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U. S. DEPARTMENT OF LABOR
JAMES J. DAVIS, Secretary
CHILDREN’S BUREAU
G R A C E A B B O T T , Chief
PROCEEDINGS OF THE
THIRD ANNUAL CONFERENCE OF
STATE DIRECTORS IN CHARGE OF THE LOCAL
ADMINISTRATION OF THE MATERNITY
AND INFANCY ACT
(ACT OF CONGRESS OF NOVEMBER 23, 1921)
HELD IN WASHINGTON, D.C.
JANUARY 11-13,1926
BUREAU PUBLICATION No. 157
WASHINGTON
GOVERNMENT PRINTING OFFICE
1926
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A D D I T I O N A L C O TIE S
OF THIS PUBLICATION M AT BE PROCUBED FROM
THE SUPERINTENDENT OF DOCUMENTS
GOVERNMENT PRINTING OFFICE
WASHINGTON, D . C.
AT
30 C E N T S P E R C O P Y
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CONTENTS
Page
Letter o f transmittal__________
MONDAY, JANUARY 11— MORNING SESSION
T ^ r ^ ^ SieA^n^ Pf / t r! n a Practical State program of prenatal care, by
¿red L. Adair M. D., assistant professor of obstetrics and gynecology,
University o f Minnesota Medical School_____________________ _ ____ _ _
Standards of prenatal care, by Robert L. De Normandie, M. D.Z instruc
tor m obstetrics, Harvard Medical School_______________________________
2
10
VanUSarcom rtRn N St&te program of prenatal care, by Carolyn Conant
20
Discussion of the papers of the morning session_______________
28
MONDAY, JANUARY 11— AFTERNOON SESSION
Stv S £ i Can ^ 1"idieS. a^d graphs’ hy Henry Schultz, director, statistical di
vision, Children s Bureau, United States Department of Labor.
H Normirndip6
° l ca" ses. o f maternal mortality, by Robert L. De
^ DScussfonM ‘ D ” nstructor m obstetrics, Harvard Medical School___
38
42
52
TUESDAY, JANUARY 12— MORNING SESSION
Midwife classes, by Julius Levy, M. D., consultant, bureau o f child
hygiene, department of health. New Jersev
Discussion_________________________________ __
“
A demonstration o f the community control of rickets, by Martha M. Eliot"
D e S ito e n t 5 t S
®
“ diTlSl° n' ChlMren's
United States
Discussion___________________________
Z_Z~
~
'—
Itliier^ ? t conferences Standards of examinations, by J. "h Z'm T soii" K noxZ
land
D ’ Cllief’ bureau of child hygiene, department of health, MaryDiscussion________________________~I~II
board of
T
th n Chi1?, ^ t t s sixth fear","before"entering"school^"by
' i i r e C t M ’ bnrean °* ni-M gygton,- State
Perzniment ebild-beallh centers la Pennsylvania, by Mary Kiggs Nobie
h e a f e . ' S s S 01 <UTWOn' bUreBU ° f ChUd health,department of
Discussion___________________________
61
66
72
76
80
82
84
89
92
TUESDAY, JANUARY 12— AFTERNOON SESSION
Stimulation of birth registration, by W illiam H . Davis, M. D
Bflrca“ ° f
D iscussion___________________________
_
chief stat-
United States De98
_
102
Inw S 111hJh A r lediw 115 r me?sion in re^ard to maternal and chll"d welfare
P b l l a d e t h l ^ n ^ ^ n f ^ ’ M' D " CTTOC0l<* lgt and obstetrician,
can popular magazines aid in campaigns to reduce Infant and
« ip ^ ^ ernai
rates? by W illiam L. Chenery, editor, Collier’s W eekly
SlCS f1iw *nd+ti,e n.ewsPaPers — Informing the public in regard to maternal
and infant hygiene, by Watson Davis, manager, Science Service
Inf1tyuotion on child health by cartoons and posters, by A . C. Mitchell"
illustrator, State board of health, Texas______________
’
Discussion of publicity for maternal and child-welfare work__Z_ZZZZZ
in
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104
110
114
117
124
CONTENTS
IV
WEDNESDAY, JANUARY 13— MORNING SESSION
The practical application of mental hygiene to the welfare of the child,
by D. A. Thom, M. D., director of the habit clinics of the Community
Health Association of B oston; director, division of mental hygiene,
Massachusetts department of mental diseases--------------------------- :--------------Discussion----------------------------------------------------------------------------------------------------Nutrition in relation to reproduction and the vitality of the offspring,
by Nina Simmonds, D. Sc., associate professor of chemical hygiene,
School of Hygiene and Public Health, Johns Hopkins University---------Discussion-----------------------------------------------------------------------Mothers’ classes, by Ada E. Schweitzer, M. D., director, division of infant
and child hygiene, State board of health, Indiana--------------- — ------------ —
Discussion---------------------------------------------------------------------------------------Little mothers’ classes, by Mrs. Gertrude C. Hasbrouck, organizer of
infant-hygiene courses, bureau of child welfare and public-health nurs
ing, State board of health,Wisconsin------------------------------------------------------------Discussion-------------------------------------------------------------------------- -------------------- -—
Page
129
137
143
1^1
157
161
164
169
WEDNESDAY, JANUARY 13— AFTERNOON SESSION
The use o f county units in relation to county organization for work under
the maternity and infancy law, by Joe P. Bowdoin, M. D., director,
division of child hygiene, State board of health, Georgia----------------------Discussion-------------------- -------------------------------------------------------------------------------The cooperation of physicians in maternity and infancy work, by Mrs.
E. N. Mathews, executive secretary, child-welfare bureau, department
of public instruction,Colorado----------------------------------------------------------------------W hy New Mexico nurses cooperate in maternity and infancy work, by
Dorothy R. Anderson, R. N., director, division of child hygiene and
public-health nursing, bureau of public health, board of public welfare,
New Mexico------------ -------------------------------------------- ------------- ;---------------------------The cooperation of lay organizations in maternity and infancy work, by
H . Y. Richards, M. D., director, bureau of child hygiene, State board
of health, Utah_________ ______________________________ _________ _____________
The cooperation of farm groups and home demonstration agents in mater
nity and infancy work, by E. H. Lauer, Ph. D., director, division of
maternity and infant hygiene, State University o f Iowa------ -------------- _—
Methods of determining the amount of time spent in maternity and in
fancy work when matching other funds, by Jessie L. Marriner, R . N.,
director, bureau of child hygiene and public-health nursing, State board
of health, Alabam a______________________________________ _________________ 7 —
Cost of separate items of work, by Elizabeth M. Gardiner, M. D., acting
director, division of maternity, infancy, and child hygiene, department
of health, New York------------------------------------------------------------------------------------Discussion of the papers of the afternoon session---------------------------------------Appendix.— Persons who attended the conference---------------------------------- —
172
174
176
160
163
186
189
193
196
205
JVTAP
States accepting the benefits of the act for the promotion of the welfare
and hygiene of maternity and infancy, with dates of legislative accept
ance_______________________________________________ ------------------------ ■'-*--------------
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**
LETTE R OF TRANSM ITTAL
U.
S.
D
e p a r t m e n t of
L
abor,
C h i l d r e n ’s B
ureau,
Washington, A pril 29, 1926.
S i r : There is transmitted herewith a report o f the conference o f
State directors in immediate charge o f the local administration o f
io
act> held in Washington, January 11 to
Id, 1926. I his is the third conference o f this sort which the Chil
dren s Bureau has held. Although the proceedings o f the first two
were not published, it has been decided in response to many requests
to publish the proceedings of this year’s conference. It is believed
that the papers and discussions will be useful not only to State and
county health officers, but to many private agencies which are at
work on similar programs and to interested professional and lay
groups.
J
Respectfully submitted.
TT
T
G r a c e A b b o t t , Chief.
H
on.
J ames J. D
a v is ,
Secretary o f Labor.
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STA TE S A CCE PTING THE BENEFITS O F TH E A C T FO R THE P R O M O T IO N O F THE W E LFA R E A N D H Y G IE N E
O F M A T E R N I T Y A N D IN F A N C Y , W IT H DA TES O F LE GISLATIVE ACCEPTANCE
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[Diagonal lines indicate States not cooperating]
\
r s i kaaBs%r™“a”>
■“
,
MONDAY JANUARY 11—MORNING SESSION
GEACE ABBOTT, CHIEF, CHILDREN’ S BUREAU, UNITED STATES DEPARTMENT OF LABOR.
PRESIDING
^
T he C h a i r m a n . It is a very great pleasure to have so many o f
you here this mornmg. In the program for this year we are carrying
out as far as possible the recommendation^ made at last year’s con5
?
h° Pe
WlU Pl ° Ve reaHy profitable. As was requested,
the prenatal ^program has been especially stressed. This morning
we begin with the general subject o f a practical State program
o f Pr.enatal care. Dr. Fred L. Adair, who has done so much work
m this held both before the maternity and infancy law was passed
and smce that time, was to begin thg discussion o f the subject for us.
Unfortunately he has not been able to come on account o f the serious
and cntmai diness o f his mother; but Doctor Boynton, director o f
the Minnesota division of child hygiene, has brought Doctor Adair’s
paper and will read it.
1
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THE PHYSICIAN’ S PART IN A PRACTICAL STATE
PROGRAM OF PREN ATAL CARE
B
y
F
red.
L.
cology,
A
T
d a ir ,
he
U
A
s s o c ia t e
n iv e r s it y
P
r o fe sso r o f
of
M
in n e s o t a
O b s t e t r ic s a n d G y n e
M e d ic a l S c h o o l
[Read by Dr. Ruth E. Boynton]
A good understanding o f the significance and purpose o f prenatal
or antepartum care must be had before an attempt is made to elab
orate an intelligent and practical program and to define the relation
ship o f the physician to such a plan for the State.1 According to the
standards o f prenatal care recently formulated by the committee
appointed for that purpose by the Children’s Bureau (see p. if))
“ prenatal care is that part of maternal care which has as its object
the complete supervision o f the prospective mother in order to preserve the offspring's and. her own happiness^ healthy and life. > Therefore all pregnant women should be under medical supervision dur
ing their pregnancy, for it is only by careful routine prenatal care
that pregnancy and labor can be made safer.”
.
I f we are created to create, and the chief end of man is man—dare
one in this modern era say that maternity is the chief function o f
women ? The carrying out o f this physiologic law is vital to the per
petuation of the human race, which we assume to be the desire o f
human beings. The proper carrying out of this function involves
many laws and principles which are as yet but imperfectly under
stood, and even those facts which are established are not generally
appreciated and applied. W e may also fairly assume that all
reasonable humans take enough pride in their being to realize the
desirability, importance, and ultimate necessity of continued improve
ment and upbuilding of the human race.
.
Much can be done' by caring for mother and future offspring dur
ing the period o f pregnancy. For instance, congenital syphilis can
be more effectually treated during pregnancy than during infancy,
and no one doubts that it could be still more adequately handled
before the onset o f pregnancy. This specific instance illustrates the
general principle that although much can be done by our present
plan o f prenatal care to preserve the happiness, health, and lives of
offspring this plan is too limited to accomplish fully the purposes
which are enunciated. While we are striving to perfect and carry
out universally the care o f the pregnant woman we must also begin
to enlarge our definition o f prenatal care or coin another name, such
as anteconceptional care or preembryonic care.
_.
,
This leads one to consider when prenatal care begins; and it must
be recognized that causes operate to affect the offspring for good or
ill before the fertilization which leads to the ultimate development
of an individual. There is a continuous chain of events without
definite beginnings or endings and all we can do is to pick up the
i The word State is here used to refer to the geographic or goyergmeptal unit,
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TH E P H Y S IC IA N S PART IX A EROGRa M OF EREX a TAL CARE
3
individual links and try to weld as strong a chain as possible for
human welfare. W e are struggling against tuberculosis as a disease
o f individuals, but do we think o f it from the standpoint o f future
generations? Do we realize or understand the ultimate possibilities
o f not propagating individuals peculiarly susceptible to tuber
culosis? Do we grasp the tremendous importance to future genera
tions o f preventing tuberculous infection in the fathers and mothers
o f the coming generation ? Can the increase o f defectives be checked
by care o f the pregnant woman? Which type o f prenatal care is
more sane and far-reaching in its results—that which is applied to
defective individuals during the anteconceptional or preembryonic
period and prevents the natural increase o f such individuals or that
plan which humanely surrounds these poor defectives who are pros
pective mothers by prenatal care which is good but hopelessly inade
quate so far as final results are concerned ? This is pointed out from
no lack o f pity for these poor unfortunates, but because the pity is
so great that one wishes there were no more o f them to interfere
with the happiness and usefulness o f future generations. One can
but praise the efforts for the proper feeding and development, both
physical and psychic, o f the infants and children o f the present
day 5but is the tremendous prenatal significance o f this program of
infant and child welfare appreciated ?
Consider the one fact o f skeletal development and the elimination
o f rachitis in its relation to childbearing. A t one time this disease
was so common in England as to bear the name English disease.
It is still common among many groups in all countries. Can one
estimate the tremendous importance o f the complete elimination o f
this disease in terms o f its result on childbearing and in preserving
the happiness, health, and lives o f both mother and offspring? In
the same manner the prevention o f faulty nutrition, o f improper
hygiene, both physical and mental, and o f disease would forestall
many unhappy results which ensue in later life and handicap both
mothers and offspring.
The prevention and appropriate treatment of such diseases as
scarlet fever and diphtheria in childhood would doubtless prevent
some o f the cardiac and renal conditions which in later life may
complicate pregnancy and labor. The prevention and appropriate
treatment o f such diseases in young adult life as rheumatic fever
would prevent many cardiac complications o f pregnancy. The rec
ognition and removal o f foci o f streptococcic infection might remove
many o f the complicating renal conditions o f pregnancy.
It might seem almost useless to talk o f the hackneyed subject o f
venereal disease, its cure and prevention, if it were not almost an
everyday occurrence to see the dire results o f gonorrheal and syphi
litic infection on both mothers and offspring. It is useless to think
o f accomplishing the purposes o f prenatal care by the treatment o f
these diseases during pregnancy. Such therapy at times can not be
avoided; but the laity should understand and the medical profession
should realize more fully the necessity for curing these diseases be
fore the onset o f pregnancy, and they should make such procedure a
more general practice.
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4
PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
Much good could be accomplished for both parents and offspring
if careful histories and physical examinations of potential fathers
and mothers could be made effectually before conception took place.
This would be in line with the idea o f periodic physical examinations,
but the point o f view would be somewhat different. The idea back o f
the periodic health examination is, o f course, the welfare o f the indi
vidual ; but here we would take into consideration not only the health
o f the prospective parent but also that o f the future offspring. This
brings up the matter of the future father and his relation to the
happiness, health, and even life o f both his wife and his offspring.
This parent has been largely ignored in prenatal plans, and yet he is
responsible for a great deal o f damage, some o f which could be
avoided by his inclusion in the prenatal program.
Proper prenatal care o f the future mother includes much more
than the physician can supply. She needs all any woman needs—
and more—to insure her comfort, happiness, and good health. Every
thing to make a suitable environment, assuring good hygiene, proper
nutriment, appropriate work, and recreation should be provided. No
physician, even granting that he has the requisite knowledge to ad
vise properly, could furnish all the social and economic desiderata
to his patients. Many things which are desirable and much that is
necessary for these women can not be furnished under the present
social and economic system. But a very important part o f any
prenatal plan is the guidance o f mothers in making the most o f the
facilities they have, and, in case o f need, assisting them to obtain the
necessities which they lack for themselves and the future baby. This
is, o f course, somewhat aside from the physician’s part in the plan;
but it is vital for the success o f his work and for the welfare o f his
patients. It is highly desirable that the physician make it a point
to see that the patient make some contacts by which these needs may
be met. This is, in fact, almost vital for the proper working of the
prenatal plan, as well as for the natal and postnatal care, which are
certainly not o f less importance. The physician’s main task is that
o f looking after the health o f his clientele, but the idea o f healing the
sick has been so thoroughly ingrained that it is difficult to inculcate
the idea o f prevention into the lay and medical mind. Unless one
grasps the fundamental idea o f prevention as applied to obstetrics,
there will be no comprehension o f prenatal care. Unfortunately not
all catastrophes can be prevented even though foreseen, so it dan be
assumed from the beginning that there probably never will be, by
any plan o f prenatal care, 100 per cent o f prevention o f the .condi
tions complicating pregnancy.
The physician’s first duty is to his patient, and if his obligations
are well met he is fulfilling to a l^rge extent his part in carrying out
the plan o f prenatal care. As an individual he can hardly solicit
the people’s patronage, but he can instruct and care for them after
his advice has been sought. The first part the physician plays in a
practical prenatal plan which we will consider is his individual rela
tionship to the prospective mother. His first effort should be to win
the confidence of his patient and assure her o f his interest in her
welfare. This can best be done by a careful consideration o f her
problems and a study o f her case. The physician who has known his
patient from infancy has a peculiar advantage provided he has the
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TH E P H YSIC IAN 'S PART IN A PROGRAM OE PRENATAL CARE
5
necessary intelligence and training to understand the events which
have taken place in her past life. Most physicians have not the
advantage o f this first-hand knowledge o f their patients. They
elicit their information by careful questioning and examination of
the patient herself, and perhaps even by interrogation of the parents
and husband. It is usually better to obtain the necessary informa
tion from the patient alone, because usually more accurate and com
plete data are given thus than when a third person is present. It is
also true that oftentimes more valuable information can be obtained
from parents or husband when the patient is not present. In general
these exhaustive inquiries are not necessary ; and yet one never knows
in which cases information of the utmost importance is being missed.
There is, however, so much room for improvement in the routine
management o f prenatal cases by the physician that one need not
consider overmuch the exceptional cases until the general level o f
obstetric practice has been raised above its present level.
When the patient is first seen a good history should be taken so
as to bring out the events in her past life. Facts relative to her early
development and nutrition should be elicited. History o f previous
diseases, such as scarlatina, diphtheria, rheumatic fever, tonsillitis,
variola, tuberculosis, and venereal infections should be obtained.
Indirect evidence and history of possible exposure to various in
fections often give valuable information. The facts as to previous
vaccination are important, as serious results for both mother and
fetus may be prevented. The occurrence o f conditions which have
required surgical intervention should be noted, also the history o f
goitrous conditions, thoracic disease, and acute or chronic abdominal
affections. The possibility o f persistent foci o f infection should not
be overlooked. The sexual life o f the woman should be considered
from the standpoint o f her puberal development and menstrual
history. The character o f previous pregnancies, labors, and puerperiums is important, and this information may best be obtained by
questions which will bring out the facts in chronological order. The
date o f termination should be ascertained, the period o f gestation,
complications, etc., that occurred during the labor. The immediate
and remote outcome o f this process, as affecting both mother and
offspring, is o f the greatest value in establishing future methods o f
procedure. It is o f course obvious that careful and accurate data
regarding the existing pregnancy should be obtained.
A careful physical examination should be made not only to estab
lish the patient’s status with reference to the pregnancy itself but
also to determine as accurately as possible the physical and mental
condition o f the woman. It is not necessary to go into the details o f
this examination, as every physician should know the steps neces
sary as a routine, and should then make such additional investiga
tion as may be needed in individual cases. Special observations o f
importance for the management o f obstetrical cases should be added
to those usually employed in the physical examination o f patients.
Such a study should be sufficiently thorough and accurate to deter
mine whether the woman is in an approximately normal condition,
and if not, the nature and import o f the complicating condition.
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6
PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
It is not sufficient to make only one examination o f the patient.
She must be seen repeatedly during pregnancy in order to be super
vised intelligently. I f this is not done some affection may develop,
and the woman may be in a serious condition before it is realized.
In my experience it has not been sufficient to trust to the patient
herself to come for these periodic observations. Many will not come
o f their own accord so long as they feel w ell; and this is not a safe
guide, as many do not feel ill until some toxemia or other condition
has reached a serious stage. It is therefore necessary for the physi
cian or someone to follow up these cases at least until the laity is
more cooperatively intelligent regarding prenatal care than at the
present time.
Final obstetric examination should be made a few weeks before the
date at which confinement is expected in order to determine the
condition o f the mother and the size and position o f the fetus. Need
less to say, in determining how, where, and by whom the patient
should be cared for at the time o f delivery, one should be guided by
the information previously obtained; otherwise the good prenatal
care may have been for naught and the natal care may prove disas
trous to mother or offspring or both. Good prenatal care is nothing
but the proper foundation for good natal attention. Neither is
complete in itself, and if either is inadequate both may result in
failure. Nor are they complete without the best of postnatal care.
Improper postnatal care may thwart the results,of good prenatal
and natal care.
The advice, care, and attention which the physician gives to the
woman during her pregnancy, labor, and puerperium are based on
the evidence and information which the physician has obtained.
Naturally the management o f cases is not identical, and instructions
will differ; but there are some fundamentals which should be covered
in all cases, though the details differ according to the peculiarities
o f the different individuals.
It is not necessary to go into details regarding the hygiene of
pregnancy. The main facts are, or should be, common knowledge.
Any physician should know these facts, and i f he does not it is
easy for him to obtain them if he is interested. It is one o f his
duties to provide the -patient with this information in some way.
He must decide on his instructions and vary them according to the
individual needs o f his patients. He must continually be on the
lookout for abnormal conditions which are both accidental and
incidental to pregnancy. It is part o f the physician’s task to obtain
the cooperation o f his patient so that he may be informed at the
earliest possible time o f any symptoms indicating complications.
Only in this manner can events which lead to disaster for mother
and offspring be avoided during pregnancy. Last, but by no means
least, the prospective mother must be shown the necessity and manner
o f preparing herself (and her home, i f need be) for the reception
o f the newcomer. It is only during pregnancy that proper prepa
rations can be made for the all-important natal and postnatal care.
Here is another important task for the physician in his relation
to his individual patient. Prenatal care is not an end in itself but
only a means to an end.
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THE PHYSICIAN S PART IN A PROGRAM OP PRENATAL CARE
7
The physician also has a relationship to his community. He is
granted the privilege o f medical practice by the State, and in con
sequence he incurs certain obligations. Chief among these is that
o f teaching and helping the community to prevent disease and death
among its members. It should be one o f his functions to cooperate
in every way with the various agencies o f his community in an effort
to apply prevention o f death and disease in connection with the
practice o f obstetrics. ^It is his job to educate; to demonstrate by
his methods o f obstetric care that he knows the importance o f the
proper examination and observation o f pregnant women.
Again, there is a relationship between members o f the medical
profession. One member should not hesitate to give advice and
help, or to receive it from another professional man who is qualified
to give it. There remain the specialist in obstetrics and the general
practitioner or inexperienced obstetrician to consider. The ex
perienced specialist really should not care for the routine and normal
obstetrical cases. He should rather reserve his energy and ability
for the more trying and hazardous cases. On the other hand, the
practitioner and inexperienced obstetrician should not hesitate to
seek from others the benefit of their greater experience for the
welfare o f his patients.
The relation o f the practitioner to clinics is o f great impor
tance. Many patients can not afford to pay an adequate fee for
prenatal, natal, and postnatal care. Some can not pay for any o f this
service and should receive this care in a free or per diem clinic.
Other patients are able to pay for part o f the service and can em
ploy a physician for this portion o f their care. There should be
the fullest cooperation between the physicians and these clinics
to the ultimate benefit o f all concerned. There should be helpful
teamwork between those who practice obstetrics and the maternity
wards o f hospitals so that complicated cases can be hospitalized
promptly and cared for properly before it is too late to prevent
disastrous consequences. Hospital facilities for the care o f ma
ternity patients have been and still are woefully inadequate. Phy
sicians should cooperate in plans to develop and improve such hos
pital facilities not only in large centers o f population but also in
counties and small cities, where their existence is even more im
portant.
What the individual physician should do, as outlined above, the
medical profession should also do on a larger scale. The community
should be educated to the necessity o f prevention in general and
to the importance o f prevention o f maternal and fetal mortality
and morbidity. There is nothing more important to the community
than the production and protection o f normal human beings. Proper
obstetric care, as represented by prenatal -care, is one o f the most
important ways o f ^accomplishing this result. The medical pro
fession. should be vitally interested in fostering a State plan for
carrying on this work. There should always be frankness and
harmony between those who are officially responsible for carrying
on the work and those who are actually in the field. Both are
W°J
i°r
we^ are
mankind and attempting to save life
and health. No plan of prenatal care can be successful in any
State where the participation and cooperation o f the medical pro-
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$
PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
fession has not been obtained, for the physicians are the persons to
carry on the work with women in pregnancy and labor and with
the newborn. The plan is, and should be, mutual. The maternity
and infancy program can be carried out successfully in no other
way.
Teachers and teaching institutions are indispensable in the ac
complishment o f any State plan. Physicians already in practice
need to be taught and helped to keep abreast o f obstetric progress.
Specialists must be taught and trained through years o f instruction.
Practitioners must be prepared during the undergraduate course
and the interne year. This means that there must be good teachers,
well trained and with adequate time and energy to make teaching
their main work. It means also that there must be adequate teach
ing hours for obstetrics, adequate equipment, and patients who can
be used clinically for demonstration without harm or discomfort
to themselves or offspring.
Investigators are always o f the greatest importance in any field.
Competent ones are scarce, and their facilities are none too good.
The problems are numerous, and they will sooner or later be
solved. Investigators should be included in any practical State
plan— at least to the extent that desirable material should be made
available for their careful study. Physicians should recognize and
cooperate in furthering this plan.
There must, therefore, be close cooperation among officials, prac
titioners, and the medical profession. The laity and physicians must
understand each other. The former must realize that careful prepa
ration and years o f study are necessary qualifications, and the latter
must know that the people wish real service which gives results.
Obstetric practitioners must cooperate with one another, and men
must realize their own limitations and recognize the qualifications
o f others along special lines. A ll should strive for better institu
tional facilities and organizations for maternity care. There should
be closer contact between practitioners and teachers and teaching
institutions. Investigators should be encouraged and supplied with
material for study from all available sources. W e should all realize
the value o f statistics and especially vital statistics, and should co
operate to the fullest extent in obtaining accurate and valuable
reports. It is also important that we recognize the desirability o f
certain changes in reporting terminations o f pregnancy, especially
those pregnancies which result in stillbirths and nonviable premature
fetuses. Physicians should recognize the fields of activity occupied
in prenatal work by nurses and social workers. Each should take
pride in his own work and respect the ability and usefulness o f those
in other fields o f activity so that all may work together in harmony
for the preservation o f the happiness, health, and lives of mothers
and their offspring.
The C h a i r m a n . W e are going to postpone our discussion until
the end o f the morning session. You will remember that at last
year’s conference it was voted that the Children’s Bureau should
undertake to have a committee prepare standards on prenatal care
which you might use in your own State work. W e began shortly
after the last conference and have the printed pamphlets ready for
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TH E P H Y S IC IA N ^ PART IN A PROGRAM OF PRENATAL CARE
9
distribution at this conference. Since the discussion o f these stand
ards will involve discussion o f Doctor Adair’s paper I am going to
vary the program slightly. Doctor De Normandie was good enough
to serve as chairman o f the committee on prenatal standards and to
organize the committee. I am sure that all o f you are grateful to
him, as I am, for all the work he has done on the committee and also
because he is here with us this morning. W e shall have copies o f the
pamphlet distributed and then we shall hear from Doctor De Nor
mandie.
[Copies of Standards of Prenatal Care (Children’s Bureau Publication No. 153) were
distributed]
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STANDARDS OF PREN ATAL CARE
B
y
R
obert
L. D
e
N o r m a n d ie , M . D ., I nstr u c to r
H a r v a r d M e d ic a l S c h o o l
in
O b s t e t r ic s ,
A t the meeting held in October, 1924, similar to the one which you
are now holding, it was suggested that standards for prenatal care
be drawn up for the use o f physicians at clinics and in private work.
This request originated, I believe, because there is such a wide vari
ance o f opinion regarding what constitutes proper prenatal care.
W ith Miss Abbott’s help I appointed the following committee: Dr.
Fred L. Adair, of Minneapolis; Dr. Rudolph W. Holmes, o f Chicago;
Dr. Ralph W . Lobenstine, o f New Y ork ; Dr. Frank W. Lynch, of
San Francisco; Dr. Florence L. McKay, o f Albany; Dr. James R.
McCord, o f Atlanta; Dr. C. Jeff Miller, o f New Orleans; Dr. George
Clark Mosher, o f Kansas C ity; Dr. Otto Schwarz, o f St. L ouis; and
Dr. Annie S. Yeech, o f Louisville.
I sent first to each member o f the committee an outline o f possible
standards with the request that each member criticize constructively
each point made and return the criticism to me. When the majority
o f the committee agreed on one point to be added or taken from the
outline I made the addition or omission and reconstructed a second
copy o f the standards. This outline was then sent to each member
for further criticism. After much correspondence I called a meet
ing on May 2, 1925, in Washington. A t this meeting were present
Doctor Adair, Doctor Schwarz, Doctor McKay, Doctor Mosher, Dr.
Alice Pickett (who was designated by Doctor Yeech to act in her
stead), and Doctor Kraker, acting director o f the maternity and
infant-hygiene division o f the Children’s Bureau.
At the very beginning o f the correspondence with the various
members it became clear that only by compromise could any such
group o f physicians agree on what was essential for an outline on
prenatal care which would not be too bulky. Each one made con
cessions on certain details which he would like to have included in
the standards. The result is this outline which you now have in
your hands and which I wish to go over with you point by point.
It has been demonstrated for many years that prenatal care is an
important part o f the care o f the pregnant woman i f the happiness,
health, and life o f the mother and the child are to be preserved. I f
that is so— and I think every one o f you will agree that it is a true
statement— every pregnant woman should be under medical super
vision during her entire pregnancy. Even if a woman is under con
stant supervision the pregnancy and labor can not be wholly safe;
but it can be made safer than it now is.
Throughout these standards we are insisting that the facts which
are obtained be recorded; in other words, that there be a history o f
every pregnant patient who comes under the care o f the physician
or the clinic. The patient’s history must be gone into. The diseases
that she has had, particularly whether there is tuberculosis in her
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11
history or exposure to tuberculosis, must be known. Scarlet fever,
tonsillitis, rheumatism, and diphtheria are especially to be noted;
for you all know o f the complications that may arise either in the
kidneys or in the heart from these acute infectious diseases. Surgical
conditions and operations, especially abdominal or pelvic operations,
must be recorded. The patient’s menstrual history, its cycle, thé
amount o f flow, duration, and whether or not pain is present must
also be recorded.
Next comes the question o f previous pregnancies and labors i f the
patient is a multigravida. It must bé insisted that the data o f a l l ,
previous pregnancies be obtained. That means abortions, miscar-'
riages, and criminal abortions as well as full-term pregnancies; for
many patients will tell only o f full-term babies and will give no
inkling that they have had abortions unless they are questioned care
fully. In regard to each pregnancy the following points must be
determined : The date o f termination, the period o f gestation, and
any complications that occurred during pregnancy; the type o f
labor; its onset, whether it was spontaneous or induced ; the duration
o f labor ; and how that labor terminated, whether it was spontane
ous (a normal delivery) or artificial (an operative delivery) ; and, if
it was operative, by what method the delivery was accomplished.
The puerperium must be inquired into—-whether the patient made a
normal convalescence, whether infection was present, whether any
hemorrhage took place, or whether any operation followed a stormy
convalescence. The outcome o f these pregnancies must also be
known— whether the baby was alive or dead at birth, whether macer
ation was present, and whether the baby came at term or was pre
mature. The duration o f breast feeding, if breast feeding was pos
sible, must be recorded; and finally it must be known whether the
babies are now alive, and, if they died, what they died from, espe
cially i f they died within the first two weeks o f life.
Then follow the details in regard to the present pregnancy. What
were the character and date o f the last menstruation? Inquire
carefully whether that period was an absolutely normal period, for
an abnormal period may be the first suggestion of an extra-uterine
pregnancy, or it may be due to the fact that pregnancy began just
before a period rather than after the period. I f that is known it may
explain at a later date the fact that the fundus, is enlarging more
rapidly than was expected. Determine whether the patient is having
nausea and vomiting, and how severe this is. I f she is far enough
advanced in her pregnancy find out when she first felt life. In
the absence o f definite menstrual dates the time when the patient
felt life will help to a slight extent to determine when the labor may
be expected ; but do not be too certain that life is felt at the half-way
point, for it is a very variable phenomenon. From the date o f the
last menstruation we estimate the date o f the delivery.
With this history obtained we then proceed to a physical examina
tion. This we insist upon as a necessary part o i prenatal care, a
part that all too seldom is done in a satisfactory manner. Whether
or not physicians proceed in the physical examination in the order
that we have suggested is o f course immaterial. These are, however,
the main points that must be recorded. Again we insist that the
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
recording o f the facts obtained is most important. The blood pres
sure has come to be an essential part o f prenatal care. It is just
as imperative for a physician to take the blood pressure when he
sees his pregnant patients as it is for him to go about visiting
his patients with his bag and his stethoscope or with his thermom
eter. Without it satisfactory prenatal work can not be carried out.
