for  example,  as  the 
examinations  of  young  and  middle-aged  men  during  the  universal  draft  of 
the  late  World  War;  from  postural  surveys  made  of  the  entering  classes 
of  Harvard,  Yale,  Smith  and  other  colleges;  from  numerous  surveys 
throughout  the  country,  including  an  intensive  and  rather  complete  sur- 
vey of  body  mechanics  covering  a  period  of  two  years  among  1,708  chil- 
dren of  both  sexes,  made  under  the  auspices  of  the  Children's  Bureau  of 
the  Department  of  Labor  in  a  large  public  school  in  Chelsea,  Mass.  From 
all  of  these  findings  the  committee  concludes,  very  conservatively,  that 
"perhaps  seventy-five  per  cent  of  the  male  and  female  youth  of  the  United 
States  exhibit  grades  of  body  mechanics  which,  according  to  the  stand- 
ards of  the  committee,  are  imperfect."  In  the  Chelsea  survey,  children 
under  seven  years  of  age  had  better  postures  than  those  between  seven 
and  nine  years  of  age.  Ninety-two  per  cent  of  all  the  children  examined 
at  Chelsea  showed  poor  body  mechanics,  the  boys  being  slightly  better 
than  the  girls.  However,  between  the  ages  of  seven  and  nine,  ninety-nine 
per  cent  of  the  children  showed  poor  posture.  As  the  age  increased  up  to 
fourteen  years,  poor  posture  gradually  decreased  until  it  was  present  in 
eighty-eight  per  cent.  These  percentages  are  interesting  when  compared 
to  tlrose  of  the  World  War  and  colleges  where  we  find  eighty  per  cent  as 
the  figure.  There  is  no  question  but  what  similar  findings  would  be  pres- 
ent in  any  section  of  this  country  and  one  naturally  asks  that  if  such  a 
condition  is  so  common  can  it  have  any  effect  on  the  health  of  our  children 
in  their  growing  period  or  in  their  later  adult  life. 

This  brings  us  t©  our  third  question;  namely,  Can  we  associate  good 
body  mechanics  with  good  health  and  bad  body  mechanics  with  poor 
health?  In  answering  this  question  I  shall  quote  freely  from  the  Com- 
mittee report,  as  follows : 

"One  of  the  most  complicated  and  yet  mechanically  efficient  products  of 
the  age  is  the  automobile.  It  is  incomparably  less  complicated  and  less 
efficient  than  the  human  body,  yet  the  driving  public  are  frequently  made 
aware  of  the  fact  that  slight  disturbances  of  alignment  in  an  automobile's 
working  parts  and  slight  dysfunction  of  its  electrical  organs  may  inter- 
fere with  its  function,  and  cause  it  to  develop  chronic  diseases. 

"Lack  of  perfect  alignment  in  an  automobile  causes  friction,  and  fric- 
tion means  unnecessary  wear  and  tear.  While  the  margins  of  safety  are 
wider  in  the  human  body,  it  is  demonstrable  that  tasks  performed  with 
less  effort  cause  less  fatigue.  The  more  perfect  the  equilibrium,  the  less 
reflex  muscle  tonus  is  required  to  maintain  the  poise  and  the  less  fatiguing 
the  veluntary  muscle  effort  to  change  from  one  position  to  another. 

"It  would  seem  reasonable  to  suppose  that  combustion  within  the  body 
would  be  favored  by  continuous  adequate  aeration  of  the  lungs;  that  cir- 


178 
culation  would  be  favored  by  providing  sufficient  space  for  unimpeded 
action  of  the  heart ;  that  the  functions  of  the  abdominal  and  pelvic  viscera 
would  be  favored  by  a  free  excursion  of  the  diaphragmatic  pump  and  by 
a  sufficient  support  of  the  abdominal  wall  to  keep  the  stomach  from  sag- 
ging and  the  intestines  from  being  crowded  into  the  pelvis. 

"The  development  of  poor  body  mechanics  may  be  very  gradual. .  There 
is  usually  a  partial  or  complete  compensation  for  its  immediate  unfavor- 
able effects.  It  would  be  unreasonable,  therefore,  to  expect  that  these 
effects  would  become  quickly  evident,  dependent  as  they  are  upon  the  type 
and  structure  of  the  individual.  Neither  would  it  be  reasonable  to  expect 
that  these  possible  effects  would  disappear  with  the  quickness  of  a  labora- 
tory experiment  while  poor  body  mechanics  was  being  converted  into  good 
body  mechanics.  Nevertheless,  clinical  observation  over  a  considerable 
period  must  be  of  positive  value  and  inferences  of  evidential  value  may 
be  drawn  from  repeated  records  of  changes  from  poor  body  mechanics  to 
good  body  mechanics.  Especially  is  this  so  in  those  instances  in  which 
there  have  appeared  to  be  no  other  factors  which  could  fairly  have  been 
held  responsible  for  the  improvement  observed." 

With  these  things  in  mind  the  following  summary  of  the  clinical  evi- 
dence obtained  by  the  committee  is  interesting : 

"1.  Failure  to  gain  weight  and  disturbances  of  digestion  in  spite  of 
appropriate,  adequate  diet  and  favorable  living  conditions  are  frequently 
associated  with  poor  body  mechanics. 

2.  If  there  be  present  no  organic  lesion,  weight  tends  to  increase  and 
digestive  disturbances  to  disappear  as  poor  body  mechanics  is  changed  to 
good  body  mechanics. 

3.  Irregular  and  insufficient  defecation  tends  to  become  regular  and 
ample  with  the  acquirement  of  good  body  mechanics. 

4.  Cyclic  vomiting  and  certain  presumably  toxic  crises  have  ceased 
concomitantly  with  the  correction  of  poor  body  mechanics. 

5.  Increase  in  alertness,  resistance  and  a  sense  of  well-being  are  usually 
associated  with  the  change  of  poor  body  mechanics  into  good  body 
mechanics." 

"Sir  Charles  Sherrington's  theory  of  postural  tonus  which  he  was  able 
to  prove  even  in  the  decerebrate  preparations  seems  to  afford  a  sufficient 
explanatory  physiological  basis  for  the  beliefs  of  psychologists,  anthropolo- 
gists and  anatomists,  for  the  clinical  experience  of  clinical  investigators 
and  for  the  findings  of  such  surveys  as  have  been  made. 

"The  erect  posture  of  man  necessitates  an  almost  unconscious  but  con- 
stant muscular  contraction  (postural  tonus)  in  order  to  equalize  the  force 
of  gravity.  It  is  fair  to  assume  that  the  greater  departure  from  effortless 
equilibrium,  from  balance  and  counter-balance,  from  good  body  mechanics, 
the  greater  will  be  the  amount  of  reflex  muscular  action  or  postural  tonus 
required  to  maintain  the  body  in  an  erect  position.  There  exists  a  fairly 
constant  ratio  between  the  amount  of  reflex  contraction  required  and  the 
amount  of  muscle  fatigue  induced.  Poor  body  mechanics  is,  therefore, 
more  fatiguing  than  good  body  mechanics.  Fatigue  exerts  an  unfavorable 
effect  upon  the  health  and  well-being  of  children. 

SUMMARY  OF  ROUND  TABLE  ON  THE  HANDICAPPED  CHILD* 

Alfred  F.  Whitman 

Executive  Secretary,  Children's  Aid  Association 

Dr.  Gordon  Berry,  of  Worcester,  former  President  of  the  American 
Federation  of  Organizations  for  the  Hard  of  Hearing,  in  considering  the 
question  of  the  physically  handicapped  child,  has  asked  how  Massachusetts 
measures  up  to  covenant  thirteen  of  the  Children's  Charter  which  pledges, 
"For  every  child  who  is  blind,  deaf,  crippled  or  otherwise  physically  handi- 

*  Meeting  of  the  Massachusetts  Committee  of  the  White  House  Conference  on  Child  Health 
and  Protection  at  Worcester,  May,  1932. 


179 
capped,  and  for  the  child  who  is  mentally  handicapped,  such  measures  as 
will  early  discover  and  diagnose  his  handicap,  provide  care  and  treatment, 
and  so  train  him  that  he  may  become  an  asset  to  society  rather  than  a 
liability.  Expenses  of  these  services  should  be  borne  publicly  when  they 
cannot  be  privately  met."  In  the  care  of  the  blind,  or  partially  blind  chil- 
dren, Massachusetts  could  do  more  than  it  has,  even  though  in  its  work  at 
the  Perkins  Institute  and  in  seventeen  cities  of  the  State  the  Common- 
wealth is  already  doing  much  for  this  type  of  child. 

The  survey  of  crippled  children  made  by  the  Department  of  Public  Wel- 
fare and  published  in  December,  1931,  showed  a  census  of  6,141  such  chil- 
dren, one  sixth  of  whom  were  in  institutions.  While  the  report  indicates 
that  on  the  whole  our  State  has  done  well  for  its  crippled  children,  Dr. 
Berry  asks  if  we  are  to  be  satisfied  when  we  are  told  that  one  third  of 
these  Massachusetts  cases  are  due  to  infantile  paralysis  while  at  the  same 
time  we  know  that  there  is  very  little  crippling  in  most  cases  of  this 
disease  if  prompt  and  efficient  medical  care  is  given. 

The  deaf  and  hard-of -hearing  comprise  the  largest  group  of  physically 
handicapped  children  in  the  country.  The  deaf  may  be  defined  as  those 
who  have  lost  their  hearing  before  speech  could  be  acquired.  In  the  United 
States  there  are  two  hundred  schools  for  the  deaf,  caring  for  18,767  chil- 
dren. Massachusetts  has  six  such  schools.  Of  great  value  to  the  hard-of- 
hearing  is  the  work  of  the  one  hundred  leagues  making  up  the  member- 
ship of  the  American  Federation  of  Organizations  for  the  Hard-of -Hear- 
ing. These  leagues  have  been  much  interested  in  lip  reading  work  and  in 
efforts  to  discover  partial  deafness  in  childhood  in  the  hope  that  efforts 
applied  during  its  incipiency  may  control  and  even  prevent  deafness.  A 
group-testing  audiometer  has  been  devised  and  over  one  million  children 
in  the  country  have  been  tested  already.  It  is  estimated  that  three  mil- 
lions of  our  school  children  have  sufficient  deafness  to  present  an  educa- 
tional and  social  and  economic  problem.  In  many  cases  it  was  not  sus- 
pected that  the  child  was  deaf  but  it  was  thought  to  be  inattentive. 

Dr.  Berry  suggested  several  necessary  steps  in  overcoming  these  and 
other  physical  handicaps:  the  first,  greater  efforts  in  detecting  incipient 
cases;  the  second,  adequate  medical  care  when  needed;  the  third,  educa- 
tion of  the  handicapped  child  so  that  his  defect  would  be  minimized 
through  corrective  measures  and  so  that  his  compensatory  functions  be 
recognized  and  developed  to  the  utmost. 

Mr.  Cheney  C.  Jones,  Superintendent  of  the  New  England  Home  for 
Little  Wanderers,  and  for  the  past  three  years  President  of  the  Child  Wel- 
fare League  of  America,  briefly  reviewed  the  recommendations  of  the  1909 
and  of  the  1919  conferences,  emphasizing  the  significance  in  the  fact  that 
those  conclusions  had  stood  the  acid  test  of  time  and  of  progressive  criti- 
cism and  were  reaffirmed  by  the  1930  meeting.  During  this  twenty-year 
period  there  has  come  a  remarkable  development  in  relief -giving  private 
and  public;  the  Mother's  Aid  program  has  had  its  genesis  and  grown  to 
country-wide  proportions;  the  Children's  Bureau  was  established  and  the 
Child  Welfare  League  of  America  was  formed  and  there  has  been  in- 
creased activity  and  efficiency  on  the  part  of  the  state  departments  of 
welfare  in  their  supervision  of  child  welfare  work. 

Mr.  Jones  said  that  one  of  the  most  fundamental  principles  back  of 
these  developments  was  that  of  recognizing  the  value  of  the  child's  own 
home.  Another  was  found  in  the  scrapping  of  ancient  feuds  on  the  subject 
of  foster  home  care  versus  institutions  in  favor  of  a  careful  study  of 
each  child's  individual  needs  which  might  be  met  by  institutional  care  or 
foster  home  care  both  of  which  at  the  Washington  meetings  were  grouped 
together  under  the  one  term,  Foster  Care. 

Mr.  Jones  suggested  several  searching  questions  which  every  citizen  of 
Massachusetts  should  ask,  the  answers  to  which  challenged  social  work, 
both  private  and  public. 

Mr.  Theodore  A.  Lothrop,  the  Executive  Secretary  of  the  Massachusetts 
Society  for  the  Prevention  of  Cruelty  to  Children,  and  the  Chairman  of 


180 
the  Massachusetts  Commission,  which  was  created  by  the  1929  legislature 
for  the  purpose  of  revising  our  child  welfare  laws,  presented  the  state 
program  in  the  social  legislation. 

Dr.  Samuel  W.  Hartwell,  Director  of  the  Worcester  Child  Guidance 
Clinic,  presented  the  mental  hygiene  aspects  of  the  handicapped  child  in 
a  paper  on  personality  problems.  He  contended  that  just  as  a  child  suf- 
fers from  physical  defects  that  are  obvious,  so  he  may  be  handicapped 
just  as  seriously  because  of  some  of  the  less  patent  witnesses  of  the  inner 
life.  Some  of  these  difficulties  result  from  a  lack  of  emotional  adjustment 
which  child  guidance  clinics  are  trying  to  remedy.  Dr.  Hartwell  said  that 
mental  hygiene  is  increasingly  permeating  work  for  children  and  is  a 
powerful  factor  in  coordinating  the  various  aspects  of  child  welfare 
work.  He  also  gave  a  picture  of  a  child  welfare  clinic  as  it  should  be. 
He  finds  that  Massachusetts  is  in  the  forefront  in  its  work  for  defective 
and  emotionally  unstable  children,  but  believes  that  we  should  increase 
our  treatment  facilities  to  keep  pace  with  diagnoses  and  recommenda- 
tions of  the  child  guidance  clinics. 

Mr.  Paul  Beisser,  General  Secretary  of  the  Henry  Watson  Children's 
Aid  Society,  Baltimore,  Maryland,  and  an  officer  of  the  Child  Welfare 
League  of  America,  reported  on  the  developments  and  influence  of  the 
Conference  in  various  parts  of  the  United  States.  He  emphasized  the 
fact  that  the  White  House  Conference  was  not  merely  a  series  of  dis- 
cussions culminating  at  Washington,  not  the  forty  volumes  of  informa- 
tion and  facts  which  will  eventually  be  published,  not  the  hundreds  of 
concrete  recommendations  which  have  been  made,  but  something  more 
vital  than  that.  To  be  sure  some  machinery  and  soma  resulting  organ- 
ization is  implied,  but  when  we  see  what  the  present  emergency  situa- 
tion is  doing  to  our  machinery,  our  forms  of  organizations,  and  our 
standards,  we  realize  that  that  product  alone  from  a  White  House  Con- 
ference is  not  enough. 

The  more  vital  thing,  even  though  it  is  more  indefinable,  is  that  the 
Conference  represents  the  force  of  ideas,  of  winged  sentiment.  It  makes 
childhood  the  vital,  throbbing  concern  of  statesmen,  a  matter  by  no 
means  below  the  dignity  of  governments.  It  represents  a  dynamic  force 
of  the  dimensions  of  a  trend,  a  movement.  An  analogy  might  be  seen 
in  the  anti-cruelty  movement  where  with  all  the  mechanics  of  legisla- 
tion, protective  societies,  court  action,  a  technique,  the  real  essence  was 
in  the  trend  toward  the  idea  of  children  as  human  beings  with  rights 
rather  than  private  property  chattels.  Mr.  Beisser  mentioned  by  way 
of  illustration  a  few  of  the  events  which  have  followed  the  meetings  at 
Washington.  Bearing  out  his  statement  that  the  Conference  did  not 
culminate  with  the  Washington  sessions  in  November  of  1930 : 

At  least  twenty-eight  of  the  states  have  had  programs  on  the  White 
House  Conference. 

Massachusetts  was  one  of  the  few  States  in  a  position  to  carry  on 
the  work  through  the  assignment  of  a  professional  worker  al- 
ready engaged  in  state  welfare  work  for  the  period  of  one  year. 

State  and  city  conferences  of  social  work  are  featuring  the  White 
House  Conference  program,  frequently  printing  valuable  ma- 
terial in  their  proceedings. 

The  organization  of  lecture  courses  and  discussion  groups  similar 
to  those  held  in  Lowell,  Massachusetts. 

The  discussion  of  Conference  findings  by  such  related  groups  as 
Campfire  Girls,  Rotary  Club,  American  Legion,  Council  of*  Re- 
ligious Education,  medical  groups  and  others. 

The  official  designation  of  Children's  Charter  Day  by  the  State  of 
Indiana. 

The  publication  of  proceedings  in  a  set  of  forty  volumes,  fifteen 
pf  which  are  already  in  circulation. 


181 

HOW  MASSACHUSETTS  CHILD  COUNCIL  CAME  INTO  BEING 

Mary  R.  Lakeman,  M.D. 

Secretary,  Massachusetts  Child  Council 

Executive  Secretary,  Governor's  Committee  for  the  White  House 
Conference,  1931-1932 

At  the  close  of  the  White  House  Conference  on  Child  Health  and 
Protection  in  1931,  steps  were  taken  to  spread  its  findings  among  the 
citizens  of  the  several  states. 

Massachusetts  Committee 

In  Massachusetts  a  year  ago  last  spring  (1931),  Governor  Ely  ap- 
pointed a  committee  of  fifteen  men  and  women,  all  active  in  some  one 
of  the  various  fields  of  child  welfare,  as  a  State  White  House  Confer- 
ence Committee.  Dr.  George  H.  Bigelow  was  appointed  chairman;  a 
small  appropriation  was  made  available  by  the  Governor,  an  office  sup- 
plied and  an  office  secretary  appointed  to  serve  for  one  year.  Dr.  Bigelow 
delegated  the  writer  to  act  as  secretary. 

After  some  discussion,  the  Committee  agreed  that  with  the  limited  re- 
sources available  we  could  probably  reach  the  people  more  satisfacto- 
rily by  the  spoken  word  than  in  any  other  way.  So,  a  competent  chair- 
man was  appointed  for  each  of  the  four  sections,  and  sub-committees 
immediately  set  to  work  selecting  and  inviting  speakers  to  respond  to 
calls.  A  questionnaire  was  prepared  by  the  Chairman  of  the  Public 
Health  Section.  Dr.  Bigelow  sent  out  a  letter  offering  speakers  to  the 
various  organizations  which  exist  in  such  abundance  in  our  Common- 
wealth. Applications  began  to  come  in  promptly,  and  by  the  end  of  the 
year  365  talks  had  been  given  in  105  towns  or  cities. 

Institutes 

Two  Institutes  were  held  in  October,  one  in  the  eastern,  the  other 
in  the  western  section  of  the  State.  In  these  Institutes  we  endeavored, 
and  I  believe  with  some  success,  to  interpret  the  findings  of  the  White 
House  Conference  to  leaders,  such  as  officers,  committee  chairmen  and 
members  of  child  welfare  organizations,  civic-minded  persons  in  individ- 
ual communities,  etc.  The  purpose  was  to  inspire  these  people  with  so 
much  enthusiasm  that  they  would  go  back  to  their  groups  and  their  com- 
munities, find  out  what  their  individual  problems  were,  and  do  some- 
thing about  it! 

In  One  City 

Apparently  some  of  them  did  do  something  about  it,  although  it  is 
difficult  to  point  out  definite  results.  It  is  always  so  easy  to  confuse 
propter  hoc  and  post  hoc.  Several  communities  made  practical  use  of  the 
White  House  Conference  standards  as  a  "yardstick" — e.g.,  in  one  teach- 
ers' college  an  enterprising  teacher  of  biology  set  her  classes  to  work 
on  their  own  responsibility  to  measure  up  to  prescribed  standards  for 
a  teachers'  college.  She  also  applied  the  grade-school  standards  as  a 
measuring  rod  in  two  training  schools  with  truly  astonishing  results. 
A  physical  examination  was  made  of  each  child,  whereas  previously  the 
school  doctor  "had  not  gotten  around  to  it,"  being  busy  in  other  direc- 
tions. Milk  was  supplied  for  the  children  needing  it.  Last  year  there 
were  many  children  who  could  not  bring  their  pennies  but  this  year 
only  three  out  of  eighty-one  failed  to  bring  their  pennies  from  home! 
This  was  interpreted  as  indicating  that  the  parents  had  become  con- 
vinced of  the  value  of  the  mid-forenoon  milk.  The  children  responded, 
as  children  always  will,  to  sound  teaching  of  health  habits  and  the 
class  showed  an  average  gain  of  more  than  four  pounds.    From  this 


182 
school  the  word  recently  came  that  the  health  program  is  gaining  head- 
way and  that  the  children  in  one  of  these  schools  already  have  an  aver- 
age gain  of  three  pounds  to  their  credit. 