The systolic and diastolic readings must be taken, the patient’s
temperature and pulse recorded, and the weight taken. We all
agreed that the weight is a significant item o f the prenatal care, for
many o f us have come to feel that a patient who gains rapidly dur
ing her pregnancy is much more apt to develop a toxemia o f
pregnancy and a possible eclampsia than one whose weight is kept
within normal limits. The patient’s general nutrition, the chest
examination, inspection o f her breasts, mouth, and extremities are all
essential. Then comes the abdominal examination with careful
palpation; and auscultation o f the fetal heart i f the patient is far
enough advanced.
Kelatively very few pregnant patients have a vaginal examination
the first time they appear in a physician’s office. Make it clear when
you talk over these standards that vaginal examinations during the
last month o f normal gestation should not be made without strict
aseptic precautions; and at no time, if vaginal bleeding is present,
should a vaginal examination be made without these precautions.
W hy do we suggest that a vaginal examination is necessary early
in pregnancy? Especially to determine the existence o f a preg
nancy. You all have known o f patients who have been carried along
for months only to have it determined that they are not pregnant
or that some abnormal pregnancy exists. A vaginal examination
determines the probability o f a pregnancy and whether there is
anything abnormal in the position o f the uterus or whether any
pelvic tumor is present. The presence o f a venereal disease is dis
covered— a fact extremely important to know early not only for the
welfare o f the mother but for that o f the baby also. A speculum
examination o f the cervix is advised because o f the many cases that
present an eroded cervix and may show troublesome bleeding. I f
this occurs it causes the physician and the patient much annoyance
unless the source o f the bleeding is established.
We suggest that the pelvic measurements be taken at this first
visit o f the patient'to the physician. Whether or not it is done at
the first time is really immaterial. The point is that i f they are
taken the first time, it is done and out or the way, and there will
be no slip-up later— for you will all agree that pelvic measurements
must be taken in the course o f the pregnancy. I do not think it
is necessary that pelvic measurements be taken in multigravidse who
have had average-sized children without difficulty. The measure
ments suggested are the usual ones which tell the size and the type
o f the pelvis. They are the intercristal, the interspinous, the ex
ternal conjugate, the diagonal conjugate, and the transverse diam
eter o f the outlet. When you come to talk over these pelvic measure
ments you may be questioned as to how they are to be taken, and you
must know. I assume that you do know how they are taken. There
is one point to be remembered: That in taking the transverse diam
eter o f the outlet the physicians may not all have the little outlet
pelvimeter, but thev all have fists; and after the palpation o f the
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STANDARDS OF PRENATAL CARE
13
pelvic contours, the sacrum, the coccyx and ischial spines, and the
attempt to reach the promontory the fist can be rocked between the
tuberosities; and, knowing what the fist measures, one very quickly
determines whether the outlet is contracted.
The blood must be taken for a Wassermann reaction and sent to a
laboratory o f unquestioned standing. Wa^sermanns are taken as a
routine throughout the country in all the large clinics, but they are
seldom taken as a routine in private work. It should be the routine
in private as well as in hospital work, for only thus will be found
the occasional syphilitic case which may give the patient untold
misery unless it is discovered early.
The routine urinalysis must be done, and i f there is any sugges
tion o f urinary complications, a microscopic examination o f the sedi
ment is necessary; and in many cases a 24-hour specimen must be
obtained.
When this complete physical examination is done and it is deter
mined that the patient is pregnant, the physician must give minute in
structions to the patient in regard to the hygiene of pregnancy. Fortunately we have some excellent publications of the Children’s
Bureau and o f the various State health departments on the hygiene
o f pregnancy, and if the physician is busy and in a hurry there is
no reason why these publications should not be given to the patient
to read over carefully. A t the next visit to the physician the patient
may ask about any o f the points in the pamphlets which she does
not understand. My feeling is that in a busy clinic these publica
tions should be given to each patient.
Let me go over with you the various points in more detail than
the mere list which you have, before you :
A. Diet. The chief point to be made clear to the patient is that
she must have a generous mixed diet— that is, the essential elements
that go to make up a well-balanced ration, proteids, fats, carbohy
drates, a liberal amount o f water, and a satisfactory amount o f mineral
matter. When the nausea is present six small meals a day rather
than the usual three will give much relief. The old saying that a
pregnant woman must eat for two has long since been exploded, and I
have already spoken o f the untoward results that may come when
a patient puts on a great amount of weight, because o f the danger of
a toxemia o f pregnancy. She must be warned not to listen to her
friends about the food that she should eat, for she may eat any kind
o f food that she knows she can digest. I f she has an idiosyncrasy
for any type o f food, o f course that food must be eliminated from
her dietary during her pregnancy. The proteid element in the food
puts the greatest strain on the kidneys, and the patient must be ad
vised to have a low proteid intake, especially in the latter part of
her pregnancy. However, there is absolutely no need that she elim
inate all meat, fish, and eggs the last two or three months o f preg
nancy, as many women think they must. ' Too high an intake o f fats
and carbohydrates makes the patient gain rapidly and will frequently
cause considerable indigestion. When the patient is eating too much
carbohydrate food, sugar frequently appears in the urine; and un
less it is quickly cleared serious damage may result. Milk, fruit,
and vegetables (especially the leafy ones) add to the vitamins and
mineral substances that are needed during pregnancy, also to
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
the amount o f water taken. I f the patient is heavy and fat
the drinking of much milk is questionable ; and the calcium may be
given to advantage in the form o f the carbonate. Drinking at least
eight glasses of water a day throughout the pregnancy must be in
sisted upon. Coffee and tea must be used in moderation, and alcohol
should be omitted.
B. Exercise, rest, sleep, and recreation. The physician should find
out to what exercise the patient has been accustomed and determine
whether she should be allowed to continue the same amount. Stren
uous athletic exercise should be prohibited. Walking is the best
possible exercise for the pregnant patient. How much she can walk
depends wholly upon whether or not she feels fatigue. A. simple
rule is that if the patient comes back from a walk and after resting
for half an hour gets up feeling refreshed she has not walked too
far; but if she is fatigued or is unable to sleep that night the length
o f the walk should be reduced. Many patients get much exercise
in their housework, but they must be cautioned about overdoing,
lifting heavy pieces of furniture, or doing a hard day’s washing.
O f course this hard housework can not be avoided by all patients,
but each must be told to do as little work as possible at the time when
she would be menstruating if she were not pregnant. She must
be made to comprehend that thè uterus is more irritable at what
would be a menstrual period were she not pregnant than at any other
time during the month and that therefore the liability to a mis
carriage is greater.
The question o f whether or not a patient shall work m mills otten
arises. Various legislative bodies have recognized the fact that preg
nant women should not work up to the date o f delivery. The law
regarding this varies in different parts o f the country, and obviously
it is a difficult thing to enforce. The fact, however, remains that
pregnant patients should not be employed in mills for any length oi
time. I f a pregnant patient thinks she must work in a mill, she
should be allowed to have periods o f rest in the morning and in the
afternoon.
.
. ,
We appreciate that it is difficult for many patients to obtain tne
rest which is so needful in order to have them go through their
pregnancies in good condition, but if we constantly reiterate that
rest is a necessary part o f their well-being many more will take it
than think they can at the present time.
Eight hours’ sleep every night is essential. Many women get
along for a while on less sleep than this, but sooner or later the lack
o f sleep begins to show itself in various ways. Many patients have
in early pregnancy an uncontrollable sleepiness which at times
greatly upsets them. I f careful examination shows everything to
be normal we can assure the patient that it will very shortly wear
off and need be no cause for alarm. On the other hand, it may be
one o f the symptoms o f a 'toxemia o f pregnancy ; and until this is
ruled out we must not regard it as negligible.
Recreation is extremely necessary for pregnant women* I he hum
drum existence that many housewives lead is a serious obstacle to
their well-being, and patients need periods of play as well as o±
work. They must be cautioned about taking long automobile rides
over rough roads. Long touring is a common cause of abortion, and
the .automobile should be forbidden if the patient has ever shown the
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STANDARDS OF PRENATAL CARE
15
slightest suggestion of miscarrying. I see no reason why she should
not drive herself, provided she drives carefully and slowly over good
roads; but if automobiling causes backaches and other discomforts
it should be stopped. Each physician feels differently in regard to
the various types o f recreation which a patient may take, according
to the results which he has seen arise from these forms o f recreation!
Ku
Pomts to be remembered in regard to the clothing
are that the clothes must be warm, and at no time should they be
allowed to be tight around the abdomen. Garments that hang from
the shoulders are to be preferred. The corsets for the first three or
tour months o f the pregnancy may be the ones which the patient has
been accustomed to using unless she has a pendulous abdomen. Such
a woman will feel more comfortable if she puts on a maternity corset
early. 1 here are many satisfactory makes o f maternity corset. One
that is satisfactory for one patient will not suit the next; nor is it
necessary that every patient wear corsets during her pregnancy, for
many women go through quite comfortably without any corset. If,
however, unpleasant bearing-down and pulling sensations develop,
then well-fitting, comfortable corsets will give support. The highheeled shoes o f the present-day fashion put a severe strain on the
patient s back muscles and should not be allowed. Low-heeled, wellSttipg, well-shaped shoes should be worn.
D, E, and F. The patient’s skin must be kept in good active con
dition, for this is one o f the three means o f excretion. A daily
warm bath keeps the body clean and the pores wide open. It is
well to explain to the patient that as the pregnancy advances and
the abdomen en laces little red lines may appear, due to the stretchg o f the skm. This stretching often gives a sensation o f burning
and tingling. Nothing need be done in regard to these lines except
to assure the patient that no harm will come from them. External
applications occasionally make them feel a little more comfortable
but will not eradicate them. The marked pigmentation that some
times appears, especially m brunettes, is annoying; but I know o f
nothmg that will prevent it. The patient may be assured that it
will all disappear after pregnancy and that in the course o f a few
weeks she will regain her former complexion.
Even more necessary than the care o f the skin is the care o f the
bowels and the kidneys. The patient must have at least one good
dejection a day. Recall to her the reason for this—that the baby
is growing rapidly and the products of not only her own metabolism
but ot the baby s metabolism must be eliminated, and that this is
done by the skin, bowels, and kidneys. This will impress upon her
the necessity o f keeping her bowels free. Many patients dislike
f L u t - f cat? artlc ™ pregnancy because o f the fear o f forming
tne habit; but even i f this fear is reasonable the daily movement
s essential, i t a satisfactory movement is not obtained by regulation o f the diet a cathartic must be taken. The milder ones work
satisfactorily m the majority o f cases but they may have to be
changed as the pregnancy advances. The kidneys should secrete
at least 3 pints o f urine m every 24 hours. The 24-hour amount
ot urine should be measured occasionally, and the patient will probaky i iaveI
b,e told bow ,t° do this. This amount can not be se
creted unless the patient is drinking from six to eight glasses o f
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PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
water a day. The patient must be warned that the passing of
high-colored urine at any time must be reported to the physician.
G. The care o f the teeth. Patients must have impressed upon
them the advisability o f having their teeth looked after during
their pregnancy. Apparently there has been a deep-rooted idea
among the laity that women should have no dentistry done while
they are pregnant. You have all heard the old saying “ For every
child a tooth.” Necessary work must be done, and there is not any
reason why a needed extraction should not be performed; but diffi
cult, painful work that can be avoided should be avoided. Patients
should be advised about brushing their teeth regularly after every
meal; and if during the nausea period there is much belching up
o f acid-tasting secretion the mouth must be washed out with an
alkaline mouth wash.
H. Care o f the breasts. Each physician probably has his own
idea o f how the breasts should be looked after during pregnancy.
It varies considerably in different parts o f the country. The only
thing that I would suggest to you is that patients be warned not
to pick off the crusts that come on the nipples the last few months
o f pregnancy. Infection may result from this, and it is much bet
ter for them to put on some simple ointment on retiring at night.
A t the bath in the morning the incrustations can be removed easily.
I. Intercourse during pregnancy. Every patient should be told
that there may be a risk o f abortion in the early months o f preg
nancy as a result o f intercourse. It should be advised against at
what would be a menstrual period were the patient not pregnant.
Intercourse in the middle three months is o f less risk than at other
times, but it should be forbidden absolutely in the last two months
o f pregnancy because o f the danger o f infection.
J. Maternal impressions. I suppose it is reasonable for any pa
tient at some time or other during pregnancy to wonder whether her
child will be well formed and without any congenital marks. .That
is a perfectly natural thing. She must be told, however, that there
is no such thing as maternal impressions. No baby is “ marked ”
because o f some unpleasant sight which the mother saw during
pregnancy. From a physiological standpoint there is no possibility
that such a thing as this can occur, and it is well to make this clear
to patients early in their pregnancy. The cause of malformations
and congenital markings we do not know, but we do know that the
beginnings of thesfe take place very early in the pregnancy, probably
before the patient herself realizes that she is pregnant.
K. Hygiene o f the home and preparation for home delivery.
There is scarcely time for me to go into this subject in detail, but if
the patient is to be delivered at home the preparations for a home
delivery must be gone over in minute detail at some time in the
course o f the visits to her physician, so that the necessary things
will be ready for the delivery at least a month before the expected
date of confinement. This list is a variable one depending greatly
upon the economic status o f the patient. The absolutely essential
things are relatively few. There are many things that may be added
to the layout which increase the comfort o f the patient.
L. Mental hygiene. It is not strange that most patients in their
first pregnancy should have many misgivings o f the outcome of
the labor; and early in the pregnancy the physician should straighten
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STANDARDS OP PRENATAL CARE
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out their point o f view in every possible way. Exactly when this
ought to be done is not always easy to determine, but in one o f the
nrst tew visits o f the patient to the physician the opportunity to
explain the phenomenon o f labor will come up, and by it great
reassurance may be given the patient. Friends are apt to tell the
patient o f the tragedies o f childbirth. These can readily be ex
plained, her point o f view can be, improved, and it can be made
clear to her that if patients are looked after throughout their pregnancies these grave disasters are very, very rare. A candid talk
will do more than anything else to give her a proper attitude toward
her pregnancy and delivery. Exactly how one is to speak to each
patient depends wholly upon the things which are bothering that
patient. No two patients are alike, and therefore the physician
does not talk in the same way to all.
There are the instructions that should be given to a patient verv
soon in her pregnancy. The first visit o f the patient to her physician
is a most important one and can not be gone over hurriedly and in
a tew moments. Such an outline as I have described to you can not
be carried out in less than an hour. It is an hour well spent, not
y .
patient but also for the physician. The patient’s state
mind is helped materially, and the physician determines what her
condition is early in the pregnancy.
The patient should be seen by the physician at least once a month
during the first six months, then every two weeks or oftener as indications arise; and m the last month weekly visits are in many cases
f t 1 u * • •^ Properly qualified nurse may work in coni unction with
the physician in the observation o f the patient. The nurse, however
must not assume any responsibility for her medical supervision: and*
her visits do not take the place of visits to the physician. When the
patient is far removed from the physician such visits by a nurse are
j*’ i
. y do not m any way lessen the physician’s responsi
bility for keeping watch over the patient.
A t every visit to the physician the patient’s general condition must
be investigated, the blood pressure taken, urinalysis done, and the
pu se and temperature taken. The patient’s weight should be care
fully followed, impossible. I f the pelvic measurements were not
taken at the first visit, they must be taken before the seventh month,
pelvimetry is only suggestive. It does not prove that a disproporíon is present. For that reason it is most important that abdominal
paipatmn be carefully carried out. Abdominal, palpation in the
eighth and ninth months shows whether or not there is any obvious
disproportion between the fetus and the pelvis, and i f there is obvious
aisproportion the proper method o f delivery must be determined,
n many cases malpositions can be determined and may.be corrected,
it must always be known before labor begins whether a possible disproportmn is present and whether in a primigrávida there is descent
o f tne presenting part into the pelvis. I f a disproportion does exist—
and every physician should be able to determine this— special care
must be taken to avoid vaginal examinations just prior to or after the
onset o f labor because o f the danger o f serious infection should any
operative procedure later become necessary. The individual patient
must be studied. The physician must never assume that everything
is normal. It must be known in every case that no disproportion is
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE'
present. I f the prospective labor offers a probable chance o f being
difficult, the patent should be sent to a well-equipped hospital tor
6We ali appreciate that pregnancy is a physiological condition, but
because o f the fact that it may quickly become pathological it is
necessary to instruct each patient at her first visit to report to the
physician any untoward symptoms. Whether physicians go over the
list as we have given it, or whether they make the statement to the
patient that she must be absolutely well at all times and that any
thing abnormal must be reported at once is immaterial, .ram m tne
lower abdomen and vaginal bleeding must be reported at once. A
bleeding case calls for investigation, for it is only by careful over
sight and study that the mortality in such cases can be cut down.
It is because many physicians regard slight bleeding as not abnormal
or o f not enough importance to investigate that we obtain rucD baa
results in the bleeding cases. It must be made clear that when a
bleeding case does appear and a vaginal examination becomes neces
sary, it must be done under strict aseptic precautions. I t a hospital
is not available means must be at hand to control any hemorrhage
that may occur.
• -u*. T+
Earely does a toxemia o f pregnancy develop overnight, it is
usually o f slow onset, and only by careful medical supervision and
treatment can an eclamptic condition be p r e v e n te d . Cooperation
between the patient and the physician is essential. I t either tails
eclampsia may develop and disastrous results follow. But with con
stant vigilance on the part o f the physician and cooperation on the
part o f the patient the number o f eclamptic cases which occur
throughout the country can be greatly diminished. •
When a patient is to be looked after-by a midwife arrangements
should be made for the patient to have the prenatal care to which all
prospective mothers are entitled. I f in this prenatal care it has been
seen that a normal delivery is not likely to occur the patient should
be transferred from the care o f a midwife to that o f a physician or a
clinic. By careful prenatal care it is possible to overcome the bad
results o f lack o f supervision o f midwives.
I can hear many o f you say that such standards as we have out
lined for prenatal care are impossible to carry out successfully. 1
agree with you that at the present time these standards can not be
fully carried out. I am sure you realize, however, that each year
there are thousands o f deaths which are due chiefly to thei lack ot
prenatal care; and we must overcome this situation. Difficult opera
tive work is done in emergencies, and the results are not good, ih e
majority o f deaths in obstetrical work come from two preventable
causes, puerperal septicemia and albuminuria and convulsions.
Prenatal care will reduce the deaths from septicemia because it will
determine before labor begins which are the difficult cases and will
lower the number o f vaginal examinations that are necessary,
will also lower the deaths from convulsions because the preeclamptic
condition is discovered and proper medical treatment is carried ou
early. Without prenatal care the conditions that are present
throughout the country will continue, and it is for this reason that
we insist that the standard aimed at must be high. W e admit it is
a standard which at the present time can not be insisted upon; yet
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STANDARDS OF PRENATAL CARE
19
the only way in which we can approach it is to urge that you
directors, when you go back to your various States, take these
pamphlets and talk about the standards not only to groups of physi
cians and nurses but to the women of the States as well. Explain
to them the reason for prenatal care. Show to them the dire results
which come from the lack o f prenatal care, and also show them that
childbirth can be made much safer with this care. Make it clear to
them that it is an insurance for their safe delivery, for it is well
known that the careful physicians throughout the country who give
intelligent prenatal care to their patients lose practically no patients,
that there are few stillbirths in the practice o f these men, and very
few deaths in the first few weeks of the life o f the infant.
Do not give the idea, when you talk o f prenatal care, that it is a
panacea for all the obstetric mortality in the country. Prenatal care
means medical supervision o f the pregnant woman. It will not
prevent all the emergencies that arise in obstetric work. But good
obstetrics can not be done without it, and what we need is that good
obstetrics be available to every pregnant woman. Prenatal care is
a means to this end, and if we are to accomplish this our standards
must be high.
The C h a i r m a n . A s I said, the discussion o f Doctor De Nor
mandie’s very interesting paper will be at the end o f the morning
session also. We shall have now Miss Yan Blarcom’s talk about the
nurse’s part in a State program for prenatal care. You already
know Miss Van Blarcom as the author o f Getting Ready to Be a
Mother, Obstetrical Nursing, and other books of especial interest
to both the medical and nursing professions.
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THE NURSE’S PART IN A STATE PROGRAM OF
PREN ATAL CARE
B
y
C arolyn C o n a n t V
an
B
larcom ,
R. N.
Broadly speaking, the nurse’s part in a State program o f pre
natal care is to assist the doctors in carrying out the prescribed
details o f supervision, instruction, and care o f expectant mothers
and to work toward the ideal o f having every expectant mother
in the land under medical care from the beginning of pregnancy.
The nurses’ duties in such a scheme have been fairly well stand
ardized wherever high-grade, organized obstetrical service has been
inaugurated. For this reason, it seems to me, there is little as to
details or routines that one could oifer to highly specialized workers
such as comprise this audience. The only possible suggestions that
I can make are very general, intangible ones that are not easy to
put into definite words without seeming to be unduly sentimental or
romantic. They relate to the qualities, to the attitude and spirit
o f the nurse herself who is selected to help in carrying out a State
program for prenatal care.
Not uncommonly an organization is established, routines o f medi
cal and nursing work are adopted, a registered nurse, perhaps with
special public-health and obstetrical training, is appointed, given
routines to follow, and set to work. AH this seems to me a small
part of what needs to be considered in connection with the nurse’s
role. For I am convinced that no matter how well she may be
trained, the quality o f the nurse’s mind and the spirit that pervades
her work are the determining factors in the effectiveness or futility
o f her endeavor.
I f prenatal care were a prescription that the» doctor could write
for health and safety o f the maternity patient and her baby, it would
probably be enough for the nurse to be accurate, intelligent, and
conscientious in executing the terms o f the prescription. But pre
natal care, as I understand it, is something in the nature o f coopera
tive effort by doctor and nurse to reorganize and regulate, accord
ing to an accepted standard, the everyday lives of expectant mothers
in their care. As no two o f these patients are likely to have the
same tastes, habits, and mental attitudes, it may require considerable
ingenuity to mold their lives into the desired form. But that is
what has to be done, in a measure, for the patient’s own conduct,
24 hours a day, 7 days a week for 40 weeks, is really the deciding
influence for or against the success o f prenatal care. It is essential,
then, to convince and educate the patient about the sustained im
portance o f little things, and in a sense, to live her life along with
her through a tedious, monotonous period. Encouraging, explain
ing, reassuring, helping her as she needs it and when she needs it.
This, it seems to me, while she performs certain specified duties,
constitutes a large part o f the nurse’s share in any program for
prenatal care,
20
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Th e
nurse
*s
part
in
a
prog
ita At
oe
pr eUa^al
care
2i
Accordingly, before outlining the nurse’s duties as to periodic
visits, observations, instruction, and the like, something very impres
sive and stirring— thrilling if you like— must be communicated to
her if her work is to reach the fullest effectiveness. Before she
is even ready to begin, a few facts and beliefs must become so
deeply rooted in her consciousness that they will color everything
she thinks or says or does. It might be well to start her off by
portraying her threefold position; namely, her relation or responsi
bility to doctors, to patients, and to the community.
1. D octors.— In her relation to the doctors the nurse must be so
convinced o f the rightness o f their procedures that she gives un
questioning loyalty and confidence, since her work is o f necessity
an interpretation o f their ideas and wishes. She must appreciate
the fact that every detail of maternity work originates in and is
guided by the. medical profession. From the imposing machinery
o f official organizations down to bathing the eyes o f a baby in a
remote mountain cabin, the entire scheme is the interpretation and
application o f medical teaching— application to individual mothers
and babies o f the practices that it has been demonstrated will safe
guard the lives and health o f these patients. 'This relation, then,
rests upon a foundation o f the nurse’s loyal support o f the doctor
and his work.
Patients.— As to the patients, the nurse in her turn must win
from them trust and confidence as she imparts the things it is de
cided they should be taught. It may not always be easy to con
vince a patient that details o f care which seem to her wholly un
related to her own or her baby’s welfare will actually increase
their chances for life and health; that she is literally taking care
o f her living, growing baby by taking care o f herself. The advice
and instruction will be followed consistently, as a rule, only if
the patient has an almost affectionate reliance upon the nurse’s
ability and sincerity. Here, then, the nurse’s satisfactory relation
rests inevitably upon a foundation o f the patient’s trust and
friendship.
3. The community.—In visualizing her relation to the community,
the nurse should be helped to see in it a privilege as well as an
obligation. It should be borne in upon her that her service is o f
such public importance that the future welfare o f the race literally
depends upon the aggregate o f such work as hers, since widespread
prenatal work can not succeed without nurses. To give her a grasp
o f the reality o f the work she is undertaking she should be in
formed o f the large number o f women and babies throughout the
country at large who die year by year from preventable conditions
associated with childbirth, and also, what is perhaps o f even greater
importance, the uncounted mothers and babies who drag out
wretched existences because they did not quite die from the same
general causes. Contrasted with these she may be given a rosy
picture o f the mothers and babies who are not only alive but well
and robust because they have had just such care as she will help
to give to the patients within her professional horizon. That care
is every expectant mother’s right and the nurse should be taught
to harp on that idea— adequate care for all maternity patients—
and to shoulder it as her responsibility to work toward bringing
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22
PROCEEDINGS, MATERNITY AND INEANCY CONFERENCE
about that ideal. This means persuading not only the prospective
patients but also the public at large that good maternity care is
both urgent and feasible.
Accordingly, a valuable part o f the nurse’s community service will
be to dispel that death-dealing belief that having babies is a natural
process and if let alone will take care o f itself. She should never
lose an opportunity to convince people that this process, like all
other, natural functions, reaches a satisfactory consummation when
conditions are favorable. No one denies the value o f good soil,
warmth, and moisture in raising flowers or vegetables, nor the ne
cessity o f doing away with weeds, harmful insects, or blight. But
only rarely is this the attitude taken toward raising babies. How
ever, when husbands, mothers, and other advisers do see baby cul
ture in the same light as horticulture we shall have more expectant
mothers under care and supervision. Another function for the
nurse in the community is to be so right in her own attitude, so
earnest and ethical that she will win over the doctors in the o ffing
to a belief in the appropriateness o f prenatal clinics and prenatal
nursing service for their own patients.
In summing up the threefold aspect o f the nurse’s function we
come to feel that the entire structure rests upon a broad, inclusive
foundation o f mutual faith and o f unquestioning belief in the right
ness o f it all.
Great pains should be taken, in my judgment, to explain to the
nurse just what are the conditions that are so destructive o f life
and health among mothers and babies and why watchful care will
rob these conditions of their terrors; what is known o f the accom
panying physiological changes and what they mean; the very earliest
and mildest symptoms, how they are anticipated and prevented;
and above all the tragic importance o f securing prompt treatment
when such symptoms appear.
The nurse should have a very clear idea, simplified though it be,
o f the whole scheme o f complications, what is known o f their causes,
the accepted methods o f prevention and cure, with steady emphasis
upon prevention. She should be helped to grasp the sickening fact
that the majority o f maternity patients who lose their lives, die
from lack or care that we know perfectly well how to give. Not
care that is experimental but care whose efficacy has been proved.
In short they have died from neglect!
The thing to be burned and seared into the nurse’s brain is that
the ideal we are striving for and that she must help to achieve, is
adequate care for every expectant mother. This means getting every
expectant mother under care and then making that care so satis
factory and effective that it will save her and her baby. T o reach
that end we need to have complete and skillful maternity service
more widely available in this country and the lay public so widely
convinced o f the pressing urgency o f good care in all cases that such
care will be demanded.
What we need, apparently, is not that the high peaks o f obstetrical
work shall be higher, making it possible to save a few mothers from
rare complications, but that the average o f the care given to all
patients shall be raised. Every detail ox the care and supervision o f
even so-called normal cases should be regarded as o f such impor-
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THE NURSE S PART IN A PROGRAM OF PRENATAL CARE
23
tance that it will be performed with the utmost pains. Every ex
pectant mother should be taken seriously. This should be repeated
over and over and never lost sight of. Every expectant mother
should be taken seriously!
For practical reasons it would seem that the scheme of care should
be cut down to the simplest minimum that is compatible with
safety, and then the nurse and patient alike should be taught to
regard every tiny detail with the respect that it merits. That
those in high places give high value to the minutiae of obstetrical
service is not enough. The whole matter needs to be exalted in the
minds o f the many to the plane it now occupies in the minds
o f comparatively few. The nurse should appreciate this, and by
precept and example o f her directors she should be so constantly
impressed by the dignity and enormous importance o f all aspects of
maternity service that her attitude will be insensibly communicated
to her patients and the public.
In addition to a general unawareness on the part o f the public,
there are a thousand and one obstacles to prenatal care in the
minds o f expectant mothers themselves. One, for example, may feel
that it is a good thing for the mass but that she is sure to be all
right! Another may lack encouragement from an unbelieving
or unsympathetic husband who remembers a mother that had a dozen
or so but never began bothering until the baby started to come.
Another may look upon it all as a harmless nuisance for which she
has no time, while still another may have that very common, illogical
feeling born o f fear that if she puts herself under care the doctor
will be sure to find something wrong. Also that it is bad business
to be thinking too much about yourself, and so o n !
So the nurse must be helped to see that there is not only ignorance
but indifference and distrust standing in the way of widespread
acceptance o f and seeking for prenatal care.
blow, to be a little more specific, the nurse’s part in prenatal care,
whether it concerns one patient or an entire State, is to secure for the
doctor sustained, first-hand, up-to-date information about the pa
tient’s condition and to transmit to the patient, by repetition, simpli
fication, and adaptation, the advice and information the doctor wants
her to have but which he rarely has time to dwell upon as long and
as often as he would like, for each patient. In a sense the nurse
functions as the eyes and mouthpiece for the doctor during the inter
vals between his consultations. This assistance, then, seems to
consist chiefly o f ( 1 ) watching, ( 2) teaching, and what may perhaps
be described as (3) sustaining.
1. The details o f the watching are likely to be specified in the
routine observations the nurse is instructed to follow at each con
ference with the patient. The importance o f recording each observa
tion, no matter how well and normal the patient may be, and
o f promptly transmitting the report to the doctor after each visit,
must be emphasized. The requirements for taking temperature,
mood pressure, and testing urine should, in my judgment be so rigid
that one would never hear the nurse say that these observations
are made “ as indicated ” or u when indicated.” A ll possible symp
toms should be observed and reported before the necessity is indi
cated. The doctor then, o f course, may do as he thinks best.
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24
PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
But too much importance can not be placed upon the value o f
complete pictures o f the patient both mentally and physically. And
in this connection I feel strongly that the nurse should be urged to
note such intangible symptoms as depression in a woman who is
ordinarily cheerful, fatigue out o f proportion to the effort made,
and perhaps a newly developed tendency to carelessness, since it
may indicate fatigue, or depression, or both. The nurse should
be aware that these delicate symptoms may be the first evidence o f
toxemia and not only report them promptly but increase her own
watchfulness. Being the doctor’s eyes in truth may be one o f the
most valuable services the nurse can offer in the prevention o f
complications.
( 2) The teaching has four general aspects, as I see it, somewhat
as follows:
(a) Teaching the expectant mother how to take care o f herself
and her baby during the nine months before the baby is born. It
seems to me very worth while here to give the mother the feeling
from the very beginning that the baby is there, a living being,
and that she is actually taking care o f it all those nine months before
she can see and hold it in her arms.
(b) Describing to the patient the changes in her own body, as
sociated with pregnancy, that she is likely to notice and perhaps
not understand, and also the common symptoms o f complications
which she may detect and should report.
(c) Teaching the patient how to prepare the baby’s outfit, includ
ing clothes, toilet tray, bed, etc. And also to try to visualize with
the patient what it is going to be like to have the baby in the
home, help her to anticipate a sense o f the baby’s presence and fit
it into her own life and into the routine o f the home.
(d ) Helping the patient to prepare for the home delivery, i f that
has been determined upon. This means such things as bed, dressings,
nightgowns, and the like.
.
In connection with the nurses’ teaching I think we should bear
in mind the educational value o f equipment. Demonstrations are
much more easily understood than verbal descriptions. In the case
o f the baby’s clothes, it almost invariably gives the prospective
mother a thrill to see and handle them and the cozy, pleasant atmos
phere that is created while the clothes are in the making helps to
build up the relation that is so desirable. There is something very
winsome about baby clothes, and to actually work over them, under
standing the purpose of their design and texture, gives the expectant
mother an increasing sense o f the reality o f her own living, develop
ing baby. The equipment at the maternity center need not be elabor
ate nor expensive, but there is a minimum without which the nurse
can scarcely be expected to teach effectively. In addition to the
layette there should be a model o f an improvised bed for the baby—
a box or basket— a doll to dress and undress, the toilet tray equipped
with articles needed for mother’s and baby’s daily toilet, a bed to
use in demonstrating preparation for home delivery, and the mini
mum o f these dressings, which need amount to little more than
pads and newspaper protectors for the bed. With the model toilet
tray before them it is possible for the mothers to see how they can
assemble an entirely satisfactory one from things they have in the
house.
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THE NURSE S PART IN A PROGRAM OP PRENATAL CARE
25
The nurse will sometimes need no little ingenuity in adapting
the routines and details o f care as prescribed by her organization*
to the mentality, traditions, and varied demands o f the daily lives
o f the patients. But this she will have to do, for though the
circumstances and personalities o f the patients may be infinitely
varied the general needs o f all expectant mothers are the same.
I think that the nurse should never be allowed to lose this view
point—that no matter what the difficulties may be, no matter what
ffie patient stands before her needing something
that the nurse can give and she must meet that need no matter
what it requires o f her. She must carry the message to Garcia.
3. When we come to the third aspect o f the nurse’s role, that o f
giving moral support or sustaining the patient, I think we have about
come to the heart o f the matter, so far as she is concerned. For after
all, the point o f every bit o f study, work, and planning is what
happens to the individual patient. What she does and how she
lives are almost the proving point o f the entire scheme. No two
patients are in the same situation, financially, socially, and so on,
nor for a variety o f reasons will any two give quite the same response
to the advice the nurse may give. But, for all o f that, we must
produce something like uniform results in the way the patients live
their lives.
It becomes necessary, therefore, for the nurse to study each one
o j her patients and bring herself to such a state o f sympathy and
understanding that she will see the problem from the patient’s
standpoint, so far as that is humanly possible. To get inside the
patient’s mind, in a sense, so as to feel and appreciate all of the
doubts and difficulties that present themselves to her. And also
to make the patient feel that she does see the thing through her
eyes. Through all o f this the nurse must have such absolute faith
in the urgency and feasibility of the measures she is advocating that
she will be able to communicate this faith to her patient. And the
principles and purposes o f her teaching must be so clear in her own
mind that she will be able to help each patient to adapt and adjust
them to the possibilities o f her own daily life; that is, applying
the theories to practical things in each patient’s home.
In connection with this effort to inspire the patient’s confidence
and win her cooperation it seems to me worth while to beard the
lion in his den and anticipate the fears that we have good reason to
believe most patients entertain. Very often these fears are buried
so deep the patient will scarcely admit them even to herself, much
less to her family, friends, or even the doctor. But they are there
and she wakes up at night and remembers the neighbor that had
convulsions, or some one who had hemorrhages or fever or worse
still, the one who died and left a motherless baby robbed o f the af
fection and understanding it should have had. And inevitably she
runs over in her mind the women who have had ill health since the
birth o f the baby, and she thinks, too, o f the babies who have been
bom dead or died during early infancy. Each time she marks a
day from the calendar she knows she has cut down the distance to
be run before she reaches the moment that may hold in store one o f
^ p ossib ilities she has been thinking of. I f a woman is
thoughtful or even moderately imaginative it is difficult to think o f
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26
p r o c e e d in g s ,
m a t e r n it y
and
infancy conference
her moving steadily forward for nine months toward an inevitable
conclusion without considering the possible dangers, particularly
when there is a legion o f friends burning to tell her o f them. It
literally makes life over for some women to have the nurse tell
them o f the disasters that they may expect to hear o f from their
friends and then clear the air by explaining that the very things
they most fear are preventable and that the whole purpose o f all
that is being done for them and with them is to avert those identical
catastrophes.
Then there are the reasons why the expectant mother may not
want to have a baby. When she and the nurse get into the habit o f
sitting down and talking things over in a gossipy, leisurely fashion
it is amazing how often an objection to motherhood of one kind oír
another will show its head. One woman may be selfish and resent
the inconvenience of having a baby because o f the inroads it will
make upon her luxuries and freedom. Another may feel unfit to
meet the responsibility o f rearing a child. There may be wellgrounded anxiety about the financial drain o f a new baby m the
family or there may be merely a habitual unwillingness to accept
any important change in the general scheme o f her life. There are
almost countless reasons for not wanting a baby, but I have never
heard o f one that couldn’t be shattered to bits and completely dis
pelled by the mother herself if she could be encouraged and helped
into a different mental and emotional state. The woman who is
reachino- forward eagerly for the moment when she can actually
hold her own baby—the one for whom life is simply an ecstasy o f
anticipation—has no room in her thoughts for anything but a
hungry welcome for her child. Over and over we see the nurse who
loves babies and knows the joy o f caring for them communicate her
own thrill and enthusiasm to the reluctant prospective mother and
transform her attitude into one o f happy expectancy.
The actual work o f the prenatal nurse is carried on by visiting
the patients in their homes and also having the patients visit the
maternity centers for individual consultation and group instruction.
Visiting the patient in her home occasionally is valuable because
the nurse learns something more about the patient as an individual
when seeing her in her own environment than is possible away
from it. And more than that, by knowing the patient in her own
home the nurse can be more helpful in adapting and adjusting
the desired routine o f personal hygiene to her possibilities. And
in the home she can help in a practical way to assemble the desired
equipment from things already in the house or that may be easily
procured. Having the patient visit the center also has advantages,
for in addition to saving the nurse’s time it offers opportunity for
teaching and for demonstrating the equipment. And there is a
friendliness about the group instruction that is worth while.
The character and extent o f the instruction and supervision given
by the nurse is, o f course, decided by the medical board o f her or
ganization and is often affected by the conditions under which the
work is conducted. The nurse in a rural community, for example,
may take blood pressures and make urinalyses, while in cities, rich
in doctors and medical institutions, these observations may not be
among her duties, But whatever the details may be the general
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care
27
alwnv^fn th»d ^ 1?e^ pirit PerI ad“ g the work are the same.
And
the
nurse s
part
in
a
program
op p r e n a t a l
compete and
eye ** tbe ldeal ^or which we are striving—
complete and efficient care for every maternity patient.
. T f i T Pomt tilat 1 feel should be made repeatedly is that
thought it is granted to be desirable to send primiparae Î n d com
m en te
bf , fer
g r e ^ n u m b e r o f maternity
patients are and probably will continue to be cared for in their
homes. In other words, the widespread problem o f maternity care
is largely a problem o f home care.^ I f we are to raise the Standard
mi +
given to all patients throughout the country great pains
must be taken in preparation for home delivery. This planning
is logically a part o f the nurse’s prenatal work, and it should be
incumbent upon her not to disrupt the household but to make these
thTukrtab
W
least, P f sible disturbance and commotion I
think there would be much less objection on the part o f a o-nnd
aToui it
iT and
Z d nif°ithw
Z g aba?5ieY
were and easier
^ 3 transaction.
, fust fa d e
about
if it were
simplerf th4
and ecozier
The nurse really can do a great deal toward this end i f she realizes
that satisfactory preparation for a clean delivery may be made
without taking down all the pictures, ripping up the carnpt nT1ri
generally destroying the peaciof the’ home! gl X S
it X u ld be
impressed upon her That lack o f confusion is ready a mark o f
efficiency and that she promotes the patient’s welfare by making
the event as happy and comfortable as possible all around.
g
final HPSi a11 thpa tr hav<T had
say seems too general to be pracÜi aV ® ut
feeling about the nurse’s part is this—i f she did
effectively for every expectant mother all that the ideal program
allots to her we should have almost no problem. For bv “ all ”
I mean all the intangible service included in “ watching,” teach
ing, and sustaining.
It is the endeavor to have it all done effectiv elj that constitutes a task. In the end, given average training
and intelligence, I feel sure that the nurse’s sp irih -h fr attitudf
toward her work—is the most influential factor in her equipment
She should be dignified and at the same time have an enthusiasm*
and even gaiety, that will infect her patient. She should do all
that comes within her province to make her patient’s adventure a
joyful one. This she will do i f she loves her work and brings to it
a sense o f romance and wonder, even reverence, for the great recurrmg miracle o f a new life that is taking place before her.
Ihe nurse engaged in maternity work who infuses into it some
to*
T w Without
S L thf f-itf IT think
^ V aÎ
d° scarcely
Wel1 theavoid
w?rk failure.
is assigned
to ther.
shet0
can
fa£ 6fR P1?
sum:.uP by saying that the nurse’s part is to
take the hand o f thé patient as she treads the long road o f expect
ancy, pressing it warmly always, holding it firm over the rough
places, and steadily giving the best she has to offer of tenderness
understanding, and skill.
tenuerness,
101848°'—26----- 3
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DISCUSSION OF THE PAPERS OF THE MORNING SESSION
The C h a i r m a n . I am going to turn the chair over to Doctor
Haines now during the discussion. I am very happy to say that
Doctor Haines is one of you, so I really hardly need to introduce her
as the new director of the maternity and infant-hygiene division
o f the Children’s Bureau.
[Dr. Blanche M. Haines took the chair]
The C h a i r m a n . We have approximately three-quarters o f an hour
for discussion. No one has been asked to lead, but we expect you
all to take your part and to ask questions that will help you carry
out the standards. Not only have we had standards in prenatal care
from the physician presented to us, but we have also had a standard
in prenatal care given us for nurses. I am sure that you wish to
consider how you are going to put these standards into operation
in your various States. Has anyone a question to ask Doctor De
Normandie, or Miss Van Blarcom, or Doctor Boynton?
Doctor G a r d in e r . I should like to ask whether the obstetrical
units in the States where they have them make internal examina
tions and routine Wassermann tests. We have not yet done it in New
York, for obvious reasons; but I think we must do it very soon, and
I should like to have a little encouragement.
Miss M a r r i n e r . That is done in the maternity center in B ir
mingham.
.
.
Doctor G a r d in e r . I have in mind the migratory units particularly,
where there is not very much center work.
Doctor B o y n t o n . Pelvic examinations are made in our prenatal
clinic in Minnesota. W e do not do Wassermanns routinely, although
they are done in occasional cases; but every woman who comes to
our clinic for examination does have a pelvic examination.
The C h a i r m a n . D o you limit that at all in relation to the length
o f time o f pregnancy?
Doctor B o y n t o n . O f course a vaginal examination is not made
within the last two months o f pregnancy; a rectal examination is
made, however.
Doctor K o e n i g . W ho makes these examinations?
Doctor B o y n t o n . W e have been very fortunate in having welltrained obstetricians, Doctor Adair’s associates, from St. Paul or
Minneapolis, to act as clinicians in our itinerant clinics.
The C h a i r m a n . Doctor Adair has conducted some demonstration
clinics, has he not—you might call them demonstration clinics—for
local physicians? Has not that been the type o f your work?
Doctor B o y n t o n . That has been more or less the type o f our
work. Our prenatal clinics have been itinerant, and it has been our
purpose to examine as many expectant mothers in a community as
would come to these clinics. Before the clinic, however, the
physicians in a community have talked over the plans, have co
operated in these clinics, and have been urged to bring any com28
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DISCUSSION OF THE PAPERS
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plicated cases about which they might wish to have consultation at
the time o f the conference.
I believe that pelvic examination is extremely important from an
educational standpoint in these itinerant conferences because it
teaches the women that this is part o f a thorough prenatal examina
tion. It not only teaches the women themselves that we consider
that a part o f a good prenatal examination, but it also further im
presses upon the community the fact that that is a part o f a prenatal
examination.
Doctor B l a c h l y . Acting upon Doctor Boynton’s advice at the
previous conference, I tried a few o f these in Oklahoma along the
same lines, and we have had a greater number of demands from the
county medical associations for our obstetricians to do this work
than we have obstetricians to supply the demand. They make in
ternal examinations.
The C h a i r m a n . And do you'make routine W assermann tests?
Doctor B l a c h l y . We recommend routine Wassermanns in e v e r y
case that we reach through the mail in our prenatal literature. As
we have not held many prenatal clinics, I can not say whether a
routine Wassermann has been taken in every instance.
Doctor K o e n i g . A s Arkansas is largely a rural State we hold
itinerant conferences all the time; and as our nurses go about doing
work and organizing for them we also advertise for our prenatal
conferences. I wonder what we can do there where we have in
adequate medical service and where midwives make at least 25 per
cent o f the deliveries. W e have requests continually from the expectant mothers that they be given pelvic examinations. I have felt,
and. Doctor Garrison has felt, that we had to be very careful in
making pelvic examinations because we wanted to be ethical and
professional. Should I make pelvic examinations at these confer
ences without consulting the^ family physician—and many times the
women have no family physician? I wonder how far we should go
at child-health conferences in making these examinations and what
would be the best procedure. I have made a number o f examinations_ thus, but always in the presence o f the woman’s family
physician. I wish we could have some help on that. Although the
mothers come to conferences, they hesitate to tell us about them
selves unless we take them privately. They do not talk about these
conditions with the freedom that the city mother does, yet we should
so much like to help them. We have only two prenatal centers in
Arkansas, and our conditions there, o f course, are very different from
what they are in the North and West.
C hairman » I think that we should like to hear from some o f
the States that have been doing prenatal work, as New York and
Pennsylvania, on the attitude or on your procedure in relation to
the family physician. Doctor Gardiner, do you examine patients
at your itinerant conferences in New York, and how far do you go
when that patient is already under the care o f the physician?
Doctor G a r d i n e r . W e do not accept any patients at our prenatal
consultations unless they come with the permission o f their physi
cian, except unregistered cases and the cases o f midwives. However,
is increasing very much. The percentage o f cases rexerred to the consultations for 1925 is double that which prevailed in
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
1924. Our reports come to the office and are there transcribed, then
a full report is given to the family physician from the office. O f
course, a different procedure is followed when those consultations are
turned over to the local people. A. great many o f our standards
then fall down, but I believe the principle is maintained that only
patients are taken who are not registered with physicians or who
have the request or permission o f the family physician.
Doctor S t a d t m u l l e r . D o you have that request in writing ?
Doctor G a r d in e r . The physician must send a note, a written per
mission or request.,
.
_
The C h a i r m a n . Doctor Noble, have you something from Pennsyl
vania to add to this discussion?
_
Doctor N o b l e . I am afraid we have nothing to offer as long as you
are talking about itinerant clinics. We have nothing o f that sort
in Pennsylvania. We have only 11 permanent centers under^ State
control and 72 centers not under State control -chiefly in Philadel
phia and Pittsburgh in connection with large, rich, and well-organ
ized hospitals. I can not speak for those clinics at all. Our 11 State
centers are struggling, I think, through a very discouraging part
o f their history. I shall have to look back three or four years to
see any gain at all in the clinic work for prenatal care.
What we are emphasizing to-day in Pennsylvania is the field work,
the home visiting, which the public-health nurses can do. W e are
trying our best to link that with the work o f private physicians
by having the town where it is undertaken canvassed very carefully
by the nurse. Sometimes the nurse, accompanied by one o f our field
organizers, makes a personal call on every physician, explaining^ ex
actly the meaning o f the prenatal care which we wish to have given
to the patient and of having their cooperation. The physicians are
asked to sign a card stating that they are willing to have their
patients receive this care; or we ask them whether it can be taken tor
granted that if patients mention their names the patients may receive
care from this public-health nurse; or they state on the card, with
their signature, that they would rather refer each individual to whom
they wish that care given. That is, they reserve in their minds some
cases to whom they think this nurse should not give care. W e are
encouraged about this kind of prenatal care, and it is being carried
on by the State nurses who are equipped with the bags, which I
think we mentioned last year as lying more or less idle. Now a good
many nurses are actually going out and finding the patients and
giving this kind o f care.
Our two greatest problems are the physician who does not know
or does not believe in prenatal care because he does not understand
it, and an entirely apathetic laity such as Miss Van Blarcom has
pictured, who have no idea o f the meaning or necessity o f prenatal
care.
'
.
.
1
T ,
W e are trying to talk to the women just as hard as we can. 1 am
trying also to devise ways in which we can go out and talk to the
physicians a little harder. But we have no permanent itinerant
clinics.
.
.
Doctor I n g r a h a m . H o w often are these meetings or clinics held i
Doctor N o b l e . We try to have them conducted weekly by a local
physician just like our permanent child centers—no itinerant work
whatever.
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I ngraham. Can you hold these permanently in little
Doctor N o b l e . N o, in towns o f 10,000 or 8,000 people.
Doctor K n o x . We have done nothing in Maryland that is any
contribution to this line at all, but I wish to say just a word from
the standpoint o f the physician. A ll o f us, o f course, are very much
concerned, I think, in directing a larger amount o f the ordinary
practitioner s time into preventive lines. Certainly no line o f pre
ventive medicine has more importance than this work, and the physidan should give a larger part o f his time to prenatal care, because
the hazard o f the lives o f both mother and child is very real and
° V he physician is particularly concerned. It seems to me
l ^ ° Sf
in ckar£e o f child-health work in our various States
snould at least query whether by stressing prenatal, clinics held by
State organizations or by State physicians we may be assuming a
®?]Pe^hat dangerous attitude. Are we not perhaps making it more
difficult to encourage the physician to do this work himself?
You know Doctor Emerson has said that our ideals must be not
J™mker o f children that come to our clinics for corrective work
not the number of mothers that receive prenatal care or are delivered
through State clinics, but the number o f children without physical
delects that each year enter the first year in school; that are without
the detects because parents themselves have brought these children
m TtlT / ° i eii’ own Physicians and received this kind o f help.
In Maryland we have been trying a somewhat different plan. We
have been having our well-known obstetrical men deliver lectures on
obstetrics (just as they have been doing, I know, in New York State)
to groups o f physicians in the different parts o f Maryland, including
one or two talks about prenatal care very much along the lines that
.Doctor De Normandie has just given us. These have been very
carefully and very appreciatively received. County medical societies have turned out, m one instance almost to a man, and have
realized that they do not know all they ought to know about preiai th° « gh >th?y. ar.e 7 ™ * $ to Sive ih Then, it seems to
me, the health officer s duty is to bring the community, the laity, up .
to this point o f view and refer them back to the physicians to show
them that they can not get satisfactory service for mother and
child without prenatal care, and have it brought to them through
their own physicians.
s
Certainly the normal process o f childbearing must be in charge
o f the physician, prenatal care must be considered an integral part
o f it, and it must remain largely the work o f the general practitioner
1 hope that we can bear this m mind and that our clinics will have
important^Hne°Se o f increasmg tke work .of the physician in this
In Maryland we can not prevail upon the country woman to come
to prenatal clinics separate from child-health conferences We
fW ^
a +nT b?J o f
MaJbe they will in the future, but
they will not do it now. But the nurses, just as has been said
concerning Pennsylvania, find these cases. The mothers sometimes
come to our child-health conferences and the nurses find these cases
by the score and take them early in their pregnancy to their own
physicians. Then it is the duty o f the leaders in obstetrics, it seems
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DROCEEDINGS, MATERNITY and infancy conference
to me, to teach these physicians a little bit more; and it is certainly
our responsibility, as public-health officers, to get a larger propor
tion of the women o f the community in the hands o f their physi
cians early.
Doctor G l e a s o n . I wish to support what Doctor Knox has said.
In Rhode Island we are not doing a great deal in the way o f pre
natal clinics; in fact, as a State department we have not one. What
we are trying to do is this very thing; namely, to build up in the
minds o f the public and in the minds o f the physicians the need
o f prenatal care; and wherever our workers who go into the homes
meet these prenatal cases they refer them to their family physician
and„ lead the women to demand proper prenatal- care from their
respective family physicians.
Mrs. H o w e . The situation is very much the same in Arizona. We
have no prenatal clinics, but our nurses have gone into the highways
and the byways and gotten in contact with the prenatal cases. The
one discouraging situation that I encounter is, when you have got
ten an expectant mother in the attitude o f wanting to accept the
best o f prenatal care, finding the physician unable to give it.
Doctor B a r n e t t . I think that is true for all o f us. I am speak
ing from a physician’s standpoint. The first thing we do in Xexas
is to write to the secretary o f our county society, where we have a
nurse in a county, and tell him that we are having this nurse come
there. W e take this up from the physician’s standpoint and ask
for his cooperation and for the cooperation o f the medical society.
W e do not have the clinics—we can not have them in rural districts.
It is all right for the larger centers, but we are not trying to have
theta in the rural districts. But when we have a health conference
at any point we receive from the physicians assistance that we would
not have otherwise, and cooperation also. This is the result o f
sending the nurses to them directly when we first go to the county
to talk over our program with them. But if a nurse enters a
county and goes to see a physician’s patients without consulting him,
making suggestions to them, and sending them to him, the physi
cian is very likely to be annoyed.
The C h a i r m a n . Doctor De Normandie, will you tell us how we
are going to get these standards across to the physicians? I think
we all agree that we want these standards.
Doctor D e N o r m a n d i e . I have talked throughout the New Eng
land States more or less on standards similar to these. I do not
know how we are going to make the men realize the importance
o f it. It comes back to the teaching o f obstetrics in the medical
schools.
You simply have to talk it to the physicians constantly, constantly.
I think better than talking to them is letting the laity know what
is right; that is, women are coming to me constantly because they
have been taught; and in Boston it is reiterated that they must
consult a physician very early. Just before I came away I had a
patient who said, “ I don’t know as you will look after me n ow ;
I am three months along and I have seen nobody.” That is the
proper attitude to get a woman into if she is going to have good
medical care.
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On© word about the time it takes to put such standards as these
over. Up to the point where you begin to talk on the hygiene o f
pregnancy it goes very quickly; from then on it is slow, careful
work, carefully chosen words to explain in nonmedical terms what
you mean by the hygiene o f pregnancy. I think it is the best work
that we do when we sit down and talk to a patient and get her into
the proper frame o f mind. Now, can nurses do that unless they are
specially trained? They are not all Miss Van Blarcoms; they can
not talk the way Miss Van Blarcom can. Yet they must talk that
way i f they are going to put it over satisfactorily. I am sure that
Miss Van Blarcom is a tremendous help, going around to the nurses
and talking the way she does. I know that the question came up
about putting anything concerning nurses into these standards.
We talked and we talked about that phrase, and we finally compro
mised on that which you will see on page 3—■
“ a properly qualified
nurse working in conjunction—.” “A properly qualified nurse.”
There is the whole rub. Many nurses do a tremendous amount o f
damage. They undo all that some o f us physicians have tried to do
by talking to our patients. The nurses should be taught just as
thoroughly as the physicians; yet that is not being done. The stan
dards for nursing care are all different throughout the country. In
Massachusetts there are certain hospitals to which I would not send
an obstetrical case because o f the care.
I do not know how we are going to put these things over unless
we constantly talk it, talk it, talk it. It seems very discouraging.
You go around and talk to these various men, and they say they
do it. But you know very well they do not do it. I see it all the
time. Obstetrical consultation work is the worst type o f consulta
tion work there is in medicine. It is because they will not do what
they have been taught to do. W e are teaching them the funda
mentals o f obstetrics properly, but a lot o f these men throughout
the country have no conscience in obstetrics. That is the trouble, I
think.
Miss M a r r i n e r . Doctor De Normandie, do you or do you not
indorse the claim o f some o f the specialists in venereal-disease con
trol that the period o f pregnancy is the most auspicious time for the
treatment o f luetic conditions?
Doctor De N o r m a n d i e . I am not certain as to whether that would
be the best time to treat every luetic case, but every pregnant case
that turns up should have a Wassermann.
Miss M a r r in e r . I was informed recently that we nurses might tell
patients that that is the most auspicious time for such treatment.
Doctor De N o r m a n d i e . I do not think that is a fair statement. I
think the most auspicious time is the moment it is found out.
Doctor S c h w e i t z e r . There are a number o f points in which I
have been interested. I must say first that in Indiana we have no
prenatal clinics in connection with our State department. I know
o f a very effective one in connection with the State university, and
whatever others are in operation are under local supervision in the
larger cities, o f which we have very few.
With regard to lay education—I do not wish to encroach on what
I am going to say later, but I feel that it is pertinent to bring this
to your attention now* W e have had since February, 1924, groups
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PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
consisting o f one physician and one nurse, working in various parts
o f the State in systematically organized territory to bring this mat
ter before the lay public; and we have not limited our discussions
to pregnant women. A ll women have been invited. Mothers may
bring their daughters to these classes, and we have received in this,
I think, a great deal o f cooperation from the lay public. In fact I
know that a good many women have gone directly from the class
to their family physicians fo r prenatal care, although they had
not previously thought about going early. I do not say this in any
spirit o f levity, but just to show you what the actual conditions
are. Occasionally a woman says, “ I went to my physician as you
said, but he looked at me and said I was all right. He did not o f
fer to give me any examination. What shall I do?” Now, what
would you advise her to do in that case? I usually tell her to go to
a physician who will give her that kind o f care. I f the physician
whom she has consulted does not consider that kind o f care impor
tant, there are physicians who consider it so and who will give her
adequate care. She must not stop until she finds that sort o f phy
sician.
We have sent into every county where we have worked a letter
telling the physicians in the county that the physicians and nurses
are coming. The letter is accompanied by a, questionnaire as to the
physician’s own standards o f prenatal and obstetric care, his stand
ards o f infant care, and a request for any suggestions that he may
wish to make concerning what should be taught in his own commun
ity. W e do this on the assumption that the physician himself knows
what the community needs better than we can possibly know. W e
have sent these letters to all physicians whose addresses we could
obtain in every county, and up to September 30, 1925, we had re
ceived TO replies. The physicians who sent in these replies said
that almost no septicemia had occurred in their practice. W e as
sume that these physicians are all honest in their statements, and
we made a report on that basis. Wre said that the physicians who
replied to these questionnaires—without saying anything about those
who did not—were evidently well versed in obstetric practice and
used the best standards in their w ork; and that evidently they were
getting results because they had no septicemia or almost none in
practices extending from 10 to 25 and 30 years. That is a very
good record, I should say. Although a large number did not reply
to the questionnaires we regard the evidence submitted by the men
who did reply as very fine. I shall talk more about that later.
The C h a i r m a n . Miss Van Blarcom, we should like to know o f
some specific instances in which nurses have really helped in the
prenatal programs o f States. Can you give us something on that?
Miss V a n B l a r c o m . What can be accomplished by nurses who
love their work and carry it on with enthusiasm is illustrated by
the recent inauguration and rapid development o f a prenatal pro
gram in Tioga County, N. Y. I refer to the demonstration under
taken by the division o f maternity, infancy, and child hygiene o f the
New York Department o f Health, in cooperation with the Tioga
County Medical Society and the Maternity Center Association of
New York City. My understanding is that the conditions under
which the work was started were about average, with the usual
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amount o f indifference or resistance to prenatal care on the part of
the laity and most o f the physicians. But the effort to convince
the physicians and patients o f the value and feasibility o f prenatal
care has been astonishingly successful, and credit for much o f this
success seems to be given frankly to the nurses loaned by the Matermty Center Association, who had been carefully and wisely chosen,
ih ey loved their work and were enthusiastic and resourceful; having
worked under the inspiring guidance o f Miss Louise Zabriskie, they
brought to their undertaking just the attitude and spirit that I at
tempted to describe m my paper. B y their ability, personality, and
sincerity they have practically won over the entire county, and at the
end o f six months, if I remember correctly, more than one-half o f the
expectant mothers in the county had been referred to the nurses
by the physicians themselves. One physician in a remote part of the
county was so eager to see the work extended that he offered a part
ot his home or office to be used for mothers’ clubs, or as a place where
visits could be made. My impression o f the demonstration is
that the nursing side of it is really a model o f what can be done by
the right kmd o f nurses under the right kind o f direction.
ih e CHAmMAN. I think Doctor Tallant, o f Philadelphia, an
obstetrician on the staff o f the Philadelphia General Hospital, is in
the room. Doctor Tallant, will you not add something to this dis
cussion %
Doctor T a l l a n t . I am afraid that perhaps my experience will
not be of much help to you because, o f course, it is so largely city
experience, and_ what you are all interested in is work in the rural
districts. But I know that in the small towns in the rural districts
you have in many o f your States the foreign population, and that
is what we have had to deal with in the southeastern part o f Phila
delphia where much o f my work has been; and I feel that getting
the confidence o f the foreign population is one of the great thing?
that we need to do in putting forward any standard o f prenatal
work. 1 hat can be done m the clinics as we hold them, where we
have many Italians, Russian Jews, and Poles to deal with. The
Itafian people m particular seem to be very willing to be looked after
and like to come to the clinics, especially if you can say two Italian
words. I f you can say “ bello bambino” then they will beam; or if
you say bella Italia ’ ; either one will be enough. I f you can iust
make them see that you are interested, that you want them to come
tnat you want to talk to them—and the best way to get at them o i
course, is through the clinics to which they bring their children
for examination. When they see that you are interested in the babies
they know that you will be interested when another baby is coming
and then they wish to come and consult you about the baby that is on
the way.
J
T That rc^dy Ml I can tell you that has a bearing on your problem.
It is true that I had some work in a very rural district in devastated
I ranee during the war, but I hardly think that that would be at all
akin to any work you are doing.
Miss L o c k w o o d . Our experience in Delaware has shown that if
we depend on the prenatal clinic for demonstration we will have very
little work done in the State. Miss Van Blarcom has brought out
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
the real crux o f the situation when she says that the woman who
goes to the home must be o f the type who can carry the message.
Most o f our work is rural, but it extends throughout Wilmington,
which is the only city in the State; so you can see what a varying
situation we have to meet. W e have in Wilmington two prenatal
centers to which we can send women. Comparing that with what
we have in the rural sections, which is just one-half the population,
we find that very few women take advantage of this prenatal clinic.
I am very sorry to say, and I think that Doctor Knox will agree
with me—in fact, he has said what is in my own mind—that the
work will have to be done in an entirely different way in some o f our
States. The only one who can accomplish this work is the rural
nurse. She is carrying the message and is getting it over. I have
felt many times so discouraged that I wondered if it was worth
while; and yet we constantly receive calls for the nurse to come to
women, and we are being asked whether the women can obtain this
information. W e are blocked in certain ways, but on the whole the
trend is upward. W e are getting the message to the women and to
the community.
Now, we may talk about taking what we hear at this conference
back to the organizations and talking to the women. W e are all
doing that, I know, in every State. But a very large number o f
people never come where we can tell them about it. They never come
to mothers’ meetings, nor anything else. W e reach only a certain
group o f people, the best ones, probably, in the community; and
although they do need good maternity and prenatal instruction they
can get it. But the largest part o f our population, who need it most,
are those who will not attend any meeting. They are the ones to
whom we must go, and go, and go, to get the message to them.
I think we have all assumed the attitude that this thing can be
done very rapidly. I have been so full o f enthusiasm that I felt it
could be done in one fell swoop. But it can not be done in that way.
W e all have our discouragements along the line— although I do not
think that anyone in any State could have more than we have had in
Delaware. W e have had it from every possible source, but we are
getting the message over. And who is getting the message over?
Those nurses who are going about in the cars and going into those
homes, and who keep on going and never stop. So I feel encour
aged, because we are receiving inquiries, and because requests are
made that the nurse come to these cases into whose lives you would
not think it would be possible to instill a ray o f hope. Consequently
I am not nearly as discouraged to-day as I was two years ago when
we had more money. We are accomplishing the work; and it is
being done by going back and working with those people in the
community.
Doctor K o e n ig . Are those nurses who go back and forth your own
State nurses or are they county nurses ?
Miss L o c k w o o d . I think we all vary so in our administration
that it is difficult for us to visualize what happens in each State.
W e all have to solve our individual problems in the way that suits
us best. In Delaware they are all State nurses. W e have two centers
in Wilmington and one place outside, near Wilmington. We have
visiting nurses in Wilmington, also State nurses who have centers,
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prenatal, maternity, and tuberculosis, under the State board o f
health. So our system is one that radiates throughout the State,
and we are not dependent on the local nurse or the local welfare
association, or whatever you may have in yo’ur State. W e control
the nursing situation throughout rural Delaware. The only trouble
is that we have not enough nurses to control the situation.
Doctor De N o r m a n d i e . May I ask if the prenatal clinics are run
by nurses ? I think you made that statement.
Miss L o c k w o o d . N o , we have only the centers in Wilmington.
We have no prenatal clinics in Delaware. The nurses, o f course,
are in charge o f the centers where these clinics are held.
Doctor De N o r m a n d i e . But the clinics are held by physicians
with a physician in charge ?
Miss L o c k w o o d . Certainly.
[Meeting adjourned.]
,
MONDAY JANUARY 11—AFTERNOON SESSION
BLANCHE M. H AIN ES, M. D., DIRECTOR, MATERNITY AND INFANT-H YGIENE DIVISION,
c h i l d r e n ’ s BUREAU, PRESIDING
The C h a i r m a n . We shall follow the plan that we had this morn
ing, and consequently we shall expect you to keep note o f the first
paper as well as the last, and be ready to discuss all o f them at the
same time.
There has been a rather general desire for something on vital
statistics in relation to the infancy and maternity program, and we
have asked Mr. Henry Schultz, o f the statistical division o f the
Children’s Bureau, to speak to us on the use o f studies and graphs
in this connection.