There  is  nothing  remarkable  about  this  story  of  the  beginnings  of 
health  work  in  an  outlying  school  in  a  poor  district,  except  that  the  in- 
centive to  act  came  from  the  definite  standards  outlined  by  the  Com- 
mittee on  the  School  Child  of  the  Section  on  Education  and  Training. 
Hitherto,  a  state  of  inertia  had  existed,  presumably  owing  to  a  lack  of 
leadership.  The  school  nurse  had  too  many  children,  the  teachers  didn't 
realize  what  they  could  do,  the  school  physician  was  waiting  to  be 
called,  and  it  remained  for  this  one  energetic  person  to  set  the  wheels 
in  motion,  with  the  ideals  of  the  Children's  Charter  as  her  objective. 

In  a  Small  Town 

In  one  small  town  a  group  of  people,  representing  the  various  organ- 
izations existing  in  that  community,  have  met  several  times  to  consider 
town  problems.  The  movement  in  this  instance  was  inspired  by  the 
Home  Demonstration  Agent.  Application  of  the  White  House  Confer- 
ence "yardstick"  showed  that  there  was  distinct  need  of  a  new  central 
school  building.  Although  everybody  had  talked  about  it,  no  one  did 
anything  about  it.  The  superintendent  of  schools  presented  the  need 
for  a  new  consolidated  school  building  to  this  group,  representing  as  it 
did  every  active  organization  in  the  town.  A  school  health  survey  was 
soon  made  with  definite  recommendations  by  the  State  Department  of 
Public  Health,  and  we  are  gratified  to  learn  that  a  definite  movement  is 
now  on  foot  to  secure  a  new  building.  Again,  it  may  be  true  that  this 
new  school  would  have  been  built  had  there  never  been  a  White  House 
Conference,  but  the  fact  remains  that  the  impetus  given  by  discussion 
by  community  leaders  of  the  existing  situation  as  compared  with  the 
standards  set  by  the  White  House  Conference  Committee  on  the  School 
Child  did  result  in  the  taking  of  definite  steps  which  led  to  action. 

In  a  Larger  Town 

A  similar  council  met  in  a  larger  town  for  the  specific  purpose  of 
starting  health  work  for  the  preschool  child,  beginning  with  a  "summer 
round-up"  last  spring.  Public  opinion  was  aroused  through  a  series  of 
discussions,  and  the  cooperation  of  the  medical  profession  deliberately 
sought  and  secured.  A  permanent  Well  Child  Conference  is  now  under 
way  with  the  full  sympathy  and  support  of  the  physicians. 

In  a  Public  Library 

The  Boston  Public  Library,  under  the  stimulus  of  the  Children's 
Charter,  did  its  bit  by  arranging  a  series  of  exhibits  and  talks  on  child 
care,  rotating  among  a  number  of  branch  libraries.  This  year  we  learn 
with  satisfaction  that  a  similar  plan  is  being  carried  out. 

A  Possible  Health  Unit 

We  still  hope  that  the  concentrated  efforts  of  two  or  three  of  our 
speakers  of  the  Public  Health  Section,  which  were  made  in  three  or 
four  adjoining  communities  may  eventually  culminate  in  the  develop- 
ment of  a  District  Health  Unit.  It  takes  a  long  time  to  convince  a  New 
Englander  that  he  can  buy  better  service  by  pooling  his  interests  and 
his  resources  with  his  neighbor,  but  we  still  have  hopes  of  that  health 
unit,  though  it  has  not  yet  come  into  being ! 

Massachusetts  Child  Council 

Greatest  of  all  the  results  of  last  year's  work  is  the  Massachusetts 
Child  Council,  which  through  the  broad  foresight  of  the  Board  of  Di- 
rectors of  the  Massachusetts  Child  Labor  Committee  is  supported  by 


183 
the  resources  (slender  though  they  be)  of  that  organization.    Fortune 
was  kind  in  freeing  for  service  as  its  executive,  Mr.  Herbert  C.  Parsons, 
a  man  without  a  peer  in  his  own  field  of  probation. 

The  Council  has  held  several  meetings,  with  practically  a  full  re- 
presentation of  its  twenty-three  members,  each  one  of  whom  is  the 
leading  spirit  in  a  State-wide  organization,  the  main  objective  of  which 
is  one  or  another  phase  of  child  welfare.  Five  are  commissioners — 
Public  Health,  Public  Welfare,  Mental  Diseases,  Labor  and  Industries,  and 
Education — the  remaining  eighteen  representing  State-wide  agencies  pri- 
marily concerned  with  child  welfare.* 

At  present  we  are  attempting  to  find  out  to  what  extent  the  well- 
being  of  our  children  is  being  affected  by  the  trying  period  through 
which  they  have  been  passing.  We  fancy  we  see  a  somewhat  disturbing 
tendency  to  disregard  human  values  in  the  inevitable  drive  to  reduce 
expenditures. 

The  Council  has  also  met  a  group  of  leaders  in  those  educational  or- 
ganizations which  have  an  interest  in  children  and  their  welfare  and 
has  presented  its  program  to  that  group.  These  organizations  have  been 
asked  to  cooperate  in  bringing  before  the  public  certain  dangers  to 
our  children  in  our  efforts  toward  economy.**  Some  of  the  exposed 
points  seem  to  be:  (a)  Health  provisions,  such  as  employment  of  school 
nurses;  (b)  Recreation — Already  two  cities  have  practically  suspended 
all  municipally  supported  playgrounds  and  indoor  recreations;  (c)  In 
the  public  schools,  support  of  the  State  department's  policy  of  preserv- 
ing the  features  which  count  in  terms  of  general  development  of  the 
child  is  perhaps  the  needed  action;  (d)  At  the  points  where  the  health 
of  the  school  child  is  touched,  the  ground  gained  in  medical  and  dental 
examination  is  to  be  defended. 

The  Council  will  probably  not  concede  that  the  defense  of  ground 
already  gained  is  the  only  concern.  While  there  will  be  bad  traveling 
for  proposals  that  require  new  or  increased  expenditures,  either  state 
or  local,  there  are  measures  that  need  support  and  not  money. 

The  main  purpose  of  the  Council  at  the  present  moment  is  that  the 
children  of  our  State  may  be  prevented  from  suffering  from  the  effects 
of  the  depression  and  its  attendant  unemployment. 

Program 

Let  me  present  the  five  items  of  the  program  on  which  our  Council 
has  started  this  fall : 

1.  The  summoning  to  our  aid  of  the  organizations  which  numerously 
exist  for  the  education  of  the  public  and  the  incitement  to  ac- 
tivity in  each  community. 

2.  A  general  child  conference,  on  the  same  plan  in  general  as  the 
Institutes  which  were  profitably  promoted  by  the  White  House 
Conference  Committee.    (This  will  be  held  in  the  early  winter.) 


*  The  full  Council  membership  is  as  follows:  Dr.  George  H.  Bigelow,  Commissioner  of  Public 
Health ;  Miss  Ida  M.  Cannon,  State  Conference  of  Social  Work ;  Mr.  Richard  K.  Conant,  Com- 
missioner of  Public  Welfare ;  Dr.  E.  Granville  Crabtree,  Mass.  Society  for  Social  Hygiene ;  Mr. 
John  D.  Crowley,  American  Legion ;  Mr.  Roy  M.  Cushman,  Boston  Council  of  Social  Agencies ; 
Dr.  Henry  B.  Elkind,  Mass.  Society  for  Mental  Hygiene;  Dr.  William  Healy,  Judge  Baker 
Foundation  ;  Mr.  Sheldon  Glueck,  Professor,  Harvard  Law  School ;  Mr.  Curtis  M.  Hilliard,  Cen- 
tral Health  Council ;  Mr.  Cheney  C.  Jones,  Child  Welfare  League  of  America ;  Mr.  Frank  Kiernan, 
Mass.  Tuberculosis  League ;  Dr.  George  M.  Kline,  Commissioner  of  Mental  Diseases ;  Dr.  Mary 
R.  Lakeman,  Mass.  Department  of  Public  Health ;  Mr.  Theodore  A.  Lothrop,  Society  for  the 
Prevention  of  Cruelty  to  Children  ;  Dr.  Leroy  M.  S.  Miner,  Dental  Hygiene  Council ;  Mr.  Willard 
A.  Munson,  Extension  Service,  Mass.  State  College;  Mr.  Herbert  C.  Parsons,  Mass.  Child  Labor 
Committee ;  Mr.  Edwin  S.  Smith,  Commissioner  of  Labor  and  Industries ;  Dr.  Payson  Smith, 
Commissioner  of  Education ;  Dr.  Richard  M.  Smith,  American  Academy  of  Pediatrics ;  Miss 
Marjorie  Warren,  Travelers  Aid  Society  ;  and  Mr.  Alfred  F.  Whitman,  Children's  Aid  Association. 

**  Fifteen  of  these  organizations  were  represented  at  a  recent  meeting.  These  were :  Junior 
League,  Mass.  Civic  League,  Mass.  League  of  Women  Voters,  Mass.  Organization  for  Public 
Health  Nursing,  Mass.  Parent-Teacher  Association,  Mass.  State  Federation  of  Women's  Clubs, 
Mass.  Teachers  Federation,  Mass.  Home  Economics  Association,  Mass.  Relief  Officers  Association, 
Mass.  Attendance  Officers  Association,  General  Federation  of  Women's  Clubs,  New  England 
Health  Education  Association,  Better  Homes  in  America,  Kiwanis  Club,  and  the  American  Associ- 
ation of  Hospital  Social  Workers. 


184 

3.  Informal  conferences  to  be  held  at  several  centers  in  the  State 
by  means  of  which  it  is  planned  to  get  together  representative 
persons  for  a  thorough  discussion  of  the  local  situation.  (With 
this  material  in  hand,  plans  for  a  long-time  program  will  be  for- 
mulated.) 

4.  Supplying  speakers  for  organizations  on  the  plan  and  largely 
using  the  same  list  as  was  effectively  used  by  the  White  House 

'   Conference  Committee. 

5.  Close  watching  of  legislative  proposals. 

Summary 

Thus  are  twenty-three  State-wide  forces  gathered  together,  each  one 
with  attention  riveted  on  the  whole  child,  in  a  united  endeavor  to  inte- 
grate the  plans  already  being  worked  out  in  the  best  interests  of  child- 
hood, to  seek  out  the  weak  points  and  to  add  support  to  strong  ones  in 
the  care  of  our  little  folks.  The  Council  is  in  no  sense  &  new  organiza- 
tion. It  is  probable  that  no  one  of  the  groups  concerned  will  radically 
modify  its  methods,  which  have  been  worked  out  with  due  regard  for 
its  particular  purposes,  but  each  member  is  prepared  to  adapt  his  pro- 
gram at  the  point  of  contact  with  others,  wherever  overlapping  is  dis- 
cerned or  a  need  found  to  have  been  overlooked  in  the  past. 

If  we  can  each  one  "grow  at  our  lines  of  intersection"  there  is  no 
question  but  that  the  children  of  Massachusetts  will  profit  by  a  better- 
balanced,  more  unified  program,  which  will  result. 

THE  PURPOSE,  PLANS  AND  POSSIBILITIES  OF  THE 

MASSACHUSETTS  CHILD  COUNCIL 

Herbert  C.  Parsons 
Administrative  Vice  President,  Massachusetts  Child  Council 

The  formation  of  the  Council  has  been  publicly  received  with  all  neces- 
sary acclaim.  Clearly,  it  is  recognized  as  filling  a  wide  gap  in  the  organ- 
ization of  forces  for  the  service  of  the  welfare  of  children  in  the  State — 
not  the  creation  of  new  ones  but  the  massing  of  those  with  which  the 
State  is  blessed.  It  may  well  stand  for  a  Children's  Bureau,  a  common 
feature  of  state  governments,  an  outstanding  one  in  the  federal  govern- 
ment, hitherto  having  no  replica  in  Massachusetts.  It  has  the  disadvan- 
tage of  being  without  governmental  financial  support  and  the  advantage 
of  being  free  from  governmental  restraints  and  responsibilities.  It  can  go 
as  far  as  its  representative  members  will  have  it  go.  It  will  keep  going  as 
long  as  the  moderate  budget  of  its  initiating  organization,  the  Massa- 
chusetts Child  Labor  Committee  can  be  made  to  balance,  a  problem  which 
is  not  the  Council's  worry,  except  secondarily. 

How  big  a  fellow  "The  Whole  Child"  is  can  only  be  realized  by  contem- 
plating how  many  are  the  challenges  he  extends  to  the  community  in 
which  he  lives.  The  concern  as  to  him  is  that  he  shall  get  a  normal  devel- 
opment for  the  exactions  of  a  future  of  which  there  is  nothing  more  cer- 
tain than  that  its  demands  upon  men  and  women  will  be  more  intense  as 
indeed  its  opportunities  are  to  be  more  rich.  The  membership  of  the 
Council  is  itself  a  manifestation  of  the  variety,  as  well  as  the  seriousness, 
of  the  concerns  that  the  child  in  this  State  at  this  moment  and  in  future 
days  shall  have  his  chance  for  a  full  life  and  be  ready  to  meet  it  un- 
hampered by  physical,  mental  or  moral  handicaps. 

The  members  of  the  Council  have  been  asked  to  suggest  definite  ways 
in  which  its  work  may  proceed  as  they  see  needs  in  their  respective  fields. 
Their  responses  are  a  graphic  indication  of  its  possible  usefulness  and  its 
needed  activities.  Before  enumeration  of  them  and  of  such  others  as 
amplify  the  list,  it  is  requisite  to  consider  the  existing  situation  as  to  all 
social  economics.  At  a  time  when,  if  conditions  were  normal,  there  would 
be  full  occasion  for  efforts  to  keep  Massachusetts  moving  forward,  it 


185 
becomes  necessary  to  set  up  defences  against  attacks  upon  what  has  al- 
ready been  gained.  Much  that  has  been  won  in  the  course  of  years  and  at 
the  expense  of  great  effort  and  persistent  demand  is  now  in  peril  of  a  re- 
duction in  outlays  which  takes  little  or  no  note  of  human  values. 

Moreover,  unemployment  and  impoverishment  are,  to  an  extent  that  no 
one  has  measured,  putting  children  who  would  ordinarily  be  well  cared 
for  and  happy,  under  afflictions  and  denials.  The  flood  gates  of  relief  have 
been  opened  and  money  publicly  and  privately  provided  is  flowing  in 
channels  which  have  not  hitherto  invited  it.  In  the  fullest  possible  meas- 
ure of  relief,  going  into  homes  that  have  not  before  needed  it  and  would 
have  scorned  it,  the  children  are  being  given  a  new  experience,  with  woe- 
ful possibilities  of  distortion  of  their  outlook  on  life.  They  can  but  share 
the  humiliation  which  still  attends  charitable  aid.  The  child  mind  is  a 
fertile  field  for  the  development  of  resentment  which  in  the  adult  is  re- 
duced by  some  degree  of  rationalizing.  Thus  while  one  hand  of  the  public 
is  giving  practical  aid,  the  other  needs  to  be  occupied  with  protecting 
children  against  the  damages  poverty  inflicts,  both  when  unrelieved  and 
when  externally  relieved. 

So  the  problem  of  child  welfare  promotion  becomes  in  large  part,  for 
the  time  being,  that  of  protecting  children  from  the  hurts,  not  so  much 
of  present  deprivation  as  of  permanent  harm.  It  takes  on  the  two  phases 
of  compensation  to  the  child  for  what  he  is  denied  and  of  holding  fast  the 
ground  that  has  been  gained  in  the  interest  of  his  health  and  training. 

The  first  requirement  in  this  situation  is  that  there  shall  be  knowl- 
edge of  what  is  actually  happening  and  what  is  distinctly  likely  to 
happen.  Efforts  already  made  to  get  this  information  have  hardly  done 
more  than  to  reveal  that  next  to  no  definite  facts  are  known.  There  is 
ample  apprehension  but  it  is  singularly  uninformed  and  without  a  re- 
course for  the  needed  knowledge  either  to  dispel  or  justify  it.  The  Coun- 
cil has  an  inescapable  responsibility  to  go  to  the  local  sources  for  sup- 
ply of  the  facts  as  to  how  the  child  is  being  disadvantaged  and  pre- 
cisely what  changes  in  policy  and  suspension  of  sound  and  needful  pro- 
visions are  impending. 

To  summarize  in  the  broadest  fashion  the  suggestions  that  have  been 
made  by  members  of  the  Council  at  previous  sessions  and  when  inter- 
viewed by  Dr.  Lakeman,  it  is  evident  that  there  is  no  field  represented 
here  which  does  not  present  a  pressing  need.  It  is  also  shown  that  in 
many  instances  the  problem  reaches  over  from  one  field  to  another,  giv- 
ing additional  ground  for  the  existence  of  such  a  union  of  effort  as 
the  Council  may  well  try  to  provide. 

The  health  of  the  child  has  extroardinary  need  of  protection  at  a  time 
when  families  are  reduced  in  means.  The  reaching  of  underfed  chil- 
dren is  both  a  health  and  relief  concern;  nutrition  is  an  acute  problem 
and  relief  agencies  have  all  the  need  of  the  expert  aid  of  the  health  ex- 
perts. Again  the  competent  examination  of  school  children  and  the 
maintenance  of  the  school  nursing  system  are  of  mutual  concern  to  the 
health  and  school  equipments.  The  well-child  clinic  has  established 
its  place  and  here  there  is  need,  as  in  all  clinical  stations,  for  regula- 
tion which  will  prevent  or  reduce  the  needless  frequency  of  resort  to 
them. 

In  relief,  beyond  what  has  already  been  indicated,  there  is  need  of 
local  community  effort  to  keep  children  from  getting  a  notion  of  depend- 
ency— as  if  it  were  normal  and  to  be  ordinary;  along  with  insistence  on 
wholesome  occupation. 

In  the  labor  field,  certain  employments  are  under  high  pressure,  as 
in  certain  cities  the  use  of  boys  for  magazine  salesmen;  others  are  giv- 
ing instances  of  sweat-shop  wrongs,  with  the  attending  iniquities  of  in- 
duced immorality.  From  this-  quarter  comes  also  the  warranted  protest 
against  the  impairment  of  the  attendance  officer  service. 

Mental  hygiene,  at  a  time  when  its  need  is  greatest,  is  being  made  to 
suffer  a  lessened  attention. 


186 

The  transient  child  is  a  new  appearance,  the  extent  of  which  is  in- 
dicated in  the  experience  of  the  Travelers  Aid  Society  and  it  imposes 
a  responsibility  on  communities  for  individual  attention,  recreation  and 
educational  relief,  as  well  as  the  closely  directed  family  aid. 

The  schools  are  in  a  situation  of  particular  peril  from  an  unreasoning 
reduction  of  budgets,  probably  a  greater  peril  in  the  next  rather  than 
this  year. 

Recreation  is  being  radically  reduced.  One  large  city  has  entirely 
suspended  all  its  directed  child  recreation  playgrounds  and  indoor  rec- 
reation in  the  winter. 

Measures  recommended  by  the  Children's  Commission  and  not  en- 
acted come  to  consideration  with  added  emphasis  as  in  the  instance 
strongly  cited  by  Mr.  Crowley  of  the  need  of  regulating  the  boarding 
homes  where  children  beyond  the  present  age  limit  of  three  years  are 
subjected  to  intolerable  conditions. 

The  administration  of  the  juvenile  delinquency  laws  is  so  far  from 
consistent  with  its  purpose  and  design  as  to  constitute  a  reproach  upon 
the  state  and  a  failure  to  prevent  the  advance  into  adult  criminality. 
It  is  probable  that  an  effort  will  be  made  in  the  next  legislature  to  re- 
peal the  recent  statute  requiring  physical  and  mental  examination  be- 
fore commitment  to  the  juvenile  institutions. 

The  extension  service,  proceeding  from  the  State  College,  challenges 
attention  in  its  well-considered  program  for  reaching  the  communities 
and  inciting  them  to  provision  of  recreation  for  all  age  groups,  improv- 
ing instead  of  reducing  educational  opportunities,  adult  education  and 
health,  proceeding  on  a  survey  of  their  needs  and  available  facilities 
for  meeting  them. 

Far  from  complete  as  is  such  summary,  it  amply  suggests  the  stirring 
of  the  consciousness  of  the  people  of  the  State,  and  the  holding  of  all 
ground  thus  far  taken  in  the  aid  of  the  development  of  children  to  the 
best  that  they  can  be. 

Plans  for  the  carrying  out  of  the  purposes  for  which  this  group  has 
already  shown  it  stands  include: 

1.  The  summoning  to  our  aid  the  organizations  which  numerously 
exist  for  affectuating  the  education  of  the  public  and  the  incitement  to 
activity  in  each  community.  Dr.  Lakeman  has  prepared  a  careful  list 
of  such  bodies.  A  meeting  with  their  representatives  in  special  confer- 
ence at  an  early  date  is  intended. 