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B
y
H
enry
B
S c h u l t z , D ir e c t o r , S t a t i s t i c a l D
U n it e d S t a t es D e p a r t m e n t
ureau,
iv is io n ,
of
L
C h i l d r e n ’s
ab o r
An ex-president o f the Royal Statistical Society is reported to
have justified the very abstract and mathematical nature of his
presidential address on the general theory that there ought to be at
least one paper at every convention which no one, or hardly anyone,
can understand. I suppose that those responsible for this program
must have taken a leaf out of Professor Edgeworth’s philosophy,
otherwise I can not explain my presence here to-day.
Statistics to most persons is the driest, the most uninteresting o f
all imaginable subjects. It is commonly supposed to be nothing more
than a mere collection o f figures, rows and columns of them—the
dry bones which are juggled by liars, pleaders for special interests.
That statistics is also a body o f laws and principles, a method o f
procedure which guides, or should guide, the collection, analysis,
comparison, interpretation, and presentation o f numerical data;
that statistics is also the handmaiden o f the social sciences; that
statistics is, in short, a new method o f acquiring knowledge, an ex
plorer, occupying a position something like that of the telescope
in the physical sciences, has not been so very well known—not even
among the rank and file o f the social workers.
To a certain extent this condition may be explained by the train
ing and attitude of mind o f most social workers. The social worker
is primarily a case worker. That is to say, he is a particularizer
more than a generalizer.
When a mother brings her infant to the child-health conference
you examine him. You weigh him. You measure him. You try to
find out everything about his physical well-being, and you advise
the mother as to his care and his general welfare. Another mother
comes with her baby, and the same procedure has to be followed.
T o act on the experience o f the first child would o f course be ridic
ulous.
When a youngster is brought to the court on charges o f juvenile
delinquency modern methods require that everything that caused
the delinquency, his home and social surroundings, and his inherited
traits, be carefully looked into. Some agencies even require that he
be given a psychological as well as physical examination in order
to discover what remedial measures may be applied.
When a family applies for relief to a charitable organization that
family becomes a case for investigation. Every effort is made to
find out why the family is in the condition in which it finds itself;
whether, for example, it is due to the illness or incotapetency o f the
wage earner or to other causes. Inquiries are also made as to the
age, sex, and schooling o f the dependent children, and as to many
other factors which will throw light on the needs o f the family
under consideration. T o act on the basis o f the previous history o f
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STATISTICAL STUDIES AND GRAPHS
39
another family would, of course, not get us very far. Each family
must be treated separately.
The foregoing examples illustrate the method o f the case worker.
It studies the characteristics peculiar to the case in hand. It is the
only method available for the purposes in view, and no criticism
is intended on this score.
But the statistician is interested not so much in individual differ
ences as in the characteristics common to the group as a whole. He
has no quarrel at all with the other methods o f approach. They have
their place; but a stage arises in every investigation where none
but the statistical method can be used to advantage.
Let us say that you, as a physician, are called upon to answer the
question whether a given child is normal or abnormal as regards
weight, height, or any other characteristic. You can not possibly
decide this question on the basis o f individual experience. Such a
question requires a statistical approach. You must weigh and
measure thousands upon thousands o f children to find out the average
weight or height, determine by how much the weight or height
o f the child under consideration differs from the average, and then
apply statistical methods to discover whether the difference is sig
nificant or not.
That is to say, the statistician overlooks a good many individual
characteristics, in order to be able to discover those characteristics
which are common to the group as a whole. I f the case worker may
be conceived o f as looking at the trees rather than at the forest, the
statistician may, in contrast, be pictured as training his telescope on
the forest and not on any particular tree.
I f the two types o f workers could carry on their work without ever
coming in contact with each other, no difficulties would arise. But
most problems, especially those relating to the social sciences, are
interrelated, interconnected. A stage arises where the social worker
must become a statistician or must seek the aid and advice o f one,
and it is at this point that many difficulties arise. The social worker
is apt to carry over to his statistical work a good many o f the charac
teristics or habits o f thought and action common to case work. It
is not at all surprising, therefore, to find that many o f the “ statis
tical ” reports o f social agencies are nothing more than compilations
o f case records. I dare say all o f you will find, i f you take pains to
do it, “ statistical reports ” which are filled with such material as the
follow ing:
One parent was found to have deserted the family, another ill. One child
was in a reform atory; another ran away from home. The youngest girl was
rather pert.
Now, there is really no reason why statistical reports should be
cramped with all that detail. One often asks himself after reading
page after page o f such material, “ What o f it ? What is the bearing
o f all this upon the topic under discussion?”
Perhaps the construction o f an ordinary graph will serve to illus
trate, i f we give wings to our imagination, the main differences be
tween the two points o f view that I have been comparing. For this
purpose I have taken the liberty o f enlarging a few charts which
appear in that excellent little volume “ Vital Statistics,” by Whipple.
tTechnical explanation, of charts on wall of conference room was given]
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PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
What conclusion may be drawn from the difference in the attitude
o f mind o f the case worker and o f the statistician for the work that
we are all engaged in ? I f you are going to make any investigation /
o f a statistical nature— again I wish to emphasize that no criticism is
intended o f the case method where it is applicable—the first thing
to do, it seems to me, is to write out—I repeat—write out the ques
tions which your particular study is supposed to answer. Examine
these questions. See that they mean something definite and concrete
to your friends and associates as well as to yourself. Then, most
important o f all, decide on the base o f the particular study. Find
out to whom that study ought to apply, what years it ought to cover,
etc. Having decided upon this, get up a provisional schedule and
be sure that each and every question appearing on your schedule
covers a specific point. Be careful to define every term. Do not use
vague and indefinite terms such as “ normal child,” “ normal,”
“ shape,” “ family,” or “ household,” if you can avoid them. They
are treacherous, they are misleading, they do not mean the same
things to all persons.
Having carefully defined each and every one o f your terms, having
planned a preliminary schedule, have it criticized by competent
people. See to it that all constructive criticisms are incorporated.
Send a few schedules out into the field with instructions to your
agent to fill out a few— say, 100 schedules. You will find that your
agent will probably make certain suggestions that you-will want to
incorporate. You will find that you may have to reword your in
structions, revise the schedule on the basis o f these suggestions, draw
up a new set of instructions to agents. Then, and only then, should
you proceed with the printing o f the schedule and with the field
work.
After your data have been gathered and brought to the office, after
they have been classified and listed, the first thing to do is to get a
few summary tables; not detailed tables which simply recapitulate
the actual data—you may just as well use the schedules—but a few
tables which actually summarize, which bring out the most im
portant items under consideration. When you have done this, ex
press your results in terms of averages, standard deviations, or co-j
efficients o f correlation. Do not use vague terms. I f for the'
particular purpose in view a summary of certain case records is
necessary, make such a summary, but do not confuse the statistical
part o f your study with this case description.
Now, why should the statistician ask these things o f the social
worker? What has he to give in return? In the first place, the
trouble will pay for itself. You will get scientific results. You will
be able to answer certain questions which otherwise can not be
answered. But, most important o f all, you will be enabled to disen
tangle causes. It may interest you to know that it was to obtain a
solution o f certain problems in vital statistics and biometrics that
modern statistical methods were invented. The problem is the old
one o f how to measure the effects o f heredity and environment. To
make it concrete, suppose that we are required to find the relation
between infantile mortality and the alcoholism o f the parent. Not
being able to experiment with, children as we do with guinea pigs in
the laboratory, we have to go from city to city, from locality to
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41
locality, and note the infant mortality and the percentage of alcoholic
parents in each locality.
Let us assume for the purpose o f the argument that the figures
show that as th.6 percentage o i alcoholism increases from community
to community the rate o f infant mortality also increases; 99 people
out o f 100 would conclude that there must be a definite causal connec
tion between infant mortality and alcoholism. As a matter o f fact
such a conclusion would be entirely unwarranted. W hy? Because,
if the father is alcoholic, in all probability he does not work all the
time. I f he does not work all the time the mother may have to go
to work. I f the mother has to go to work the child is probably
neglected. The family may have to buy a cheaper food supply. The
milk may not be o f the best kind. The family may need to live in
poorer quarters where the child does not have the benefit o f fresh
air and sunshine. How much o f the increased mortality is due to
alcoholism in the organism of the parent, and how much o f it is due
to the environmental factors? Such a question could not have been
answered in the eighties; the factors are too complicated. But in
the nineties the statisticians, mathematicians, and biologists invented
a new calculus which forms the basis o f modern statistical methods.*
I may say without any fear o f contradiction that within certain
limits the statistician can answer this question to-day. A ll he re
quires is definite data as to the possible disturbing elements—size of
family, father’s earnings, milk supply, housing conditions, and all
other factors that are related to infant mortality. I f you can supply
him with the requisite data, he can tell you how much, i f any, o f
the increase in infant mortality is due to the alcoholism o f the
parent, how much is due to the poor physical surroundings and how
much is due to other factors.
In other words, when the statistician is asking you to see that the
foundations—the data—should be beyond reproach, he foresees the
vast superstructure which may be constructed on the well-laid foun
dation. B y laying the proper foundation— accurate statistical data—
and by taking advantage o f the best that statistical theory has to
offer, we shall succeed in doing a good deal for one who has not inap
propriately been styled “ our enemy—the child.”
The C h a i r m a n . The next paper was to be given by Doctor Adair.
In the envelopes that we have passed around this afternoon you will
find Doctor Adair’s study on infant mortality, stillbirths, and neo
natal mortality. You have the information there, although no
doubt he could have made it much more interesting if he could have
been here to discuss it with you. W e shall pass on then to the next
topic, which is “ How to make a study o f causes of maternal mortal
ity/ by Doctor De Normandie. This seems to me to be very impor
tant at this time. W e have arrived at the point where we feel that
something must be done with the maternal mortality, and in order to
work it out we must know a little bit more about the causes that lead
up to it, Doctor De Normandie will tell us where to begin.
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HOW TO MAKE A STUDY OF M ATERNAL MORTALITY
By
R
obert
L. De N o r m a n d i e , M. D.,
H
arvard
M
e d ic a l
I nstructor
S chool
in
O b s t e t r ic s ,
In making a study o f the causes o f maternal mortality we follow
the International List o f Causes o f Death and include all deaths of
women due more or less directly to childbearing. The group under
which these deaths are listed is called “ the puerperal state,” and
“ the word puerperal is used in the broadest sense, including all af
fections dependent upon pregnancy, parturition, and diseases of the
breast during lactation.”
In this group o f the puerperal state there are eight divisions, num
bered from 143 to 150, inclusive, in the last edition o f the Interna
tional List o f Causes o f Death. Let us go over these divisions quickly,
^for anyone making a study o f maternal mortality must have the chief
'points clearly in mind.143. Accidents o f pregnancy.
а. Abortion.
б. Ectopic gestation.
c. Others under this title.
144. Puerperal hemorrhage.
145. Other accidents o f labor.
а. Cesarean section.
б. Other surgical operations and instrumental delivery.
c. Others under this title.
146. Puerperal septicemia.
147. Puerperal phlegmasia alba dolens, embolus, sudden death.
148. Puerperal albuminuria and convulsions.
149. Following childbirth (not otherwise defined).
150. Puerperal diseases o f the breast.
There is need of but little comment on this list. Statisticians
would have much to say to you in regard to the proper grouping
of the deaths. The only points to which I wish to call your atten
tion are thege. A criminal abortion resulting in death is not to be
classified under the puerperal state. When a pregnant woman re
ceives a serious accident which in itself is enough to cause death, the
death is to be classified under the accident and not the puerperal
state. When a pregnant woman suffering from a long-standing
chronic disease such as tuberculosis or cancer dies such a death does
not go in the puerperal state.
When a pregnant patient dies from certain o f the acute infectious
diseases the death is generally classified under this disease and not
in the puerperal group. The only chief exception to this rule is
with influenza. In the United States the death o f a pregnant woman
in the influenza epidemic was classified under the puerperal state,
although in England the classification was just the opposite; and
this explains why our puerperal mortality in 1918 jumped so. How
the deaths are classified by the statisticians when two causes o f death
are returned may be learned by reference to the Manual o f Joint
Causes o f Death. The reasons for these various classifications I
know nothing about, and they are beyond the scope o f this paper.
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STUDY OF MATERNAL MORTALITY
43 .
The deaths classified under the puerperal state by the statisticians
in the various divisions o f vital statistics are the groups o f cases
which we must study in any analysis of the causes o f maternal
mortality. Whether all puerperal deaths are recorded depends o f
course upon the proper classification by the attending physician.
Wherever there has been any accurate study o f maternal mortality
there has always been found a certain discrepancy when the deaths
in the childbearing age (which is regarded as from 14 to 44 years)
are checked up with the birth returns in the period under study. For
some reason, either through carelessness or through some ulterior
motive, physicians may cover up the fact that a birth has occurred.
For that reason it is very necessary that whenever a death takes place
following or during pregnancy, the word “ puerperal ” should be
added to the death certificate in order that the death may be classi
fied properly. It is obvious that if we are to have a complete study,
not only must the death registration be complete, but the certifica
tion must be accurate.
In this list o f deaths as obtained from the registrar o f vital sta
tistics the following must be obtained: The name o f the woman,
her home address, place o f death, the name of- the physician in charge,
and the certification o f the cause o f death. I f the death certificate
was not signed by the physician in charge a note should be made of
the name o f the person who did sign it and the reason for it if pos
sible. With the list obtained, the intensive study o f each case begins.
Frankly, I do not know what to say in regard to the importance o f
studying the social and economic condition o f the woman and her
family. I am sure, however, that to put any extended study on this
part o f the inquiry is not so important as the study o f the medical
care the woman had. I can not believe that the woman’s birthplace
or her race has any real bearing on the patient’s death. How much
income the family has is significant, o f course; for the poorer the
individual, the poorer the type o f medical service obtained will be
unless the patient happens to be in a community where charity cases
are well looked after; and such communities are usually those where
large medical schools exist and the cases are used for teaching
purposes.
M y advice is, that the investigator studying the deaths go at once
to the physician who signed the death certificate and seek his coop
eration tactfully and intelligently. You must be careful never to
antagonize him, never to let it appear that there is criticism, for i f
you do rub him the wrong way once the information which you will
receive thereafter will be o f little or no value.
You will find in the majority o f cases which you study that the
physician has no history o f the case and no record o f the cause o f
death, no temperature charts, and little ¿hat you can go by except
his memory. Here a difficulty arises, for all studies o f maternal
mortality take place from a year to two years after the deaths
occur, and it is obviously difficult for a busy general practitioner to
recall the details o f a death which took place months ago. He may
be willing and anxious to help you, but it is impossible for him to
give you much information that is worth while. These are the two
chief difficulties in studying maternal mortality—lack o f records on
the part o f the physician, and the long interval between the death
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
and the beginning o f the investigation. XJntil we can impress upon
all physicians that records should be kept and until we can investi
gate maternal deaths more quickly than we have in the past, our
results o f course will be unsatisfactory.
I f the death occurred in a hospital there may or may not be
satisfactory records to look over. The American College o f Sur
geons is doing a splendid piece o f work in insisting upon satisfactory
records i f a hospital is to be classified in the class A group. The
majority o f patients, however, are not delivered in hospitals; and
therefore we can not expect to find complete records on all maternity
cases there.
There are certain items of each patient’s history which we ought
to know, i f they can be obtained. We must know the number o f her
pregnancies, the character of her pregnancies, the outcome of each,
whether the previous children were bom alive or were stillborn, and
the type o f her previous deliveries. These all may have some bearing
on the pregnancy which caused her death. Her medical history is
very significant, especially in regard to the condition o f her heart
and kidneys. But it is in the last pregnancy that we are especially
interested. A careful investigation must be made into the prenatal
care received. It is not sufficient to ask the physician if she had
such care, for many physicians will say “ yes,” but when you question
further you will find that the care given consisted possibly o f one
or two visits before the delivery, and one or two examinations o f
the urine. That, of course, is not prenatal care; and although the
physician says care was given, this must be classified as no prenatal
care or at least as unsatisfactory care. W e have already seen what
prenatal care should be; and unless the physicians approach such
a standard we can not classify their patients as having had such
care. It is also well to find out whether the woman had any super
vision by a visiting nurse, and, i f she did, o f what this consisted.
When we come to the delivery we must know whether it was nor
mal or operative. I f it was a normal delivery the number o f vaginal
examinations made should be found out i f possible. It is ob
vious that no man will remember how many vaginal examinations
he made on any individual case unless he keeps a careful record o f
each case; and that, as I have said, he seldom does. You can find
out, however, what is his custom. Does this man make many vaginal
examinations, or does he have recourse to rectal examinations en
tirely during labor? Also one must find out whether or not he uses
rubber gloves and what his technique is. I f it was an operative de^
livery the length o f labor must be ascertained, the type o f labor
the patient had, and the operation that was performed. Find out
whether pituitrin was used. A careful questioning regarding the
third stage o f labor will many times give you a clue to the cause of
death.
These are all general points which must be found out and re
corded. There are other more detailed points to be ascertained de
pending entirely upon the cause o f death as given in the certificate
or points to which the inquiry up to this stage leads. T o this point
the inquiry is applicable to any o f the eight groups o f the puer
peral state, but from this stage the questions must be more specific
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STUDY OP M A T E R IA L MORTALITY
45
if we are to find out accurately where the responsibility, i f a n y ,
for the death lies.
Let me explain what I mean by this. I f the cause of death of
the case which one is studying is classified under 143, accidents of
pregnancy, only thorough questioning can determine whether the
abortion was spontaneous, self-induced, or criminal. Many times
the fact that a criminal abortion has been done can not be estab
lished, no matter how searching the inquiry is. The real cause of
death must be carefully sought since the great majority o f these
cases die from either hemorrhage or sepsis. It further must be de
termined whether a curettage was done following this abortion, and
i f possible it should be determined whether or not the patient had
a temperature when the operation was performed, for it is well
known that a curettage following an abortion in a patient who is
running a temperature is a very serious procedure and may carry a
very high mortality.
I f the death is from ectopic gestation the onset and duration o f the
condition must be carefully studied, and whether the patient was
operated upon must be ascertained, -and whether it was an emergency
or an elective operation.
In the third division under this section pernicious vomiting of
pregnancy is the most important cause o f death. Here it must be
determined whether the death occurred because the patient refused
operation on religious grounds, or whether the physician allowed
the patient to become so seriously ill that when an operation was per
formed her death followed.
The condition in which the patient
was when the physician was first called should be made clear, for
many o f these serious vomiting cases are not seen until the patient’s
life is in jeopardy.
The so-called “ therapeutic abortion” is not recognized in the
classification o f deaths, but in all studies on maternal mortality it
must be noted whether one was done, what the reason was for doing
it, and whether a consultation was held. The chief reason for doing
a therapeutic abortion is a serious chronic disease which would jeop
ardize the patient’s life if the pregnancy were allowed to go on.
Now in regard to the bleeding cases (group 144). Here it is im
portant to find out how early in the pregnancy the patient showed
any signs o f bleeding; whether this bleeding recurred, at what in
tervals, and the amount of blood lost; what was done for her, or
whether anything was done. Too many physicians regard slight
bleeding in pregnancy as not abnormal, and make no effort to dis
cover the cause o f it. It must be thoroughly impressed upon both
the laity and the profession that any bleeding by vagina in preg
nancy is abnormal and must be investigated.
I f the cause o f death was postpartum bleeding we must carefully
investigate the type o f the patient’s labor, whether she had an opera
tive delivery, or whether any other abnormalities were present.
Here again the management of the third stage must be carefully
ascertained, for many times the bad management of the third stage
causes a postpartum hemorrhage.
Other questions that it is well
to ask in regard to postpartum hemorrhage are how soon after de
livery the physician left the patient and whether she was in satis
factory condition with a dropping pulse rate when he went. A
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
secondary postpartum hemorrhage arises only when products o f con
ception are left behind, and that can be obviated by careful inspec
tion o f the placenta at the time of delivery—a simple preventive o f
trouble which relatively few men carry out conscientiously. Care
ful questioning shows the type o f puerperal hemorrhage o f which
the patient died, and we can determine accurately in which subdivi
sion each death should be placed.
Section 145. Other accidents o f labor. This you will remember in
cludes Cesarean section, instrumental delivery, breech delivery—prac
tically all operative procedures and difficult labors. I f a Cesarean
section was performed on the case in question, certain points must be
carefully studied. First, what was the indication for doing a section ?
Second, was the Cesarean section one o f election or of emergency ?
Third, did any vaginal examinations immediately precede the opera
tion? Fourth, were the membranes ruptured before operation was
performed? Fifth, was the patient in labor; and, if she was in
labor, how long had she been in labor ; and what was its type? It is
a well-known fact that a Cesarean done by competent operators be
fore labor begins or at the onset of labor carries with it a mortality
up to about 2 per cent. But the moment that Cesareans are done fol
lowing operative manipulations from below, vaginal examinations, or
long labor with ruptured membranes, the percentage immediately
rises to 10 to 15. There is no question that when Cesarean sections are
done under these latter conditions it means that the patient has not
had adequate prenatal care. A t the present day no woman should go
into labor unless a method o f delivery has been carefully determined
upon beforehand. By that I mean that if there is a probable dispro
portion present she should be sent where competent help can be ob
tained at once. This is why the previous history o f multigravidae is
so important. I f a patient had a difficult labor in her first preg
nancy, the physician should have found this out early in the present
pregnancy. Many patients move out o f rural communities to cities
after they have had one disastrous obstetric experience.
I f possible the temperature chart should be seen in regard to any
death from Cesarean section, fo r by it one can very quickly deduce
the probable real cause o f death. Cesarean section o f itself seldom
causes death, the great majority o f deaths resulting from sepsis; and
i f by inspection o f the chart it is seen that the patient ran a septic
temperature it is fair to say that the patient died o f sepsis and not as
three death certificates were signed (in Massachusetts) a short while
ago when Cesarean sections had been performed—o f ileus, paralytic
ileus, and vasomotor paralysis.
In my opinion few deaths should be classified as due per se to in
strumental delivery and other surgical operations. The deaths nearly
always follow because o f either sepsis or severe trauma to the pa
tient’s soft parts, not infrequently rupture o f the uterus or bladder,
with sepsis following. It is for this type of case that sepsis is not given
as the cause, the death being attributed to a hard operative delivery.
T o determine under this heading the real cause o f death is difficult
because it necessitates determining the ability o f the physician to do
operative work. I do think, however, that it is perfectly fair, in re
gard to these deaths due to operative delivery, to question carefully
the preparation o f the patient and the technique. By that I mean,
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STUDY OF MATERNAL MORTALITY
47
Did the physician have adequate help at the time o f delivery, or did
he first etherize the patient himself and then quickly do the delivery—
an obvious possible mode o f infection? What was the preparation o f
the patient? Was she shaved, and what methods of sterilization did
he carry out ? Did he have any sterile goods to cover the operative
field ? That perhaps would be a superfluous question in the majority
o f cases, because we know that such details are neglected very many
times. But unless we question carefully the physicians who con
stantly have these deaths, unless they realize that they are going to be
checked up, shall we not continue to have this unnecessary loss o f
life ?
On the other hand, plenty of men trying to do honest, con
scientious work get into serious difficulties now and again. How can
it be otherwise, with the training that they get in operative obstetrics
in the medical schools at the present time? Again, many physicians
call for help too late in obstetrical work, for they think that the
majority o f cases will come through fairly well in spite o f bungling
operating and that a death will come to them but rarely. Because
o f this fact they hope to get by in every case. A death in this
group usually means that there has been a lack o f intelligent
medical supervision o f the patient and that an error was made in
the method o f operating—either the wrong operation was performed
or it was badly done. Here again careful inquiry will show the real
cause o f death and indicate where the responsibility lies.
Now let us take up section 146, puerperal septicemia. When a
death is recorded as occurring from septicemia there is no question
that this is the true cause o f death, for no man will sign a certificate
“ puerperal septicemia ” if there is any possible opportunity for
him to assign the death to any other cause. The deaths in this group
account for 40 per cent o f all the puerperal deaths in the country.
Oliver Wendell Holmes said years ago, in speaking o f the con
tagiousness o f puerperal fever, “ Whatever indulgence may be
granted to those who have heretofore been the ignorant causes o f so
much misery, the time has come when the existence o f a private
pestilence in the sphere o f a single physician should be looked upon
not as a misfortune but a crime; and in the knowledge o f such
occurrence the duties o f the practitioner to his profession should
give way to his paramount obligations to society.” There are, X am
glad to say, no such terrible epidemics of puerperal fever now as
there were years ago, but the fact remains that hundreds o f women
die each year from sepsis. Therefore when a patient is found to
have died from sepsis it devolves upon the physician in charge o f the
case to prove conclusively that he delivered the patient according
to good surgical technique.
It is along these lines that your inquiry must be laid. First we
must know whether a case had proper prenatal care, for it is only
by good prenatal care that we can eliminate the difficult emergency
operating that carries with it a high death rate, usually from
sepsis. Second, we must question the preparation o f the patient.
The investigator must know what proper preparation i is and
whether this preparation was carried out; whether the patient was
shaved, whether it was a soap and water scrub or whether iodine or
one o f the newer preparations was used. It is also necessary to
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determine carefully the type of labor that the patient had, the
number o f vaginal examinations that were made, and the technique
that was used. The burden o f proving that he carried out a proper
technique rests upon the physician, for we know that in all except
a few cases sepsis is caused by poor technique and ought to occur
very, very rarely in any physician’s practice.
Any physician practicing obstetrics who has a death from sepsis
«very once in a while is a danger to the community, and I feel that
we have a full right to question minutely his technique and his
methods o f procedure. He is not a safe man to have about, and
it is by a study o f maternal mortality that these men are discovered.
I f they have any conscience they soon see that they are being ques
tioned and will attempt to mend their ways. It is true that any
one of us may a¡t any time have a case of sepsis. Occasionally we
may lose a patient from sepsis, but only very rarely. The kind of
man to whom I refer is the physician who is having more or less
sepsis all the time, who is losing one or two or more patients a year
from sepsis. In questioning this type o f man you will meet with
opposition, and you must question as tactfully as possible. Many
men go through their medical careers without ever losing a patient
from sepsis. Yet the medical profession at large is blamed for
this bad situation which relatively few physicians are causing.
These deaths are due to carelessness. The surroundings o f the
individual case, if proper technique is used, have little or nothing
to do with, the death. O f that I am confident9 for each year throughout the country many thousands o f cases are delivered where the
surroundings are anything but sanitary, and yet deaths seldom
follow.
The care the patient received after delivery is important. When
did the physician see this case after delivery, how early did un
toward symptoms appear, and what treatment was given, and was
any intra-uterine manipulation o f any sort done?
I would not give you the impression that for every death from
sepsis the physician is to be blamed, for that is not so ; but I do
say that in the large majority of cases o f sepsis the fault is with
the physician. It is in regard to these cases that we must study
the cause carefully, investigating the attendant most thoroughly,
whether a physician or a midwife was present. I know o f no way
to improve this situation unless there is an investigation of these
maternal deaths. A step in improving this condition unquestion
ably is making sepsis reportable. It is now reportable in only 16
otates o f the country, and in these States the law is not enforced.
In section 147 are those deaths which are classified as sudden
deaths or from embolus. It would seem that these deaths could
be studied quickly and readily; but upon a little thought it will
appear clear that under this classification are put many deaths
which should go elsewhere. The investigator o f these cases must
be very tactful and circumspect. There would seem to be little
ctoubt, it a patient had developed a phlebitis and in the course of
íí?1Sj phJ?bltls sudde1
nJy showed respiratory distress and died, that
the death was caused by an embolus; or, if in the course o f a normal
puerperium the patient suddenly became cyanotic and died, that
this death also was caused by an embolus. Such deaths as these
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are among the tragedies in obstetrical work. On the other hand,
some patients die in the course o f a hard operative delivery, often
times before it is accomplished; and the death is put down to an
embolus. That may be the true cause o f death, but my own opinion
is that many more such cases die from a rupture of the uterus or
some other severe traumatism than from an embolus. Yet the death
certificate is signed “ embolus,” and it is accepted without question
by the registrars. It is obvious that since this cause o f death is
accepted without question it not infrequently covers up bungling
operating, and only by careful inquiry will one be able to determine
the real cause o f death. Even then one would not be sure o f the
accurate cause unless an autopsy had been obtained, and autopsies
are asked for and obtained relatively seldom in obstetrical work.
Section 148 includes the cases dying from puerperal albuminuria
and convulsions—that is, the toxemias o f pregnancy and eclamp
sia— and there are certain leading questions which will clear up the
responsibility for a death under this condition. First, was the
patient under any medical supervision before the convulsions ap
peared ? I f the patient was not under supervision the medical pro
fession evidently could not be blamed for such a maternal death.
Unfortunately very many such cases occur, and until we can edu
cate the women o f the country to the point o f realizing that medical
supervision is necessary for their well-being, we shall continue to
have these deaths. I f the patient has been under supervision you
must find out how long she has been under care; and what specific
care she had; what her condition was when first seen; how often
the blood pressure was taken; and how often urinary examinations
were made; and at what time before her death she first showed
troublesome symptoms. It is well known that a woman under proper
supervision, although she may develop a toxemia o f pregnancy, will
seldom develop an eclampsia and die. This is shown by the fact
that in two large hospitals in Massachusetts the total number of
cases o f eclampsia in 20,759 deliveries was 91, and o f this number
only 20 had received clinic care. There were only 8 deaths among
these 20, whereas the number o f deaths among those 71 patients who
had received no clinic care was 27.
We must determine how cooperative the patient was in carrying
out the physician’s orders. On the other hand, it is just exactly
as important to find out whether the physician in charge gave ade
quate supervision after the patient put herself under his care. We
must further find out whether the patient was put to bed as soon as
troublesome symptoms appeared, whether she had hospital treat
ment early, or whether she was rushed to a hospital when she was in
extremis. Careful questioning readily discovers where the respon
sibility for the death lies. It is much easier to place the responsi
bility in this group than it is in almost any of the others. I f we find
that the responsibility lay with the patient we must be frank and say
so. Many times, however, we will find that it is the physician’s fault
and that he has given no adequate supervision. It must be remem
bered that in the rural communities where physicians are far re
moved from their patients a close supervision o f the pregnant pa
tient is very difficult. It can, however, be carried out much better
than it is at the present time i f we constantly reiterate to the physi
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cians and to the laity what the causes o f maternal mortality are and
how they can be prevented.
The last two sections, 149 and 150, need very little explanation or
questioning. They include but few cases, and it is easily discovered
why these cases are so classified.
You will find in the course o f your inquiries that many o f the
deaths occurred in hospitals. I f a patient dies in a hospital you
must ascertain whether the patient was rushed to the hospital at the
last moment because o f trouble which she had developed outside or
whether the patient, had planned to go to the hospital anyway. You
must find out the standing o f the hospital in which the patient died,
you must know whether it is a well-run institution with a separate
maternity service, whether it has a delivery room, whether it has a
training school for nurses. A ll points which would have any bear
ing on the patient’s welfare must be carefully investigated. I f the
patient died in a hospital from some form o f sepsis you must find
out i f other septic cases were there at the same time. The prepara
tion o f the patient must be inquired into, and whether there is proper
supervision o f the nurses doing the nursing work. Technique in
hospital work must be excellent or sepsis will creep in, and sooner
or later it will become virulent with dire results.
Some o f the States require all maternity hospitals to be licensed
by the State, but the supervision maintained is not always what it
should be, and the results o f the treatment in them are not carefully
investigated.
I have gone over many points that should be developed in any
study o f the causes of maternal mortality. To what do they lead?
What can we do with the results after we have obtained them by
weeks o f painstaking investigation? I assume that the object o f
analyzing the causes o f maternal deaths is to determine wherein lies
the responsibility for them. In other words, are any of these deaths
preventable? I have gone over with you briefly the various points
I think important to have recorded. To be o f value these points must
be gathered in a schedule or outline so that they may be tabulated
and analyzed. These tables should show the number o f deaths in
each o f the eight groups o f the puerperal state. I f we have been
successful in our investigations an analysis o f these tables will show
many points which will help to answer our question, “ Are any o f
these deaths preventable? ” It will show us who looked after the
patients—whether the attendant was a physician, a midwife, or
merely a man midwife. It will show us what sort of medical super
vision the patient had during her pregnancy—whether it was in
telligent medical supervision, or whether she had the supervision o f
a visiting nurse with a doctor in nominal attendance, or whether she
had no supervision at all.
The deaths following operative deliveries can be studied intensively,
and it can readily be discovered where the responsibility lies. Analy
sis o f the bleeding cases will show which were the placenta prsevias,
which were the separated placentas, and which women died from
postpartum hemorrhage. It will show the treatment given to each
patient, and whether the attendant lived up to the best or even to
good obstetrical teaching, or whether he neglected his patient. In
the same intensive way the deaths under the other headings are all
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studied and analyzed. There is no need of going over each one, but
1 do want to say a few words about the deaths from sepsis and from
puerperal albuminuria and convulsions. These two causes include
about 65 per cent o f the deaths o f women who die in childbirth. We
know the number o f these deaths would be much reduced if the
women had had adequate medical care.
The responsibility for sepsis lies with the attendant at the delivery
in by far the greater number o f cases. The technique at delivery is
faulty. How can we improve this situation, which is a reproach to
America ? The only way I can see is to have the maternal deaths in
vestigated each month, and when sepsis is found to be the cause to
summon the attendant before some board for explanation. Some
thing radical like this must be done, for in 1921 in thé death-registra
tion area 6,057 women (40.3 per cent) died from sepsis. We have
failed to profit by what Doctor Holmes said long ago.
In regard to the eclamptic cases I feel less strongly, because, many
times there are extenuating circumstances and we must not be too
harsh, especially as the cause o f this condition is not known and the
treatment varies greatly in different parts o f the country. But for
those physicians who still persist in refusing to give intelligent pre
natal care to their patients I have no sympathy. I believe these men
must be supervised more closely. W e must appreciate the fact that
the standard for obstetrical work in any given community must be
a reasonable one. What is right and reasonable here in the East can
not be demanded in a homesteading community in the West or among
the colored p eop leof the South. We know that the only way to pre
vent this terrible maternal mortality that is present among us is to
have skilled medical care for every woman during her pregnancy
and puerperium. That does not nxist to-day. It will not come for
years. The sooner the laity is acquainted with these facts the sooner
will it demand better obstetrical care. A ny community obtains about
the type o f medical work for which it asks. I f a community is satis
fied with midwives, no good physician will go1into that community.
Therefore, as I see this situation, to improve it is to educate the laity
to demand better service. Then the deaths that are chiefly prevent
able will be wiped from our mortality lists. Remember, it is not the
physicians in the remote towns o f our country whom I criticize. They
do the best they can without hospitals and without nurses to aid them.
These are not the men that need supervision. They do need help.
The only way they can keep out o f serious difficulties at times is to
send their patients to a city. Yet that is not always possible, and
then they do as well as they can—possibly better than many o f us
would do who are accustomed to have everything ready for us in
well-regulated hpspitals.
Intelligent prenatal care and clean hands will do much to lower
the rate o f deaths due to preventable causes. There is no doubt that
a slight general decrease in the death rate in the puerperal state has
taken place, but it has not decreased as it should have. I am con
fident that constant study and analysis o f the deaths with well-guided
publicity for the results will cause great improvement to take place.
The mere enumeration of the number o f deaths is o f no avail.
Careful analysis must be made o f each death in the manner I have
suggested. Facts are what we must have, incontrovertible facts, and
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these can be obtained by such an analysis as I have outlined. With
the facts before us we can go into a community and say “ here are
your results for the past year.” We can then point out which are
the deaths that should have been prevented, others which with our
present medical knowledge could not have been prevented, and a
third group which might have been prevented had skilled care been
available more quickly. Let the medical societies take action, call
the attention o f their members to the results, and insist that better
work be done. Is not such action within the province o f the various
societies? Let the medical profession make the criticisms quietly
and within its own meetings, but let us begin to do something con
structively, and not let thousands o f women die each year without
a more serious effort to improve a condition which many o f us feel
is a blot on the name o f our country and on humanity.
DISCUSSION
The C h a i r m a n . We have now some time for discussion o f the two
subjects that have been presented this afternoon.
Miss A b b o t t . We had several inquiries during the past year with
reference to possible studies along the general lines that Doctor De
Normandie has outlined. I wish to ask whether he thinks that if a
State director wishes to make a study in two or three places—or in
one place— a continuous study o f births and deaths as they occur
should be made or whether they should try to do them for a year
or two years previous. We could have a much latger number if we
included past deaths. Next I should like to know whether the per
sonnel to undertake it ought to be a physician or physicians. I f it
is done currently it is not possible to use a full-time worker on it in
the usual community.
Doctor De N o r m a n d i e . I think we ought to have a continuous
study. I think this occasional study in Massachusetts, another one
over in Washington, and another one down South is not advisable.
It ought to be a continuous study i f we are going to accomplish
anything.
Miss A b b o t t . The health officer can make a continuous study, but
i f we wish to get something to report on, what period o f time ought
it include?
Doctor De N o r m a n d i e . I think it ought to be several years, not
just one year. I am sure physicians should do it. You have no right
to send a social worker to quiz a physician on a death. A physician
will likewise resent having a nurse come in. But he has no right to
object to having the case studied by another physician. I am per
fectly sure that we can study these deaths i f we have physicians do
i t ; but they must know what they are talking about. They need to
ask searching, technical questions. I f the work is undertaken I
should like to see it done on the standardized questionnaire, not in a
haphazard way in one State and then another. I am certain that
' it must be done continuously, and we must let the men know that
they are being checked up. I f the men who are getting the bad re
sults realize that they are being checked up, they are going to mend
their ways.
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Doctor N o b l e . May I inquire whether it should ever be done under
the State offices, or whether it should be done under the medical
profession as an organization?
Doctor D e N o r m a n d i e . I think the State has a perfect right to do
this.
Doctor N o b l e . W ill the State stand for it? Pennsylvania would
not.
Doctor D e N o r m a n d i e . Y o u mean the medical men would not
stand for it?
Doctor N o b l e . Yes. They would not stand for it as coming from
the State. A t least, that was the only explanation. "We had the
machinery ready.
Doctor De N o r m a n d i e . I dare say they won’t stand for it at pres
ent, but you must keep at them till they do. X think the medical
society wishes this to originate from within the medical profession;
otherwise the medical profession is going to be driven to do some
thing that they do not care to do. Do not misunderstand that. We
shall be made to clean house. As I have stated, I do not think the
rank and file o f the medical men are doing this bad work; but you
do not know who is doing the bad work, nor do I.
Doctor N o b l e . Well, we knew. We got the list. The point was
that we got the list all ready with the names and addresses o f the
women and o f the physicians who attended them, and we had the
letter written; but we could not go on.
Doctor De
N
o r m a n d ie .
I
think a mere letter will not do it.
Doctor N o b l e . N o , but that was another thing I wished to ask__
whether you thought any o f it could be done by correspondence.
Doctor D e N o r m a n d i e . W e did some investigation o f maternal
mortality in Massachusetts by questionnaire. That method is very
unsatisfactory, and I think if we had had a physician go around
the State to investigate and to meet these various men we should
have gotten very much further.
Doctor N o b l e . Did not Massachusetts do just that?
Doctor D e N o r m a n d i e . Well, we did for a while, but we have not
done it as a continuous study. Only last week I made this same sug
gestion in a city in Massachusetts—namely, that the medical society
have a standing committee to investigate these deaths month by
month—but the suggestion fell on barren ground.
Doctor C r u m b i n e . When I was a State health officer in Kansas
we had a little experience in an effort to study maternal mortality,
and we were entirely unsuccessful. I think we made every reasonable
effort m the collection o f data and preliminary steps and sending
physicians, and still it was a failure. We selected Shawnee County
mciuding the rural districts as well as the capital city o f Topeka.
We advised the county medical society— we did not ask their per
mission, as we did not wish to bring it up for discussion—but in a
friendly way we advised the county medical society that we proposed
to make that study and asked their cooperation. There was no
dissent from that announcement, yet we found when our medical
nuin went to investigate these cases at the home or the physician’s
office (he went first to the office o f the physician in charge of the
case) we were utterly unable for a majority o f the cases to obtain
data really bearing on the subject. W e were put off with one excuse
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or another. It was impossible to obtain reliable information, and
the whole experiment failed. I think Doctor De Normandie has told
us the only way, and that is a long way off, I fear; namely, by the
medical men themselves. I am sure that we made no error in our
approach to that subject. We tried it very thoroughly and sincerely,
yet it was an absolute failure.
Doctor De N o r m a n d i e . I think we ought to go to our various State
societies and say, “ There are 25 men in this community that will not
give information,” and then see whether the best men in the com
munity will not say, “ Who are those 25 men?” In every community
there are men who desire to have good work done and who will sup
port an investigation. I know if we tried in Massachusetts some
men would fight it and might give us false information, but we would
very soon find out who those men were; and I believe that the medical
profession can do it.
-Miss A b b o t t . Doctor De Normandie, I am not quite clear as to
your position. Just what should the State do and not do ?
Doctor De N o r m a n d i e . I think the States can do these things;
Doctor Crumbine thinks they can not. I should like to ask Doctor
Lakeman, who is here from Massachusetts, whether she thinks that
we can do that in Massachusetts. I do not know how different Massa
chusetts is from the rest o f the country.
Doctor L a k e m a n . We met a great many obstacles in Massa
chusetts and „had a great many difficulties and a few stumbling
blocks. Only a very few physicians objected to being interrogated,
and in each case where it was followed up it was found that at least
something might be said for the physician. Two o f our three investi
gators never had any trouble whatever.
Doctor D e N o r m a n d i e . I can see why one might develop a good
bit o f trouble by asking too pointed questions. An investigator
might be a good investigator, but she might have made the physician
angry, and that is no way to find out things.
Miss M a r r i n e r . About seven years ago I made a few o f those
investigations in Alabama for the Children’s Bureau, and also in
Peoria, 111. In an entire year I met only one physician who objected
in the least to the questions I asked him, and before I left the office
he told me the whole story and took the blame o f the woman’s death
on his own shoulders. I have not done such investigating since I
have been connected with the State board o f health, but I believe that
it could be done whenever we wished to make an investigation of
maternal deaths in Alabama. I believe we could do it and that the
physicians would support us in it. At the present time our State
medical society has a committee on maternal welfare, and its chair
man is working in the closest cooperation with the State bureau of
child hygiene and public-health nursing. Whatever field work he
wants done we do through our State board, turning the results over
to him; and we are assembling the statistics and data for a report
at our next medical association meeting in the Spring.
Doctor M c C o r n a c k . We have reduced the mortality in the hos
pitals o f the State o f Washington, but I believe it is not possible for
private practice. We have no hold on the physician at all. We have
not his records nor anything of that sort. We have followed out
very closely the requirements made by the hospital standardization
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committee, so that every death in every one of our hospitals is thor
oughly investigated. The physician has to give an explanation o f
the deaths. A t first this criticism was resented very much, but where
the records show what a physician has done then he has to face
the record— for instance, giving pituitrin at the wrong time and
other things of that sort. In our hospital meetings, which are quite
friendly, the men have had to explain these things. They have been
told by the obstetricians that pituitrin was given at the wrong time,
or that this case should not have been curetted at that time, or some
thing o f that sort; and this has greatly decreased our hospital mortal
ity. A physician thinks twice now before he gives pituitrin, and he
thinks two or three times before performing an operation. But I
think you can not do very much outside where you have no hold
whatever on the physician. I known there are some places in our
State where I would want a good heavy bodyguard along with me
i f I went to ask a physician why his patient died.
Miss A b b o t t . Most o f these committees appointed by the medical
societies to make an investigation will not have any money to make
the investigation with, nor any organization for doing it. I wonder
whether it would not be possible for some kind o f combination to be
made between the medical society and the State agency whereby
the investigation could become a joint piece of work with the pro
fessional organizations directing or helping to direct the investiga
tion in a way which would make for medical support o f both method
and findings.
Doctor De N o r m a n d i e . I think that is an excellent suggestion,
Miss Abbott. O f course we have not the money, and they do not
like to put the money out in such a thing.
Mi^g A b b o t t . I know. They have relatively a very small amount
o f money for all the things they want to do.
Doctor De N o r m a n d i e . I f the Federal Government should under
take this, and a first-rate physician—not of the community—who
knew the obstetrical questions to ask and the routine to be gone
through should do the investigating, that seems to me far better
than having a local person do it. A local physician objects to hav
ing others know too much about the ins and outs o f things that go
wrong with his practice, whereas i f you have outsiders go in they do
not remember so long.
What Doctor McCornack said about this hospital in Washington
is exactly what happened in Massachusetts. Those o f us who are
connected with class A hospitals are very careful o f what we do;
and if the men who come in there are not careful and conscientious
and if they make one mistake, they are hauled up before the staff
meeting and are held to strict accountability. For example, one
man did a Cesarean the other day with no indications whatsoever,
and the woman died; I saw that man walking around before the
staff meeting, and I never saw him so uncomfortable in my life.
That man will never perform another Cesarean without some indi
cation. That hospital is the one where those three cases I have re
ferred to— ileus, paralytic ileus, and vasomotor paralysis— occurred.
Because o f those three cases there is now on the wall o f the surgeon’s
room o f that hospital a notice “ No Cesarean shall be done without
consultation with another member o f the staff.” In other words, they
are talking over their cases.
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The C h a i r m a n . What do you think about making puerperal sepsis
reportable in the States?
Doctor De N o r m a n d i e . I really do not know what to say about
that. I know that things are unsatisfactory now. I think it is a.
step, and if it is enforced it might help. O f course we do not know"
exactly what to report as sepsis. That is the great question. F or
instance, I have a patient now running a septic temperature, but I
am confident that she has not uterine sepsis. Whether that should be
reported is a big question. I should like to know how it works outin the States that have had it reported. From what I have read
it works out pretty satisfactorily in England. New York has it, I
think, but I do not know what New York thinks o f it.
Doctor G a r d in e r . I suppose some cases are not reported, but we are
getting better and better reporting o f both cases and deaths in New
York.
Doctor De N o r m a n d i e . What do you do after they are reported?'
Doctor G a r d in e r . We send an investigator. The local districtState health officer investigates those cases. I do not know just
what effect that has in reducing the number.
In any of the larger States which have good vital-statistics de
partments the studies could be carried on perfectly well. But after
you get all this information accumulated and tabulated just how are>
you going to proceed next? Those facts are matters that we want
brought home to the private physicians and in their own communi
ties. Shall we separate it into counties so that they can be handled®
in county societies? Or shall we proceed as has been suggested and
perhaps subsidize a State society to conduct some o f these investiga
tions? I think we might do that in New York State, but doubtless
more than one State ought to be doing it at the same time and ¿n the
Same manner, as part o f the same schedule.
Doctor De N o r m a n d i e . They should be on the same schedule so
that the statistics may be comparable.
The C h a i r m a n . I s anyone here from any other State that reports
puerperal sepsis?
Miss L o c k w o o d . I can not tell you anything about what we do in
Delaware after they are reported, because I think that up to the
present time nothing has been done; but I think it very likely that
the machinery o f the State board o f health will move in that direc
tion before very long. We are now getting State board o f health
service on a new basis, and there are many things to be taken up.
That is one o f the things that has not yet received attention. How
ever, if there is any case o f that kind in a district the nurses in that
district immediately make an investigation. O f course that does not
go very fa r ; there is a great deal more to be done; but to have some
body looking into it does help considerably.
Doctor G a r d in e r . In New York we publish a little card o f pocket
size and send it to every physician in the State, giving the causes
o f death that are really puerperal according to the national classi
fication. There is a very long list, and we found a great many cases.
The deaths were not being reported, evidently because the physicians
did not understand them to be puerperal deaths. Since we sent the
cards out we have had very much better reporting, and that is a
simple thing for almost any division or department to do.
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The C h a i r m a n . Another question that conies to my mind is
whether we should make a study o f neonatal mortality at the same
time as the study o f maternal deaths and with the same personnel.
Doctor D e N o r m a n d i e . I think they are two entirely different
studies. Neonatal deaths, which I should think would include those
at two weeks, is a very much bigger study than the maternal death
rate; that is, a much larger, much more important, much more diffi
cult study must be made. There are a greater number of deaths, and
the cause o f death is less known. There comes in a new question.
Mr. Schultz, inanition is an accepted form o f death in a newborn
infant, is it not ?
Mr. S c h u l t z . I think so.
DoctQr D e N o r m a n d i e . N o w that is an accepted cause o f death,
and you can not go farther than that. You can not find out any
thing more. I should not like to see the two studies done together,
because I fear we should not get anywhere.
May I ask Mr. Schultz to answer some of my questions or criticize
one or two o f those statements that I made. Should criminal abor
tion be regarded as a puerperal death ?
Mr. S c h u l t z . I am not sure o f it. I remember having had a
communication from the Public Health Service as to changes in the
classification, and I can not say just exactly how these changes will
be carried out; but I do know that an attempt is being made to
work out a standard definition in connection with the health office
o f the League o f Nations.
Doctor D e N o r m a n d i e . I know that? but I was wondering whether
you know anything about the question o f criminal abortion and
about an accidental death i f the woman was pregnant.
Mr. S c h u l t z . I think you are right about the second, but I do
not remember the first one.
Doctor D e N o r m a n d i e . I hoped if it was not so you would say
so frankly, because we had several o f those deaths in Massachusetts.
W e have about 600 deaths a year, but a very few (I think some
thing like 30 cases) were nonobstetrical deaths, and o f course it helps
if 30 o f those 600 can be eliminated. For instance, we had one case
o f a woman who died who had a miscarriage at five months just
before she died. She had a carcinoma of the larynx, yet the case
was classified as puerperal death. That is wrong, is it not?
. Mr. S c h u l t z . I think that is wrong, but there is no way o f telling
just what kind o f classifications are followed by the various States.
I know there is confusion worse confounded.
-n r P ° ct-0 r
N o r m a n d i e . That i s what we found in Massachusetts.
What is a maternal death? That is what they got mixed up on.
Doctor S t a d t m u l l e r . In California we tried to investigate about
500 deaths that we had one year. On some o f the deaths we did
not attempt to go out and visit the physicians, and that point came
up. I wrote to the Census Bureau and was told those deaths were
to be included in the maternity mortality. I thought that we might
eliminate some o f those early deaths from the number; but I con
sulted three different people and wrote the Census Bureau, and they
wrote back that they should be included. O f course they are not
criminal, in the sense that we could not prove that they were.
Doctor De N o r m a n d i e . I understand that they make a distinction
between self-induced and criminal abortion.
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Doctor S t a d t m u l l e r . That may be the point, then; but they wrote
me a rather general answer that abortions were included, and con
sequently I assumed this to mean either self-induced or criminal.
Doctor B o y t o n . I should like to ask i f anyone can give a good
reason why our maternal death rate is figured on 1,000 live births
instead o f 1,000 total births including stillbirths?
Mr. S c h u l t z . That question has been discussed time and time
again, but I may say very briefly that expediency had a good deal
to do with it. It is practically impossible to ascertain the exact
number o f stillbirths. What is a stillbirth or what is not a birth
at all entered into this question, so that, taking into consideration
what we can obtain and what we can not obtain, this seemed to be
the best basis to use.
•
Doctor K n o x . I should like to say a word in reference to this
very unsatisfactory classification o f early or neonatal deaths. I
do believe they are different, and they ought to be considered some
what separately from the maternal deaths. But certainly in the
future we are going to consider the condition o f the mother in de
termining the cause o f death o f the child in the first two weeks, and
I believe that the Census Bureau’s method o f classification will have
to be altered to some extent to take into consideration the condition
o f the mother. Whether that mother has had a serious hemor
rhage, even though she lives or dies, may determine the neonatal
death o f the child from inanition, i f you please, or from congenital
debility; and so we can not intelligently increase our knowledge
regarding the cause o f neonatal mortality until we link it with the
condition o f the mother very much more closely than we are now
linking it in our vital statistics.
The C h a i r m a n . It is too bad that we did not have Doctor Adair’s
paper along with this discussion, because so much comes out in that
in regard to the study o f neonatal mortality and its relation to the
type o f care the mother has had, the type o f delivery, the trauma and
the like. Has anyone else anything to ask or to suggest in regard
to making this study?
Doctor U n d e r w o o d . O f course we know that the State has a right
to insist that mothers have the best prenatal care and a right to
make this study; and i f it is to be made I believe there is a proper
place to begin. I am sure that it is some one’s duty to arrange
this, but I do not think that a committee from a medical society,
State medical association, or local medical society can accomplish it
satisfactorily. We have had such committees appointed in Missis
sippi by local medical societies (I know o f none being appointed by
the State association), but these committees do not function. They
have no funds, and the members have not the time to devote to this
work.
I am sure that the Children’s Bureau, in cooperation with State
boards o f health— say, through the division o f maternity and infant
hygiene—should inaugurate such a study, engage some person or
persons to do this special work, and let them go before the medical
societies o f the State, the local component societies o f the State
association. Explanations should be given as to just what the work
is and what information is wanted, and the cooperation o f each
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59
society should be requested. I am certain that coo^feaL^ffifidll be
granted cheerfully in most instances, and if at first
cceed we would succeed later, if we kept hammering away^kj^Rj'^ie
State board o f health could do this work through its ^ u j^ a u f^
maternal and infant hygiene with the full cooperation of comT^h&a
appointed from local medical societies. I am sure we cou ld ^ a a l^
a success o f this study, and it is high time we began.
In Mississippi for several years we have had puerperal sepsif
reported,-but nothing has been done about it. The physicians in *
each county report to the county health officer each month the num
ber o f cases o f puerperal sepsis. The county health officer makes a
report to the State health officer once a month. W e have the infor
mation, but we have done nothing about it.
The C h a i r m a n . Doctor De Normandie, have you any idea o f the
cost o f such a study ?
Doctor De N o r m a n d i e . No, I have not the slightest idea. It all
depends upon your personnel, I should think. You must have firstrate personnel or you are not going to accomplish much. May I ask
Doctor Underwood whether there were more deaths from sepsis in
Mississippi than were reported ?
Doctor U n d e r w o o d . I am very much afraid so.
The C h a i r m a n . I s that true in New York?
Doctor G a r d in e r . I think that is the feeling.
Doctor De N o r m a n d i e . So it is not very satisfactory?
Doctor G a r d in e r . We are doing it now by questionnaire, and we
do get a great deal of information; but we also get a little side
stepping.
Doctor L a k e m a n . It might possibly help to answer the question
concerning the expense o f the study to know that our 984 cases were
studied in about iy 2 years by three people working very nearly full
time. They did a few other things.
The
C h a i r m a n . And they were all physicians?
L a k e m a n . A ll physicians.
C h a i r m a n . Did you have the cooperation of
Doctor
The
society and the local medical societies?
the State medical
Doctor L a k e m a n . W e had the cooperation in the way that was
mentioned, and I think Doctor Crumbine said that it was announced
that we were going to make the study. The announcement was
received in a perfectly friendly fashion. [Laughter.]
The C h a i r m a n . Then the way to begin these studies is to begin,
is it not? Well, I hope we can all begin.
Doctor M c C o r n a c k . I think i f you announce that you are going
to do this and then ask for cooperation you will be more likely to
receive it than if you become involved in a discussion as to whether
it should be done or not.
[Meeting adjourned.]
,
TUESDAY JANUARY 12—MORNING SESSION
x
M ISS •MARTW T. PHELAN, EXPERT IN MATERNAL AND IN FAN T CARE, MATERNITY AND
IN FAN T-H YGIEN E DIVISION, CHILDREN’ S BUREAU, PRESIDING
The C & a i r m a n . Some of the directors have asked that we have a
roll call this morning, because we do not seem to know one another
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very well So we will begin the meeting by asking the various
directors to stand up when their States are named.
[The chairman called the roll of States and directors]
subject for this morning’s conference is maternity care and
the infant and the child o f preschool age. Doctor Levy, o f New
Jersey, will be the first speaker. He will discuss the midwife
problem and the method o f handling it in New Jersey
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B
y
J
u l iu s
L
evy,
D
M. D.,
C o n s u l t a n t , B u r e a u of C h il d H
H e a l t h , N e w J ersey
y g ie n e ,
e p a r t m e n t of
Recognizing that there are large differences among the various
States I have thought it best to indicate in a very broad way the
nature o f New Jersey’s program in organization and something o f
its results, hoping that you will bring out in your own questioning
whatever special information you may desire, or in whatever way
we can be o f service to other States who are interested in this par
ticular problem.
It may help you for me to give a little picture o f the State o f
New Jersey, which is relatively a small State sandwiched in between
New York and Philadelphia. Some people claim that all the good
things go through New Jersey. Some o f us think that some of
them stay.
New Jersey consists o f 21 counties, the largest o f which has 810
square miles and the smallest 43. The population is a little more
than 3,200,000. The largest population in one county is 652,000,
and the smallest is 19,400. The smallest county (that o f 43 square
miles) ranks second, with a population o f more than 600,000. This
is due to the fact that it is an industrial center just across the river
from New York. There are 5 cities, each with a population greater
than 100,000; 12 cities o f more than 25,000; 18 cities o f 10,000 or
more, and about 785 municipalities o f 2,500 or less. New Jersey
has about 3,000 physicians. There are 69 large general hospitals
with free clinics, including prenatal clinics, which are being devel
oped throughout the State. There are 7 State hospitals to care for
tubercular, feeble-minded, epileptic, and insane persons; and about
30 small private hospitals and maternity homes. The number
according to counties ranges from 1 small private hospital to 14
large general hospitals. In one county there is no hospital o f any
kind.
The number o f births in 1925 was 76,530. The maternal mortality
rate was 6 and the infant mortality rate 70. That may give you a
Very superficial picture of New Jersey.
Now in regard to midwives. The law requiring the licensing o f
midwives was passed in New Jersey in 1892. The licensing and
the suspending and revoking o f licenses are under the control o f
the State board o f medical examiners, not under the State depart
ment of health. When we reorganized our child-hygiene bureau
the State department o f health, quite o f its own volition, without
the request o f anyone or specific authority from any source, under
took the supervision o f midwives. It has been generally held by
those who know us that we are not a very law-abiding bureau;
that is, we felt that the supervision o f midwives was a necessity
for the protection o f child life, and we merely went ahead and
supervised them. Some people still question our authority.
61
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lii Order to give you a clear picture o f the supervision o f mid
wives I think it desirable to sketch in a rapid fashion the childhygiene program, because to my mind— as things apply in New
j ersey—the midwifery program should not be thought o f or under
taken as a separate activity or entity. A s I have said, we were
interested in supervising mid wives merely because we considered it
essential and necessary for the proper protection of child life. We
had no preconceived notions afid no convictions about the midwife.
We knew that when we started work they were attending about
30,000 births a year, which represented about 42 per cent o f all the
births occurring. Wh knew that they had an immense influence
upon not only the newborn baby but also upon the mother’s atti
tude toward this baby; that the midwife, being often o f the same
race and nationality, with the same traditions and prejudices, would
have an immense influence for good or evil in the later care o f this:
infant. So I wish to make clear that our work with midwives
was prompted wholly by our feeling that she exerted a highly
important influence upon the survival o f the infant and upon its
proper care. W e would not consider establishing a midwifery pro
gram except as part o f an organized child-hygiene program.
In organizing the child-hygiene program in New Jersey we
thought that the most economical and efficient way of protecting
child life was to place in a limited area one nurse who would be
responsible for all the important factors that enter into the health
and life o f the child. That included prenatal care, and care o f the
newborn baby, the preschool child, and the school child. You know
that we have designated that as the continuous child-hygiene
program.
. . .
. .
.
Having placed a nurse in a definite, limited district to undertake
these activities and certain related activities, such as the supervision
o f boarding homes, o f unmarried mothers, o f the prevention o f oph
thalmia, we then developed the idea o f a district supervisor o f
nurses, having one nurse direct the activities o f as many nurses as
we thought she could supervise.
A ' jf $ .
The district supervisor then is responsible for all the child-hygiene
activities in her district, and these include the activities o f the
midwife.
'
.
In the central organization we have an assistant who supervises
the midwifery activities o f the district supervisors. I believe that
in the field there should be one person taking care o f all the activi
ties, whereas it may be desirable to have^in the central office some
person who is a specialist in one o f the activities o f the field.
I think with that sketch I may indicate to you what we believe
have been the results o f this field o f activity and something o f the
methods. Perhaps the clearest way is to contrast the conditions
that we found in 1919 with the conditions that we are able to report
in 1925. Inasmuch as I shall be dealing with figures, I want to
assure you that we have made every effort to have these figures be
facts. I mean by this that we have not permitted our assistants to
report impressions o f midwifery activities. They are allowed to
tabulate only those things that they could be confident were true,
and they have taken the time to make surveys of specialized types
o f midwifery activities so that we could assure ourselves o f the status
o f the midwife’s work.
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In 1919 the midwifery work consisted o f having one supervisor
Covering two counties. In 1925 there were 12 district supervisors
working in the 21 counties. In 1919 licensed midwives numbered
946, and 450 o f these were active; in 1925 there were 398 licensed
midwives, In 1919 they delivered 42 per cent o f the births; in 1925
they delivered 23 per cent o f the births. This change in percentage
o f cases delivered is partly, I have no doubt, the result o f super
vision, but it is also partly the result o f restricted immigration.
In 1919 there were 262 women practicing without a license. In
1925 there were 11 unlicensed midwives, all o f whom have been re
ferred to the State board o f medical examiners for prosecution. I
frankly admit that before 1925 we did not refer these 11 midwives
for prosecution; that is, they were working in areas where we
thought they were needed. Since that time either licensed midwives
have come into the district, or transportation has become o f such a
nature that we think the midwives are unnecessary, and we have
then moved for prosecution. In other words, we have not been in
fluenced altogether by the legality o f the question; we have been
influenced by what we considered the practical indications of the
situation.
This question o f unlicensed midwives and how to get rid o f them
may interest you considerably. In the first place, we feel that you
should not make it a principle to get rid o f all unlicensed midwives.
Some unlicensed midwives are better than licensed midwives. We
think it should be settled on a practical basis. I f a study indicates
that a certain woman renders very helpful and useful service in a
district, we would supervise her and direct her work just as i f she
were licensed, merely waiting for the time when we Think she is
unnecessary and then telling her she must either obtain a license or
cease practicing. We have not had very much difficulty in the
elimination o f these 251 unlicensed midwives. A great many gave
up their practice as soon as they realized that they were going to
be very closely watched; some gave it up just as soon as we could
show them that we had considerable evidence against them; others
gave it up when we explained to their families (they were often com
fortably placed) that midwifery was an undesirable activity for the
mother and might lead her into serious trouble. So we have had
many women cease voluntarily and others as a result o f prosecution,
although we have relied very little on the law and on prosecution.
We have come to this conclusion as the result o f very interesting
experiences. We have one midwife who is prosecuted about every
six months; and every six months she pays a fine o f $250. Every
once in a while she goes to jail six months, and when she comes out
she practices again. In such a case prosecution is absolutely use
less. We can not persuade her to quit; we can not force her to quit;
we can keep on punishing her. It is somewhat analogous to our
general criminal procedures. We have very little confidence in
them.
In regard to some o f these check-ups whereby we try to determine
the status o f m idwifery: In 1919 the midwives hardly knew that the
law required them to use silver nitrate in the eyes o f the newborn,
and cases o f ophthalmia were frequent, although such a law had
been on the statute books for years and an appropriation o f $2,000
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had been made for the purchase o f silver nitrate. In 1925 it was
definitely proved that 98 per cent o f the midwives used silver ni
trate in the eyes of the newborn, and we seldom hear o f ophthalmia
any more. That is the result o f a very intensive investigation o f the
activities o f each midwife. The investigation may consist o f ques
tioning the mother o f each newborn baby at certain times o f the
year or in certain districts and areas, but the statement is based on
the result o f a very intensive, and so far as I know, an honest inves
tigation o f the facts. Ophthalmia is practically unknown in New
Jersey. I mean now the ophthalmia o f gonorrheal nature. Thetfe
is a certain amount o f general ophthalmia, o f course.
In 1919 the survey showed that about 32 per cent o f the midwives
carried a spare bag and equipment— and that word “ spare ” is very
loosely interpreted. In 1925 a recent check-up showed that 87 per
cent o f the midwives carry very good bags and equipment. Now we
mean a very definite thing by the term “ good bag and proper equip
ment.” It must include: A leather bag with three removable, wash
able linings, a ^-pound package o f sterile cotton, 1 yard o f sterile
gauze unopened, umbilical dressings in sealed envelopes, cord tape
in sterile bottles, umbilical scissors, two clamps, baby scale, ther
mometer, boric-acid powder, lysol, fluid extract o f ergot (1 ounce),
rubber gloves, clean all-over apron, nail brush and wooden stick,
liquid green soap in shaker bottle, silver nitrate, midwife’s case-book,
and a card for reporting an abnormal case. Before we classify that
bag as good it must contain all these things. I f any one o f these
things is absent it is not counted a good bag.
This results from the inspection o f the bag in tHe home—not merely
on display wjiere a midwife can perhaps substitute a fancy-looking
bag. It is the result o f the investigation o f the bag in the home as
the midwife uses it.
The midwives in New Jersey are using this uniform equipment.
We have arranged through the midwives’ association that they shall
purchase at wholesale prices from one o f our large cotton-manufac
turing houses sterile goods o f a uniform character.