2.  A  general  child  conference,  on  the  same  plan  in  general  as  those 
which  were  profitably  promoted  by  the  State  White  House  Conference 
Committee. 

3.  Informal  conferences  to  be  held  at  several  centers  in  the  State. 
It  is  planned  to  get  together,  in  as  many  of  these  as  possible,  represen- 
tative persons  for  a  thorough  discussion  of  the  local  situation.  It  seems 
that  only  by  such  means  can  the  actual  situation  be  discovered. 

4.  Supplying  speakers  for  organizations  on  the  plan,  and  largely 
using  the  same  list  as  was  effectively  used  by  the  White  House  Confer- 
ence Committee. 

5.  Close  watching  of  legislative  proposals,  such  for  example  as  are 
already  projected  to  strike  from  the  statutes  all  mandatory  require- 
ments upon  cities  and  towns — and  there  may  be  expected  a  flood  of  such. 

Beyond  these,  there  are  the  continued  frequent  use  of  the  radio,  cor- 
respondence and  interviews  with  key  persons  in  the  several  fields,  and 
newspaper  publicity,  constituting  the  fullest  possible  development  of 
the  Council's  relations  to  the  people  of  the  State. 

Finally,  you  are  the  people.  There  is  positively  no  other  organized 
group  of  defenders  of  the  interests  of  childhood  in  our  good  State.  The 
money-saving  drive  is  being  powerfully  organized.  The  Economy  Lea- 
gue has  not  only  financial  resources  but  already  a  large  membership. 
Thus  far  it  gives  no  indication  of  the  least  interest  in  human  values. 
Indeed  my  one  attempt  to  point  out  in  a  letter  to  the  Boston  Herald 


187 

that  there  were  such  values  to  be  regarded  and  conserved,  resulted 
only  in  an  editorial  rejoinder  which  put  me  in  the  discredited  company 
of  educators  who  must  be  made  to  understand  that  they  are  to  sit  down 
and  be  quiet.  Shall  we  obey? 

THE  IMPORTANCE  OF  GUARDING  INFANTS  AGAINST 
INFECTIONS 

Gaylord  W.  Anderson,  M.D. 
Director,  Division  of  Communicable  Diseases 

Analysis  of  mortality  figures  of  the  acute  infections  and  diseases 
of  childhood  discloses  the  seriousness  of  the  problem  of  these  conditions 
among  children  under  two  years  of  age.  There  was  a  time,  before  this 
problem  was  well  recognized,  when  parents  deliberately  exposed  chil- 
dren to  measles  and  other  diseases  so  that  they  might  "have  the  disease 
and  be  over  with  it,"  but  since  we  have  been  informing  the  public  of 
the  seriousness  of  diseases  at  this  age  such  a  practice  has  been  decreas- 
ing, although  there  are  still  uninformed  mothers  who  fail  to  recognize 
the  danger. 

A  review  of  recent  figures  emphasizes  the  fact  that  this  is  one  of  the 
important  problems  of  the  present  day.  For  example,  in  Massachusetts 
during  1931,  82  per  cent  of  the  deaths  due  to  whooping  cough  were 
among  children  less  than  two  years  of  age  while  only  14  per  cent  of  the 
cases  occurred  in  this  age  group.  In  other  words,  the  chances  of  a  fatal 
outcome  under  two  is  one  in  fifteen  in  contrast  to  one  chance  in  four 
hundred  over  that  age. 

Measles  shows  a  very  similar  picture.  Last  year,  58  per  cent  of  those 
dying  from  this  disease  were  under  two.  The  enormity  of  the  menace  is 
not  disclosed,  however,  until  we  learn  that  only  7  per  cent  of  the  cases 
were  in  this  age  group. 

The  same  general  rule  holds  to  a  greater  or  less  degree  for  other  dis- 
eases of  childhood.  Even  the  common  cold  is  dangerous  to  young  chil- 
dren because  it  is  so  frequently  followed  by  some  more  serious  disease. 
Small  babies  cannot  properly  control  the  secretions  of  the  nose  and 
throat  when  they  have  an  infection  ,and  very  frequently  the  germs 
causing  the  increased  secretions  invade  the  middle  ear  through  the 
Eustachian  tubes  from  the  throat  and  the  child  will  have  an  ear  in- 
fection which  not  only  endangers  the  hearing  but  often  ends  fatally. 
During  1931,  21  per  cent  of  those  dying  of  infections  of  the  ear  and 
mastoid  in  this  State  were  under  two  years  of  age.  No  doubt  many  of 
these  deaths  might  have  been  prevented  if  the  babies  had  been  pro- 
tected against  upper  respiratory  infections. 

Another  disease  which  may  follow  a  cold  is  pneumonia.  Again  the 
child  is  not  able  to  handle  the  secretions  properly  and  some  of  the  ma- 
terial is  aspirated  into  the  trachea  and  bronchi,  setting  up  an  infection 
of  the  lung.  Last  year  16  per  cent  of  the  deaths  from  pneumonia  in 
Massachusetts  were  among  children  under  two  years  of  age.  A  large 
number  of  these  deaths,  and  there  were  over  six  hundred,  could  have 
been  prevented  if  the  babies  had  been  properly  guarded  against  expo- 
sure to  colds  and  other  infections. 

Influenza,  which  often  can  hardly  be  distinguished  from  a  cold,  is 
likewise  dangerous  among  the  young.  In  1931,  12  per  cent  of  those  dy- 
ing of  influenza  were  under  two. 

The  time  will  no  doubt  come  when  we  shall  be  able  to  actively  im- 
munize infants  against  these  dangerous  infections  and  prevent  many 
of  the  deaths,  just  as  smallpox,  which  used  to  be  as  prevalent  as 
measles,  is  no  longer  an  important  public  health  problem  in  this  State. 
Because  of  our  compulsory  vaccination  law  and  its  enforcement  in  most 
of  the  communities  of  the  State,  there  was  only  one  case  of  smallpox 
per  100,000  population  during  a  ten  year  period,  1919-1928.   In  contrast 


188 
to  this,  there  were  eleven  states  in  the  Union  that  had  over  100  cases 
per  100,000  population  during  the  same  period  and  one  state,  which  has 
a  law  that  prohibits  anyone  being  compelled  to  be  vaccinated,  had  272 
cases  per  100,000. 

The  best  time  to  vaccinate  a  child  is  before  six  months  of  age,  while 
it  is  still  in  the  cradle.  There  is  less  reaction  at  that  time  and  the 
mother  can  guard  the  vaccination  sore  against  secondary  infection. 
When  the  child  gets  older,  it  is  practically  impossible  to  keep  it  from 
handling  the  area  and  secondary  infection  is  much  more  likely  to  occur. 

This  is  also  the  age  at  which  immunization  against  diphtheria  should 
be  done.  By  giving  the  child  immunity  before  one  year  of  age,  we  prac- 
tically eliminate  any  chance  of  its  ever  having  the  disease.  On  the 
other  hand,  if  immunization  is  put  off  until  school  age,  there  is  a  good 
chance  that  the  child  will  contract  the  disease  before  it  has  a  chance 
to  be  immunized.  Almost  one  third  of  the  cases  of  diphtheria  in  this 
State  last  year  occurred  among  preschool  children. 

We  look  forward  to  the  day  when  other  diseases  can  be  as  effectively 
prevented  by  specific  means  as  smallpox  and  diphtheria.  However,  We 
ought  to  realize  that  we  must  not  sit  and  wait,  for  there  is  much  which 
can  be  done.  Thousands  of  children  have  not  yet  been  protected  against 
diphtheria,  hundreds  have  not  received  smallpox  vaccination;  scores  of 
mothers  in  every  community  have  not  been  taught  to  care  for  infants 
in  such  a  way  that  they  are  protected  against  infections  at  a  time  in 
their  lives  when  such  protection  is  most  needed. 

PLAY  —  A  NECESSARY  FACTOR  IN  THE  LIFE  OF  EVERY  CHILD 

Elizabeth  M.  Laurie 

Research  Assistant,   Department  of  Educational  Investigation  and 
Measurement,   The  School  Committee  of.  the  City  of  Boston 

A  joyous  childhood  is  the  right  of  every  child.  It  is  easy  for  adults  to 
believe  and  to  say  so  glibly  that  such  is  the  condition.  Security  that 
comes  with  a  good  home  and  understanding  parents,  and  a  wholesome 
play  life  are  the  two  factors  that  contribute  largely  to  the  happiness 
of  children.  Any  worker  who  studies  the  problems  of  children,  who 
visits  the  homes  and  who  observes  children  at  play  can  offer  hundreds 
of  cases  of  unhappy  maladjusted  children.  It  is  claimed  that  every 
individual  must  realize  a  sense  of  security  if  he  is  to  make  his  best 
adjustment  to  life.  We  could  add  that  every  child  must  be  sure  of  at 
least  one  person.  Dr.  Adler  speaks  of  this  person  as  "the  trustworthy 
other  person."  Without  security  a  child  cannot  enter  into  his  heritage 
of  play  life  with  a  free  mind  and  without  vague  apprehensions.  We  all 
feel  disturbed  when  we  notice  one  child  who  is  not  playing  with  his 
group— rthe  solitary,  pathetic  figure  who  stands  on  the  edge  of  the 
playground,  or  the  boy  who  says  that  he  would  rather  read  in  his  room 
or  wander  alone  through  the  woods.  Sometimes  this  child  is  the  dis- 
agreeable, defiant  one  in  his  class.  Sometimes  he  is  the  timid,  shrink- 
ing one.  Both  evidences  are  merely  symptoms  of  something  far  more 
deep  rooted.  Lack  of  security  is  the  cause  of  many  of  our  home  and 
school  maladjustments.  How  can  we  expect  a  child  to  succeed  in  school 
and  to  take  his  normal  place  in  play  life  with  his  friends  when  he  does 
not  know  what  the  situation  will  be  when  he  returns  home?  Constant 
friction  in  the  home,  often  terminating  in  actual  brawls,  is  not  condu- 
cive to  childhood  happiness.  Without  joy  a  child's  play  life  is  most  in- 
adequate. The  broken  homes  of  today  are  without  doubt  tincturing 
child  life  with  unhappiness  and  fears  that  have  their  foundations  in 
lack  of  security.  If  these  fears  and  doubts  persist  and  the  child  does 
not  compensate  in  his  life  outside  the  home,  there  is  a  very  real  prob- 
lem. The  fact  that  ninety  per  cent  of  the  boys  in  one  of  our  reforma- 
tories are  from  broken  homes  is  sufficient  evidence  of  the  need  for 
drastic  action. 


189 

What  can  we  offer  as  at  least  a  partial  solution  in  our  schools?  We 
can  study  the  unhappy  maladjusted  children  of  our  nursery  schools, 
our  kindergartens  and  our  primary  schools.  It  is  very  difficult  to  change 
the  pattern  as  the  child  grows  older.  The  symptoms  should  have  been 
observed  when  the  child  was  younger.  The  child  who  is  solitary,  the 
child  who  cries  easily,  the  child  who  cannot  adjust  to  other  children 
should  be  studied. 

What  can  we  offer  as  at  least  a  partial  solution  in  our  homes?  Par- 
ents can  look  upon  children  as  individuals  rather  than  as  little  beings 
who  were  all  made  from  the  same  mold.  They  can  attempt  to  see  that 
each  child  has  normal  healthy  relationships  with  other  children  and 
that  each  has  an  adequate  play  life. 

Therefore  in  the  consideration  of  happy  child  life  two  avenues  of 
thought  are  open.  First,  the  child  must  know  security  if  he  is  to  take 
his  place  among  his  mates.  Secondly,  the  child  should  have  a  normal 
play  life.  / 

It  is  very  difficult  for  boys  and  girls  to  achieve  success  in  school 
when  their  homes  are  inadequate  and  when  their  parents  apparently 
have  little  interest  in  what  they  are  doing.  Teachers  should  realize  that 
children  carry  over  their  home  experiences  into  the  school.  The  school 
either  duplicates  the  unfortunate  experiences  or  it  compensates  for 
them.  When  home  and  school  both  fail  the  child  is  lost.  If  the  teacher 
understands  the  problem  of  each  child,  she  can  offer  the  child  oppor- 
tunities for  success.  Success  and  the  approval  of  his  friends  may  pre- 
vent the  boy  from  the  inadequate  home  from  getting  into  serious  dif- 
ficulties. 

Through  play  the  nursery  school  teacher,  the  kindergartner  and  the 
progressive  primary  school  teactier  give  satisfactions  and  opportunities 
for  doing  things.  Through  the  spirit  of  play  the  child  accomplishes 
worthwhile  tasks,  he  knows  self-activity  of  the  highest  type,  and  he 
gains  confidence  in  his  own  abilities.  Success  brings  more  joy  and 
more  sound  mental  hygiene  than  all  else. 

Very  often  the  adult  concept  of  play  is  far  from  correct.  Some  think 
of  it  merely  in  terms  of  physical  activity — of  running  or  jumping.  Some 
consider  play  a  waste  of  time.  They  want  even  th©  five  year  old  to 
begin  to  think  of  the  seriousness  of  life.  They  see  no  value  in  the  imi- 
tative plays  of  children.  They  do  not  see  that  children  are  living 
through  life  experiences  in  their  play  and  are  knowing  wholesome, 
happy  relationships  with  others.  For  example,  the  plays  of  store,  of 
house,  of  the  farmer  and  of  the  postman  illustrate  this  point.  When 
children  are  busily  working  together  making-  reproductions  of  boats,  of 
trains  or  of  aeroplanes,  they  are  engaged  in  worthwhile  tasks.  It  is  not 
mere  amusement.  Some  adults  do  not  realize  that  it  is  through  these 
interests  that  we  can  best  teach  children.  It  seems  almost  unbelievable 
that  there  are  still  some  fathers  who  say,  "I  had  to  study  from  nine  un- 
til four  every  day,  but  my  boy  is  wasting  his  time  playing.  I  send  him 
to  school  to  learn  and  the  teacher  allows  him  to  play  store  and  to  build 
ships."  Any  field  worker  will  vouch  for  the  truth  of  the  oft-repeated 
phrase  of  mothers,  "It  doesn't  make  any  difference  whether  or  not  the 
children  attend  kindergarten,  they  only  play  there.  Of  course,  I  am 
glad  to  have  John  go  to  kindergarten  because  then  I  know  that  he  is  not 
on  the  street."  If  the  mothers  are  generous  they  say,  "He  does  learn 
a  few  songs." 

The  underlying  principle  of  growth  and  development  through  play 
is  not  recognized.  If  parents  would  realize  the  serious  results  that  fol- 
low when  a  child  is  robbed  of  his  play,  they  would  seek  more  knowledge 
of  child  training. 

Four  cases  may  serve  to  illustrate  the  serious  consequences  that  fol- 
low when  a  child  is  deprived  of  his  right  to  play.  Two  cases  show  the 
direct  results  that  followed  when  parents  robbed  the  children  of  the 
right  to  play  with  other  children.    Two  cases  show  the  maladjustments 


190 
that  followed  when  children  had  no  sense  of  security  in  their  home  life 
and  where  the  school  could  not  compensate.    All  four  children  were 
failures  in  school — all  were  without  friends — all  were  without  normal 
outlets  for  play. 

John  was  a  five  year  old  boy.  He  was  attending  a  kindergarten.  After 
two  weeks  of  school  life  his  teacher  was  worn  out.  John  acted  like  a 
little  savage.  He  struck  other  children,  he  destroyed  their  work  and  he 
disobeyed  every  rule  of  the  school.  A  study  of  his  home  life  revealed 
the  story  that  John  had  never  had  an  opportunity  to  play  normally  with 
other  children.  His  play  life  had  been  confined  to  one  small  upstairs 
piazza  with  practically  no  toys.  His  reaction  when  placed  in  a  wonder- 
ful world  of  children  and  toys  was  to  experiment  with  both.  When  his 
mother  allowed  him  to  go  to  the  playground  to  play  normally  with  chil- 
dren he  adjusted  to  this  new  condition.  He  is  now  in  grade  one  and  is 
very  well  adjusted.  Just  a  little  understanding  and  a  desire  to  find  the 
cause  of  the  trouble  undoubtedly  prevented  John  from  becoming  a 
more  serious  problem. 

-  Helen  was  a  five  year  old  girl.  She  was  attending  grade  one.  She  was 
failing,  of  course,  for  she  was  not  mentally  old  enough  for  reading.  A 
study  of  the  home  told  a  similar  story  to  John's  except  that  this  little 
girl  was  being  forced  into  a  primary  grade  by  a  father  who  said  that  he 
did  not  believe  in  "all  this  play"  for  children.  He  went  to  school  when 
he  was  four  years  old,  and  he  was  not  given  much  time  for  play.  An 
observer  would  have  known  this  to  be  true  before  he  mentioned  it.  The 
home  was  not  a  happy  one.  There  was  no  jolly  companionship  and  even 
the  mother  appeared  afraid  of  the  father.  The  little  girl  did  not  play  on 
her  return  from  school.  She,  too,  was  only  allowed  to  go  out  on  a  small 
upstairs  piazza.  Had  this  situation  continued,  this  timid  shrinking 
child  would  have  become  a  failure  and  perhaps  even  more  serious  re- 
sults would  have  followed 

When  all  this  was  explained  to  the  father,  he  agreed  to  allow  Helen 
to  attend  a  kindergarten  and  to  play  with  other  litle  children  in  the 
afternoon,  even  if  he  did  consider  his  family  superior  to  others  in  the 
neighborhood. 

Helen  now  appears  to  be  a  normal  little  girl  very  much  interested  in 
her  dolls  and  her  play  life  with  her  friends. 

Robert  was  a  five  year  old  boy.  He  was  attending  grade  one.  He  had 
spent  one  year  in  kindergarten  and  had  apparently  been  very  happy. 
When  he  entered  grade  one  he  seemed  a  different  boy.  He  screamed 
every  day  when  his  grandmother  attempted  to  take  him  to  school.  It 
was  necessary  to  drag  him  into  the  building.  During  the  day  he  watched 
the  clock  and. sobbed  part  of  the  time.  Both  grandmother  and  teacher 
did  not  know  what  to  do.  In  order  to  determine  whether  or  not  to  put 
him  back  in  the  kindergarten,  they  asked  for  a  mental  examination.  The 
study  revealed  two  things.  First,  that  the  boy  had  superior  mental 
ability,  and  secondly  that  he  had  lost  his  feeling  of  security.  During  the 
examination,  he  told  the  examiner  that  his  mother  had  died,  that  his 
father  had  told  him  that  his  mother  was  now  watching  over  him,  and 
that  he  wanted  to  stay  at  home  in  case  his  mother  returned. 

The  boy  had  thought  it  over  but  the  problem  was  too  big  for  him.  It 
was  necessary  to  tell  the  boy  that  his  mother  could  not  return  before 
he  would  apply  himself  to  his  school  work. 

Now  in  an  excellent  progressive  first  grade  he  is  very  well  adjusted. 
His  father  is  spending  much  time  with  him,  and  the  boy  is  leading  a 
normal  busy  life.  His  superior  ability  plus  his  active  play  life  should 
enable  him  to  do  very  well  in  his  work.  The  loss  of  his  mother  will  be 
a  serious  handicap. 

The  story  of  Tom  is  a  much  sadder  one.  Tom  is  a  thirteen  year  old 
boy  who  is  failing  in  school.  He  is  a  solitary  boy  who  never  goes  to  the 
playground.  He  prefers  to  go  away  by  himself.  He  has  no  normal  play 
life  and  no  one  has  ever  been  able  to  remedy  this  situation.    Tom's 


191 

mother  has  never  wanted  him  nor  liked  him  and  Tom  is  conscious  of 
this  fact.  Tom's  father  belongs  to  that  negative  group  of  rather  low 
mentalities.   He  is  a  nonentity  in  his  home. 

Tom  has  never  known  any  sense  of  security.  The  school  has  never 
been  able  to  offer  him  any  compensation  for  the  lack  at  home.  He  has 
never  entered  into  a  boy's  normal  play  life. 

Now  it  is  almost  impossible  to  do  anything  with  him.  His  attitude 
of  defiance  is  a  well-built  barrier  between  himself  and  the  world.  He 
has  never  known  a  joyous  childhood. 

Two  thoughts  offer  themselves  in  conclusion.  Every  child  has  a  right 
to  a  wholesome  play  life.  Without  some  security — without  someone  on 
whom  he  can  truly  depend,  the  child  cannot  adjust  himself  to  a  happy 
successful  life. 

MENTAL  HYGIENE  FOR  CARDIAC  CHILDREN 

Mrs.  T.  Grafton  Abbott 

Publicity  Director,  Committee  for  Home  Care  of  Children 
•     with  Heart  Disease 

The  mental  problems  of  the  child  shut  in  with  heart  disease  are  prob- 
ably not  very  different  from  those  shown  by  any  child  in  bed  over  a 
long  period  of  time.  We  do  not,  however,  have  available  as  yet  sufficient 
data  on  this  important  subject.  On  sheer  assumption  alone  it  is  fair  to 
state  that  in  addition  to  the  various  behavior  aspects  of  the  long-time 
bed  patient,  we  frequently  find  in  the  case  of  the  cardiac  child  the 
phenomenon  of  fear  over  the  involvement  of  his  heart  which  he  knows 
to  be  a  vital  organ. 

Fear  of  Heart  Disease 

In  discussing  the  mental  hygiene  suitable  for  such  a  group  this  fear 
element  as  an  inhibiting  factor  ought  to  be  taken  into  consideration 
first  for  it  is  a  very  real  dread  long  after  the  original  symptoms  have 
disappeared.  We  find  a  hold-over  of  timidity  and  overcaution  which 
very  definitely  colors  the  thinking  of  the  cardiac  child.  He  is  inhibited 
in  normal  activities  due  to  the  thought  that  his  play  or  excitement 
might  bring  on  the  heart  attack  which  he  has  learned  to  fear.  This  is 
usually  more  pronounced  in  the  parents  (especially  the  mother)  than  in 
the  child  himself. 

It  is  important  from  a  therapeutic  standpoint  that  we  recognize  this 
phase  in  his  mental  life  and  try  to  remove,  by  conscious  and  deliberate 
effort,  some  of  his  over  apprehensive  ideas. 

A  certain  Jewish  boy,  who  had  a  congenital  heart  which  was  rela- 
tively unimportant  as  far  as  his  activities  were  concerned,  became  nerv- 
ous, timid,  and  fearful  lest  he  die  in  his  sleep.  Much  of  this  was  caused 
by  maternal  oversolicitude.  The  boy  finally  started  to  read  the  encyclo- 
pedia in  order  to  be  well  informed  on  the  subject  of  his  heart  condition. 
His  morbid  fears  increased  and  he  accentuated  his  condition  by  his 
thinking  in  this  way.  One  of  the  doctor's  recommendations  after  re- 
assuring him  was  that  he  stop  reading  the  encyclopedia. 

Sense  of  Isolation 

Many  of  our  cardiac  patients  without  proper  understanding  feel  iso- 
lated and  withdrawn.  This  is  very  natural  as  they  have  to  be  segre- 
gated from  their  group  over  a  long  period  of  time.  They  lose  interest 
in  their  associates  and  life  becomes  uneventful;  often  they  live  in  a 
world  of  unreality  compensated  for  by  various  unhealthy  emotional 
attitudes.  The  child  may  become  sensitive  due  to  his  situation  and  the 
loss  of  prestige  in  the  family.  Sometimes  by  being  overdemanding  of 
attention  or  querulous  and  complaining  (another  attention-getting  de- 
vice), or  actually  selfish  through  his  own  self-pity  and  overconcentra- 


19« 
tion  on  his  immediate  situation,  he  becomes  a  serious  disciplinary  and 
family  problem. 

It  is  here  that  parents  can  definitely  help;  first,  by  establishing  a 
correct  attitude  themselves  toward  the  necessary  invalidism,  one  not  of 
pity  but  of  facing  the  situation  as  a  challenge  and  an  opportunity  to 
make  the  best  of  the  matter  no  matter  how  difficult.  This  parental  atti- 
tude is  quickly  assimilated  by  the  child  and  his  emotional  set  is  largely 
conditioned  thereby. 

The  second  way  that  parents  can  help  from  a  mental  hygiene  stand- 
point is  to  offer  substitutive  interests  for  those  of  which  the  child  is 
deprived.  It  is  most  important  that  this  be  done  almost  immediately 
after  the  child  is  put  to  bed,  rather  than  to  wait  until  he  has  developed 
neurotic  or  antisocial  behavior  symptoms. 

One  little  Italian  girl,  who  had  been  in  bed  over  a  long  period  of  time, 
finally  lost  all  interest  in  her  school  and  even  when  she  was  Wefll  enough 
to  go,  no  longer  had  the  desire.  The  social  worker  finally  hit  upon  the 
device  of  dressing  her  up  in  some  new  and  pretty  clothes,  thereby  in- 
flating her  ego  and  making  her  feel  her  superiority  in  this  respeet. 
This  made  her  very  definitely  change  her  attitude  and  she  was  willing  to 
start  in  again. 

One  little  boy,  who  was  in  bed  quite  a  while,  was  given  a  canary  and 
also  a  magic  lantern.  His  room  immediately  became  the  center  of  at- 
traction for  the  children  in  the  neighborhood  and  he  enjoyed  quite  a  bit 
of  prestige  thereby  which,  from  a  psychotherapeutic  point  of  view,  re- 
sulted in  a  very  good  adjustment  to  his  invalidism. 

The  Committee  for  the  Home  Care  of  Children  with  Heart  Disease  is 
directly  responsible  for  the  In-Bed  Club  which,  under  the  auspices  of 
the  Massachusetts  General  Hospital  does  just  this  thing  for  its  cardiac 
children;  namely,  substituting  new  interests  for  the  old.  It  provides 
them  with  a  new  interest  the  moment  they  are  put  to  bed,  giving  them 
thereby  a  feeling  of  belonging  to  a  group  and  still  being  able  to  share 
in  group  activities  as  a  member  of  a  group  of  children  with  limited  pro- 
grams in  bed.  They  no  longer  have  a  sense  of  isolation  and  of  being 
different  for  they  now  have  a  pin  of  membership  and  a  bed  jacket  and 
a  monthly  magazine  plus  endless  activities  to  keep  them  interested, 
such  as  puzzles,  picture  cards  and  other  things  which  are  sent  to  them. 

Adolescence 

The  adolescent  who  has  been  a  patient  and  still  is,  is  especially  diffi- 
cult to  adjust  because  he  may  become  secluded  and  withdrawn  and 
compensate  by  a  life  of  phantasy  even  leading  in  some  cases  to  a  be- 
ginning Schizophrenia.  He  needs  group  interests,  an  inflation  of  his 
ego  and  a  re-evaluation  of  his  potentialities.  This  can  be  accomplished 
through  Adolescent  Clubs  or  through  the  medium  of  a  Big  Brother  or 
Sister  versed  in  some  knowledge  of  mental  hygiene. 

Training  in  Mental  Hygiene 

It  is  tremendously  important  both  for  parents  and  social  workers 
that  they  have  an  understanding  of  the  elementary  principles  of  mental 
hygiene  in  order  that  they  do  not  identify  themselves  too  closely  with 
the  patient  and  that  they  may  help  him  in  becoming  objective  in  his 
adjustments  to  his  situations. 

To  this  end  it  is  necessary  to  work  with  parents  of  cardiac  children 
individually  or  in  groups  with  the  idea  of  their  own  emotional  recon- 
struction and  their  needed  help  in  dealing  with  the  cardiac  child. 

Withdrawal  from  school  is  a  very  devastating  experience  for  children 
and  their  desire  to  keep  up  to  grade  is  of  great  importance  from  a  men- 
tal hygiene  approach  to  the  problem.  They  should,  when  possible,  al- 
ways be  encouraged  to  continue  their  studies  at  home.  Through  their 
tutors,  (many  of  whom  are  volunteers)  the  Massachusetts  General  Hos- 


193 

pital  is  able  to  keep  these  patients  interested  in  school  achievement. 
One  little  girl  through' such  help  actually  was  able  to  graduate  with 
her  class.  She  had  a  decided  aptitude  for  drawing  and  finally  was  able 
to  exhibit  some  of  her  work,  most  of  which  had  been  done  in  bed. 

HOME  VISITS  IN  RtJRAL  SCHOOLS 

Ruth  E.  Barnum,  R.N. 
Westfield,  Massachusetts 

There  are  various  reasons  why  the  home  visits  in  rural  schools  are 
very  important.  Parents  have  fewer  contacts  outside  of  the  home.  Thus 
their  information  and  help  in  regard  to  the  health  of  their  children  are 
much  more  limited.  The  visits  in  the  home  seem  to  fill  a  gap  between 
the  school  and  the  home  in  protecting  the  health  of  the  child.  The  nurse 
fills  a  place,  better  than  anyone  else  perhaps,  in  which  she  can  perform 
such  duties  as  may  arise  in  promoting  the  physical  welfare  of  the 
child.  Postal  card  notification  is  not  very  satisfactory,  although,  as  we 
know,  that  method  could  not  be  entirely  discarded  at  certain  times.  One 
cannot  overcome  the  fact  that  it  is  a  cold  and  impersonal  way  of  draw- 
ing the  parents'  attention  to  the  health  problems  of  their  children.  The 
school  nurse,  who  works  closely  with  the  principal  and  the  teachers, 
and  sees  the  children  at  school,  is  the  logical  person  to  effect  the  home 
contact,  and  her  instructions  are  best  received  in  the  home. 

It  is  often  an  advantage  to  plan  visits  in  advance  but  to  make  a  pro- 
gram flexible  enough  to  take  care  of  any  unexpected  emergencies.  To 
call  at  times  most  convenient  for  the  mother  in  the  home,  helps  her  to 
give  more  thought  and  attention  to  the  particular  errand,  thus  giving 
the  nurse  a  better  opportunity  to  accomplish  what  she  has  in  mind.  To 
include  in  that  call  conference  about  each  child  in  the  family,  often 
saves  making  a  second  call.  I  have  found  this  often  necessitates  keep- 
ing a  record  for  each  child  which  can  be  referred  to  easily  and  quickly. 
A  part-time  nurse  especially  realizes  the  importance  of  making  the  most 
imperative  calls  first,  for  even  though  it  would  seem  that  the  worst  de- 
fects would  be  corrected  sooner  than  the  minor,  yet  many  times  it  is 
not  the  case.  The  carrying  of  printed  material  on  various  subjects,  to 
leave  with  parents,  often  proves  a  help. 

Some  situations  especially  take  a  little  planning  on  proper  approach, 
not  only  in  a  home  of  poverty,  superstition  and  ignorance,  but  also  in 
the  home  of  the  better  class,  carelessly  busy  or  apparently  indifferent. 
Sometimes  a  very  few  words  with  a  child  gives  a  nurse  an  index  to 
ideas  in  a  home.  For  an  example:  while  talking  to  a  girl  of  twelve  years 
about  her  teeth  she  said,  "My  mother  says  that  there  is  no  use  in  ever 
filling  teeth,  but  when  they  get  bad  enough  have  them  pulled." 

If  a  nurse  goes  into  the  home  assuming  an  attitude  of  authority  that 
must  be  obeyed,  she  will  always  fail  to  gain  the  best  cooperation,  al- 
though she  may  gain  her  point.  Sometimes  a  parent  may  be  prejudiced 
against  a  nurse  before  she  enters  the  home,  as  she  may  conceive  the 
idea  she  is  interfering  with  her  authority  over  her  children.  In  that 
case  she  may  be  less  cordial.  However,  the  lack  of  a  cordial  reception 
does  not  mean  the  feeling  remains  but  often  the  nurse  leaves  her  in  a 
more  cordial  mood.  If  this  is  not  the  case,  however,  a  nurse  should  not 
be  discouraged  and  accept  this  as  a  final  attitude,  for  a  second  or  third 
visit  may  prove  more  successful.  She  must  not  stop  until  something  is 
done  but  must  remember  it  is  her  privilege  as  well  as  duty  to  do  all  in 
her  power  to  save  a  child  from  deformity,  disease  and  death  and  to  make 
an  effort  to  lay  a  physical  and  moral  foundation  for  splendid  womanhood 
and  manhood. 

In  looking  over  data  concerning  home  calls  made  by  six  nurses  in 
thirty-six  weeks,  ten  calls  were  the  highest  average  for  one  week,  and 
two  the  lowest  average;  but  about  six  calls  would  represent  the  mini- 
mum,   I  read  this  statement:  "The  number  of  home  calls  that  a  school 


194 

nurse  makes  is  an  important  index  to  her  value  and  efficiency."  And 
the  question  followed:  "What  shall  be  the  standard  of  achievement  in 
this  important  work?"  In  thinking  it  over  myself,  it  seems  to  me  it 
depends  and  rests  on  the  fact  that  the  health  problems  of  one  commun- 
ity, however  reasonably  numerous  and  different  in  kind,  really  do,  to 
quite  an  extent,  differ  from  those  in  another  community  and  therefore 
would  not  require  just  the  same  number  of  calls.  The  most  conspicu- 
ous cause  of  the  lack  of  success  of  health  education  in  the  school  is 
the  lack  of  information  and  necessary  cooperation  on  the  part  of  the 
home. 

When  a  nurse  enters  a  home,  there  is  a  great  deal  she  can  learn  with- 
out being  in  any  way  curious  or  inquisitive.  How  much  easier  it  is  for 
a  boy  or  girl  to  leave  a  clean,  orderly  home  with  his  teeth  brushed,  thor- 
oughly washed,  hair  combed  and  all  the  details  which  go  to  give  him  a 
wholesome  and  neat  appearance  in  the  school  room.  After  seeing  some 
homes,  isn't  it  a  wonder  these  children  look  as  well  as  they  do?  That 
seems  a  tremendous  problem  as  to  what  a  part-time  nurse  can  do  to 
better  these  home  conditions,  for  the  children  from  these  homes  are  so 
handicapped. 

Home  visits  not  only  afford  an  excellent  way  but  really  the  only  way 
to  find  out  about  the  preschool  children  in  the  home.  Often  there  is  a 
baby  in  the  home  and  every  mother  is  made  happy  by  some  little  atten- 
tion shown  to  this  most  important  member  of  the  family,  and  without 
seeming  inquisitive  the  nurse  can  learn  about  the  baby's  health,  its 
food,  how  it  is  dressed,  and  any  problem  the  mother  has  in  regard  to 
its  general  welfare.  If  conditions  are  not  favorable  to  the  child's  de- 
velopment the  nurse  can  give  the  mother  various  suggestions,  or  some- 
times direct  attention  to  some  Infant  Welfare  station  or  whatever  or- 
ganization a  county  or  nearby  city  affords  for  better  and  healthier 
babies.  Every  effort  should  be  made  to  secure  correction  of  health 
handicaps  before  the  child  begins  school  life.  Corrections  during  this 
period  may  prevent  permanent  injury  to  health  and  make  possible  a 
remedy  at  an  age  when  the  discomfort  may  be  the  least.  The  child  then 
enters  school  as  nearly  perfect  as  possible  and  prepared  to  derive  the 
utmost  benefit  from  his  educational  opportunities. 

In  investigating  the  cause  of  unexplained  absence  of  a  child  from 
school  a  nurse  sometimes  finds  a  child  with,  for  example,  a  discharging 
ear,  defective  eye,  ringworm  or  whatever  the  ailment  may  be  and  en- 
courages the  mother  to  tell  what  she  has  been  doing  for  it.  It  will  fre- 
quently be  found  that  the  mother  has  been  trying  to  do  something  but 
has  not  appreciated  the  seriousness  of  the  condition.  A  nurse  should  be 
informed  as  to  any  available  hospital,  dispensary  or  relief  agencies, 
the  hours  of  different  clinics,  and  procedure  to  obtain  admittance  for 
free  treatment,  and  if  parents  are  unable  to  take  a  child,  a  nurse  can 
prove  of  assistance.  In  a  small  community  the  doctor's  office  might  be 
the  only  procedure.  Often  times  cases  of  communicable  disease  are  dis- 
covered and  proper  quarantine  and  school  exclusion  established  and 
the  general  infection  of  the  school  prevented. 

After  the  school  physical  examination,  the  nurse  in  explaining  to  a 
parent  the  nature  of  the  defect  or  defects  of  a  child,  can  sometimes 
suggest  a  physician's  advice  and  explain  the  necessity  for  having  handi- 
caps corrected,  for  sometimes  to  them  a  defect  seems  minor  but  is  one 
which  the  nurse  knows  may  be  a  handicap  through  life.  It  may  require 
frequent  and  repeated  visits  and  much  moral  suasion  to  induce  parents 
to  take  the  proper  steps  toward  medical  care.  In  such  cases,  the  nurse 
must  be  kind  and  sympathetic,  having  due  respect  for  the  superstitions 
and  traditions  of  others,  but  at  all  times  she  must  be  friendly  in  trying 
to  shape  their  ideas  in  leading  them  to  her  goal — the  proper  care  of  the 
child.  Just  how  easily  the  nurse  is  able  to  bring  parents  to  her  plans 
depends  largely  upon  her  ability  to  understand  the  parents'  point  of 
view.    It  is  important  that  the  nurse  understand  the  child's  point  of 


195 

view  and  the  parents'  point  of  view  and  then  from  this  angle  may  she 
hope  to  bring  them  to  an  understanding  of  her  vision  for  the  child.  A 
common  point  of  view  must  be  reached  else  failure  in  the  particular 
case  at  hand  is  liable  and  worse  still  any  hope  for  future  cooperation 
of  the  family  is  given  a  severe  blow.  The  financial  situation  is  often  the 
real  reason  for  failure  to  secure  proper  care  for  children  even  when 
specific  defects  and  their  results  are  pointed  out  to  intelligent  parents, 
but  this  obstacle  may  be  removed  by  the  nurse  without  any  offense  to 
family  pride  if  she  is  wise  in  her  treatment  of  the  subject.  A  nurse  can 
often  help  parents  to  see  that  many  children  are  regarded  dull  or  men- 
tally defective  and  who,  because  of  handicapping  health  defects,  are 
unable  to  make  the  most  of  their  education.  They  fall  behind  in  their 
school  work  and  become  discouraged  and  in  some  cases  leave  school. 

Some  well  educated  parents  are  absolutely  ignorant  of  the  simplest 
laws  of  health  and  what  these  mothers  need  is  a  knowledge  of  the  laws 
of  health  rather  than  medicine.  The  mother  as  well  as  the  child  should 
be  instructed  in  personal  care  of  the  body,  the  importance  of  ventila- 
tion and  sunshine,  proper  diet,  suitable  clothing,  amount  of  recreation 
and  sleep,  importance  of  correct  posture,  the  irreparable  damage  done 
by  tea  drinking,  coffee  drinking,  or  candy  and  pastry  eating  by  young 
children. 

The  problem  of  children  removing  rubbers  and  wraps  in  the  class 
rooms  comes  from  failure  to  cooperate  by  the  mother,  as  a  child  is 
often  told  by  the  mother  to  wear  a  heavy  sweater  in  the  class  room. 

In  cases  of  scabies,  impetigo  and  pediculosis,  unless  the  nurse  ob- 
tains help  from  the  mother's  treatment  of  the  child  in  the  home,  how 
can  she  succeed  in  her  results  of  treatment  at  school?  Printed  material 
presented  to  parents  often  helps  in  the  family  budget.  It  is  important 
to  urge  right  and  nutritious  diet.  Try  to  teach  through  the  parents  that 
a  child  can  think  more  quickly,  accomplish  more,  play  better,  be  a 
better  man,  or  woman,  provided  he  will  feed  himself  intelligently. 

The  child  should  be  taught,  through  parents  and  nurse,  the  old  adage, 
"An  ounce  of  prevention  is  worth  a  pound  of  cure."  It  is  easier  and 
more  economical  to  educate  than  to  reform  or  to  imprison. 

But  above  all,  the  child  should  be  taught  that  physical  and  mental 
development  follow  principles  of  intelligent  thinking  and  living,  and  a 
child  should  be  made  to  realize  and  see  the  ultimate  reward  of  what  he 
practices; 

In  home  visits  a  nurse  has  to  possess  a  broad  mental  view,  patience, 
a  cheerful  disposition,  good  sound  sense  and  judgment,  faculty  for  keen 
observation  and  a  good  memory,  imagination  and  vision  which  will  en- 
able her  to  see  results  in  her  work  in  future  generations. 


MILK 

The  relative  food  value  of  raw  and  pasteurized  milk  has  been  frequently 
discussed  from  many  different  angles.  The  United  Stated  Public  Health 
Service  now  reports  the  results  of  a  very  extensive  investigation  which 
should  settle  this  disputed  subject. 

About  two  years  ago  certain  raw  milk  interests  circularized  the  pub- 
lic with  the  report  of  experiments  which  purported  to  show  a  superior- 
ity of  raw  milk  over  pasteurized  milk.  The  unreliability  of  these  so- 
called  scientific  experiments  was  very  evident  when  it  was  found  that 
the  raw  milk  used  was  from  cows  that  had  been  fed  a  very  special  diet, 
whereas  the  pasteurized  milk  had  been  obtained  from  a  corner  grocery 
and  came  from  cows  fed  an  ordinary  diet.  Obviously  these  two  milks 
could  not  be  compared  as  to  their  food  value. 