It was found in 1919 that 21 per cent o f the midwives carried vari
ous instruments, such as a speculum, wired catheters, curettes, and
hypodermics, and prescribed drugs such as morphine, laudanum, par
egoric, iron, arsenic, and strychnine. In 1925 we still occasionally
discover a midwife who will give a hypodermic—but this is usually
at the suggestion or request of a physician, especially in the foreign
groups— or she will prescribe cathartic pills, but very rarely. For a
little while they were using hypodermics o f pituitrin, but we feel
quite confident that it is extremely rare for that to happen in New
Jersey to-day.
In regard to the clinical thermometer, which is so very important
from the standpoint o f the detection o f early sepsis and fever, it was
found that many midwives carried thermometers but could not read
them, and never attempted to read them. They do that to impress
themselves. [Laughter.] In 1925 we can definitely state that 80
per cent o f the midwives have their thermometers and actually and
regularly use them.
Seventy-seven per cent o f the midwives call physicians on abnormal
cases. In speaking of abnormal cases, I do not mean difficult labor;
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but any abnormality, whether in pregnancy, in labor, or in the new
born infant.
You may be interested in this fact which makes clear this point:
Physicians were called in for 476 o f the 540 abnormal cases actually
reported in 1925, on forms supplied for the purpose. The physician’s
own observation and report was made on many of these reports.
I think these facts are enough to give you an idea of the definite
ness o f our procedure with the midwife. W e have clearly in our
minds the things we wish them to do and the things we do not Wish
them to do. The supervisors are required to report definitely on the
things they do and the things they do not do. It is not merely gen
eral educational propaganda or campaign work. It is a very specific
and definite procedure.
You will be impressed by the amount o f time which the district
supervisor-gives to this work. It can only be estimated, but it appears
to us that about one-fourth o f the district supervisor’s time is given
actually to the supervision o f the midwife. Our report shows 3,473
visits made directly to midwives; 2,015 prenatal cases reported by
midwives to the supervisor or to prenatal clinics ; 54 puerperal deaths
investigated, also 33 infant deaths, and 62 stillbirths. These investir
gâtions are made merely to give the district supervisor detailed in
formation in regard to the midwives’ methods and procedure, and not
to fix responsibility looking toward prosecution.
The midwives are organized into county associations entirely under
their own control. They elect their own officers and conduct their
meetings, with the advice and guidance o f the district supervisor;
but it is an absolutely autonomous organization, as you will readily
see when you note some o f the czar-like things that are done once in
a while. Last year they held 83 monthly association meetings with
an attendance o f 1,075. A t these midwifery meetings an attempt is
made to have a regular course o f lectures. W e suggest the list o f
subjects to the district supervisors, who are then expected to talk it
over with the county medical society, in the hope first o f familiariz
ing them a little better with what the health department is doing in
midwifery work, and, secondly, to have them suggest the best physi
cians for delivering these talks. They are o f very fundamental char
acter, such as : The importance o f the prenatal period, a normal preg
nancy, labor and delivery, asepsis, the premature and immature baby,
venereal diseases and their control, the nurse and the midwife, and
normal nutrition in the infant.
In 1924 we held our first State-wide conference o f midwives. You
will be very interested to know that it was held in the Academy of
Medicine. That was quite a victory. We even got the president o f
the State medical society to come and address the midwives. He was
a little shocked and surprised when he saw them all there. W e also
had the director from the American Child Health Association there.
I think he got a few surprises. The midwives came from all over the
State. They wore white uniforms, and they had a very lively discus
sion. You may be interested in one point they made: They had been
instructed by us to refer all abnormal cases to physicians, and one of
them got up and said, “ That sounds perfectly proper and good, but if
it is, we think that the doctors ought to be compelled to refer all nor
mal cases to us.” [Laughter.] From some of the statistics we have
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elaborated on maternal mortality we are almost disposed to agret
with them. The midwives now look forward to this annual confer
ence as a regular event.
The most recent development has been getting the midwives to do
urinalysis on every case. They are able to purchase now at nominal
price a urinalysis outfit, and to date they have ordered about 100 sets
voluntarily through their own organizations. I always wish to em
phasize that. It is not something we are giving them or anything
they are being ordered to do. These things are done o f their own ac
cord as the result o f persuasive pressure.
To show what can be done with midwives I wish to mention briefly
a recent development in Newark. You know that infant mortality
to-day simmers down practically to neonatal mortality. In all the
States and cities that have done any kind o f intelligent child-hygiene
work the deaths o f infants under. 1 month constitute about one-half
o f the deaths under 1 year o f age; and the deaths under 1 week con
stitute about one-fourth o f the total. That being so, there will be no
reduction o f infant mortality unless this early mortality can be at
tacked.
It occurred to us that it would be very fine if we could get a record
o f births the day the babies were born. A t a conference with mid
wives we explained the situation to them. W e had a postal card
printed with the department’s address on one side, and on the other a
blank for merely the date, name, and address o f the birth. We are
receiving to-day the cards for about 90 to 95 per cent o f all the babies
delivered by midwives within 24 hours after their birth. That is in
Newark, not in the State as a whole. I think by just mentioning this
incident I have made clear what can be done in active cooperation
with the midwife.
DISCUSSION
The C h a i r m a n . We have found that there are in the United States
about four types o f mid wives with which we are dealing; namely
( 1 ) The foreign-born midwife, who has been discussed in Doctor
Levy’s paper; (2) the Mexican midwife, who is found in the border
States, such as Texas, Arizona, New Mexico, and California; (3)
the American-born midwife, who has no training, who is a good
friend and neighbor, who is helping her friends and neighbors where
there is a lack o f medical service, and who does not pose as a midwife
nor receive pay— and I will cite my own State, Michigan, as having
a goodly number o f those— and (4) the Southern midwife, who is
usually a negro. I am going to limit this discussion by calling on
some o f the people who can tell us o f the type o f work done with each
o f these groups.
<
In the Children’s Bureau we have a negro physician who is helping
in the South. She has been in Tennessee and is now working in
Georgia, and I am going to ask her to talk to you about the negro
midwives for just a moment.
Doctor W h i p p e r . The midwives in Georgia are rather hard to find
because they live at such great distances and in such places that one
would hardly, know anyone lived there. It seems that many o f them
would like to deny doing the work, but after you get in touch with
them and let them understand that there is no harm coming, that you
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are really going to help, and probably show them pictures of some
o f the other midwives, they respond readily and are very easy to
teach. Many o f them can not read nor write. Some can sign their
names, others can n ot; but they are very anxious to learn. We teach
them by demonstration, and as soon as they are taught they are as
eager as little children to come up before the class and show that
they know how to do the work. Frequently they can not tell you
how— at least they think they can not—but after a while you get
them to talking freely and they get the work done, though their
English is not always the best.
I wish to tell about a piece o f work that was done in Atlanta.
There were 84 midwives in that class. I had taught them to do the
prenatal work, to tell the women just what to do during the whole
time, to get in touch with them as soon as possible, so as to give them
all the information possible. I had a nurse who was very good in as
sisting, and I had a prenatal clinic formed there. The negro physi
cians in the community came in and helped out. About 15 or 20
women came each week, and while each patient was being examined
I talked to the other women about prenatal care. We had a socialservice club connected with the church in whose parish house we
were working. They taught the people how to make the children’s
clothing and the obstetric package, and how to make the things out
o f virtually nothing. They were poor people, and we told them to
bring anything and we would show them how to make something
out of it. They did. When we were through with that we got the
midwives really to do the work we were trying to accomplish. They
were telling us they were doing it, but we saw that they did ; and
when they took blood tests we would take the specimens to the city
laboratory and have examinations made.
The C h a i r m a n . Doctor Smith, will you tell just a little about the
American type o f midwife and how you are reaching her?
Doctor S m i t h . W e have a difficult problem among the midwives
in Michigan. By a survey we found that in 1923 about 1,113 mid
wives were reporting births. Some of these are under supervision,
and, especially in Detroit, they are very well supervised and are
under local regulation. Just recently I succeeded in getting the
rules and regulations approved by the State council, and they have
gone to the printer; so we are hoping to send a copy o f the State
rules and regulations to all midwives in the State very soon.
Although the midwives are not licensed in Michigan—that is some
thing we have to look forward to—we are holding what we call mid
wife classes throughout the State. We have a physician and a nurse
who go from county to county holding classes not for midwives
alone, but for all women, but we are urging the midwives to come.
At these classes we take up prenatal care and child care and also
demonstrate the preparation of obstetrical kit and layette and of the
various things necessary for home delivery.
We find it very difficult to get the midwives out to these classes, but
the numbers are increasing. I think our problem relates to the for
eign-born women in the upper peninsula more than to our Americanborn midwives, and there we are trying to do some intensive work.
W e have found that where the midwives are operating the maternal
mortality has not been affected, but we do find that the infant mor-
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tality appears to be higher in the parts o f the State where the mid
wives practice. So we are hoping to do still more work among the
midwives this coming year.
The C h a i r m a n . Miss Anderson, will you tell us a little about your
work in New Mexico ?
Miss A n d e r s o n . During the past year through the courtesy of the
Children’s Bureau we have been loaned a midwife instructor for our
Spanish-American mid wives. W e have very many o f them because
the population o f New Mexico is largely o f Spanish and Indian de
scent.
Our midwives are a necessary evil because we have extremely iso
lated districts. Our mountain districts are very numerous, and in
the winter they are snowed in. They may be 80 to 100 miles from any
ethical physician or a physician o f any kind. Physicians charge $1 a
mile, so that is prohibitive, and we have been very appreciative of the
work that is done with our midwives. They can not read nor write
nor speak English, so you see we have a great problem there. But
we teach them as the negro midwives are taught, by demonstration;
and we have gotten them from the stage where they were dirty and
carried no equipment but their hands, and might cut the cord with
the carving knife as the only instrument available, to at least some
equipment and to wearing an apron and washing their hands before
instead of only after the delivery.
The C h a i r m a n . Does anyone wish to ask any questions o f Doctor
Levy before we call upon him in this discussion?
A D ir e c t o r . I should like to ask what program his is in regard to
instituting breast feeding for the babies cared for by midwives and
in regard to continuing it.
Doctor B r y d o n . I was very much interested in what Doctor Levy
said about having midwife education constitute a part o f his childwelfare program rather than a separate and distinct unit. In speak
ing o f the child-welfare program do you mean the whole maternity
and infancy program, or do you mean that part which we usually
speak o f as the child part in contradistinction to the maternity part
o f the program? The reason I wish this made clear is that I feel
so positively that the midwifery-education program should be a
part— should not be separate, but should be a part— of the maternity
program ; that if we get the program well under way it will include
prenatal midwife education, education o f the mother, and a campaign
against neonatal mortality and infant mortality.
Doctor N o b l e . I should like to ask Doctor Levy what he thinks
about the automatic elimination o f the midwife in the course o f time
i f immigration is not renewed. In Pennsylvania the age o f the mid
wives, as we gather them together and see how very old some o f them
are, shows very clearly that they can not go on practicing much
longer. New mid wives are not being licensed, and the children o f the
present foreign mothers are not going to wish to call in midwives.
This should result in an automatic elimination. Does he not think
this reasonable to say to the physicians who wish to eliminate the
midwives?
^
Doctor V e e g h . I should like to know his standards for granting a
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Doctor K o e n ig . I f we are going to try to eliminate the midwife
(which we are gradually doing in Arkansas) and to raise her stand
ards and to prevail upon the physicians to tolerate midwives in a
State like Arkansas, where they really are a necessity—I wonder if
it would not be better to instruct the midwives to take the urine to a
physician, as we are doing. I should like also to ask whether Doctor
Levy has. other classes o f instruction between the monthly meetings,
and who conducts them. W e have nurses and physicians conducting
our classes in the county.
The C h a i r m a n . Doctor Levy, will you respond to these inquiries ?
Doctor Levy. I shall do the best I can. I believe the first point to
make is that with the reduction of cases delivered by midwives there
has been no reduction of maternal mortality. Now do not forget that
point. It will-influence considerably your attitude toward the mid
wife. I f at any moment we had knowledge or experience that would
demonstrate that with the elimination of the midwife we were re
ducing maternal mortality we should have a magnificent impetus to
hurry her elimination.
Some one (from Michigan, I think) stated that the highest infant
mortality seems to have been found among the cases delivered by
midwives. I should be interested in getting those figures. Through
out New Jersey the lowest neonatal mortality rates are found among
the women delivered by midwives.
Doctor N o b l e . That is the case in Pennsylvania also.
Doctor L e v y . I am not saying it is because they are delivered by
midwives; therefore you must not give the impression, either to
yourselves or to anyone else, that when you say you had a group in
which the highest neonatal mortality was among those delivered by
mid wives it is because they were delivered by midwives. Let us
try to keep the facts straight because that is the fundamental basis
of the whole discussion.
. In regard to instruction on breast feeding—that will, I think, help
the answer to Doctor Brydon’s question: To our minds the midwife
question is merely part o f the child-hygiene question. The estab
lishment and maintaining of maternal nursing depends very much
on the instruction the mother receives in the first two or three weeks
after the baby’s birth. Her attitude is determined—her attitude is
influenced— immensely by the midwife, so that our supervisors are
expected to instruct the midwives just as intensively in regard to the
proper care, nursing, feeding, and management of the baby as in
regard to the prevention o f sepsis. After all, when you think that,
for instance, with 12,000 births there are 85 maternal deaths, but
there are 12,000 babies whose lives can be affected, you will realize
that numerically^the great problem is the baby and not the mother,
although dramatically the death of the mother is a much greater
thing. Your only hope at best is to prevent maybe 10 deaths o f
mothers; but by the instruction you give in the nursing and care of
the baby you are influencing the whole health and life o f 12,000
babies.
~
/
,
So we have a very definite, positive instruction. The midwife
must teach the mother how and when to nurse, and if the mother
can not nurse the child then the midwife must consider that an ab-
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PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
normal case and not advise the woman what to do but merely advise
her to consult a physician. That applies to the premature baby, the
immature baby, and you see how it comes in now with that 24-hour
notification. The nurse is there in 24 hours, and if the midwife
does not report it the nurse will, and this will be counted against
the midwife.
About the automatic elimination? I have taken a very fatalistic
attitude toward the midwife question ; that is, I have said it is quite
outside o f my control. A ll I know is that there are midwives de
livering women, and our job is to make them as good as possible.
Whether they will increase or whether they will decrease is quite
aside from the question. You may be interested to know that some
time ago a very violent attack was made on the midwives in Phila
delphia, and they were all dumped into the Delaware River, which
is rather close to New Jersey [laughter], but no constructive pro
gram has been offered yet. So I myself never waste time discussing
whether midwives are going to increase or decrease; I am interested
only in the fact that as you eliminate the woman who engages in
midwifery you naturally reduce the number o f midwives; yet if the
physicians continue running up the fees to $300, $500, $1,000 a case,
there may come back an altogether different type o f midwife, charg
ing $25, $50, or $75; and she will be a highly trained woman whether
she be a nurse or not.
As to the standards for licensing: To my mind they still are not
what they should be, but New Jersey requires two years’ training
in a recognized school. I think it is a lot o f paper talk, about the
recognized school. It is so arranged that she can spend a day a week
in a school, which I think is all wrong. To my mind Bellevue is
doing the best piece o f work in that direction by requiring continuous
attendance for at least six or eight or nine months. The objection
made to that is that it makes it diflicult to take the course. Well,
the more difficult the better, because then only the worth-while persons
do it. Then they must pass an examination conducted by about a
dozen physicians who ask them very, very difficult, questions in anat
omy and physiology; and if they pass these it does not indicate
that they are going to be any better midwives than if they did not
pass. That is true o f a lot o f physicians who have passed. I mention
that because i f I can make clear (and I will bring that out in another
point) that the only thing that is worth while— and I am talking
a little bit in an exaggerated fashion when I say “ only
is close
follow-up after the midwife is practicing.
I do not care very much about classes. I care about following
the midwife into her home on her postpartum case, on her delivery*
on her patient’s baby. You have the best example in physicians;
they have had the best instruction in the world, yet see how few
Doctor Noble finds she thinks she can trust to take care o f the babies
in the State o f Pennsylvania; and Doctor Knox finds it very difficult
to find pediatricians to go down and examine babies in Maryland.
On that score we feel again that such work is fine, but the results wili
depend on what you get the person to do who is there all the time, not
the person who makes a nice State visit once in a while.
So the standards are high, but I want you not to be deceived by
standards. Do not think that if you make standards for your State
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you are going to eliminate midwifery. You need standards to enable
you to prevent certain types o f women from practicing, but the re
sults will depend on how closely you follow up the midwife all the
time. Specifically, we conduct no other classes than these lectures,
and at the monthly meeting o f the midwives with the district super
visor she constantly discusses with them their own detailed cases.
About urinalysis: My attitude there again is a practical one. I f
you believe that your purpose is to eliminate the midwife, the worse
you can make her the sooner you will eliminate her. Perhaps you
might be prompted to go at it in that way. We are prompted merely
by the problem, since physicians will not do urinalyses for their own
prenatal cases, how are you going to get the midwife to do them?
One o f the great difficulties we have in prenatal work in New Jersey
is inducing the physician to do something which makes it worth while
for a woman to go to him after the nurse has prevailed upon her to
go. So we believe, from a practical standpoint, that i f we can get the
midwives to make urinalysis for albumen and sugar, which is very
simple, we will get them to send abnormal cases to the physician—
which I want to say is our basic attack. Make them realize that it is
to their own advantage, i f they wish to continue in the profession, not
to mix themselves up with abnormal cases. Therefore we must help
them to identify abnormal cases, to recognize them, and to refer them
to the physician.
The C h a i r m a n . Our next speaker is Doctor Eliot, o f the childhygiene division o f the Children’s Bureau. I think there is a little
misunderstanding in the field about these two divisions o f the Chil
dren’s Bureau. The child-hygiene division is concerned with research
work, whereas the maternity and infant-hygiene division is respon
sible for the administration o f the maternity and infancy act. Doctor
Eliot is in charge o f the rickets study which is being carried on in
New Haven and she will give us many helpful suggestions.
/
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A DEMONSTRATION OF TH E COMMUNITY CONTROL OF
RICKETS
By
M a r t h a M . E l i o t , M . D . , D ir e c t o r , C h i l d - H y g i e n e D i v i s i o n ,
C h il d r e n ’ s B u r e a u , U n it e d S t a t e s D e p a r t m e n t op L abor
In October, 1923, the United States Children’s Bureau undertook
in New Haven, Conn., in cooperation with the department o f pediat
rics o f Yale University, a three-year demonstration which had for
its main purpose the prevention-or control of rickets in a city com
munity. For some time it had been known that rickets could be pre
vented in animals by the use o f cod-liver oil, sunlight, or artificial
ultra-violet light; but little had been done to show that similar means
could be used to prevent or control rickets in infants. Because o f the
great number o f factors involved in the development o f rickets and
the complexity o f the problem a great many theories had been ad
vanced with regard to the etiology and cure o f this disease. Not un
til a short time before the demonstration was started had the facts
about the effect o f sunlight and cod-liver oil become sufficiently clear
to warrant a study such as has been undertaken in New Haven.
Rickets was first described as a clinical entity by Glisson 1 about
1650. Until that time, and indeed for a long time afterwards, rickets
was confused with other conditions such as scurvy, scrofula, rheu
matism, and other diseases o f the bones. It was true that children
suffering from scurvy or scrofula were frequently the victims o f
rickets as well, but not until late in the nineteenth century was
rickets clearly defined as a separate disease. Its treatment has been
as varied as the theories regarding its etiology. Cod-liver o i l 2 was
originally used as a medicine by the fishermen o f the northern Euro
pean countries, but its therapeutic value was not recognized by the
medical profession until much later. The first report^ o f the ad
ministration o f cod-liver oil by a physician was in 1766 in England,
when a case o f severe rheumatism was cured by its use. In 1822
it was known to be in use in the Netherlands for rickets and scurvy,
and shortly afterward reports o f the cure o f rickets with cod-liver
oil came from France and Germany. In the last half o f the nine
teenth century it fell into disuse, and its efficacy in the treatment o f
rickets was not widely appreciated again until the early twentieth
century. That poor hygiene and bad housing had much to do with
rickets was generally believed, but the specific effect of ultra-violet
light was not known until quite recently. In 1919 Huldschinsky 3
reported the cure o f rickets with artificial ultra-violet light, and in
1921 Park and Howland 4published a report showing that cod-liver
1 Glisson, F., et a l.: De rachitide, sive morbo puerili qui yulgo “ The Rickets ” dicitur,
tractatus. Second edition. London, 1660.
2 Guy, Ruth A .: “ The history of cod-liver oil as a remedy.” American Journal of
Diseases of Children, Vol. XXVI, pp. 112-116.
* Huldshinsky, K .: “ Heilung von Rachitis durch künstliche Hohensonne.” Deutsche
med. Wochenschr., 1919, Vol. XLV, p. 712.
4 Park, E. A., and J. Howland: “ The radiographic evidence of the influence of codliver oil in rickets.” Johns Hopkins Hospital Bulletin, 1921, VoL XXXII, p. 341.
72
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73
oil has a specific curative effect upon rickets. The proof o f these
observations was demonstrated by Roentgenograms o f the rachitic
and the healing bones. Since then there has been much investigation
showing the curative and prophylactic value o f sunlight and codliver oil in rickets of animals and their curative value in human
rickets.
The district o f New Haven selected for the demonstration has a
population o f approximately 13,500, one-third being Negroes and
two-thirds a mixed population o f Italians, Irish, Polish, and native
Americans. This selection was made because it is well known that
Negroes and Italians are particularly susceptible to rickets. The
staff consists o f two full-time and one part-time physicians, three
visiting nurses, two social investigators, an X -ray technician, and two
clerks. The office is located centrally in the district and is equipped
with an X -ray machine and a mercury-vapor quartz lamp. The
cooperation o f the health department o f New Haven, the State board
o f health, the New Haven Medical Society, the Visiting Nurse Asso
ciation, and other social agencies was sought at the beginning o f
the study. Without their assistance much o f value to the investiga
tion would have been lost.
The daily routine o f the demonstration has been compara
tively simple. The board o f health has sent to the Children’s
Bureau office the birth certificate o f the babies born in the dis
trict during the period o f investigation. I f a local physician had
signed the certificate one o f the Children’s Bureau physicians called
to explain to him the purpose o f the demonstration and to ask his
cooperation. In this way many o f the physicians o f New Haven
have become familiar with the demonstration at first hand. After
the physician has been seen once the receipt o f further birth certifi
cates is reported to him by letter. The staff has made constant
effort that these young babies should not be brought to the C hil-'
dren’s Bureau office to be examined without the knowledge and con
sent o f the family physician. When the nurse delivers the birth
certificate to the mother this gives an opportunity to tell the mother
about the Children’s Bureau and to make an appointment to have
the baby examined. General nursing advice about the care o f the
baby is also given at this visit. The first examination is made as
early as possible, preferably before the end o f the baby’s first month
o f life. An attempt has also been made to have monthly repeat
examinations throughout the first year, and examinations once every
two months throughout the second year. Each time a thorough
physical examination is given, including weight and measurements;
and in addition a Roentgenogram is taken o f the bones o f the baby’s
wrist. The physician gives to the mother general advice on feed
ing and care o f the baby. Cod-liver oil and sun baths are recom
mended at the first examination and at each subsequent one; and the
mother is urged to return regularly for the repeat examinations.
The nurses make follow-up visits at the home to see that the physi
cian’s advice is carried out as far as is possible.
It is of great importance to demonstrate to the mother how to
give cod-liver oil and sun baths to the baby. Unless she is actually
shown how to hold the baby to prevent his spitting out the oil she
probably will not succeed in giving it. The nurse demonstrates this
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either at the office or in the home. With the baby lying across her
lap she pours out the proper dose, holding the spoon in her right
hand. W ith her left hand she holds the baby’s mouth open by press
ing the cheeks together between her thumb and fingers. The oil may
then be poured little by little into the baby’s mouth. I f his mouth is
not held open until the oil entirely disappears the baby will spit out
what is left. It is frequent for babies to spit out oil not yet swal
lowed, but it is rare that one actually vomits the oil. As the baby
grows older it is more difficult for the mother to give the oil. It is
best to teach the baby to take it directly from a spoon and not mixed
with other food. Some babies will learn to take cod-liver oil if it
is always followed closely by orange juice. The cod-liver oil may
be mixed with orange juice if this is done just before it is given.
Other vehicles may be tried, but they are not very successful. Deter
mination on the part o f the mother to teach the child to take the
pure oil is far more important than any vehicle.
The demonstration has brought out the fact that almost all babies
can take cod-liver oil. Many babies do not like it and have to be
taught to take it. The chief difficulty is not with the baby but with
the mother. It is often difficult to make the mother realize the
importance o f giving this o il; but if she can be convinced o f its value
there is usually very little actual difficulty in administering it to the
baby. It is best given before the bath in the morning and before
the baby is put to bed at night. It is remarkable how willing many
babies are to take cod-liver oil, and many children learn to like it.
The oil should be given by the spoonful and not by drops. I f it
has been recommended first by drops a considerable effort may be
required to wean mothers away from this method when larger doses
should be given. The fact that cod-liver oil is a food, supplying
elements for normal growth, must be explained clearly to the mother.
She must be taught that including cod-liver .oil in the baby’s diet, is
as important as including orange juice in the diet. Babies 2 weeks
old can take a half-teaspoonful o f pure cod-liver oil twice a day;
babies 2 months old can take a teaspoonful twice a day; babies 3
months old iy 2 teaspoonfuls twice a day, and even 2 teaspoonfuls may
be given twice a day without digestive disturbances. Cod-liver oil
may bring about constipation in some babies. Experience has shown
that even large doses o f it have not been followed by diarrhea.
Cod-liver oil may be given the year around. During the hot sum
mer months, when babies are receiving long sun baths, the oil may
be omitted. I f it is omitted during July and August it should be
started by the first o f September and continued throughout the
winter.
A t the time o f the first examination the physician describes to the
mother how to give sun baths to her baby. More important than
this is the actual demonstration by the nurse in the baby’s home. In
the South the outdoor sun baths can be given all the year around,
and in the North they can be given from March until November.
During the winter in the northern part o f this country it is impos
sible to expect mothers to give extensive sun baths to their babies
out o f doors. A t this season indoor sun baths may be given inside
an open, sunny window—preferably in the morning. It is important
that the baby lie in the patch o f sunlight coming through the open
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75
space. On sunny winter days the baby may often take its nap out
doors in a place protected from the wind but receiving the full
benefit of the warmth of the sun. Throughout the spring, summer
and autumn the mothers can be taught to expose their babies daily
to the direct sunlight out of doors. All babies should be tanned on
their faces, arms, legs, and bodies by the middle of June.5
As the demonstration is not yet completed no final conclusions
caji be drawn. There are, however, some findings at the present time
which are o f interest. In approximately 90 per cent o f the group o f
little babies which have been followed from month to month a very
slight degree o f rickets has been found by Roentgenograms before
the infants reach the age o f 6 months; and 65 per cent o f this group
shown this^ first degree o f rickets before they are 4 months
old. These earlier manifestations o f the disease, therefore, have
not been prevented by the amount o f cod-liver oil and sunlight
g^pn. If, however, the mothers have continued to give these babies
cod-liver oil and sun baths as advised, this first degree o f rickets has
not increased but has been kept under complete control. Although
clinical evidence o f slight rickets has appeared as these babies have
grown older the deformities have not been of a marked degree. I f
the treatment had not been begun until after the babies had reached
6 months o f age it has been difficult to control this first degree of
rickets; and some o f this group o f babies have developed more
marked clinical evidence o f the disease. This slight degree o f rickets
as shown by Roentgenogram may appear in the breast-fed babies as
well as in those fed artificially. It occurs in white and negro babies
alike, in the moderately well off and in the poor.
Two control series o f children have been studied. The first is a
group o f children under 5 years o f age living in the district at the
beginning o f the demonstration. The second is a group o f babies
bom within the period o f the demonstration but living in other
parts o f the city and receiving no antirachitic treatment. It has
been found that about 35 per cent o f the first control group have the
deformities o f either moderate or marked rickets at an average age
o f approximately 30 months, and 27 per cent o f the second group
have already developed moderate or marked rickets at an average
age o f 10 months. Only 4 per cent o f the group o f 116 children
averaging 13 months o f age reported in May, 1925, who received
adequate antirachitic treatment showed more than a slight degree
o f rickets. Careful inquiry into the history o f the control group
reveals the fact that 4.8 per cent had convulsions previous to the
time o f examination. Only two children in the group who have
received cod-liver oil have had convulsions to date. One did not
receive treatment until after he was 6 months old, and the other
was treated with cod-liver oil o f unknown source. Up to the present
time no convulsions have occurred in children who have taken ade
quate cod-liver oil and sun baths.
In the light o f these facts it would seem important that cod-liver
oil and sun baths be given to all infants at the earliest possible age
and continued regularly through the first two years o f life. Though
the children o f the dark-skinned races perhaps need more intensive
Washtoglonail1926) Sunlight for babies (United States Children's Bureau Folder No. 5,
101848°—26----- 6
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prophylactic treatment because o f their great susceptibility to rickets
the children o f the fair-skinned races must not be overlooked. Large,
rapidly growing, breast-fed babies and premature babies are also
very susceptible to the disease. It is not possible to tell which child
may advance from the almost universal slight degree o f rickets to
a more marked degree o f the disease. Sun baths are accessible to
everyone in the spring, summer, and fall; and apparently cod-liver
oil can be taken by nearly all babies whose mothers learn to give it.
DISCUSSION
Doctor B l a c h l y . I should like to ask what is being done, or has
been done, in regard to feeding the mother before the baby is born
for the prevention o f rickets.
Doctor K o e n i g . I wish to inquire—because we are constantly
asked this—what kind o f cod-liver oil to give to children. Not
only the mothers but also the physicians ask us. W e have assumed
in our work in Arkansas that the cod-liver oil was given ^in the
way o f treatment, and in advising that the child have cod-liver oil
we have suggested that it be given under the Supervision o f a physi
cian, in that way gradually gaining the confidence o f the physicians,
Is that the best way to proceed, or should we tell the mother right
out to use cod-liver oil?
Doctor M c C o r n a c k . I should like to ask Doctor Eliot how she
gives cod-liver oil. In the State o f Washington we believe so thor
oughly in orange juice and cod-liver oil that in our private practice
we make it a rule that every case that comes into our office, no mat
ter whether a breast-fed baby or not, gets cod-liver oil after it is 2
weeks old. That is absolute routine. But the physicians in our com
munity consider that when we give any medicine at all we are prac
ticing. So we have decided to put in our next list—and I am very
happy to see it in this list that was passed around here to-day—a
recommendation that cod-liver oil be given, I think this list says
after the first month. That takes it out o f the scope o f a medication
and puts it in the same position as orange juice. It is an actual
necessity for the child to have orange juice for his artificial diet,
and especially is it necessary for him to have cod-liver oil not as a
medicine but as a food; and the physicians have readily accepted
that attitude and appreciate now all over the State that we are not
prescribing when we give cod-liver o il; that it is a matter o f routine
of our private practice.
Probably nothing is more embarrassing to a pediatrician who sees
a child a day or two after it is born and follows^him right along
through the first year than to see rickets develop^ right under his
nose— and it does. The first time such a case came to my notice I
was very much embarrassed about it. I happened to be with a phy
sician a few days after that and told him about it, and he just laughed
it off, saying that o f course that happened all the time. There is
more to rickets than sunlight and cod-liver oil. W e may possibly
find later that an intestinal affair is contributory after all.
Doctor K n o x . I should like to ask if anyone here has any data
as to how many obstetrical operations, or what proportion, are neces
sary because o f rachitic pelvis?
Doctor E l i o t . There are some data on that subject.
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C O M M U NITY CONTROL OF RICKETS
77
Doctor K n o x . I think that is an exceedingly important point for
us to remember when people pooh-pooh at rickets as a disease that
will cure itself a little later as the child grows up. We must re
member that we can not, maybe for 15 or 20 years, see the results o f
rickets.
The C h a i r m a n . I wonder i f anyone has made any study in re
gard to that. Have you done so in Massachusetts, Doctor Lakeman?
Doctor L a k e m a n . W e have made no study df that. I think it is
an excellent suggestion. We have some material that might help
us. I am very much interested in sunlight treatment for pregnant
mothers, and I wish Doctor Eliot would tell us what they have done
along that line.
Doctor E l i o t . In answer to the first question about the prenatal
treatment o f the mother I should like to say that we are making
some studies along that line. We have been following a number of
the pregnant mothers in our district and ascertaining what they
are eating. We are advising certain improvements in their diet.
Some o f the mothers have taken our advice, others have not. .W e
have really been making more o f a study o f what they are doing than
making a great effort to change their diet. We are anxious to make
a special study o f the babies of this group o f mothers. I can not
give you any data on this study yet because we have not finished it.
With regard to the use o f sunlight for pregnant mothers I would
also say that during last summer we carried on a study with a small
group o f women. We had them sun themselves thoroughly; but
what the outcome for that particular group o f babies will be I can
not tell you yet.