A  recent  issue  of  the  Public  Health  Reports*  contains  the  results  of 
the  United  States  Public  Health  Service  investigations  into  the  relative 
value  of  pasteurized  and  raw  milk.  Records  were  obtained  of  several 
thousand  children  divided  equally  into  two  groups.   The  one  group  had 

♦Public  Health  Report,  September  23,  1932. 


196 

used  raw  milk  for  at  least  the  last  half  of  the  child's  life;  the  other 
group  had  had  nothing  but  heated  milk.  These  children  were  carefully- 
measured  as  to  weight  and  height  with  respect  to  age,  it  being  felt  that 
with  so  many  children  in  the  study  if  one  type  of  milk  had  a  greater 
food  value  than  the  other,  those  children  using  this  milk  would  obvi- 
ously show  up  better  under  such  measurements.  The  results  of  these 
studies  showed  that  there  was  no  significant  difference  in  either  the 
height  or  weight  of  the  children  in  the  two  groups,  and  that  what  slight 
difference  there  was,  was  in  favor  of  those  that  had  used  the  heated 
milk. 

On  the  possibility  that  there  might  be  other  factors  that  had  entered 
into  this  study,  these  children  were  carefully  classified  according  to 
race,  the  financial  status  of  the  homes  from  which  they  came,  and  the 
question  of  supplemental  foods,  such  as  fruit  juices,  vegetables  and  cod 
liver  oil.  The  difference  between  the  groups  was  so  slight  that  they 
could  be  considered  as  entirely  comparable  groups.  What  few  differ- 
ences there  were  only  suggested  a  slightly  greater  value  of  the  heated 
over  the  raw  milk. 

Finally,  these  children  were  studied  as  to  the  incidence  of  various 
diseases  which  might  be  connected  with  tlie  consumption  of  milk. 
Those  using  the  raw  milk  showed  an  appreciably  higher  incidence  of 
diphtheria,  scarlet  fever  and  intestinal  disturbances.  Likewise,  rickets 
was  more  prevalent  among  those  using  raw  milk  than  those  drinking 
the  heated  milk,  possibly  due  to  the  greater  use  of  cod  liver  oil  among 
the  latter  group. 

This  article  from  the  Public  Health  service  is  so  valuable  as  a  dem- 
onstration that  the  relative  food  value  of  these  two  milks  is  equal, 
that  it  should  be  read  carefully  by  all  interested  in  this  subject.  It  is 
unfortunate  that  prejudices  and  emotions  have  so  often  been  allowed 
to  take  precedence  over  reason  in  matters  of  this  type.  The  Public 
Health  Service  has  rendered  an  extremely  valuable  service  in  compiling 
data  of  this  sort,  which  to  any  reasoning  person  would  show  that  pas- 
teurized milk  is  just  as  valuable  a  food  as  is  raw  milk,  and  is  certainly 
infinitely  safer. 

AN  ISLAND  VISIT 

Susan  M.  Coffin,  M.D. 

Well  Child  Conference  Physician 

The  four  members  of  the  Well  Child  Conference  Unit  met  at  the  New 
Bedford  wharf  where  the  "Alert",  the  regular  boat,  was  waiting  to  take 
them  all  to  Cuttyhunk.  The  "D.  H.  0."  and  "Mrs.  D.  H.  0."  were  also 
aboard,  making  their  first  trip  to  the  Island. 

All  baggage,  clinic  and  personal,  had  been  safely  stored  in  the  tiny 
cabin,  along  with  the  mail  bags,  a  rusty  kitchen  stove  and  packages 
galore — the  cabin  also  housed  two  women,  three  little  girls  and  one 
man,  "Islanders"  going  home.  How  they  all  squeezed  in  was  a  mystery! 
Fortunately  the  Unit  folks  preferred  open  air. 

The  "Alert"  pushed  off  and  was  soon  bouncing  gayly  over  the  Bay, 
the  wind  increasing  every  minute.  All  the  "off  Islanders"  kept  their 
dignity  and  their  breakfasts  except  the  clinic  doctor  who  sadly  sacri- 
ficed both  to  the  fishes.  The  Consultant  Nurse  didn't  feel  so  well  either, 
but  sat  tight  and  didn't  waste  her  breakfast;  if  the  more  cheerful  mem- 
bers hadn't  produced  peanut  brittle  and  eaten  it  visibly  all  might  have 
been  well.  Some  of  the  "Islanders"  were  seasick,  too,  and  all  'lowed  it 
was  "quite  a  sea",  so  that  was  some  comfort!  One  Island  lady  in  the 
cabin  felt  that  the  younger  members  of  the  Unit  were  quite  reckless 
"running  'round  the  boat  so — were  you  trying  to  get  drowned?",  said 
she.  But  they,  being  good  sailors,  only  laughed  at  her  fears.  The  three 
small  girls  were  returning  home  after  having  been  "off  Island"  to 
visit  the  dentist,  and  friends  or  relatives.  We  learned  later  that  all 
the  children,  old  enough  to  need  dental  care,  who  had  been  examined  at 


197 

the  Well  Child  Conference  in  1931,  had  been  to  the  dentist  since  then. 

Finally  the  "Alert"  reached  calmer  waters  and  ceased  to  toss  its  pas- 
sengers about  and  cover  them  with  spray.  The  Island's  familiar  outline 
hove  in  sight — a  very  welcome  vision  to  the  seasick  ones  on  board!  It 
was  cold,  too,  but  all  discomforts  were  forgotten  as  everybody  scram- 
bled joyously,  if  stiffly,  up  on  to  the  wharf.  Just  then  along  came  an- 
other boat  bearing  the  school  superintendent,  the  newly-appointed 
school  nurse,  a  new  visitor — the  4-H  Club  worker — and  a  picnic  party 
of  high-school  seniors,  all  from  Marthas  Vineyard.  The  "Alert"  had 
made  her  trip  in  slightly  over  two  hours  but  the  Vineyard  boat  had  been 
much  longer  owing  to  rough  water.  One  of  their  members  had  also 
been  seasick  and  the  afflicted  ones  exchanged  experiences  and  condo- 
lences later.  The  pile  of  clinic  baggage  was  finally  counted  out  and 
loaded  onto  one  of  the  two  motor  trucks  on  the  Island,  to  be  trundled 
up  to  Town  Hall. 

Then  everybody  hurried  along  the  narrow  cement  walk  which  leads 
across  the  marsh  to  a  small  summer  hotel  on  the  hillside.  They  found 
a  warm  welcome  awaiting  as  always — this  was  their  third  visit — and 
their  cordial  hostess  had  a  hot  dinner  all  ready,  deliciously  fresh  sea 
food — lobster  and  all!  The  seniors  had  brought  their  own  lunches  so 
they  ate  out-of-doors  and  then  explored  the  Island.  Everybody  else, 
including  the  Island  teacher,  ate  inside  and  did  justice  to  the  meal.  The 
teacher  here  has  a  typical  country  school — fifteen  pupils,  all  grades, 
and  not  only  that,  but  Sunday  school  and  Sunday  church  service  and 
all  the  "doings"  on  the  Island,  are  her  deep  concern.  This  neighborhood 
is  mighty  fortunate  to  have  for  the  teacher  one  who  is  so  devoted  to  her 
children  and  community. 

No  naps  were  allowed  after  dinner — too  much  to  do !  The  Unit  folks 
went  at  once  to  the  Town  Hall  "just  up  the  hill".  Opposite  it  is  the 
little  church  and  beside  it  the  tiny  but  well-filled  public  library;  next 
to  that  the  one-room  schoolhouse — a  very  well-kept  school  building;  it 
even  has  screens  in  the  windows ! 

At  Town  Hall  the  Unit  workers  set  up  the  exhibit  and  made  arrange- 
ments for  the  evening  meeting  and  the  next  day's  work. 

The  superintendent  was  found  running  the  school.  Some  mischievous 
visitor — of  course  it  couldn't  have  been  a  high  school  senior? — rang 
the  school  bell  before  one  o'clock  and  the  children  left  their  dinners 
half  eaten  and  chased  up  to  the  schoolhouse.  Nobody  was  going  to  be 
late  when  there  was  "company,"  no  matter  what  the  home  clock  said. 
When  the  superintendent  strolled  in  to  look  around  a  bit,  while  waiting 
for  "teacher"  to  come  back,  there  they  all  sat,  solemn  as  little  owls. 
So  the  "Supe"  taught  school  until  Teacher  appeared,  a  little  excited 
over  the  school  bell  having  been  rung  unofficially. 

Everybody  was  invited  to  visit  the  school.  The  4-H  lady  told  the  girls 
and  boys  all  about  the  4-H's — "Head,  Hand,  Heart  and  Health"  and  how 
a  club  was  to  be  started  then  and  there.  Meantime  the  D.  H.  0.  and 
the  school  nurse  went  calling  on  the  parents  to  get  acquainted  and  also 
to  get  the  necessary  signed  request  slips  for  toxin  antitoxin  inoculations 
which  were  to  be  given  next  day.  One  family  was  going  "off  Island"  very 
early  next  day,  so  those  children  and  their  mother  came  up  to  Town 
Hall  in  the  late  afternoon  to  have  inoculation,  medical  and  dental  exam- 
inations and  nutrition  instruction. 

Supper  was  served  promptly  at  six — the  superintendent  and  high- 
school  boys  and  girls  had  had  to  leave  early  for  the  Vineyard  so  the 
supper  party  was  reduced  in  numbers,  but  not  in  appetites !  After  sup- 
per there  was  a  brief  rest  period  and  then  the  school  bell  rang  out  again 
and  everybody  went  off  to  the  evening  "Health  Meeting"  in  Town  Hall. 
It  was  a  glorious  night,  moonlight  bright  as  day  on  land  and  sea,  the 
surf  still  running  "white  horses"  up  and  down  the  beaches — a  beauti- 
ful sight! 

Town  Hall  was  brightly  lighted,  warm  and  cheerful.    Every  family 


198 

was  represented  in  the  audience,  which  was  mostly  ladies.  When  we 
remarked  on  that  fact  to  our  skipper  he  replied,  "The  women  folks  have 
all  the  say-so  anyhow — the  men  don't  need  to  go."  However,  three 
brave  gentlemen  did  attend  and  were  a  support  to  the  D.  H.  0.  The 
D.  H.  O.  and  the  4-H  Club  worker  were  the  speakers  of  the  evening  arid 
they  received  excellent  attention  and  interest.  The  "new"  school  nurse 
was  introduced.  This  is  the  first  appointment  of  a  school  nurse  to  the 
Island  and  is  a  real  achievement.  All  the  workers  were  called  upon  by 
"Teacher"  to  stand  up  and  look  pretty  while  she  told  off  each  one's 
"name  and  station" — it  was  as  bad  as  going  to  school  again !  After  the 
formal  meeting  was  over,  everybody  stayed  for  some  time  to  talk,  ask 
questions  and  look  over  the  exhibit  of  books,  posters,  foods,  etc. 

Next  morning  the  real  business  of  the  day  began  about  8.30  A.M.  as 
the  D.  H.  O.  had  to  get  back  to  the  mainland  by  way  of  the  Coast  Guard 
boat  which  left  in  mid-afternoon.  All  the  children  but  one  baby  Whose 
mother  was  ill  and  one  who  was  under  six  months  of  age  had  their  first 
toxin  antitoxin  inoculation  (the  D.H.O.  plans  to  return  in  two  weeks 
for  the  second  inoculation)  ;  also  the  only  child  who  hadn't  been  vac- 
cinated had  that  done  at  this  time.  There  was  naturally  some  excite- 
ment over  being  "pricked"  (inoculated)  and  apprehension  was  apparent 
for  a  few  minutes  until  the  first  brave  boy  had  his.  Turning  around 
to  his  friends,  who  were  watching  the  doctor's  every  move,  he  ex- 
claimed,, "Oh,  gee,  that  didn't  hurt!" 

Medical  and  dental  examinations  of  the  children  were  started,  taking 
the  fifteen  school  children  first,  which  occupied  all  the  forenoon. 

After  lunch  all  the  children,  school  and  preschool,  came  back  to  the 
hall  for  "pictures" — no,  not  movies,  there  is  not  the  right  current  yet — 
just  delineascope  still-films,  but  they  enjoyed  them  and  the  workers 
talked  with  the  children  about  them.  The  big  boys  were  allowed  to  run 
the  delineascope  in  turn  which  added  to  the  general  interest.  In  the 
afternoon  the  five  preschool  children  and  two  babies  came  for  their 
examinations,  with  their  mothers.  The  preschool  children  had  had  their 
toxin  antitoxin  at  the  morning  session.  All  the  children  did  very  well — 
only  a  few  small  wails  and  only  one  small  person  who  strenuously  re- 
fused complete  examination. 

When  each  child  had  been  examined  by  doctor  and  dental  hygienist 
the  nutritionist  talked  with  the  mother  and  with  the  older  children, 
too.  One  boy  who  was  "listening  in"  asked  the  nutritionist  very  politely 
what  she  had  eaten  when  she  was  a  little  girl  and  did  she  know  just 
what  was  right  to  eat  then?  She  assured  him  that  nowadays  we  know 
much  more  about  what  children  should  eat. 

Just  before  sundown  work  was  finished  and  there  was  time  to  climb 
to  the  top  of  "the  hill"  and  see  the  sun  go  down  in  all  its  glory.  It  does 
take  sea  or  mountains  to  produce  prize  sunsets.  This  was  one  of  the 
most  gorgeous. 

After  supper  the  "Unit"  put  on  its  best  bib  and  tucker,  or  whatever 
substitute  it  could  produce,  and  hied  to  Town  Hall  once  more — this  time 
on  pleasure  bent.  "Teacher"  had  promised  the  grown-ups  a  party! 
Forfeits,  yarns,  dancing,  Virginia  reel,  etc.  and  some  of  the  best  cakes, 
all  home  made  (what  was  left  was  auctioned  off  to  the  highest  bidder) . 
A  pleasant  evening  was  had  by  all. 

Next  morning  was  grand  for  travel,  fair  weather,  a  calmer  sea. 
Everybody  was  packed  up  and  ready  to  start  in  good  season.  This  time 
the  baggage  went  to  the  fishing  wharf  farther  up  Island,  hauled  in  a 
cart  by  faithful  Dobbin.  A  motor  boat  had  been  chartered  for  the  sail 
back  to  New  Bedford  because  the  "Alert"  only  goes  on  Wednesdays  and 
Saturdays  and  this  was  on  a  Friday. 

Just  as  everybody  was  gathered  on  the  porch  to  say  farewell  to  their 
kind  hostess,  around  the  corner  of  the  house  came  a  procession — two  by 
two,  very  dignified,  no  hopping  or  skipping.  All  the  school,  headed  by 
"Teacher,"  came  to  escort  the  Unit  to  their  boat  with  flowers  and  due 


199 
ceremony.  The  neighbors  waved  farewells  as  the  line  wound  down  the 
rocky  little  road  to  the  harbor.  Some  of  the  members  of  the  Unit  cov- 
eted painted  wooden  floats  used  by  the  fishermen,  to  take  home  for 
souvenirs  and  use  as  footstools.  The  big  boys  got  some  fine  ones — one 
was  quite  different  from  all  the  rest  and  the  youngster  who  presented 
it  to  the  nutritionist  explained  that  this  was  a  "foreign"  float — it  came 
from  Newport.  A  bouquet  was  presented  to  each  lady  as  she  climbed 
(more  or  less  gracefully)  off  the  wharf  into  the  boat.  Farewells  and 
invitations  to  come  again  next  year  were  shouted  as  the  little  boat 
started  off. 

The  sail  to  the  mainland  was  calm  and  uneventful — no  breakfasts 
lost — no  indispositions — a  safe  landing  accomplished.  The  1932  trip 
to  the  Island  was  over.  It  joined  the  host  of  clinic  memories,  gay  and 
otherwise  and  will,  we  trust,  receive  honorable  mention  in  the  "town 
file"  records  of  the  Massachusetts  Department  of  Public  Health. 

EXERCISE  AS  AN  AID  TO  HEALTH  IN  WOMEN 

Alice  E.  Sanderson  Clow,  B.Sc,  B.S.,  M.D. 

Cheltenham,  England 

As  an  Englishwoman  who  has  never  set  foot  in  America,  I  feel  diffi- 
dent at  accepting  an  invitation  to  write  in  this  journal,  although  the 
subject  selected  is  of  equal  importance  to  women  .on  both  sides  of  the 
Atlantic. 

The  question  as  to  whether  a  woman  can  keep  herself  free  from  a 
recurrent  monthly  disability,  which  will  affect  her  work,  is  worth  the 
careful  consideration  of  those  engaged  in  any  occupation.  Since  the 
majority  of  women  are  free  from  suffering  during  the  monthly  period, 
it  behooves  the  minority  to  seek  for  a  means  of  procuring  a  like 
immunity. 

Having  come  into  personal  contact  in  a  medical  capacity  with  a  large 
number  of  women  and  over  three  thousand  senior  school  girls  and  col- 
lege students,  I  have  come  to  the  conclusion  that  practically  every  girl 
who  has  healthy,  normal  organs  and  who  enjoys  sound  health  during 
the  rest  of  the  month  can,  if  she  knows  how  to  set  about  it,  keep  her- 
self free  from  pain  and  other  disabilities  such  as  headache,  vomiting, 
and  malaise,  during  the  menstrual  period. 

The  probable  explanation  of  these  symptoms  may  be  briefly  given  as 
follows :  At  the  onset  of  each  menstrual  period  the  organs  in  the  pelvis 
contain  more  blood  than  they  do  during  the  intervals  between  the 
periods.  If,  at  the  same  time  the  circulation  be  sluggish,  congestion  in 
the  pelvic  vessels  occurs  and,  with  it,  pain  or  discomfort  is  felt.  How 
can  this  congestion  be  prevented  or  relieved?  There  is  one  organ  of  the 
body  which  can,  at  will,  be  made  to  increase  its  capacity  for  holding 
blood,  and  that  is  the  skin,  the  vessels  of  which  dilate  under  the  influ- 
ence of  heat  produced  by  exercise  or  by  a  hot  bath.  By  the  same  means 
the  action  of  the  heart  is  stimulated,  with  the  result  that  the  congested 
veins  in  the  pelvis  are  relieved  of  their  overload  and  the  pain  or  dis- 
ability associated  with  menstruation  is  prevented,  or,  if  it  has  already 
begun,  it  is  alleviated. 

The  cure  of  menstrual  disability  in  the  normal  woman  is,  therefore, 
to  keep  the  muscles  well  toned  up  by  fresh  air  and  exercise  during  the 
month  and  to  continue  the  exercise  with  unabated  energy  when  the 
period  is  due  and  after  it  has  begun,  so  that  pelvic  congestion,  with  all 
its  unpleasant  consequences,  is  not  allowed  to  occur. 

It  may  be  difficult  for  those  living  in  large  cities  to  obtain  these  con- 
ditions of  health,  especially  if  they  ride  to  and  from  their  work  and 
spend  their  time  in  the  enervating  atmosphere  of  overheated  rooms; 
but  there  must  be  few  to  whom  one  hour's  daily  walk  in  the  open  air  is 
an  impossibility,  and  this  all  too  short  period  of  activity  can  be  supple- 
mented by  exercises  done  at  home  in  quite  a  small  room.   The  effect  of 


200 
this  simple  remedy  for  pain,  sickness  or  headache  at  the  period  is  very- 
surprising  to  those  trying  it  for  the  first  time.  Some  are  too  nervous  to 
put  it  to  the  test,  fearing  they  may  do  themselves  some  harm.  My 
answer  to  these  is  that  I  have  watched  the  beneficial  effect  of  exercise 
on  over  four  hundred  sufferers,  and  have  personally  noted  the  result  of 
games,  such  as  tennis  and  hockey,  being  continued  throughout  the 
period  by  twenty-three  hundred  school  girls  and  college  students,  and 
in  not  one  case  have  I  heard  of  any  harm  resulting. 

Provided  there  is  good  health  and  freedom  from  abdominal  pain  or 
other  symptoms  between  the  periods,  there  is  no  more  risk  in  taking 
exercise  during  menstruation  than  at  other  times. 

It  is  this  freedom  from  risk  which  has  prompted  Lady  Barrett,  M.D. 
and  myself  to  publish  a  leaflet*  for  distribution  to  young  women  en- 
gaged in  industrial  occupations,  for  the  purpose  of  teaching  them  the 
hygienic  measures  necessary  to  avoid  disorders  during  the  period.  It 
is  the  lesser  degrees  of  disabilty,  considered  by  the  sufferer  to  be  not 
worth  reporting,  which  are  the  more  serious,  in  industry,  at  any  rate  in 
Britain,  because  they  are  common  among  sedentary  workers.  The 
total  loss  of  output  owing  to  these  mild  cases,  though  unrecorded,  must 
be  much  greater  than  that  due  to  the  relatively  rare  cases  prostrated 
by  severe  pain.   No  girl  can  do  her  best  work  while  "feeling  poorly." 

Almost  any  exercise,  continued  until  there  is  flushing  of  the  skin  or 
a  sensation  of  heat,  will  serve  the  purpose  of  preventing  or  relieving 
menstrual  pain,  but  the  following  series  of  exercises  has  been  specially 
selected  for  that  purpose  and  used  with  much  success  among  young 
women. 

Table  of  Exercises. 

1.  Floor  Polishing.  Kneel  on  "all  fours."  Swing  right  arm,  with 
elbow  stiff,  through  a  semicircle,  as  if  polishing  the  floor,  reach- 
ing as  far  forward  and  as  far  back  as  possible.  Repeat  swing  ten 
times  with  each  arm. 

2.  (a)  Bending.  Stand  with  feet  apart.  Stretch  arms  above  head, 
bend  forward  and  touch  ground  with  knees  straight.  Return  to 
first  position.   Repeat  slowly  eight  times. 

(b)  Twisting.  Stand  with  feet  apart.  Stretch  arms  to  side  on 
level  with  shoulders.  Twist  trunk  around  until  right  arm  points 
directly  backwards.  Twist  again  until  left  arm  points  directly 
backwards.    Repeat  vigorously  ten  times. 

(c)  Swaying.  Stand  with  feet  part.  Stretch  arms  above  head, 
sway  body  and  arms  to  right  then  left.   Repeat  slowly  ten  times. 

3.  "Rowing."  Sit  on  floor  with  knees  straight  and  feet  pressed 
against  wall.  Lean  forward  and  touch  wall  with  knuckles,  allow- 
ing knees  to  bend  slightly.   Repeat  rhythmically  twenty  times. 

4.  Right  to  Left  and  Left  to  Right.  Stand  with  feet  apart.  Swing 
right  arm  up  as  far  as  possible.  Bend  down  bringing  right  arm 
over  and  touch  left  foot.  Repeat  six  times.  The  same  with  left 
arm  and  right  foot. 

5.  Floor  Patting.  Kneel,  sitting  back  on  heels.  Twist  body  and  tap 
floor  with  both  hands  four  times  on  left  side.  Kneel  upright. 
Twist  body  and  repeat  tapping  on  right  side.  Repeat  eight  times 
each  side. 

6.  Bean  Picking.  Throw  20  small  objects,  such  as  beans,  on  the 
floor.  Pick  up  one  at  a  time  and  place  on  a  shelf  above  the  head 
using  hands  alternately.   Do  it  as  quickly  as  possible. 

These  exercises  should  be  done  with  vigor  for  10-15  minutes  for  at 
least  three  days  before  the  period  begins,  and  should  on  no  account  be 
emitted  on  the  first  two  days  of  the  period.  Some  find  it  necessary  to 
repeat  them  twice  or  even  three  times  on  the  first  day.    Some  patients 

*  "Advice  to  Young  Women  concerning  the  Monthly  Period."  Obtained  from  H.  K.  Lewis, 
Medical  Publishers,  136  Gower  St.,  London  W.  C.  1. 


201 
do  these  exercises  daily  all  the  year  round,  as  they  produce  a  sense  of 
well-being  and  help  to  ensure  a  regular  evacuation  of  the  bowel.    Con- 
stipation should  be  carefully  avoided  at  the  onset  of  the  period,  an 
aperient  being  taken  if  necessary. 

The  daily  bath  should  be  continued  during  menstruation  for  hygienic 
purposes,  while  for  those  who,  for  any  reason,  cannot  do  the  prescribed 
exercises,  alleviation  of  pain  can  be  rapidly  procured  by  immersing  the 
body  in  a  hot  bath  for  10-15  minutes.  The  disadvantage  of  this  as  a 
remedial  measure  is  that  it  must  be  followed  by  rest  in  bed  for  an  hour, 
and  the  relief  obtained  is  often  transitory. 

Many  girls  have  found  for  themselves  that  they  cannot  keep  well 
during  the  period  without  exercise  and  many  have  accidentally  discov- 
ered that  severe  pain  or  sickness,  for  which  they  have  had  to  retire  to 
bed  every  month,  has  been  entirely  prevented  by  some  unusual  exer- 
tion. One  girl  of  eighteen,  whose  period  was  always  preceded  by  pain 
so  severe  that  she  had  to  lie  down,  found  that  the  menstrual  period 
was  fully  established,  without  her  knowledge,  during  an  afternoon 
spent  pushing  children  on  a  swing  at  a  school  treat.  Another  patient, 
on  receiving  an  urgent  message  by  wire  while  wintering  in  the  South 
of  France,  rose  from  her  bed  of  sickness  and  packed  a  large  trunk. 
While  doing  so  her  pain  and  nausea  ceased  and,  to  her  surprise,  she 
was  able  to  travel  in  comfort.  Many  have  found  their  own  cure  by  con- 
tinuing heavy  farm  work  or  by  scrubbing  or  polishing  a  floor  on  the 
first  day  of  the  period,  others  by  hunting,  golfing,  rowing,  skating  or 
dancing,  or  by  merely  taking  a  brisk  walk  for  half  an  hour. 

With  the  increasing  opportunities  open  to  women  for  active  work, 
games  and  sport,  it  seems  quite  reasonable  to  hope  that  disability 
associated  with  menstruation  will  become  as  rare  among  the  women  of 
our  own  countries  as  it  is  among  the  less  civilized  races. 


GCo  tfje  ffltmovp  of 

DR.  HENRY  P.  WALCOTT 

That  Whereas,  Dr.  Henry  P.  Walcott  served  on  the  State 
Board  of  Health  from  1882  to  1915,  the  last  twenty-nine 
years  as  chairman,  during  which  period  much  significant 
and  pioneer  work  in  the  field  of  sanitation  and  hygiene  was 
undertaken  which  has  influenced  practice  in  this  country 
and  abroad,  and 

Whereas,  as  Chairman  of  the  Metropolitan  Water  and 
Sewer  Board  and  in  other  public  capacities  he  served  bril- 
liantly his  State  and  Nation,  and 

Whereas,  through  his  services  to  Harvard  University,  the 
Massachusetts  General  Hospital,  and  other  agencies  and 
institutions  in  the  field  of  medicine,  education,  public  health, 
economics  and  horticulture  he  guided  and  stimulated  pro- 
gress for  the  public  good, 

Be  it  Resolved: 

That  the  Public  Health  Council  record  its  deep  sense  of 
loss  at  his  passing  and  of  gratitude  for  his  manifold  service 
and  do  spread  this  upon  its  records  and  have  a  copy  of  the 
same  sent  to  his  family. 


(Eo  tfje  pernor?  of 

DR.  WILLIAM  E.  RICE 

The  Department  regrets  deeply  the  loss  of  a  good  friend 
and  loyal  helper,  Dr.  William  E.  Rice,  Dean  of  Tufts  Dental 
School. 

Dr.  Rice  had  a  broad  and  genuine  interest  in  all  health 
measures  as  weir  as  in  those  relating  directly  to  the  prob- 
lems of  modern  dentistry.  He  proved  a  staunch  friend  of  the 
Dental  Hygiene  Council  of  which  he  was  a  "charter"  mem- 
ber and  which  membership  he  continued  in  the  Department's 
Advisory  Committee  as  Dean  of  the  Dental  School.  Always 
an  active  member  of  the  Committee  he  assisted  in  outlining 
policies  for  dental  clinics.  He  helped  to  develop  the  state- 
wide dental  certificate  plan  and  a  graduate  course  in  public 
health  for  dental  hygienists  at  Hyannis.  He  was  one  of  the 
founders  of  the  Massachusetts  Association  of  School  Dental 
Workers  and  one  of  our  best  critics  in  the  preparation  of 
various  types  of  dental  health  leaflets.  His  ideas  and  advice 
were  promptly  forthcoming  on  all  matters  referred  to  his 
judgment  and  he  was  never  "too  busy"  to  attend  a  meeting 
of  the  Committee.   He  was  always  present  when  needed. 

More  than  all  that  he  accomplished  perhaps,  for  by  such 
intangible  things  do  we  best  measure  service  after  all,  his 
lovable  personality,  his  never-failing  good  cheer,  his  generous 
encouragement,  stand  out  in  the  memories  of  his  coworkers. 


204 


Book  Notes 


Your  Hearing  by  Wendell  C.  Phillips,  M.D.  and  Hugh  Grant  Rowell,  M.D. 
$2.00.   226  pp.   D.  Appleton  &  Co. 

This  small  book  is  dedicated  to  the  "Hypacusics",  a  word  of  Greek 
origin  used  to  denote  the  hard  of  hearing. 

The  mechanism  of  the  hearing  apparatus  is  first  explained.  The  il- 
lustrations used,  comparing  the  different  parts  of  the  organ  of  hearing 
to  various  mechanical  devices,  will  not  make  it  any  clearer  to  most 
readers  probably,  but  the  written  description  is  very  good.  Present-day 
methods  of  testing  hearing  are  adequately  described  and  diseases  of 
the  outer  ear,  middle  ear  and  inner  ear  are  discussed  in  popular  fashion. 
Two  of  the  best  chapters  in  the  book  are  the  ones  on  what  the  doctor 
can  do  for  impaired  hearing  and  what  not  to  do  yourself  for  your  own 
ears. 

Other  topics  taken  up  are  lip  reading,  help  for  the  problems  of  the 
hard  of  hearing  in  relation  to  industry,  home,  society.  Good  sugges- 
tions are  also  given  on  jobs  for  hard  of  hearing  individuals.  Sources 
and  types  of  mechanical  hearing  aids  are  gone  over  and  warning  given 
against  quack  products. 

Taken  altogether  this  book  should  be  of  genuine  value  to  all  afflicted 
with  partial  deafness. 

Community  Health  Organization  —  a  publication  of  The  Common- 
wealth Fund  on  community  health  organization.  Edited  by  Ira  V. 
Hiscock  for  the  Committee  on  Administrative  Practice  of  the  Ameri- 
can Public  Health  Association,  1932.     $2.50.     261  pp. 

"This  new  and  completely  revised  edition  of  'Community  Health  Or- 
ganization', edited  by  Professor  Ira  V.  Hiscock  of  the  Yale  School  of 
Medicine,  sets  forth  a  plan  of  urban  public  health  organization  result- 
ing from  twelve  years'  experience  on  the  part  of  the  Committee  on  Ad- 
ministrative Practice  of  the  American  Public  Health  Association.  The 
volume  is  an  administrative  handbook  for  the  public  health  officer  and 
his  staff  and  for  the  interested  layman.  It  shows  how  the  health  depart- 
ment should  be  organized  to  meet  reasonable  standards  of  service,  such 
as  those  embodied  in  the  'Appraisal  Form  for  City  Health  Work'  of  the 
American  Public  Health  Association,  what  staff  is  necessary,  and  what 
such  an  organization  costs.  The  plan  is  based  upon  a  community  of 
100,000  population,  but  it  is  easily  adjustable  to  cities  of  other  sizes. 

Studies  of  more  than  200  city  health  departments  by  the  Committee 
on  Administrative  Practice  preceded  the  publication  of  the  new  manual. 
Professor  Hiscock,  working  in  close  contact  with  members  of  a  com- 
mittee consisting  of  Dr.  Louis  I.  Dublin,  Chairman,  Dr.  E.  L.  Bishop, 
Dr.  Haven  Emerson,  Miss  Sophie  C.  Nelson,  and  Dr.  George  T.  Palmer, 
has  re-examined  the  principles  underlying  previous  organization  plans 
and  checked  them  with  present-day  experience  as  revealed  by  the  Com- 
mittee's studies.  The  result  is  a  practical  manual  embodying  the  best 
modern  thinking  with  regard  to  the  organization,  program,  and  methods 
of  the  urban  health  department  and  its  relation  to  other  governmental 
activities,  hospitals,  and  private  health  agencies." 

Youngest  of  the  Family.  Joseph  Garland,  M.  D.  $2.00.  196  pp. 
Harvard  University  Press,  1932. 

This  is  the  latest  edition  to  the  ever-increasing  list  of  books  on  child 
care  and  protection,  and  is  one  that  can  be  heartily  recommended. 

Text  and  illustrations  are  pleasing  and  clear  cut  and  the  modern 
viewpoint  is  made  interesting  in  presentation. 


205 

The  introductory  chapter  "The  Changing  Order"  is  particularly- 
timely,  one  of  the  few  prefaces  that  really  can  be  read  first  with  pleas- 
ure and  profit. 

Eeasons  are  given  for  "striving  for  quality  rather  than  quantity  in 
human  production"  and  the  fallacy  of  "the  good  old  times"  theory  of 
child  rearing  is  trenchantly  condemned  in  the  following  paragraph: 

"  'Look  at  the  children  of  the  slums,'  is  the  cry  of  those  who  have 
carefully  denied  themselves  this  opportunity;  'they  grow  up  without  all 
these  scientific  advantages  that  you  would  teach  us  are  so  necessary, 
and  they  survive  and  flourish.'  It  is  true,  must  be  the  answer,  many  of 
them  do  grow  up  without  these  advantages,  but  a  visit  to  the  wards  of 
our  hospitals  will  find  them  dying  of  pneumonia  in  the  springtime  and 
of  infantile  diarrhea  in  the  heat  of  the  summer,  or  in  the  coma  of 
tuberculous  meningitis,  acquired  from  contaminated  milk  or  from  pa- 
rental infection.  Probably  your  child  will  not  run  these  risks,  but  it  is 
because  of  the  progress  of  science  that  he  is  spared  them." 

Food  and  Your  Body  by  Mary  Pfaffmann  and  Frances  Stern.  $2.00. 
155  pp.   M.  Barrows  and  Company,  Boston. 

One  of  the  patients  in  the  ward  for  special  cases  at  the  Boston  Dis- 
pensary was  given  this  book  to  read  and  thereafter  was  called  a  pro- 
fessor of  nutrition  by  the  rest  of  the  ward. 

This  book  was  specially  written  for  children  of  the  intermediate 
grades,  but  from  the  above  story  it  may  be  seen  that  adults  get  practi- 
cal nutrition  information  in  an  interesting  way  by  reading  this  book. 
Miss  Pfaffman,  the  health  educator,  and  Miss  Stern,  the  chief  of  the 
food  clinic  at  the  Dispensary,  can  almost  be  heard  talking  and  explain- 
ing vividly  and  clearly  about  the  importance  of  food  and  your  body. 

The  plan  for  each  of  the  ten  lessons,  the  illustrations,  experiments, 
games,  stories  and  application  are  all  developed  from  experience  in  the 
clinic. 

This  little  book  will  be  of  interest  to  those  who  are  teaching  nutri- 
tion in  clinics,  in  the  home  and  in  the  school. 

Hospitals  and  Child  Health  —  a  publication  of  the  White  House  Con- 
ference on  Child  Health  and  Protection.  $2.50.  279  pp.  The  Cen- 
tury Company,  1932. 

This  publication  of  the  White  Hquse  Conference  covers  three  sec- 
tions in  detail:  Hospitals  and  Dispensaries,  Dr.  C.  G.  Grulee  of  Rush 
Medical  College,  chairman;  Convalescent  Care  and  Service  Available, 
Dr.  A.  V.  A.  Adrian,  Welfare  Council  of  New  York  City,  chairman;  and 
Medical  Social  Service  summarized  by  Ida  M.  Cannon,  R.N.,  Chief 
of  Social  Service,  Massachusetts  General  Hospital,  chairman  of  this 
section. 

I.  The  Committee  on  Hospitals  and  Dispensaries  concluded  that 
there  are  enough  beds  for  the  care  of  children  in  hospitals  in  the 
United  States  as  a  whole,  but  there  are  areas  where  hospital  beds  are 
not  available,  as  we  all  know.  The  beds  for  children,  however,  are  not 
often  definitely  controlled  by  a  pediatric  staff  and  this  appears  to  be  a 
good  deal  of  a  drawback.  Provision  for  care  of  mental  and  venereal 
diseases  is  not  what  it  should  be  for  children  (any  more  than  for 
adults).  A  wider  distribution  of  small  hospitals  for  isolation  of  com- 
municable diseases  is  much  needed. 

The  Committee  offers  definite  recommendations  on  increased  instruc- 
tion in  pediatrics  in  medical  schools,  increased  pediatric  nursing  edu- 
cation and  urges  the  cooperation  of  a  national  organization  of  pedi- 
atricians with  the  American  Association  of  Hospital  Social  Service 
Workers  and  the  American  Dental  Association.  It  also  suggests  more 
training  for  nutrition  workers  along  medical  lines,  the  closer  linking  up 


206 
of  pediatric  and  obstetric  services  in  care  of  the  newborn  and  a  study 
of  children's  hospitals  and  dispensaries  in  an  effort  to  raise  standards. 

II.  The  Committee  on  Convalescent  Care  of  Children  studied  the 
existing  convalescent  institutions  in  detail,  their  distribution,  fire  pro- 
tection, available  number  of  beds,  costs,  special  case  care,  personnel, 
visiting  medical  staff,  recreation,  school  facilities  and  records.  Dis- 
couragement was  expressed  at  the  "failure  of  physicians  and  hospitals 
to  recognize  the  importance  of  convalescent  care,  at  the  meager  facili- 
ties throughout  the  country  for  rendering  this  service,  and  at  the  appar- 
ent confusion  in  the  minds  of  many  concerning  the  true  nature  of  con- 
valescence and  the  value  of  convalescent  care." 

III.  The  Section  on  Medical  Social  Service  takes  up  about  one-half 
of  this  volume.  This  Committee  covered  all  aspects  of  social  work  as 
related  to  the  foregoing  sections — hospitals  and  dispensaries  and  con- 
valescent care. 

The  private  physician,  so  far,  deals  with  his  patients'  social  diffi- 
culties himself  largely  but  hospitals  and  clinics  today  greatly  need  the 
educated  social  worker  as  a  "part  of  the  clinical  team". 

The  social  worker  represents  the  environment  as  a  most  important 
consideration  in  medical  treatment  of  any  kind  wherever  it  is  carried 
on,  whether  in  hospital,  convalescent  institution  or  in  the  home. 

This  summary  is  too  comprehensive  to  be  covered  in  a  brief  review 
and  it  can  be  read  in  full  with  much  profit.  The  opinion  all  along  the 
line  seems  to  be  that  there  is  actual  need  of  many  more  adequately 
prepared  medical  and  social  workers. 

News  from  the  N.  O.  P.  H.  N. 

The  first  in  a  series  of  monthly  questionnaires  designed  to  determine 
quickly  the  readjustments  which  are  taking  place  in  public  health  nurs- 
ing due  to  economic  conditions,  was  mailed  last  week  by  the  National 
Organization  for  Public  Health  Nursing  to  425  agencies;  boards  of 
education;  public  health  nursing  agencies  and  boards  of  health,  which 
are  being  asked  to  cooperate. 

The  plan  was  put  into  effect  because  of  the  increasing  country-wide 
requests  for  up-to-the-minute  information  on  changes  in  policies  and 
methods  in  public  health  nursing.  It  will  continue  from  November  to 
June,  and  the  results  of  each  study  will  be  made  public  as  rapidly  as 
they  can  be  tabulated  in  the  N.  0.  P.  H.  N.  Statistical  Department.  The 
first  question,  on  relief,  asked  the  nature,  cost  and  source  of  any  and 
all  relief  given  by  the  agency. 

****** 

Mary  H.  Emberton,  a  supervisor  on  the  Visiting  Nurse  Association 
staff  in  Denver,  was  winner  of  the  first  prize  in  a  case  story  contest 
conducted  by  PUBLIC  HEALTH  NURSING.  One  hundred  twenty-four 
manuscripts  were  submitted.  Second  prize  was  awarded  to  Charlotte 
M.  Young,  R.N.,  whose  manuscript  was  submitted  by  Florence  E. 
McClinchey,  of  Mount  Pleasant,  Michigan.  Miss  Edith  E.  McCarthy  of 
Medford,  Massachusetts,  won  third  prize. 

****** 

Katharine  Tucker,  General  Director  of  the  National  Organization  for 
Public  Health  Nursing,  conducted  an  institute  in  Hartford  on  Novem- 
ber 15  at  the  invitation  of  the  Public  Health  Nursing  Section  of  the 
Connecticut  State  Nurses  Association.  Four  methods  of  supervision — 
home  visit,  office  visit,  records,  and  efficiency  reports — were  discussed 
in  afternoon  and  evening  sessions,  with  40  supervisors  representing  all 
parts  of  the  state  participating. 

All  of  the  some  six  hundred  local  agencies  which  are  displaying  the 
Certificate  of  Honor  for  100  per  cent  individual  staff  membership  in 
the  National  Organization  for  Public  Health  Nursing  will  be  proud  to 


207 
learn  that  the  certificate  has  been  awarded  a  place  in  an  exhibit  of 
fine  printing  sponsored  by  the  Institute  of  Graphic  Arts  of  New  York. 
After  being  placed  on  exhibition  at  the  Art  Center  in  New  York  for 
three  weeks,  the  exhibit  will  tour  the  country  where  it  will  be  on  dis- 
play at  museums  and  libraries  in  some  twenty  cities. 