* Doctor McCornack has really answered the question as to whether
cod-liver oil should be considered food or medicine. When we speak
about it we always consider it a food just as much as olive oil is a
food for adults. Many times one can get the idea across to the
mothers, especially Italian mothers, who say, “ We give olive oil. We
don’t need to give cod-liver oil.” W e say, “ yes, that is good food for
you, but for the baby cod-liver oil is better food.” W e always urge
cod-liver oil as a supplementary food, and we tell the mothers that
it is just as important food as orange juice. They will accept codliver oil as an important part o f the diet just as they now accept
orange juice. W e have included cod-liver oil in the standards
(see p. 79), and we have emphasized that it is a food.
i When the baby is 4 or 5 or 6 months old administering the
cod-liver oil becomes more difficult. Up to 4 months o f age the
baby can usually be handled by force if you wish, but after that you
may have to teach the mother to roll the baby up in a sheet, if he is
really very obstreperous, or to give him cod-liver oil in some other
way. We use various methods. Sometimes we mix it with the orange
juice. That works in a good proportion o f cases. Sometimes we
suggest a little molasses with the cod-liver oil, but we do not encour
age the use o f anything sweet. We use that as a last resort because
it is much better to teach the mother that the baby must learn to
take it plain. The baby who once learns can go on taking cod-liver
oil until he is 2 years old without any difficulty. I know some chil
dren in New Haven who do actually cry for it. A woman came into
our office one morning not long ago with a baby about 19 months
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78
PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
old and she said that the first thing this baby said in the morning
was “ oil, oil, oil.” But they can be taught to take it, whether they
like it or not, and o f course the whole thing is teaching the mother
that the baby must take it whether the baby likes it or not.
Doctor K n o x . When, with reference to the feeding time, do you
recommend it, Doctor Eliot ?
,
Doctor E l i o t . W e give it almost any time in reference to the
feeding. I f it is a breast-fed baby, frequently 5 or 10 minutes before
the breast feeding, sometimes immediately before the breast feeding.
Some mothers are more successful in giving it after the breast feed
ing. I f it is an artificially-fed child, we give the oil with orange
I do not know any recent figures with regard to difficult labor as
the result of rickets. I do know, however, that in France approxi
mately 90 per cent o f difficult labors are said to be due to rickets. In
this country the textbooks state that 40 to 50 per cent are due to
rickets, and yet many obstetricians believe that these figures are too
low.* On many o f the rachitic children whom we have examined in
New Haven we are making incidental studies of the development o f
the pelvis. One of the obstetricians in New Haven has become inter
ested, and the material which we have now will be followed, 1 hope,
through 10 years, possibly 15 years, from now.
Doctor
N
oble.
Y ou did not tell us the brand of cod-liver oil,
Doctor Eliot.
.
.
, 1
Doctor E l i o t . There, are two American companies (whose ad
dresses I can give you) putting up oil from fish caught on this side
o f the Atlantic. Those two oils are undoubtedly fresh; the supply
is not so great but that when we buy it we get fresh oil. The oil
that comes from Norway is undoubtedly excellent oil when it leaves
that country. Up to a recent time (whether this is still going on I
do not know) it has been imported in large hogsheads the extra space
in which is filled with air. A certain amount o f oxidation o f the oil
may take place in these hogsheads. I have been informed that im
porting companies are now bringing in their oil under nitrogen
so that oxidation shall not take place. Whether this will actually
improve the quality o f the Norwegian oil as it is used in this country
I do not know. Norwegian oil is probably very good. The ordinary
cod-liver oil procurable in a drug store and bearing only the drug
store’s name I think is not satisfactory for our purpose. But 1
believe we are safe in prescribing oil bearing the name o f any o f
the large reputable firms of this country.
Doctor B r y d o n . H o w about emulsions?
>
___ _
'
Doctor E l i o t . I would not recommend emulsions. W e do not know
what effect combining cod-liver oil with other things has upon the an
tirachitic factor in the oil. Some antirachitic factor may remain, but
we do not know how much.
'
.
g ,
D ir e c t o r . What is the antirachitic factor in cod-liver o il. - A .
radioactive substance from the sun transferred to the oil or a vita
min ?
_ ,
„
,
Doctor E l i o t . It is probably a radioactive substance o± some sort.
A D ir e c t o r . W e have been using sun-treated oil in order to in
crease that property and using smaller amounts; and we find that it
apparently does almost as well.
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dÖMMü^ITY COtfTBÖL ÖF BlCSfcfS
79
Doctor EtiOT. I have made ho attempt to Use any Oil treated with
sunlight or with artificial ultra-violet light, so I can .hot discUsS it;
Furthermore, I think We do not yet knOw how long such oil should he
treated in order to give it the highest potency;
The C h a ir m a n . Doctor Haines has asked me to call your attentidri.
again to the film in the south room showing a series o f pictures on
rickets which is very interesting.
A t the conference o f the State directors last year the bureau was
requested to appoint a committee to formulate standards for the ex
amination o f children at the child-welfare conferences. This request
was referred to the advisory committee on pediatrics, and the stand
ards are ready now and in the hands o f the printer. I believe
Doctor Haines said there are several copies of the proof here to-day,
which will be distributed, and Doctor Knox will now dicuss the
suggestions with you.
[Copies of page proofs of Standards for Physicians Conducting Conferences at Childtributed]CeilterS (United States Children’s Bureau Publication No. 154) were dis-
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ITINERANT CONFERENCES— STANDARDS OF EXAM IN A
TION
B y J. H .
M a s o n K n o x , J r., M. D., C h i e f , B u r e a u
H y g ie n e , D e p a r t m e n t of H e a l t h , M a r y l a n d
of
C h il d
<•
j
Itinerant child-health conferences generally are understood to be
conferences held at successive places, the stay at each place being
comparatively short with no definite arrangement for return to that
p-iven place in the future. These conferences can be held m a healthmobile or in a suitable room in a schoolhouse or other building.
They should always be attended by the local nurse and conducted by
a physician o f considerable experience.
The itinerant conference differs in certain particulars from a per
manent child-health conference. In the latter, usually at the same
hour each week or twice a month, a definite, standardized child-health
r(inference is held. The conferences conducted at such frequent in
tervals can and should assume responsibility for the routine care o f
children attending them. They are usually attended by children who
can not afford to have their own physician examine them. These con
ferences are for the most part limited to large towns and cities A
complete examination of the patient is made, if not at the first, at
subsequent examinations. An examination is
by a
complete history of the family, even including a great deal of infor
mation concerning the social status o f the parents Supplementary
home visits by the nurses are an integral part of these conferences,
and aid in reaching a diagnosis can be obtained when necessary
from near-by hospitals and specialists, so that the object of these
conferences can be said to be to make a complete physical examina
tion and to provide a life plan for each patient,
. . „
The obiect of the itinerant conference, on the other hand, is to a
large extent to arouse the community to the importance o f such
examinations-not primarily to study the children completely but
to examine thoroughly a great many m the community^who are not
now under satisfactory medical supervision. Such a conference
thrives best in new territory, seeks children not at present being
seen regularly by their physicians, gives them the^ once over,
urges parents to take them to their own family physicians, and a
the same time brings to the physician’s attention the advisability of
supervising well children.
gf
_ ,
,
. •
The need for this kind o f service is very real, for at present in tne
rural districts o f our State a large number, certainly the majority o f ;
children, are now growing up after infancy without adequate medical
supervision. W e need to meet and conquer the inertia of two groups. >
One consists o f the parents. This is largely a problem o f informa
tion. Most parents do not understand how much their children are
suffering through neglect of medical oversight. The other group
whose inertia must be overcome consists o f the physicians. Here
we meet a real obstacle. The whole o f the physician s training and
experience lies in the field o f diagnosis and treatment, and not m /
80
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ITINERANT CONEERENCES— EXAMIN ATIONS
)
SI
w f 1 ; a,nd for ,‘ he Physician to attempt to persuade
people who think themselves well to come to him at regular intervals
would be^misconstrued in many instances as an attempt to “ drum
n?
.Just at ^ 1S Pomt the sympathetic health officer can be
fit- riGal s?rvice- ® e. ^as 110 axes to grind, is not in any sense benefited, and can do his utmost to persuade the laity to demand from
the medical profession protective care while they are well In overmefrtl?
botIh directions the itinerant conference can
ir^P°rtant role. Parents are invited to come with their
andtiuSi* ha^pey/ an ^ ve the history briefly, see the examination,
and then have a few minutes alone with the physician, during which
^dua^chfld partlCularize concerning the specific needs o f the indiDoffitiTnofnthSp T ld 'ibe g]iVep -here: In “ aking the examination the
position o f the family physician must be constantly borne in mind
A diagnosis which perhaps he has failed to give the mother must
not be made to her j i f possible, it must be made only to the physi+fian
Nothing should be done to undermine the sta n d m / o f
the physician upon whom the whole family must depend in cast o f
sickness; everything must be done to strengthen his hands
-Local physicians are invited by letter to attend these conferences
and see the work carried on. They are informed ¿ s b t h X S e
conducting the conference can serve as consultant for any
case that they may bring m person or send with a note; and after
the conference is over each local physician receives a personal note
from the bureau with an outline o f the result o f the examination.
Thf w rf assistm&.Wlth ^ e conference receives a copy o f this note
so that she can use it to urge cases to return to their own physicians,
t i t ™f°-Pe<? that u® Physician will have the note on his desk when
mated t W £ onsults
A t these conferences it should be intimated that dmgnoses depending upon blood or laboratory tests are
not attempted. The conference is a kind o f screening process by
the a^1JoriPal jr handicapped children are detected and put
m the way of having these handicaps removed.
P
We understand o f course that to refer a handicapped child to a
general practitioner may not always be o f great assistance; but we
?eduieTsllfhAly fCOT T d thnat ^ th-e lonS ™ this is ^ best proi T f r e as the standards in hygiene m any community can never be
fipher than those which the physicians can be persuaded to
f pp*J themselves. The bureau works with and for the physician;
assists f e
° btail^ 1 b 0Spital bed for
patient and
1SS1S 5 him al?° to obtain special services when required. One
should be able in such conferences to determine:
1. The nutrition of the patient, using the height and weight
nutrition
md€X?n’ ref lemberin^ always that the diagnosisg0f
and that «Sfiii upon
sklllful weighing of a number of factors
t ldJ hat
l®.0116 of tbe most difficult diagnoses to make except
when malnutrition or overnutrition is marked.
2. The presence or absence of rickets. Here again iudgment
in incipient cases is difficult.
judgment
3. Whether there is disease of the heart.
4. Whether there is disease of the lungs.
too5: W ith e r there is disease of the abdomen (including an esti
mate of the size of liver and spleen).
6. The position of the urinary bladder.
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
7. Thé presence or absence of hernia; phimosis; abnormality o f
genitalia.
,
,
, , ^
8. The condition o f the nose and throat. In cases o f obstruction,
whether there are adenoids or hypertrophied tonsils, enlarged
turbinate bones, or deflected nasal septum.
9. The condition of the teeth. This is the more important be
cause it is often an index of the social habits of the family.
Parents, as well as the children themselves, can be graded on
children’s teeth.
10. The condition o f the eyes and ears in older children.
11. Vision and hearing. Rough tests for these may profitably be
made in the preschool year.
12. The state of the nervous system and the child’s mental age.
13. Whether the child has been vaccinated and whether he has
had the toxin-antitoxin treatment.
I f as a preliminary to this brief examination ^the nurse or her
assistant has recorded a short history o f the child, including a record
o f the character o f his birth, his feeding history^ any intercurrent dis
eases, his appetite, amount o f sleep, and condition of the bowels the
examining-physician has sufficient data to confer helpfully with both
the mother and the family physician. It goes without saying that
the more experience and skill the examining physician possesses,
the more he can make out o f an itinerant conference.
The permanent value o f such a conference depends largely upon
the tact o f the physician conducting it; upon whether or not he is
able to “ sell ” the idea o f good health to the parent and to the family
physician. It depends in almost equal measure upon the efficiency
o f the service o f the public-health nurse. She must be relied upon
not only for advertising the conference before it is held but also tor
assisting parents to take their children to their physicians to carry
out the corrective measures suggested.
DISCUSSION
Doctor B l a c h l y . I should like to say in support o f Doctor Knox’s
paper that we have tried the itinerant conferences in Oklahoma with
the most happy results so far as we now know. I wish also to say
that I started my work in Oklahoma on this principle : I went be
fore the annual meeting o f the State medical association, at their
invitation, and stated that to my mind obstetrics could not be prac
ticed by correspondence, nor pediatrics over the long-distance tele
phone, and that these two things had to be done by the man on the
fob: and that my position, as I saw it, was to bring about a more
wholesome, closer', sympathetic relation between the physician and
the patient. As the result o f that, never a day goes by that I do not
have some commendatory letter from some physician, and innumer
able ones from the mothers themselves. I have had one letter trom a
physician criticizing the stand that he thought I was taking, but he
had wholly misunderstood the purposes ox the bureau, and when
these were explained to him he became my friend. When I took over
the place in Oklahoma there were very few hospitals. Since thena
number o f splendidly equipped hospitals have been built, lh e 2Aray hospitals are the best. They have all necessary apparatus and
^About two years ago an effort had been made to introduce gradu
ate work for the physicians in the rural sections, without success.
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ITINERANT CONFERENCES---- EXAMINATIONS
83
No interest was taken in it, but now that is going over, and going
over big. The physicians of the State have asked that graduate work
be given m connection with the medical schools in Oklahoma City
and we have tentatively arranged a program in maternity and in
fancy work that the physicians who need and want that instruction
may have close at hand so that they will not have to be gone very long
from their practice.
J
6
We also had Doctor Dodson, the chief of the bureau of medical
and health education of the American Medical Association, come to
° U'TtD tate a**d give a number of very helpful addresses.
The prospects, from the standpoint of the physician, seem to
me excellent, so far as cooperation is concerned. I wonder sometimes
it those of you who have not always found it as easy as I have found
!r i°
,with the ™edlcal profession possibly have some of that
diftculty because of not really putting yourself in the other
fellow s place. I f we fully understood, as Doctor Knox so beauti
fully brought out the position and the ideals, the hopes and ambitions, and the problems of these rural physicians it might be iust
a little bit easier for all of us to get the cooperation that we must
nave it the mothers and babies are to profit by the work.
The C h a i r m a n . The get-ready-for-school conference is becoming a
more and more popular part of the child-hygiene program, and we
•S® 1ILS
0Jne°^!)!lrl crties that school boards are putting that program
into effect. I think Doctor Stadtmuller, of California, probablyhad
the vision of what this program would mean to the future school chil
dren when she initiated the program two years ago. We are verv
g ad to have Doctor Stadtmuller here this morning to talk to us
about the examination m the sixth year.
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EXAMINATION OF THE CHILD IN HIS SIXTH YEAR,
BEFORE ENTERING SCHOOL
By
E
llen
H
S.
S t a d t m t t l l e r , M. D . , D ir e c t o r , B u r e a u
S t a t e B o ar d o f H e a l t h , C a l i f o r n i a
of
C h il d
y g ie n e ,
During April and May last year a campaign to provide a physical
examination for every child who would enter school the following
fall was carried on in California. Several considerations gave rise
to this campaign. In the first place six years had elapsed since the
1918 Children’s Year campaign, which had been notably successful
in California, and it seemed fitting that the infants examined that
year should have an opportunity o f being rechecked before entering
school. We hoped to benefit the children themselves by giving an
opportunity for improvement in hygiene on the part o f the mother,
and by the correction of defects, where necessary, during the interim
between the examination and the opening o f school. A t the time of
this campaign California had only six full-time county health de
partments. We felt that our bureau would benefit by having con
tact with groups of individuals in the various counties who were
interested in child health and that such persons would assist ma
terially in developing our prenatal program in subsequent years.
W e also hoped to interest the medical profession in preventive exami
nations for children, as in many o f our rural areas the physicians
have no adequate conception of this type o f work.
W ith these objects in view we called a meeting in San Francisco
o f individuals who could be helpful with suggestions and whose
positions would give weight to our campaign. These included the
heads o f the department o f pediatrics of our two medical colleges,
the State supervisor o f physical education (this being the depart
ment in California in touch with health work in the schools), the
president o f the Parent Teacher Association, the chairman o f child
hygiene o f the Federated Clubs and o f the Parent Teacher Associa
tion, the director o f the health-center work o f Alameda County,
which has a well-defined program in active operation in Oakland
(near San Francisco) and in. the communities close to Oakland
within the county— one o f the members of our own board o f health
most interested in child hygiene. It had been my first intention to
pay pediatricians to conduct the examinations during this campaign,
but after the meeting o f this group that plan was abandoned. We
decided to address the county medical societies rather than the State
medical society and to do so only in the counties where we intended
to conduct our first year’s work.
In planning our organization work we selected the 26 counties
o f our 58 in which we felt that we could conduct the campaign suc
cessfully, believing that an initial success would permit us to enlarge
our territory in the succeeding years. The factors which we judged
necessary to make the campaign a success included a friendly medical
organization, a county superintendent o f schools interested in health
(where consequently there would be public-health nurses employed),
84
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t
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EXAMINATION OE THE C H IU ) IN IlIS SIXTH TEAR
85
Riid an interested group o f lay women who would undertake the
requisite committee work. "We had in our office a list o f all persons
with whom we had had any correspondence on child hygiene as
well as a list selected from newspaper clippings pertaining to the
same subject. Thus we were in a position to start with a possible
source o f committee material. In many counties the home demon
stration agent o f the farm bureau had started work by conducting
nutrition classes so that the public was already alive to the school
child’s need o f suitable diet.
The part which our bureau was to play in this campaign corresponded very closely to that which the Children’s Bureau played in
the National Children’s Year. We furnished- organization work
through our own staff and by the help o f a clubwoman especially
employed to form committees; publicity material both for news
papers and for use by word o f mouth in talking to groups o f men
and women; and printed forms for the actual examination, includ
ing mimeographed copies o f height and weight charts. Where the
society o f the county requested it we also furnished a
pediatrician to assist them in conducting the campaign.
Our initial step in organization was to address a letter to the
county medical societies stating that the estimated number in need o f
corrections was 30 per cent o f all school children, a conservative figure
obtained by the results o f two years’ work in San Francisco in a
similar campaign. We asked the medical society’s indorsement o f
the work in its county and the appointment o f a member o f the
society to act on the central county committee. The same procedure
was followed with the dental societies. As the health officers in rural
communities are often laymen these officers were not included in the
county committees the first year. This omission o f the county health
officer from the committee was a mistake; he should be included
beside the representative of the medical society, or, where a medical
man, acting in both capacities. Our central county committee con
sisted o f a chairwoman, usually from the Federated Clubs or Parent
Teacher Association, an active worker interested in the health o f
children; a representative from the medical and dental societies; the
county superintendent o f schools; a public-health nurse representing
her group (in many counties there was only one nurse employed).
A member was chosen to handle the publicity, either the editor of a
local paper or some one from the chamber o f commerce. The duties
o f this committee were to assist us in deciding on the location o f
the centers for the drive—spot-mapping the county, as it were, in
selecting local personnnel and in distributing the material that we
furnished to the local committees. Some expense was involved in
this work as there was mailing to be done, and occasionally it was
necessary to print in blank spaces left in our publicity material the
dates and places o f the local conferences. Often this expense was
met by volunteer printing on the part o f the local newspaper or
other prmting establishment. Although this was our skeleton plan
it had to be modified in certain areas. We found, especially in coun
ties where there were two rival towns o f the same size, that one might
not operate under the chairmanship o f the other; in such areas we
abandoned the county formation and occasionally developed local
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86
FROCEEbINGS. MATEfiNilA ANb IijfAliClf CONFERENCE
committees in smali counties, forming a committee in each o f our
union high-school districts.
'
We found the school organization most helpful in that it had wellestablished channels o f communication out from the county super
intendent’s office to the schools. Wide publicity therefore could be
given to the campaign with the cooperation of the county superin
tendent o f schools. A California law requires the registration o f
minors during the first week of school, so that there was available in /
the superintendent’s office a list o f all preschool children. In this
way the individual sheets with notices o f the examination were dis
tributed through school children to the homes. The large majority
o f the conferences were conducted in the school buildings. We
iostered this idea as much as possible. In California the schools re
ceive subsidies from both the State and the county, based upon aver
age daily attendance. Necessarily they benefit by the superior phys
ical condition o f the children examined in such a campaign. Most
people will go naturally to a school building where they might be
reluctant to attend a conference in a privately owned building. In
one county the superintendent o f schools urged upon teachers the
necessity o f obtaining, by questioning the pupils, an accurate list o f
children entering school. You will note among the literature handed
to you the forms which were perfected by her office. She also as
sisted by calling together representatives from every organization in
the county to attend a central meeting at which the object o f the
campaign was explained. As this county was small and road facili
ties radiated from the county seat it was arranged to bring all chil
dren there by automobile from outlying districts rather than to at
tempt transporting them across intervening mountainous country.
This also conserved the time o f the physicians, most o f whom lived
in the county-seat.
Only 1 o f the 26 counties originally selected was so uninterested
that we abandoned the plan o f a campaign there. We were obliged,
however, to forego it in a number of others on account o f an epidemic
among cattle. There was some danger that this epidemic might be
spread from farm to farm if people congregated at a central point.
F or every county so eliminated from our list another came forward
and asked that it be given the opportunities o f such an examination.
Consequently we finished with the number o f 26.
In our second year’s plans we benefited by the experience o f the
first year in starting the work o f organization earlier and in adding
to our staff a speaker who could go out to address local groups after
the initial formation o f committees had begun. This year we se
lected 31 counties and employed three people during February and
March to revive the committees o f the first year and to form new
ones. Many communities were ready to conduct this campaign with
out our having to do the organization work, writing in to ask if we
were ready to furnish material such as they had used the year be
fore. This year we included the health officer and were more active
in reaching the dental societies in planning our central committees.
W e also furnished motion-picture slides to be run the week before
the campaign. These stated briefly the need for such a physical examination, the local time and place being added either by hand or ■
on the typewriter. This proved a most successful method of reaching (
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EXAMINATION OF THE CHILD IN HIS SIXTH YEAR
5/
large audiences who spread the news o f the local arrangements. We
plan this year to have slides containing less writing material and
including a picture o f a child being examined, in order to indicate
tne type o f work done.
We realize that these examinations were probably not as uniform
as they would be i f they had been made by trained pediatricians; but
we believe that the interest and stimulus given to the local physicians
m regard to the health of children might be o f more benefit than a
more careful initial examination made by a stranger who left the
>1 mlght SaJ g a„ssing that during the 1924 campaign
10
WOrk was needed from pediatricians paid by the State;
nffini.thr e ? aX - T ere spent 111 ? ne countJ at the request o f the health
fficer o f a full-time county unit. The director o f the bureau did 11
t ayiSooT0rki SC?ittjred
three counties in assisting in the campaign
1 192i r ly
T ork from employed pediatricians was n e S sary, although the territory was at least one-third larger than that
covered the year before. The medical staff o f the bureau put in 6
days in assisting m the campaign. The second year, however we
^ dT r d
®Ur or^anCzing nurses return to the counties dur-
t°
d a tin g t r l ° n i r e n c c r mPalgn “ *
l0Cal nurs<ss “ conWe estimate roughly that in each year’s campaign we reached onesixth o f the actual number o f children entering school. In the first
year 4,552 children were examined, and last yfar 8,193 were exammed. ^Although four counties did not report we have a list o f 363
pky—
>?■!! dentists, 178 public-health nurses, and 481 lay workdUin iVg ^ 1925 drive* 1 am sure from conversatke loc,alu Physmians that they see the impetus which is
i -ftheIr WOrk
s» ch a campaign. The comment, “ I was very
rushed for two weeks after ^our spring campaign” indicates thatparents are anxious to build up the health o f thei^hildren and com
sequently do have many o f the indicated corrections made
California has largely centralized its school system, and with the
ansportation by bus the children come from long distances to the
m nfriibSh1' Consequently we found it very feasible to make the
lo c a t e d !^ SCh°01 the Center f 0r the Particular district in which it is
I f you will notice the publicity material that I have handed to
you, there is what we always speak o f as the yellow sheet That
J \ has been^criticized as being
scare Headlines.
We rather hoped it would be. We wished to
aP?ly tkese questions to their own children
distributed for the most part through the school children*
It had been my original idea that these w o u lf be wrapped up with
packages in the grocery and put into library books distributed
w X °Th t ranCp county llbrary, but that plan did not work out so
1W Tt 7- w lly uWere distributed better through the schools.
in f m ^l
The * 7
" f k n ° f the ritory we covered[showM fa S z itio n ThT b i ^ COl° rS meai\ the different people in the
t h o t arn ™ Th
i i areas w?re those that were not covered;
where the nonulatio» lcg mountam ranges, mountainous districts
wnere tne population is very sparse. In many places half tbe -nnmi
lataon moves down in t o n e Valley or to the S
f c ? t L winterP PSo
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PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
we felt that in omitting those areas we were not really slighting a
very large proportion o f children. This year we have nurses in some
o f those counties and have put the campaign on there.
I am not going to give you very much about the statistical material
because I thinklfigures are very hard to carry in one’s mind. But
for every 100 children in this last year’s campaign we found an aver
age o f 260 defects. O f course many of these were minor, teeth de- j
fects predominating very largely.
.
.
, ,, ~
!
In California we have no compulsory vaccination law, and tiie tirst
year we found a little less than 10 per cent o f the children entering
school had been vaccinated. W e have had a very virulent type o f
smallpox this year, and at the end of this year’s campaign we found
approximately 20 per cent o f the school children vaccinated, ih is is
double the number for last year but still far below what it ought to
be. I 'did not collect figures for the immunization, but that has been
done very actively among the school children; however, not so ac
tively in the preschool group.
rT
c ,
I wish to show you one chart here. [Indicating.] The first year
in many o f the rural communities i f a mother came in with a number
o f children they were all accepted. W e had intended to limit the
campaign to the group aged 5 to 7 years, but older children were not
turned away, and we were able to make this graph o f the increasing
defects in children from 1 to 8 years o f age. This represents about
100 children, and this represents 341, the larger number being scat
tered in this intermediate group that we were trying to meet [show
ing chart]. W e found that 75 per cent of the children had some
need for medical work and in the 8-year-old group 82 per cent were
in need o f it. So we feel that there is a great deal o f work ahead,
both for the medical profession and for ourselves.
I have been very specific in telling just what we did, because 1 al
ways find that in these conferences I get more when people tell me
exactly how they proceeded. I have not gone into theory at all. 1
have here a book containing all the material—publicity and other
items—that we used in conducting this campaign in rural California;
this might make my paper more intelligible if anyone cares to look
it over.
.
The C h a i r m a n . I think we all agree that the itinerant conference
is one o f the best ways o f stimulating interest in the medical super
vision o f babies and preschool children. We all have the vision o f the
day when we shall have a permanent program in every county in this
country; and in making arrangements fo r the itinerant clinic or con
ference we ought to keep in mind the fact that we are building the
foundation for that future program and try to leave behind some per
manent piece o f work which the community can carry on. This may
need to be done through the help o f the State bureau of child hygiene
and probably with volunteer workers to a certain degree. I f there is
a permanent nurse in the community have her do the follow-up work
as Doctor Stadtmuller has done in California. Sometimes we can
find married nurses in a community. That has been the case in many
eastern States.
Pennsylvania has been able to establish a good many permanent
centers and Doctor Noble will tell us how Pennsylvania has won the
support of the community in this work.
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\
PERMANENT CHILD-HEALTH CENTERS IN PENNSYLYAN IA
B T (W P n n IGTT N o b l e , M . D . , C h i e f , P r e s c h o o l D i v i s i o n , B u r e a u
of C h il d H e a l t h , D e p a r t m e n t of H e a l t h , P e n n s y l v a n ia
Erom the beginning o f child-health work in our State department
our chief aim has been the establishing o f permanent centers where
complete physical examinations could be given and mothers could
be instructed in infant care. This could be done only i f it were
wanted m the community because the value o f it was seen. To make
it wanted then became our ambition. In establishing child-health
? tei l we had certain resources on which we could rely:
lheJe 2Tere already public-health nurses in the field under the
State and other organizations, tuberculosis workers, socially minded
people m the federated clubs, parent teacher associations,7 and the
quaf te,rs could usually be found apart from other
State clinic rooms (where although space was sometimes available it
was not always suitable). It shortly became apparent that churches
nfV.Vateik°meS’ ?Md Physicians’ offices were less desirable than certain
Places until to-day our first effort is always to see i f the school
tn
°an J?°USe tiie 5er}ter two hours a week. Many schoolhouses
to-day burnish space and the elementary needs in the way o f furniture
(seats and tables), and there is a growing feeling on f L part o f
school superintendents, principals, and teachers that to pay attention
task
task.
i& a
r a i ? i f r ^ 0°i W° rk “
a% lightens thl teacher?
Libraries, mayors’ offices, courthouses, department stores fire-
E
i H headquarters
ATBnCf n Legl°
n r° 0mS’
empty
stores’
Red Cross, and
tuberculosis
are among
the
available
sites.
Thi« h ncSKCianSnW1 lmgi t0 c°nduct the examinations must be found.
a/
thG haf dest Problem, but as we look back over five
lessened A m o™
that Professional resistance has distinctly
Among the younger physicians particularly, i f we can
m n if? X
fhem to take charge of the centers, we have the
most wonderful cooperation; and even among the older members of
; of ^eveiitiv? pediatric? m
C***m* ea^erness to 0IW > m this phase
Present policy is that we believe it to be the prerogative o f the
local group o f physicians to determine which o f their number (one
{ W *
cail d? the health-center work most suitably. There are
still local prejudices which stand straight across our path. There are
Physfcianlntp0? 6
°Yerwor^ d general practitioner, where no
ou rafms nrp
service* Misunderstandings of
Surf fi
tdl fe’ but slowly decreasing as we contrast the pres
et with five years ago. Although we state it as our desire to have
the local group settle the. question as to which physician shall serve
it is very often impossible, to get them to mak? t L a“
d L S
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90
PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
about this. Then it devolves upon our field worker to visit the
physicians one by one in their offices, preferably taking with her
some local person, either one o f the child-health committee or the
prospective nurse. They go from office to office
call Each physician receives the individual explanation as to the
meaning o f the work. It is still the most important thing m this
interview to dwell on the exclusively educational feature and to make I
perfectly plain that there is no possibility o f its overlapping private ,
practice and, therefore, poaching on the preserves o f any pfiy^cmn.
I f before this round o f visits is made there has been some indication
as to which one or more physicians should be definitely reqne^ted to
serve, our worker is in that case the one to make the request. W e are
not in any official sense “ appointing physicians from the central
° I ? has often been hard to get a square deal for the babies and at
the same time have the full cooperation and friendship o f the physi
cians. Everyone, knows that to ask a group o f mothers to meet a
different physician every week is almost enough to kill any new
child-health center! One physician on a long term o f service, or
two or three serving turn about for three or four months at a time,
as on a hospital staff, is best.
. .
4. The final essential is a lay committee, preferably consisting o f
women willing to consider the health center a regular and exacting
engagement, who shoulder certain definite responsibilities with
regard to its equipment, its clerical and small financial needs, and
the managing and hostess work during the two hours each week.
This committee saves the time o f physician and nurse, gives addi
tional help for the smooth running o f the whole when attendance is
large: and, which is also most important, makes a yeasty nucleus m
the community by which popular interest is fomented and informa
tion spread about. Very often a women’s club which undertakes to
sponsor the baby work as one o f its- particular undertakings is back
o f the committee.
,,
. ,
... n
The child-health center is not fully organized until all these
factors have been made sure. The field worker often has to camp
down in the place and work several days to settle all details, per
sonal interviews take much time. Committee meetings must be
called and publicity started; the clergymen must be visited to get
their cooperation promised; school people must be interviewed^, and
it must be made certain that they understand the enterprise and will
back it by their personal effort. I have heard our workers sav
again and again that it was no use to go through all the motions o f
organizing unless the actual opening date was set and things were
started on the move toward “ the day.” The culmination o f the
plans is usually the house-to-house canvass by the local committee,
which is the first turn o f the wheel o f the machinery. This canvass
means ringing every door bell, inquiring about the presence of
infants and preschool children, noting the name and address o f each
child, and leaving with the mother the personal invitation and infor
mation as to the day and hour o f opening.
.
Far and wide over the State so much seed has been sown m good
ground and sprouted for us that it is not a matter o f visiting townsj1
for scouting purposes to arouse interest; but rather we receive spon
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PERMANENT CHILD-HEALTH CEKTERS IK PEK KS YLVAXTA
91
taneous and. unsolicited requests in our office for organizing help in
starting work for an already recognized need. The department
supplies literature and record forms without cost. The organizer
becomes a father confessor and periodic visitor for stimulation and
help over the rough sledding through which many centers pass
when the first interest threatens to wear off—when physicians fail
to come dependably, or the committee grows lax, or the nurse fails
to spend sufficient time visiting the homes.