The  design  for  the  Certificate  of  Honor  for  1933  has  not  yet  been 
completely  worked  out,  but  the  N.  0.  P.  H.  N.  will  again  attempt  to 
create  something  which  local  agencies  will  display  not  only  because  it 
is  a  tribute  to  the  cooperative  spirit  of  its  nurses,  but  because  typo- 
graphically it  is  a  thing  of  beauty. 

Local  agencies  which  have  received  the  certificate  for  1932  will  na- 
turally want  to  qualify  again  next  year,  and  some  special  device  as  well 
as  a  change  in  color  on  the  certificate  will  acknowledge  the  second 
consecutive  year  for  any  agency. 

But  there  are  more  reasons  for  membership  this  year  than  merely  to 
have  the  certificate.  This  winter  the  N.  0.  P.  H.  N.  will  redouble  its 
efforts  to  supply  its  members  with  information  which  will  enable  them 
to  combat  the  economic  emergency.  In  spite  of  salary  cuts  and  curtail- 
ment of  both  professional  and  clerical  staff,  national  headquarters  in- 
tends to  keep  available  up-to-the-minute  practical  solutions  to  such 
pertinent  problems  as  the  development  of  a  sound,  inexpensive  publicity 
program ;  what  special  economies  may  be  effected ;  where  programs  may 
be  curtailed  with  least  damage  to  the  service;  how  the  help  of  volun- 
teers may  be  secured  and  most  effectively  used;  and  the  part  the  pub- 
lic health  nursing  agency  should  play  in  the  community  relief  problem. 

These  are  services  which  no  nurse  can  afford  to  do  without  and  which 
few  will  care  to  shirk  the  responsibility  of  supporting. 

REPORT  OF  DIVISION  OF  FOOD  AND  DRUGS. 

During  the  months  of  July,  August  and  September  1932,  samples 
were  collected  in  191  cities  and  towns. 

There  were  1,743  samples  of  milk  examined,  of  which  390  were  below 
standard;  from  18  samples  the  cream  had  been  in  part  removed,  and 
15  samples  contained  added  water.  There  were  74  samples  of  Grade  A 
Milk  examined,  67  samples  of  which  were  above  the  legal  standard  of 
4.00%  fat,  and  7  samples  were  below  the  legal  standard.  There  were 
835  bacteriological  examinations  made  of  milk.  There  were  41  samples 
examined  for  hemolytic  bacteria,  all  of  which  were  positive. 

There  were  164  samples  of  food  examined,  of  which  29  were  adulter- 
ated or  misbranded.  These  consisted  of  1  sample  of  candy  which  was 
wormy;  1  sample  of  cream  which  was  below  the  legal  standard  in  fat; 
2  samples  of  maple  syrup  which  contained  cane  sugar;  9  samples  of 
hamburg  steak,  and  1  sample  of  sausage,  all  of  which  contained  a  com- 
pound of  sulphur  dioxide  not  properly  labeled;  12  samples  of  eggs,  7 
samples  of  which  were  sold  as  fresh  eggs  but  were  not  fresh,  1  sample 
was  cold  storage  not  so  marked,  and  4  samples  were  decomposed;  1 
sample  of  bread  which  contained  orange  and  black  molds;  1  sample  of 
an  individual  pie  which  contained  a  green  mold;  and  1  sample  of 
chicken  which  was  decomposed. 

There  were  51  samples  of  drugs  examined,  of  which  6  were  adulter- 
ated or  misbranded.  These  consisted  of  5  samples  of  argyrol  solution 
not  corresponding  to  the  professed  standard  under  which  it  was  sold; 
and  1  sample  of  spirit  of  nitrous  ether  which  did  not  conform  to  the 
U.  S.  P.  requirements. 

The  police  departments  submitted  1,379  samples  of  liquor  for  exam- 
ination, 1,359  of  which  were  above  0.5%  in  alcohol.  The  police  depart- 
ments also  submitted  14  samples  of  narcotics,  etc.,  for  examination,  7 
of  which  contained  heroin;  1  sample  of  a  white  powder  contained  a  deri- 
vative of  morphine,  sample  being  too  small  for  positive  identification; 
1  sample  of  a  white  substance  contained  antipyrin;  1  sample  of  white 


208 

powder,  and  1  sample  of  a  white  tablet  were  examined  for  narcotics 
with  negative  results ;  1  sample  of  meat,  1  sample  of  a  white  powder, 
and  another  sample,  were  examined  for  poisons  with  negative  results. 

There  were  88  cities  and  towns  visited  for  the  inspection  of  pasteur- 
izing plants,  and  220  plants  were  inspected. 

There  were  119  hearings  held  pertaining  to  violations  of  the  laws. 

There  were  47  convictions  for  violations  of  the  law,  $640  in  fines 
being  imposed. 

Samuel  Bzowski,  Joseph  A.  Morin  and  Frank  Sierpina,  all  of  Methuen ; 
Peter  Dumouselas  of  Framingham;  James  Alevakis  of  Athol;  Pacific 
Restaurant  of  Nantucket,  Incorporated,  of  Nantucket;  Louis  Equi  of 
Millers  Falls;  Frank  Gomes  of  Quincy;  George  Nearhos  of  Waltham; 
Lena  Piper,  2  cases,  of  Gardner;  Frank  Rommo  of  Milford;  Louise  J. 
R.  Pierson  of  Orleans;  Ethel  Fallon  of  Hingham;  Abe  Lahage  of  Nan- 
tasket;  and  Joseph  Nougeria  of  Plymouth,  were  all  convicted  for  viola- 
tions of  the  milk  laws. 

Allen  J.  McNeil  of  Wellesley;  Earl  Upton  of  Brockton;  and  John  C. 
Shaw  of  Taunton,  were  all  convicted  for  violations  of  the  Grade  A 
Milk  laws. 

W.  B.  Driscoll  &  Company  of  South  Boston;  Arthur  W.  Nickerson  of 
Saugus;  Joseph  E.  and  Hercules  J.  Giroux  of  Somerville;  Chester 
Gushee  of  Dorchester;  E.  Weiler  &  Sons,  and  Westwood  Farms  Milk 
Company  of  Jamaica  Plain ;  Frank  M.  Gannon  of  North  Billerica ;  J.  B. 
Prescott  Company  of  Bedford;  George  Boudreau  of  Lowell;  John  J. 
Horgan  and  William  E.  Horgan  of  Danvers;  and  Emmanuel  Mortis,  2 
cases,  of  Peabody,  were  all  convicted  for  violations  of  the  pasteuriza- 
tion law  and  regulations.  Frank  M.  Gannon  of  North  Billerica  appealed 
his  case.  H.  P.  Hood  &  Sons  of  Lowell  was  placed  on  probation  with- 
out finding  for  violation  of  the  pasteurization  law  and  regulations. 

Folsom's  Market,  Incorporated,  of  Roxbury;  Samuel  Gammerman, 
American  Beef  Company,  Incorporated,  and  Frank  Kastan,  all  of  Bos- 
ton; Ruben  Lipsky  of  Brookline;  John  Riley  of  Wollaston;  Manuel 
Bettincourt,  2  counts,  of  New  Bedford ;  and  Earl  D.  Upton  of  Brockton, 
were  all  convicted  for  violations  of  the  food  laws.  Samuel  Gammerman, 
and  American  Beef  Company,  Incorporated,  of  Boston,  appealed  their 
cases. 

Edward  T.  Killelea  and  Arthur  H.  Quint  of  Leominster;  Howard 
M.  Beverly  of  Ayer;  Michael  D.  Exidis  of  Springfield;  and  Leonard 
Hendrickson  of  Oak  Bluffs,  were  all  convicted  for  violations  of  the 
drug  laws. 

Harry  Bellanger  of  Indian  Orchard  was  convicted  for  violation  of 
the  false  advertising  law. 

Standard  Mattress  Company,  Incorporated,  of  Springfield  was  con- 
victed for  violation  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: 

One  sample  of  cream  which  was  below  the  legal  standard  in  milk  fat 
was  obtained  from  Freeman  C.  Lowell  of  Mendon. 

One  sample  of  chicken  which  was  decomposed  was  obtained  from 
F.  H.  Hosmer  of  Boston. 

One  sample  of  sausage  which  contained  a  compound  of  sulphur 
dioxide  not  properly  labeled  was  obtained  from  Grower's  Outlet  of 
Holyoke. 

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

One  sample  each,  from  Manuel  Bettincourt  and  Nathan  Cohen  of 
New  Bedford;  American  Beef  Company,  Incorporated,  of  Boston;  Mel- 
rose Manhattan  Market  of  Melrose;  Atlantic  &  Pacific  Tea  Company  of 
Revere;  John  Kaplan  and  Gavin's  Market  of  Woburn;  Rood  &  Wood- 
bury of  Springfiefild;  and  John  Tota  of  Holyoke. 


209 

Maple  syrup  which  contained  cane  sugar  was  obtained  as  follows : 

One  sample  each,  from  Harry  Small  of  Boston;  and  Biltmore  Cafe 
of  Waltham. 

There  were  sixteen  confiscations,  consisting  of  689  pounds  of  de- 
composed pork  loins;  535  pounds  of  decomposed  butterfish;  180  pounds 
of  chicken  halibut;  600  pounds  of  decomposed  mackerel;  250  pounds  of 
decomposed  blink  mackerel;  1,002  pounds  of  decomposed  large  and 
medium  mackerel;  and  638  pounds  of  decomposed  scup. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  June,  1932: — 1,459,470  dozens  of  case 
eggs;  1,122,615  pounds  of  broken  out  eggs;  5,042,868  pounds  of  butter; 
1,111,459  pounds  of  poultry;  2,040,488  pounds  of  fresh  meat  and  fresh 
meat  products;  and  5,665,380  pounds  of  fresh  food  fish. 

There  was  on  hand  July  1,  1932: — 6,648,630  dozens  of  case  eggs; 
2,522,789  pounds  of  broken  out  eggs;  6,483,138  pounds  of  butter;  3,609,- 
937x/2  pounds  of  poultry;  5,574,4361/4  pounds  of  fresh  meat  and  fresh 
meat  products;  and  16,034,581  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  July,  1932: — 612,180  dozens  of  case 
eggs;  735,090  pounds  of  broken  out  eggs;  3,377,426  pounds  of  butter; 
826,199  pounds  of  poultry;  2,903,378%  pounds  of  fresh  meat  and  fresh 
meat  products;  and  5,389,355  pounds  of  fresh  food  fish. 

There  was  on  hand  August  1,  1932: — 6,732,030  dozens  of  case  eggs; 
2,696,767  pounds  of  broken  out  eggs;  9,186,199  pounds  of  butter;  3,313,- 
526%  pounds  of  poultry;  5,295, 01Sy2  pounds  of  fresh  meat  and  fresh 
meat  products;  and  19,663,922  pounds  of  fresh  food  fish. 

The  licensed  cold  storage  warehouses  reported  the  following  amounts 
of  food  placed  in  storage  during  August,  1932: — 566,760  dozens  of  case 
eggs;  417,975  pounds  of  broken  out  eggs;  1,660,178  pounds  of  butter; 
821,022  pounds  of  poultry,  1,660,1711/^  pounds  of  fresh  meat  and  fresh 
meat  products;  and  4,466,578  pounds  of  fresh  food  fish. 

There  was  on  hand  September  1,  1932: — 6,191,580  dozens  of  case 
eggs;  2,505,692  pounds  of  broken  out  eggs;  9,455,960  pounds  of  butter; 
2,771,633%  pounds  of  poultry;  4,336,033%  pounds  of  fresh  meat  and 
fresh  meat  products;  and  21,581,056  pounds  of  fresh  food  fish. 


210 


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.  Nelson. 


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  Child  Hygiene 
Division   of  Tuberculosis 
Division  of  Adult  Hygiene     . 


State  District 

The  Southeastern  District 

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

The  Berkshire  District 


Under  direction  of  Commissioner. 
Director  and  Chief  Engineer, 

Arthur  D.  Weston,  C.E. 
Director, 

Gaylord  W.  Anderson,  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,  Alton  S.  Pope,  M.D. 
Director, 

Herbert  L.  Lombard,  M.D. 

Health  Officers 

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

Charles  B.  Mack,  M.D.,  Boston. 

Robert  E.  Archibald,  M.D.,  Lynn. 

Oscar  A.  Dudley,  M.D.,  Worcester. 

Harold  E.  Miner,  M.D.,  Spring- 
field. 

Walter  W.  Lee,  M.D.,  No.  Adams. 


211 


INDEX 

PAGE 
Abbott,  Mrs.  T.  Grafton,  Mental  hygiene  for  cardiac  children  .  .    191 

Adair,  Fred  L.,  M.  D.  and  Service,  Howard  M.,  D.D.S.,  Care  of  the 

mouth  during  pregnancy  .......      96 

Adult,  Food  for  the,  by  Octavia  Smillie  .  .65 

Advisory  committee,  Nutrition  with  or  without  an,  by  George  H. 

Bigelow,  M.D 55 

American  Red  Cross  annual  roll  call  .  .  .  .  .161 

An  echo  returns,  by  Mildred  L.  Swift  .  .  .  .  .  .83 

An  island  visit,  by  Susan  M.  Coffin,  M.D 196 

Anderson,  Gaylord  W.,  M.D.,  Special  problems  of  communicable  dis- 
eases in  the  small  community  .  .  .  .    132 
The  importance  of  guarding  infants  against  infections       .  .   187 
Athlete's  foot  (Epidermophytosis)  its  prevention  and  treatment,  by 

C.  Guy  Lane,  M.D 91 

Baby  teeth,  The  importance  of  the,  by  R.  C.  Willett,  D.M.D.   .  12 

Barnum,  Ruth  E.,  R.N.,  Home  visits  in  rural  schools  .   193 

Bellevue-Yorkville  Health  Demonstration,  Annual  report  of,  1931       .   100 
Bigelow,  George  H.,  M.D.,  Foreword  to  Rural  Health  number  .  .   109 

Nutrition,  with  or  without  an  advisory  committee   .  .55 

Trends  in  the  development  of  the  dental  programs  of  the  Mass- 
achusetts Department  of  Public  Health    ....       3 

Body  mechanics,  by  Lloyd  T.  Brown,  M.D.    .  .  .  .  .    176 

Body  mechanics  —  education  and  practice   (book  note)    .  .  .45 

Book  Notes: 

Body  Mechanics :  Education  and  Practice  .  .  .45 

Community   Health   Organization    ......   204 

Food  and  Your  Body     ........   205 

Hospitals  and  Child  Health    .......   205 

Institute  for  Child  Guidance  .......      46 

Milk  Production  and  Control  .......   161 

Principles  and  Practices  of  Public  Health  Nursing  .  .   101 

Psychology  and  Psychiatry  in  Pediatrics  .  .  .  .46 

School  Health  Program  ........   161 

Studies  —  Selected  Reprints   .......     46 

Youngest  of  the  Family  ........   204 

Your   Hearing        .........   204 

Brown,  Clifford  K.,  The  trend  toward  parent  education  .  .  .    169 

Brown,  Lloyd  T.,  M.D.,  Body  mechanics  ......   176 

Budget,  The  minimum  food,  in  1932,  by  Blanche  F.  Dimond,  B.S.     .     67 
Building  sound  teeth,  by  May  E.  Foley  .  .  .  .  .  .35 

Cancer  of  the  mouth  —  how  to  recognize  and  prevent  it,  by  Charles 

M.  Proctor,  D.M.D 21 

Cape  Cod,  The  experience  of  —  Cooperative  rural  health  work,  by  G. 

Webster  Hallett '  115 

Cardie  children,  Mental  hygiene  for,  by  Mrs.  T.  Grafton  Abbott       .   191 

Care  of  the  mouth  during  pregnancy,  by  Fred  L.  Adair,  M.D.  and 

Howard   M.    Service,    D.D.S 96 

Chadwick  clinics,   Nutrition  phase  of  the,   by  Lillian   Stuart   and 

Catherine  Leamy  .  .  .  .  .84 

Child  council,  Massachusetts,  How  the,  came  into  being,  by  Mary  R. 

Lakeman,   M.D.        ...  ....   181 

Child  council,  The  purpose,  plans  and  possibilities  of  the  Massachu- 
setts, by  Herbert  C.  Parsons   ....   184 

Child  hygiene,  Rural,  in  Massachusetts,  by  Susan  M.  Coffin,  M.D.       .   140 

Clinic,  A  Red  Cross  traveling  dental,  by  Nancy  A.  Trow  .  .34 

Clinic,  Preschool  and  prenatal  dental,  by  J.  Hal  T.  Maloney,  D.D.S.     .     31 


212 

PAGE 
Clinic,  The  Junior  League  dental,  by  Mrs.  Roswell  G.  Mace  29 

Clinic,  The  preschool  child  at  the  town  dental,  by  Helen  M.  Heffernan, 

R.N.        ...  ......     32 

Clinics,   Nutrition  phase  of  the   Chadwick,   by  Lillian   Stuart   and 

Catherine  Leamy  .......      84 

Clow,  Alice  E.  Sanderson,  B.Sc,  B.S.,  M.D.,  Exercise  as  an  aid  to 

women    ..........   199 

Coffin,  Susan  M.,  M.D.  An  island  visit 196 

Rural  child  hygiene  in  Massachusetts    .....   140 
Communicable  disease,  Special  problems  of,  in  the  small  community, 

by  Gaylord  W.  Anderson,  M.D .132 

Community  health  organization  (book  note)  ....  204 
Cooperative  rural  health  work  —  The  experience  of  Cape  Cod,  by  G. 

Webster  Hallett  115 

County  health  service  in  the  United  States,  Development  of  full  time, 

by  Wilson  G.  Smillie,  M.D.,  D.P.H 110 

Daley,  Francis  H.,  D.M.D.,  Vincent's  infection  .  .15 

Delabarre,  Frank  A.,  A.B.,  D.D.S.,  M.D.,  Prevention  of  malocclusion  13 
Dental  care,  Providing,  to  maternity  cases,  by  George  H.  Wandel, 

D.D.S 9 

Dental  clinic,  A  Red  Cross  traveling,  by  Nancy  A.  Trow  .  .34 

Dental  clinic,  Preschool  and  prenatal,  by  J.  Hal  T.  Maloney,  D.D.S.  .  31 
Dental  clinic,  The  Junior  League,  by  Mrs.  Roswell  G.  Mace  29 

Dental  clinic,  The  prechool  child  at  the  town,  by  Helen  M.  Heffernan, 

R.N .32 

Dental  hygiene,  The  teaching  of,  to  newsboys,  by  Harry  Goldinger, 

D.M.D 38 

Dental  hygiene  as  part  of  the  well  child  conference,  by  Eleanor  G. 

McCarthy,   B.S.,   D.H 4 

Dental  hygienist  in  the  schools,  by  Osirene  E.  Rowell,  D.H.  36 

Dental  program,  A  prenatal  and  preschool,  from  a  public  health  nurs- 
ing point  of  view,  by  Eva  A.  Waldron,  R.N.  .30 
Dental  program  for   the   Southern   Berkshire   Health   District,   by 

Frederick  S.  Leeder,  M.D.,  D.P.H 23 

Dental  program  of  the  Massachusetts  Department  of  Public  Health, 

Trends  in  the  development  of,  by  George  H.  Bigelow,  M.D.  .  3 
Dentistry,  Institutional,  by  Emanuel  Kline,  D.M.D.  .  .39 

Dentistry  must  embark  on  research,  by  Leroy  M.  S.  Miner,  D.M.D., 

M.D 20 

Development  of  full  time  county  health  service  in  the  United  States, 

by  Wilson  G.  Smillie,  M.D.,  D.P.H 110 

Dimond,  Blanche,  F.,  B.S.,  The  minimum  food  budget  in  1932  .  70 

Directions  for  brushing  the  teeth  properly    .  15 

Doane,  Helen  E.,  and  McKellar,  Albertine  P.,  B.S.,  4-H  club  food  work  80 
Dorward,  Florence  G.,  Staff  education  in  nutrition,  Springfield,  Mass.     77 

Eating  habits  in  children,  Good,  by  Stanton  Garfield,  M.D.       .  59 

Economy   and   health    .........  101 

Editorial  Comment: 

Mother's  Day 45 

Scamman,  Clarence  L.,  M.D.  —  Letter  from  Dr.  Chapin  .  44 

Summer  school  at  Hyannis     .......  45 

Education,  Staff,  in  nutrition  —  Springfield,  Mass.,  by  Florence  G. 

Dorward           .........  77 

Epidermophytosis   (athlete's  foot)   its  prevention  and  treatment,  by 

C.  Guy  Lane,  M.D .91 

Evaluation  of  rural  health  work,  by  W.  F.  Walker,  D.P.H.  .  124 
Exercise  as  an  aid  to  health  in  women,  by  Alice  E.  Sanderson  Clow, 

B.Sc,  B.S.,  M.D 199 


213 

PAGE 

Farley,  George  L.,  M.S.,  4-H  club  work 157 

Fissures,  Pits  and  .  .  .  .  .  .43 

Foley,  May  E.,  Building  sound  teeth    ......     35 

Food  and  Drugs,  Report  of  Division  of: 

October-November-December,  1931  .  .  .  .  .  .48 

January-February-March,  1932        ......   102 

April-May-June,  1932 162 

July-August-September,  1932 207 

Food  and  your  body  (book  note)    .......   205 

Food  at  low  cost  for  teeth,  by  Mary  Spalding,  B.S.,  M.A.  .  .10 

Food  budget,  The  minimum,  in  1932,  by  Blanche  F.  Dimond,  B.S.     .     70 
Food  for  the  adult,  by  Octavia  Smillie  ...  .65 

Four-H  club  food  work,  by  Helen  E.  Doane  and  Albertine  P.  McKellar, 

B.S 80 

Four-H  club  work,  by  George  L.  Farley,  M.S.  .....   157 

Garfield,  Stanton,  M.D.,  Good  eating  habits  in  children  .  .  .59 

Goldinger,  Harry,  D.M.D.,  The  teaching  of  oral  hygiene  to  newsboys     38 
Gonorrhea  and  syphilis  in  rural  areas,  The  problem  of,  by  N.  A. 

Nelson,  M.D ....   135 

Good  eating  habits  in  children,  by  Stanton  Garfield,  M.D.       .  59 

Habits,  Good  eating,  in  children,  by  Stanton  Garfield,  M.D.   .  59 

Hallett,  G.  Webster,  Cooperative  rural  health  work  —  The  experience 

of  Cape  Cod 115 

Handicapped  child,  Summary  of  round  table  on  the,  by  Alfred  F.  Whit- 
man          178 

Health,  Economy  and  .........   101 

Health  education,  The  value  of,  to  the  community,  by  Michele  Nigro, 

M.D 87 

Health  education  procedure  —  New  England  Health  Education  As- 
sociation ........     89 

Heffernan,  Helen  M.,  R.N.,  The  preschool  child  at  the  town  dental 

clinic       ..........     32 

Herr,  Annette  T.,  B.S.,  A.M.,  The  home  economics  extension  service 

program  in  rural  districts  of  Massachusetts       .  .  .   154 

Hoague,  Mrs.  George,  The  Massachusetts  Parent-Teacher  Association 

and  the  rural  school        .......   156 

Home  economics  extension   service  program   in   rural   districts  of 

Massachusetts,  by  Annette  T.  Herr,  B.S.,  A.M.  .  .  .   154 

Home  visits  in  rural  schools,  by  Ruth  E.  Barnum,  R.N.  .  .   193 

Hospital  technique,  Postgraduate  course  in,  International  Hospital 

Association    .  .  .  .  .  .  .  .  .   101 

Hospitals  and  child  health  (book  note)   ......   205 

How  the  Massachusetts  Child  Council  came  into  being,  by  Mary  R. 

Lakeman,  M.D 181 

Hyannis  summer  school        ........     45 

Hygiene,  Dental,  as  part  of  the  well  child  conference,  by  Eleanor  G. 

McCarthy,  B.S.,  D.H 4 

Hygienist,  The  dental,  in  the  schools,  by  Osirene  E.  Rowell,  D.H.  36 

Importance  of  guarding  infants  against  infections,  by  Gaylord  W. 

Anderson,  M.D.  187 

Importance  of  the  baby  teeth,  by  R.  C.  Willett,  D.M.D.  .  12 

Infants,  The  importance  of  guarding,  against  infections,  by  Gaylord 

W.  Anderson,  M.D '  .    187 

Institute  for  child  guidance  (book  note)  .  .  .  .46 

Institutional  dentistry,  by  Emanuel  Kline,  D.M.D.  .  .39 

International  Hospital  Association,  Postgraduate  course  in  hospital 

technique         .........   101 


214 

PAGE 

Junior  League  dental  clinic,  by  Mrs.  Ros well  G.  Mace  .  .29 

Kingsbury,  Francis  H.,  Private  water  supply  and  sewage  disposal 

problems  ......   142 

Kline,   Emanuel,   D.M.D.,   Institutional   dentistry    .  .  .39 

Knowlton,  Wilson  W.,  M.D.,  Rural  health  development  in  Massachusetts  112 
Knox,  Joseph  C,  Safe  but  unpalatable   .  .  .  .  .97 

Lakeman,  Mary  R.,  M.D.,  How  the  Massachusetts  Child  Council  came 

into  being        .........    181 

Lane,  C.  Guy,  M.D.,  Epidermophytosis  (athlete's  foot)  its  prevention 

and  treatment  ........     91 

Laurie,  Elizabeth  M.,  Play  —  A  necessary  factor  in  the  life  of  every 

child       ...  ......   188 

Leamy,  Catherine,  and  Stuart,  Lillian,  Nutrition  phase  of  the  Chad- 
wick  clinics      .....  ...      84 

Leeder,  Frederick  S.,  M.D.,  D.P.H.,  Proposed  dental  program  for  the 

Southern  Berkshire  Health  District  .  .23 

Leeder,  Frederick  S.,  M.D.,  Southern  Berkshire  Health  District         .    118 

Little,  Willard  S.,  Rural  nuisances  and  their  control  .  .    148 

Mace,  Mrs.  Roswell  G.,  The  Junior  League  dental  clinic  .  .29 

Malocclusion,  Prevention  of,  by  Frank  A.  Delabarre,  A.B.,  D.D.S.,  M.D.  13 

Maloney,  J.  Hal  T.,  D.D.S.,  Preschool  and  prenatal  dental  clinic  31 
Massachusetts  Child  Council,  How  the,  came  into  being,  by  Mary  R. 

Lakeman,  M.D 181 

Massachusetts  Child  Council,  The  purpose,  plans  and  possibilities  of 

the,  by  Herbert  C.  Parsons     ......  184 

Massachusetts  Parent-Teacher  Association  and  the  rural  school,  by 

Mrs.  George  Hoague                  ......  156 

Maternal  mortality,  by  John  Rock,  M.D.  ......  171 

Maternity  cases,  Providing  dental  care  to,  by  George  H.  Wandel, 

D.D.S 9 

McCarthy,  Eleanor  G.,  B.S.,  D.H.,  Dental  hygiene  as  part  of  the  well 

child  conference       ........  4 

Notes  from  the  White  House  Conference  .  .25 

McKellar,  Albertine  P.,  B.S.,  and  Doane,  Helen  E.,  4-H  club  food  work  80 
Medical   practice   in   rural   areas,   by   Frank   H.   Washburn,   M.D., 

F.A.C.S 129 

Mental  hygiene  for  cardiac  children,  by  Mrs.  T.  Grafton  Abbott       .  191 

Milk 195 

Milk  production  and  control   (book  note)        .....  161 

Miner,  Leroy  M.S.,  D.M.D.,  M.D.,  Dentistry  must  embark  on  research  20 

Minimum  food  budget  in  1932,  by  Blanche  F.  Dimond,  B.S.  70 

Mortality,  Maternal,  by  John  Rock,  M.D 171 

Mother's  Day 45 

Mouth,  Cancer  of  the,  How  to  recognize  and  prevent  it,  by  Charles 

M.  Proctor,  D.M.D.  .                             21 

Mouth,  Care  of  the,  during  pregnancy,  by  Fred  L.  Adair,  M.D.,  and 

Howard  M.  Service,  D.D.S 96 

Nashoba  Health  District,  by  G.  Fletcher  Reeves,  M.D.   .  .121 

Nelson,  N.  A.,  M.D.,  The  problem  of  gonorrhea  and  syphilis  in  rural 

areas       ..........   135 

News  Notes: 

American  Red  Cross  annual  roll  call       .....    161 

News  from  the  N.O.P.H.N 206 

Nigro,  Michele,  M.D.,  The  value  of  health  education  to  the  communtiy     87 

N.O.P.H.N.  news .206 

Notes  from  the  White  House  Conference,  by  Eleanor  G.  McCarthy, 

B.S.,  D.H .25 


215 

PAGE 
Nuisances,  Rural,  and  their  control,  by  Willard  S.  Little  .  .  .   148 

Nutrition,  Posture  and,  by  Alma  Porter  ......      62 

Nutrition,  Sleep  and,  by  Harold  C.  Stuart,  M.D 56 

Nutrition  —  Some  interesting  articles  on  ....    100 

Nutrition,    Staff  education   in,   Springfield,   Mass.,   by   Florence   G. 

Dorward  ......  77 

Nutrition,  Teaching,  in  an  out-patient  department,  by  Gertrude  T. 

Spitz,  A.B.,  A.M 74 

Nutrition,  White  House  Conference  publications  on  100 

Nutrition,  With  or  without  an  advisory  committee,  by  George  H. 

Bigelow,  M.D 55 

Nutrition  emergency,  by  Mary  Spalding,  B.S.,  M.A.  .  .67 

Nutrition   phase   of   the    Chadwick   clinics,   by   Lillian    Stuart   and 

Catherine  Leamy     ........      84 

Nutritionist,  Recommendations  for  the  training  of  a    .  .87 

Nutritionist,  The  value  of,  in  the  schools,  by  Mary  Elizabeth  O'Connor     78 

Obituaries    .  . 202,203 

O'Connor,  Mary  Elizabeth,  The  value  of  a  nutritionist  in  the  schools  78 
Oral  hygiene,  The  teaching  of,  to  newsboys,  by  Harry  Goldinger, 

D.M.D 38 

Out-patient  department,  Teaching  nutrition  in  an,  by  Gertrude  T. 

Spitz,  A.B.,  A.M 74 

Parent  education,  The  trend  toward,  by  Clifford  K..  Brown  .    169 

Parent-Teacher  Association,  Massachusetts,  and  the  rural  school,  by 

Mrs.  George  Hoague        ....  .  .   156 

Parsons,   Herbert  C,   The  purpose,  plans  and  possibilities   of  the 

Massachusetts  Child  Council    ......   184 

Pits  and  fissures  .  .  .  .  .  .  .  .43 

Play  —  A  necessary  factor  in  the  life  of  every  child,  by  Elizabeth 

M.  Laurie 188 

Porter,  Alma,  Posture  and  nutrition    ......     62 

Posture  and  nutrition,  by  Alma  Porter  .  .62 

Pregnancy,  Care  of  the  mouth  during,  by  Fred  L.  Adair,  M.D.  and 

Howard   M.    Service,    D.D.S 96 

Prenatal,  Preschool  and,  dental  clinic,  by  J.  Hal  T.  Maloney,  D.D.S.  .  31 
Prenatal  and  Preschool  dental  program  from  a  public  health  nursing 

point  of  view,  by  Eva  A.  Waldron,  R.N.   .  .30 

Preschool,  A  prenatal  and,  dental  program  from  a  public  health  nurs- 
ing point  of  view,  by  Eva  A.  Waldron,  R.N.  .  .30 
Preschool  and  prenatal  dental  clinic,  by  J.  Hal  T.  Maloney,  D.D.S.  .  31 
Preschool  child  at  the  town  dental  clinic,  by  Helen  M.  Heffernan,  R.N.  32 
Prevention  of  malocclusion,  by  Frank  A.  Delabarre,  A.B.,  D.D.S.,  M.D.  13 
Principles  and  practices  of  public  health  nursing  (book  note)  .  .  101 
Private  water  supply  and  sewage  disposal  problems,  by  Francis  H. 

Kingsbury        .........    142 

Problem  of  gonorrhea  and  syphilis  in  rural  areas,  by  N.  A.  Nelson, 

M.D.  135 

Proctor,  Charles  M.,  D.M.D.,  Cancer  of  the  mouth  —  how  to  recognize 

and  prevent  it  ........     21 

Program  for  public   health  nursing   in  a   country   community,   by 

Marion  C.  Woodbury,  R.N .137 

Proposed  dental  program  for  the  Southern  Berkshire  Health  District, 

by  Frederick  S.  Leeder,  M.D.,  D.P.H.  23 

Providing  dental  care  to  maternity  cases,  by  George  H.  Wandel,  D.D.S.  9 
Psychology  and  psychiatry  in  pediatrics    (book  note)    .  46 

Public  health  nursing  in  a  country  community,  A  program  for,  by 

Marion  C.  Woodbury,  R.N.       .  .  .137 


216 

PAGE 

Public  health  nursing  point  of  view,  A  prenatal  and  preschool  dental 

program  from  a,  by  Eva  A.  Waldron,  R.N.  .30 

Purpose,  plans  and  possibilities  of  the  Massachusetts  Child  Council, 

by  Herbert  C.  Parsons    .......   184 

Pyorrhea,  by  E.  Melville  Quinby,  M.R.C.S.,  L.R.C.P.,  D.M.D.  .  .     17 

Quinby,  E.  Melville,  M.R.C.S.,  L.R.C.P.,  D.M.D.,  Pyorrhea     .  .     17 

Recommendations  for  training  of  a  nutritionist    .... 
Red  Cross  traveling  dental  clinic,  by  Nancy  A.  Trow   . 
Reeves,  G.  Fletcher,  M.D.,  The  Nashoba  Health  District 

Rice,  Dr.  William  E 

Rock,  John,  M.D.,  Maternal  mortality   ...... 

Round  table,  Summary  of,  on  the  handicapped  child,  by  Alfred  F. 

Whitman  ......... 

Rowell,  Osirene  E.,  D.H.,  The  dental  hygienist  in  the  schools  . 
Rural  areas,   Medical  practice   in,  by  Frank  H.  Washburn,   M.D., 

F.A.C.S 

Rural  areas,  The  problem  of  gonorrhea  and  syphilis  in,  by  N.  A. 

Nelson,  M.D 

Rural  child  hygiene  in  Massachusetts,  by  Susan  M.  Coffin,  M.D. 
Rural  districts  of  Massachusetts,  The  home  economics  extension  ser- 
vice program  in,  by  Annette  T.  Herr,  B.S.,  A.M.  . 
Rural  health,  Foreword  to,  by  George  H.  Bigelow,  M.D.  . 
Rural  health  development  in  Massachusetts,  by  Wilson  W.  Knowlton, 

M.D 

Rural  health  work,  Cooperative,  The  experience  of  Cape  Cod,  by  G. 

Webster  Hallett 

Rural  health  work,  The  evaluation  of,  by  W.  F.  Walker,  D.P.H.  . 

Rural  nuisances  and  their  control,  by  Willard  S.  Little   . 

Rural  school,  The  Massachusetts  Parent-Teacher  Association  and  the, 

by  Mrs.  George  Hoague  ....... 

Rural  schools,  Home  visits  in,  by  Ruth  E.  Barnum,  R.N.  . 

Safe  but  unpalatable,  by  Joseph  C.  Knox       ..... 

Scamman,  Clarence  L.,  M.D.  —  Letter  from  Dr.  Chapin  . 

School,  Vegetable  cupboard  for  the  country,  by  Mary  Spalding,  B.S., 

M.A 

School  health  program   (book  note)  ..... 

Schools,  Home  visits  in  rural,  by  Ruth  E.  Barnum,  R.N.  . 
Schools,  The  dental  hygienist  in  the,  by  Osirene  E.  Rowell,  D.H. 
Schools,  The  value  of  a  nutritionist  in  the,  by  Mary  Elizabeth  O'Connor 
Service,  Howard  M.,  D.D.S.,  and  Fred  L.  Adair,  M.D.,  Care  of  the 

mouth  during  pregnancy  ....... 

Sewage  disposal  problems,  Private  water  supply  and,  by  Francis  H. 

Kingsbury        ....  .... 

Sleep  and  nutrition,  by  Harold  C.  Stuart,  M.D.       .... 

Smillie,  Octavia,  Food  for  the  adult       ...... 

Smillie,  Wilson  G.,  M.D.,  D.P.H.,  Development  of  full  time  county 

health  service  in  the  United  States   ..... 
Southern  Berkshire  Health  District,  by  Frederick  S.  Leeder,  M.D., 

D.P.H 

Southern  Berkshire  Health  District,  Proposed  dental  program  for 

the,  by  Frederick  S.  Leeder,  M.D.,  D.P.H 

Spalding,  Mary,  B.S.,  M.A.,  Food  at  low  cost  for  teeth  . 

Nutrition  emergency       ...  .... 

Vegetable   cupboard   for  the   country  school    .... 

Special  problems  of  communicable  diseases  in  the  small  community, 

by  Gaylord  W.  Anderson,  M.D.  ...... 


217 

PAGE 
Spitz,  Gertrude  T.,  A.B.,  A.M.,  Teaching  nutrition  in  an  out-patient 

department      ...  .....     74 

Staff  education  in  nutrition  —  Springfield,   Mass.,  by   Florence  G. 

Dorward  .........     77 

Stuart,  Harold  C,  M.D.,  Sleep  and  nutrition  .  .  .56 

Stuart,  Lillian,  and  Leamy,  Catherine,  Nutrition  phase  of  the  Chad- 
wick  clinics     .........      84 

Studies  —  Selected  reprints    (book  note)  .  .46 

Summary  of  round  table  on  the  handicapped  child,  by  Alfred  F. 

Whitman 178 

Summer  school  at  Hyannis  ........     45 

Swift,  Mildred  L.,  An  echo  returns       ......     83 

Syphilis  in  rural  areas,  The  problem  of  gonorrhea  and,  by  N.  A. 

Nelson,  M.D 135 

Teaching  nutrition  in  an  out-patient  department,  by  Gertrude  T. 

Spitz,  A.B.,  A.M.    .  74 

Teaching  of  oral  hygiene  to  newsboys,  by  Harry  Goldinger,  D.M.D.  .  38 
Teeth,  Building  sound,  by  May  E.  Foley  .  .  .35 

Teeth,  Directions  for  brushing  properly  .  .  .15 

Teeth,  Food  at  low  cost  for,  by  Mary  Spalding,  B.S.,  M.A.  10 

Teeth,  The  importance  of  the  baby,  by  R.  C.  Willett,  D.M.D.  .  .     12 

Training  a  nutritionist,  Recommendations  for  .  .  .87 

Trend  toward  parent  education,  by  Clifford  K.  Brown    .  .  .   169 

Trends  in  the  development  of  the  dental  program  of  the  Massachusetts 

Department  of  Public  Health,  by  George  H.  Bigelow,  M.D.  .  3 
Trow,  Nancy  A.,  A  Red  Cross  traveling  dental  clinic   .  .  .34 

Value  of  a  nutritionist  in  the  schools,  by  Mary  Elizabeth  O'Connor  .  78 
Value  of  health  education  to  the  community,  by  Michele  Nigro,  M.D.  87 
Vegetable  cupboard  for  the  country  school,  by  Mary  Spalding,  B.S., 

M.A ....   159 

Vincent's  infection,  by  Francis  H.  Daley,  D.M.D.   .  .  .15 

Walcott,  Dr.  Henry  P 202 

Waldron,  Eva  A.,  R.N.,  A  prenatal  and  preschool  dental  program  from 

a  public  health  nursing  point  of  view  .  .30 

Walker,  W.  F.,  D.P.H.,  The  evaluation  of  rural  health  work  .  .   124 

Wandel,  George  H.,  D.D.S.,  Providing  dental  care  to  maternity  cases  9 
Washburn,  Frank  H.,  M.D.,  F.A.C.S.,  Medical  practice  in  rural  areas  129 
Water  —  Safe  but  unpalatable,  by  Joseph  C.  Knox  .  .  .  .97 

Water  supply,  Private,  and  sewage  disposal  problems,  by  Francis  H. 

Kingsbury       .........   142 

Well  child  conference  —  An  island  visit,  by  Susan  M.  Coffin,  M.D.  .  196 
Well  child  conference,  Dental  hygiene  as  part  of  the,  by  Eleanor  G. 

McCarthy,  B.S.,  D.H .4 

White  House  Conference,  Notes  from  the,  by  Eleanor  G.  McCarthy, 

B.S.,  D.H .  .25 

White  House  Conference  publications  on  nutrition  ....  100 
Whitman,  Alfred  F.,  Summary  of  round  table  on  the  handicapped  child  178 
Willett,  R.  C,  D.M.D.,  The  importance  of  the  baby  teeth  .      L    .  .12 

Women,  Exercise  as  an  aid  to  health  in,  by  Alice  E.  Sanderson  Clow, 

B.Sc,  B.S.,  M.D 

Woodbury,  Marion  C.,  R.N.,  A  program  for  public 

a  country  community 


health  nursing  in 


Youngest  of  the  family  (book  note) 
Your  hearing  (book  note) 


199 
137 


204 
204 


Publication  op  this  Document  Approved  by  the  Commission  on  Administration  and  Finance 
5M.     12-'32.     Order  7066.