V The last point is one o f the main ones for emphasis. No center
can succeed without a home-going nurse. It is generally true also
that extra incentives must constantly be thought up to act as a
fillip. It is tiresome to go every week to dress and undress a baby
]ust to get it weighed!” So the alert committee and the nurse must
have new attractions, prizes for attendance, Christmas parties, valen
tine parties, May days, summer pageants, campaigns, or must arrange for instructive talks that really amount to something. In
multitudinous ways the ball must be kept rolling.
There has been considerable shifting o f control o f centers from
State to non-State control. For example, one southeastern county
near Philadelphia was turned completely over to local organizations
and independent self-support in 1924. The Wilkes-Barre baby work
now is all under control o f the Visiting Nurse Association, the last
State center being due to close January 30. There are well-attended
and well-conducted centers in Scranton and Erie where the chief
portion o f the work is under local auspices, notably o f the visiting
nurse associations. The exact number o f centers thus transferred
is not recorded. In Dauphin County, after stormy history and with
much changing back and forth, 11 centers are now firmly established
under either the Bed Cross or the Junior Bed Cross, 5 o f them being
supplied with our special maternity and infancy nursing service.
To summarize, the main points in a permanent first-class center
are: Adequate space and equipment; a local physician attending
regularly and giving complete physical examinations; a public-health
nurse who spends sufficient time making home visits; filled-out
records; a functioning volunteer committee; monthly reports to the
central office—-and children to examine.
Pennsylvania is at present paying a small stipend o f $1.50 an
hour to physicians whose eligibility for the pay roll can be estab
lished. Eligibility depends upon a center adequately housed, complete periodic physical examinations o f the undressed child, the tak
ing o f full records, and an attendance of not less than 12 babies per
month.
*
Paying the physicians was planned to arouse local interest in such
) manner that the community finally would be responsible for the
/ entire fee Our policy was to pay for 12 months and at the end o f
dhat time have a 50-50 arrangement for the second 12 months. We
|made no restrictions as to how the community should secure its half,
'whether by private subscription or otherwise. At the end o f two
years our pay would cease, and the community would pay the whole
amount. Our pay roll at present is carrying 20 physicians at $1.50,
o l whom 15 are serving in their second year and on half pay. Six
physicians have served two years. Sixteen have refused o f late to
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
send in vouchers. Calculating from the beginning, 60 have sent in
vouchers, 45 served without pay, and 7 who were originally on the
list resigned, making a total o f 112 physicians.
...
It has not been smooth sailing. Committees are slow to see their
duty and with 12 months before them do nothing. Then at the end
o f the year when the communication goes forward to them they are
taken by surprise. W e are convinced that neither the physician nor
the nurse should be burdened with the hunting up o f ways m which
this small fee can be met. I am not convinced that very much has
been accomplished in arousing local initiative to carry °n conferen
work wholly on local resources. Many have taken pay while it lasted
and are perhaps worse off to-day than if we had not started a pay
roll.
DISCUSSION
Miss L o c k w o o d . 1 should like to ask Doctor Noble how Pennsylvania is providing for the health centers. In Delaware we usually
have maintained the center through State funds. W e have nocounty
health units. We have called on some communities to furnish the
center, but we are really very unsuccessful m having center work
kept up by the local community. A fter a little while when the com
munity interest more or less la g s -it may not be because the center
is not frequented by the people that need it but because o f local
situations such as that the money is not there to be gotten for some
reason or other—we have to close the centers. Can anyone offe
a real panacea for that situation and suggest how those centers can
be kent u p 2 W e have several places where we have been m a con
tinuously upset situation and where nurses have really given up and
gone away because they could not stand the constant closing and
opening and having their work in such jeopardy.
PDoctor N o b l e . The cost o f a child-health center in Pennsylvania
is almost negligible except for the salary o f the nurse. W e have
now, I think, by the last reports (they are given to me fortnightly)
418 centers; and it is just about 50-50 between State and non-State.
A State center has a State nurse operating m it. A good many
centers have been given over entirely to local control and the' otate
nurses withdrawn. I f we could find any o f those workers that I
named this morning, a local nurse o f any sort to give it two hours a
week and the necessary home visiting, with free quarters—we will
take the easiest case— and a physician giving volunteer service, al
most the only cost after the first equipment is for a little janitor serv
ice and the keeping up o f such clerical supplies as will be necessarv. I do not quite see why Miss Lockwood should have such ter
rible difficulty i f it is purely financial. Is that your difficulty, Miss
Lockwood ?
Miss L o c k w o o d . Yes.
, . .
,
.
•
. Doctor N oble. W ith free quarters and a physician who is paid
the small sum o f $1.50 an hour or who gives his servicesf lo u r
scales do not wear out easily; and the measuring board was made
to start w ith; and i f you supply the literature I do not see why your
financial difficulties are so very great.
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PERMANENT CH ILD-H EALTH CENTERS IN PENNSYLVANIA
93
Miss L o c k w o o d . We have no trouble while we are furnishing the
whole amount, as we do in every county; and in the city o f Wilmington, where we have our own health centers, we furnish everything
-Naturally the work goes on there without giving us a bit o f trouble!
Doctor N o b l e . We have never furnished a pair o f scales nor even
a measuring board. We do not supply any little paraphernalia,
even a wash basin. W e say that all this must be furnished by the
\ col^munity before we begin. The only thing we supply is literature
and organization o f the service. That, we realize, must be supplied
continuously.
Miss L o c k w o o d . Our situation and conditions are all-so different.
W e have no county health units; we have no nurse that belongs to
any organization doing any work south o f Wilmington.
Doctor N o b l e . Have you no Red Cross nurses or community
nurses s
J
JSpSS L o c k w o o d . Not one. We have one cofnmunity nurse above
Wilmington, and we have a Visiting Nurses’ Association in Wilmington, but none below. We have a few health centers that are operated
by having the community provide a center. There is constant tur
moil about it and the raising o f the money for it. People are not
going to do this all the time; they will do it for a while only, and
we have no way o f continuing that volunteer service.
Doctor N o b l e . We have found in our health work that one o f the
good results o f all the things we are doing is the arousing o f sufficient local interest to get a community nurse. A goodly number
ot Pennsylvania s communities have now their own community
nurses because o f the interest in health which has come about
through the various things done by the State department. I do not
see, Miss Lockwood, how you can do it without having a community
nurse or some kind o f nurse available.
^
Miss L o c k w o o d . We have only State nurses, you see, who do not
live m that community. But we can not get the people even to furiiioii centers.
h o w ^ ^ d o ^ 1^
me S6n<^ °ne
wor^ers over to show you
Miss L o c k w o o d . I wish you would.
<
S t a d t m u l l e r . I will tell you how we have maintained them
m California. We never open a center unless the community will
assume financial responsibility. I f we have to put in a nurse we will
pay only part o f that nursed salary, or else we put in whole-time
nurses and have the community pay the transportation. We make
the community responsible from the beginning for a certain amount
ot the financial upkeep o f that nurse. We put a State nurse in and
contribute only a part o f her salary, deriving the rest from Red
Cross, tubercular, or school funds, or a combination o f all o f them
with the understanding that the State part is going on for only
01ie
We usually do continue beyond the end o f the year somewtiat, but it is understood at the beginning that the State share
ot the responsibility will terminate at the end o f a year, and we
do not put a nurse into a community unwilling to meet us half way.
Miss L o c k w o o d Some organizations d id that with us, but when
they were through with their program, the program ceased. The
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PROCEEDINGS^ M ATERNITY AND IN FAN C Y CONFERENCE
child-welfare work in Delaware had a very large appropriation in
the first place, and we furnished too much, I think; and since the
appropriation has been cut we are still asked to furnish everything.
The C h a i r m a n . I wish to hear from Doctor Allen, o f Wisconsin.
Doctor Allen is a new director, and she has some new plans for mak
ing the centers a community responsibility.
Doctor A l l e n . For two years I had the permanent centers through
out the State o f Wisconsin. We hold the conferences in them only
once a month. W e organized first in 16 counties with the intention
of staying one year; and at the end o f that year the people were ex
pected to maintain these centers themselves. That worked out fairly
We have six centers conducted by local nurses who are either
county nurses or industrial nurses. The examinations are made by
local physicians or by physicians hired by the State and also by
part-time physicians paid by the local people. In the little town
o f Fennimore (which has 760 inhabitants, I think) they even paid
the transportation from Madison and paid our physicians $15 a day.
They have carried their center themselves for two years at this rate,
partly by private subscription and partly by Red Cross funds. Our
centers have been very well patronized; the mothers have been very
well satisfied. We have overcome a great deal o f opposition iroin
our physicians, after we have been there long enough for them to
know that we were sending work to them instead o f taking it away.
When Doctor Haines visited us in October she felt, as I have ielt
for two years, that we were not leading the communities direcffly
enough toward the ultimate assuming o f local responsibility, She
suggested that the State try to carry at least part o f the traveling ex
penses of the physician by having an extra part-time physician on the
staff and letting the localities that wished to do so hire this physician;
and if they were having any local opposition they should hire their
own physician for carrying on their own permanent centers. So we
tried one center under local men with the local service, but the plan
did not work well. The county nurse wrote to ask if I could not do
something for them, and finally I told her we would furnish her a'
physician for $15 a day i f she wished, while we were up m that
same locality. She accepted the suggestion so quickly that 1 am
minus a physician now and must hunt up another. In the last montn
that I have offered this we have had two centers take advantage o± it,
paying $15 a day out o f local funds for a physician to spend one day
a month with them.
.,
, .
Two other places are just waiting until I can find some other physi
cian to put in for them. Now, we are carrying the work on with our
regular State physician. W e are going up into the neighborhood ot
Wisconsin Rapids to conduct conferences there hi three centers a
week, and we have just given Wisconsin Rapids the opportunity ox
hiring this physician. W e are also going clear up into the nort ern part o f the State to Rhinelander, where they could not afford o
pay all our travel expenses; and we h a v e incorporated their cen er
into our regular itinerary. They are paying $15 a day to the physi
cian. Our problem is not to get the $15 raised; that is done through
many fraternal and other organizations and through the women s
clubs; but our problem is to get a part-time physician to fill the place.
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The nursing service is carried on almost exclusively through a county
or industrial nurse. We have very few State nurses, and I have only
two maternity and infancy nurses.
Doctor Haines, when you asked me how many centers we had X
mentioned only the one carried on as the result o f our permanent
center work; there are about 45 or 50 other centers, but we are not
responsible for very many o f those. O f course cities like Milwaukee,
\ Racine, and Kenosha are cariying out their own under their own
' local physicians.
The little center at Janesville has been very successful. It is staffed
entirely by physicians chosen by the community through the medical
society.
Mrs. M a t h e w s . I wish to speak about the itinerant traveling clinic
which we have. We think it is too bad if anyone who comes to Colo
rado does not see our clinic because we have such a wonderful one.
We have a group o f 12 traveling now. It has grown since I was here
two years ago and told you all about it.
We charge the community $50 for putting on the clinic, and they
believe they are getting something very valuable for it.. We go
into a community with a pediatrician to whom we pay $50 a day
for the work. We have our two nurses, a representative o f the State
board o f health, the head o f the State tuberculosis association, and
a dentist who is paid and sent in by the State dental association. A
gynecologist is sent in by the State medical association, and we
have the director o f the State psychopathic hospital and his psychol
ogist, so that we have a full, -well-rounded clinic. The tuberculosis
people handle the weighing and measuring. Then the local physi
cian makes the entire physical examination, and next the child is
examined by a pediatrician. Mental cases and children with temper
tantrums or anything o f that kind are referred to a psychiatrist.
We have several psychiatrists, but they can not handle more than 10
cases a day. W e find that i f we are examining about 100 children
a day just about 10 per cent o f these children will have to be referred
to the psychiatrist. It is a pity though, by the way, that we have
to send those children to the psychiatrist in order to get the mother
there. [Laughter.]
We never enter a community without the full cooperation o f the
local physician. We send a bulletin to all the physicians, and if
they can not come to the clinic, i f they are not working with us,
we do not enter their community. The whole idea is that we are
there to help that physician; we are not there to establish maternity
i and infancy work on the face o f it at all; that will come later.
| Then that physician is going on with the work after he sees the
( need and after it is established.
/
We do not go in without a corps o f 20 local women who will
\ supervise and take care o f the work at that time, receiving their
( instructions as to the carrying on o f the permanent clinic. Usually
J we get all the nurses that we can, including the married nurses in
the community, to work with us. I think the whole success o f our
traveling clinics has been due to the fact that a month from the
day after our traveling clinic has gone our return nurse enters that
same community and checks lip on every child who was brought
( into the clinic. She finds out the number o f corrections made on
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
teeth, throat, and eyes, and the entire amount of work that has beeil
done in that one month. It would interest you to know the number
o f corrections made. In Leadville, for instance, we examined 245
children; and when we went back a month later 117 had had teeth
corrections, there were 22 tonsillectomies, 3 circumcisions, 2 herni
otomies, besides orthopedic cases, and 2 psychopathic cases. O f
course the physicians felt there was something really worth while
because they performed the operations. No child was taken outside
that community unless the physicians requested it. I f they did
request it for special cases, such as orthopedic cases, we furnished
transportation through the courtesy of our railroads back and forth
to the big general hospitals. So we were working with the physician
in the community.
We have these cards [indicating] and the idea is that when our
specialists go into a community and find something wrong with the
eye, or whatever it may be, they put down just “ plus, double plus,
three plus,” after the word “ eye,” etc. When the local physician
sees that card he knows there is something wrong with the eye, the
throat, the heart, or whatever it may be; but the mother does not
know. She has to go to her family physician, the local man, to learn
what that finding is; so it really goes back to him in the long run.
The very last part o f the card is the historical side on which we take
as complete a family history as we can possibly get o f the individual
taking the child to the clinic. We accept no child at the clinic that
is not accompanied by his parents— and it is not only infant and
maternity work, but it is also infancy and paternity work, because
the fathers come too. The father is almost as much to blame as
the mother, you know, if the child is not in good health. It takes
the time o f four women to get the history while one pediatrician is
busy. Our histories are as complete as we can make them, so when
the child gets to the head physician (the pediatrician) he looks on
the chart and sees exactly what that child had for breakfast, how
much milk he drinks, how much sleep he gets, whether he has been
eating pancakes and the like, and he does not need to question the
mother at all. He can put in his whole time with the examination
because the history o f the child has given him some background, you
see. So when he advises tonsillectomy he advises it on the idea that
there is a tonsil trouble in the family—the father or mother had
tonsillitis— here is the history; or the father had tonsil trouble, and
the mother had throat trouble—something o f that kind—all in the
family history.
When we leave a community the entire summary o f the investiga
tion and the diagnosis o f the findings are sent to the local physician.
The C h a i r m a n . W e are glad to hear all o f this good news about
Colorado. I want to say just one word, however, in defense of the
provisions that appear in the standards for the examination o f
children. That is supposed to take care o f the baby from the time
it is born until it enters school. You understand that that was the
proof that was given you this morning. It will not be nearly so
voluminous when yo'u get the printed form. I am sorry more could
not have been said about it. Doctor Eliot, who is on that committee,
is here : but I think she is not in the room.
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,
TUESDAY JANUARY 1%—AFTERNOON SESSION
MES. ELEANOB T. M ARSH, SPECIALIST IN PUBLIC INFORMATION, EDITORIAL DIVISION
c h il d r e n ’ s b u r e a u , p r e s id in g
The C h a i r m a n . .Although most of the afternoon session is to be
devoted to discussion o f publicity and exhibits the first person on
the afternoon program is Dr. William H. Davis, chief statistician
al statistics o f the Bureau o f the Census, who will speak on
birth-registration problems. I am very glad to introduce Doctor
Davis.
97
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STIMULATION OF BIRTH REGISTRATION
By
W
il l ia m
t ic s ,
B
H.
ureau
D
a v is ,
of
M.
the
D . , C h i e f S t a t i s t i c i a n fo r V i t a l S t a t i s
C e n s u s , U n it e d S t a t e s D e p a r t m e n t of
C om m erce
To obtain good registration o f births, two things are essential:
Good registration laws and good enforcement o f these laws. The
need o f good registration laws has already been recognized by nearly
all the States, and good laws based upon the model law have already
been enacted. But the second essential, good enforcement o f these
laws, is lacking to-day in many States. No one remedy can be
recommended, for the causes o f the nonenforcement differ in the
various States. But let us discuss briefly some o f the difficulties
which exist and attempt to find remedies. First of all, to narrow the
field o f discussion, let us assume that the State board o f health and
the State registrar are alive to the desirability o f securing good
birth registration and are willing to do their best to enforce the
law. Let us assume also that they know how the registration ma
chinery should be run, both in the central office and throughout the
State.
Then there remain four main questions for consideration:
1 . Is the difficulty a matter o f inadequate appropriations so that
the State registrar does not have enough clerical help to ferret out
the weak spots, or perhaps after ferreting them out has no field
agent to investigate further and to remedy the situation ?
2. Is the difficulty a matter o f carelessness on the part o f the
physicians, midwives, and parents?
3. Is it a matter simply o f indifference or perhaps actual hostility
on the part o f the physicians, midwives, and parents ?
4. Is the State registrar following too lenient a policy in delaying
prosecutions for a long time in the hope that persuasion will prove
effective ?
Considering first the matter o f expense and adequate appropria
tions : In this country the local registrar outside of the large cities
is paid, as a rule, 25 cents for each certificate o f birth or death which
he receives and transmits to the State registrar. In England the
local registrar usually receives a little more than 1 shilling for
similar service; so this initial expense to the taxpayer is about the
same in both countries. Twenty-five cents seems to be a reasonable
fee for the local registrars. Certainly it is not excessive, as is clearly
shown by the extreme difficulty which some State registrars have in
finding responsible individuals willing to undertake the work. Un
less a State is willing to pay such a reasonable price for the collection
o f its vital data no continuous plan o f registration is feasible. The
State pride o f individuals may be appealed to effectively for limited
drives, but it is too much to expect anyone to serve as a local registrar
for a prolonged period o f time without pay. O f course there must
be other funds to run the State registrar’s office, to bind the returns,
to provide fireproof vaults, to print necessary blanks and reports.
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STIMULATION OP BIRTH REGISTRATION
99
To cover all these additional items a tentative estimate has been
made o f 10 cents per certificate. The remedy for inadequate appro
priations is primarily publicity— publicity which will impress upon
' everyone concerned the value o f the work being done and the very
much greater value o f the work which could be done with larger
appropriations.
Considering next the matter o f carelessness on the part o f the
physicians, midwives, and parents: These persons should first be
impressed with the value o f registration, and then they should be
shown that they individually are important cogs in the registration
machinery provided for by law.
I f the difficulty seems to be indifference or actual opposition on
the part o f the physicians, midwives, and parents, it would be well
at first to follow a policy o f patience until the registrar has abundant
proof that he is not dealing simply with carelessness. If, however,
he should be once in possession of such proof he should have prose
cutions made without delay. Otherwise the registration official will
lose everyone’s respect, and registration itself will certainly not im
prove. But let us go into a little more detail regarding this mat
ter o f prosecutions, and at the same time let us consider the question
already proposed as item 3: Is the State registrar following too
lenient a policy in delaying prosecutions for a long time in the hope
that persuasion will prove effective? Surely care should be taken
not to prosecute a physician who usually reports his births well but
who in the rush o f business has simply forgotten to make a report.
The prosecution o f such a physician would be regarded as persecu
tion, and it would do much more harm than good. On the other
hand, there ought to be by this time almost everywhere a strong pub
lic opinion in favor o f prosecuting the physician who refuses to
report births or who is so careless that he fails to report many.
Still there is much to be said in favor o f a lenient policy in some
sections. There is much truth in the old saying that you can trap
more flies with molasses than with vinegar. Moreover, the good
fellowship which exists everywhere in the medical profession makes
it extremely repugnant for one medical man to prosecute another,
especially if there is any alternative. It is conceivable also that the
State registrar may know the political situation so well that he
realizes the great risk there would be to the health appropriation bills
if certain prosecutions were made. Notwithstanding the fact that
State officials upon taking office swear to perform the duties o f their
positions, many things are left to the good judgment and common
sense o f these officials; and the proper course to pursue in this mat
ter o f prosecutions is one o f them. Yet officials who constantly neg
lect to make prosecutions where they should be made must accept the
blame for the poor registration in their States and must not expect
to shift the blame to the shoulders o f others.
Ordinarily the proper course would seem to be persuasion -first
and then prosecution for any who still remain indifferent or who
defy the law and refuse to report. But there is no denying the fact
that there is probably less uniformity in the various State offices in
regard to prosecutions than in regard to any other feature o f birth
registration; and there is no denying the fact also that this absence
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
o f a fairly uniform firm policy regarding prosecutions is one o f the
greatest drawbacks to good registration to-day.
’
There seems to be no direct remedy for the unfortunate situation;
nevertheless there does exist an indirect remedy. As you know, the
birth registration law in many States requires the attending phy
sician to report a birth within 10 days. <The reason for a short time
limit is obvious as the attending physician is in close touch with the
family for about 10 days and is therefore presumably best able at j
that time to gather the facts. Certain legal cases came up in Penn- j
sylvania in which the birth records involved were declared void be
cause the birth reports filed by the attending physicians were not
sent in within the 10-day period required by law. To preserve the
legal rights of the child involved in such a case as this, the State
registrar, with the indorsement of the attorney general o f the State
o f Pennsylvania evolved a plan to require the physician to make
out an affidavit giving the reason for the delay in filing the original
certificate and swearing that the facts therein stated were true and
correct. I f the physician objected to filing the affidavit, he was
given the alternative o f going into court. Let me read to you a copy
o f this affidavit:
P E N N S Y L V A N IA STA TE D E P A R T M E N T O F H E A L T H
BUREAU OP VITAL STATISTICS
S tate
op
P
e n n s y l v a n ia ,
County of------------ ss:
Personally appeared before me---------------------------------------------------------- - wl10 being
dulv / sworn 1 according to law, dotb depose and say tbat tbe facts within
J 1 affirmed J
.
his knowledge appearing upon the birth certificate ot-----------------------------------_______________ on the
f township 1 o f________________________ county o f.
born in j k0r0Ugh J
_________■
■ Icorrect ; that the other facts
¿a y 0f ______________ ____ , 19__ , are
true and
appearing thereon are correctly recorded from information supplied to him and
that the reason for failing to file same within ten days of the date of birth as
required by the registration law was.
.[ S E A L j.
Affirmed
*
,
»
Sworn to and subscribed before me this---------- day or
19__
This"affidavit must be taken before an alderman, justice of the peace, notary
public or any other person competent to administer oaths.
Each affidavit costs the physician about 50 cents, whereas a convic
tion in court might cost him from $50 to $100. Consequently these
affidavits not only improve the legal records for the child registered j
but also serve as a mild form o f prosecution. A s an affidavit is re- /
quired for every case for which a report was not sent m within the i
legal time limit the physicians and midwives of the State are kept
constantly on the alert to make their birth reports promptly, in
fact, this simple affidavit to protect the rights o f the child has done
wonders in Pennsylvania toward improving birth registration.
Real ingenuity has been displayed in the application ox this amdavit plan in Pennsylvania to secure better birth registration. Let us
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STIMULATION OP BIRTH REGISTRATION
101
suppose that the State registrar has evidence o f six unreported cases
against one physician. Instead o f immediately demanding birth re
ports and affidavits for all six cases the State registrar submits two
o f them to the physician, stating that he has evidence o f other unre
ported births also. Thereupon the physician acknowledges his error,
sends in the reports and affidavits, and says that he will supply the
\ reports for the other cases if the State registrar will send him the
names. But the State registrar does not send these names to the phyisician. He tells him it is necessary for the physician himself to
go back over his books for the past year and send in all the unre
ported births he can find. In this way the State registrar has been
able to unearth scores of births of which he had no knowledge what
ever.
No law can be enforced unless some penalty is provided for its in
fraction, and this affidavit plan offers a minor form o f penalty which
can be exacted at the option of the State official, instead o f the
more severe penalty provided for in the registration law. I have
dwelt upon this particular remedy at some length because I believe it
is one o f great promise.
Many excellent devices have been and are being used to stimulate
birth registration, but I fancy you are so familiar with thefn that it
will suffice to mention merely a few such as baby books, an attractive
certificate o f birth to each mother of a newborn child, brightly col
ored posters in the post offices telling why births should be regis
tered, health trains, health automobiles, lecture campaigns with
motion pictures, well-advertised tests of birth registration by moth
ers’ clubs, the Children’s Bureau, and the Bureau o f the Census.
To-day 82 States send out to each mother of a newborn infant
some form o f notice that the birth record o f her child is on file. This
notice or certificate has proved o f value,, and its use should be con
tinued. O f the 15 States now outside the birth-registration area
there are 8 (Arkansas, Colorado, Idaho, New Mexico, Nevada, Okla
homa, South Carolina, and Texas) that do not send out certificates.
Good evidence has been received recently that one o f the most ef
fective ways o f stimulating birth registration is for the State regis
trar to send periodically a letter to each physician, giving him the
number o f births with which he has been credited so far for the cur
rent year and asking him to verify the number. Naturally every
physician wishes to receive full credit so he goes over his records.
The Bureau o f the Census is planning to ask each State registrar
for a monthly tabulation, by counties, of deaths o f infants under 1
s year o f age for whom birth certificates are on file. I f is estimated
/ that in a State with a population o f 1 ,000,000 such a continuous test
l o f birth registration will require the service of one clerk one and
one-half days each month; but what an excellent searchlight will be
^ focused on registration conditions in every corner o f every State.
\The State officials will know to a nicety just where the weak spots
are month by month, and they will know whether their drives for
better registration in a given locality show results or not; and the
Bureau of the Census, which must insist that good registration be
maintained, will be in a much better position than at present to fol
l o w registration conditions constantly*
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
To summarize briefly: To stimulate birth registration you must—
( 1 ) Make plain to all that good birth registration can be accom
plished only through a good registration machine. You must have a
good State registrar and a sufficient number o f clerks to carry on the
work so that at all times the central office will know where the weak
spots o f registration are and will promptly attempt to remedy the
defects.
( 2) Sell the idea o f better registration to the physicians. Sell the
idea o f better registration to the chambers of commerce. Sell the
idea o f better registration to the general public. Sell the idea o f
better registration to the individual mothers.
( 3) Let the women’s clubs and the chambers o f commerce which
are really in favor o f good registration of births not rest content
with a passive indorsement o f birth registration. Let them insist
on better registration. Let them insist that the State registrar com
pile and publish monthly the percentage o f deaths o f infants under
1 year o f age for which there were no corresponding birth certifi
cates on file. Let them insist on a reasonable enforcement o f the law.
Let them stand solidly behind the State officials when they prose
cute physicians or midwives who have persistently and flagrantly
refused to report births.
In closing, let me sketch briefly the outlook o f the present campaign
to enlarge the birth-registration area: W ith 33 States already in the
area and only 4 with unsatisfactory laws (Nevada, South Dakota,
Georgia, and Texas) there remain 11 which should be ready soon to
enter the area i f active cooperation with the campaigners is main
tained. This outlook is by no means too optimistic. The State offi
cials are alive, the Children’s Bureau and the Bureau of the Census
are ready to do all they can, the American Child Health Association,
the health section o f the Rockefeller Foundation, and the Tubercu
losis Association are all assisting. ^The vital-statistics section of the
American Public Health Association recently appointed a commit
tee to do everything possible to make the registration area complete
before 1930, and recently the chairman o f this committee, Doctor
Dublin, sent word that the chambers o f commerce were ready to
help. So with this general indorsement from all sides there should
be no question regarding the outcome.
Let me repeat once more the slogan and appeal: Every State m
the registration area before 1930. Your help needed.
DISCUSSION
Doctor S c h w e i t z e r . In Indiana the law requires registration with- \
in 36 hours, and the law also states that a physician who fails to re- j
port births within that time can not legally collect his fee for attend- j
ing a maternity case.
.
j
Doctor B a r n e t t . I should like to make a correction about sending /
out formal notification to each mother in Texas whose child is regis
tered. That is done by the bureau o f child hygiene, not by the statis
tical division.
Thé C h a i r m a n . Doctor Davis, would you like to reply to any
o f these suggestions or to say anything more ?
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STIMULATION OF BIRTH REGISTRATION
103
Doctor D a v i s . I think not. I am very glad to hear this statement
from Indiana. I did not know about that. The Texas situation I
did not know about. Our records show that Texas was not sending
them out. I am glad to hear that the work is being done in this way.
The C h a i r m a n . The next part o f the afternoon session is to be
devoted to a discussion o f publicity and exhibit methods. When
Doctor Haines asked me to preside during this afternoon’s meeting
I felt that it was both a very great honor and a very unusual experi
ence. A great honor because the publicity director, press agent, or
whatever he may be called, is very much in the position o f the oldfashioned child; he is seldom seen and almost never heard.
[Laughter.] His job is to get other people into the papers but to
keep himself out, and so it is quite unusual for a press agent or
publicity agent to speak in public. It is also an honor because pub
licity is comparatively a new profession. I don’t mean to say that
nobody has known anything about publicity until the twentieth cen
tury. That certainly is not true. A ll great men and women who have
appealed to the imagination o f people and left their imprint on his
tory have known the secret o f personal publicity, but as a profession
it is comparatively new. This is undoubtedly because our audience
to-day is so much greater than it ever has been before and so much
more complex. It is also true because the various new techniques
have been developed about' which the publicity agent must know
something.
O f course in the maternity and infancy program also publicity is
an essential part. The program would fail if it did not succeed in
reaching individual doctors, nurses, mothers, fathers, and caretakers
o f children, and succeed not only in reaching them but succeed in
making them do the sort o f things which it is known will make for
maternal and child betterment.
The subject seems to divide itself rather logically into two parts—
first o f all, the appeal to the professional group; and second, the
appeal to the general public. Doctor Alice W eld Tallant, a member
or the obstetrical staff of Philadelphia Hospital, will discuss public
ity from the professional-group point of view.
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INFORMING THE MEDICAL PROFESSION IN REGARD TO
MATERNAL AND CHILD WELFARE WORK
By
A
l ic e
W
eld
T a l l a n t , M. D., G y n e c o l o g i s t a n d O b s t e t r i c i a n ,
P h i l a d e l p h i a G e n e r a l H o s p it a l
I take it for granted that we have come together here united in
the desire to promote the health o f mothers and children, that we
know our country has lagged behind in that work, and that we are
all going to do our best to bring home to everyone the need for
improvement.
My part in the afternoon’s discussion is how best to bring this
matter before the medical profession, and I believe the nursing pro
fession as well, although I must say that in most o f the discussions
it seems to me to be taken for granted that it is the nurses who are
bringing it before the physicians. I have seldom heard that nurses
were delinquent; and I really have not thought that I need to pre
sent much on that line. Also I think Miss Van Blarcom spoke yes
terday about methods o f making appeals to nurses.
Now, how are we to interest the members of the medical profes
sion ? A fter all, there is no doubt that they are really spending their
lives for the health o f the communities in which they live, and it
would seem to be the logical thing for them to welcome any agencies
such as health organizations and Children’s Bureau representatives,
and to work hand in hand with them. W hy then do we find so many
physicians are apparently lacking in interest or even opposed to the
extension o f health work?
I suppose the simplest and most practical reasons are: First, that
these physicians do not fully realize that the conditions o f the com
munities in which they live are bad, or perhaps they have grown so
accustomed to seeing bad conditions that they have become dis
couraged and do not feel that much can be done to better them. Or—and this is a very practical point— when they see organizations com
ing in to act in their field, they fear that it is only a movement to
interfere with their practice and their means o f earning a livelihood.
Now, it is the part o f the health organization to lay before the
physician in unmistakable terms the disgrace o f our maternal-mor
tality reports and to urge him to do his utmost toward improving
conditions. But it is by no means advisable for these agencies to go
to him and say, “ You are a disgrace, and we want to improve you,”
because that does not help matters at all. It is always much easier
to feel that the disgrace belongs to somebody else. W e are more
likely to win the physician to our cause if we say, “ Conditions are
bad here; we know that it is not your fault and that you wish to
help. You are doing the best you can, but do help us to see that
things are improved.”
It is also o f prime importance to the Children’s Bureau and the
organizations o f the States to convince medical men that through
these organizations the aims and work o f physicians can be furthered.
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INFORMING PHYSICIANS AS TO A PRENATAL. PROGRAM
105
I believe that this can be done first by finding out in what way physi
cians need help, and then by showing them that these organizations
can help them in just that particular way. More than that, you must
bring to them a realization that a want which they never knew ex
isted is waiting to be fulfilled. The basic principle of the successful
advertising o f any commodity is to create a demand for it.
There is a story too good not to be true, that a certain well-known
remedy came into being as the result of a bet that through advertis
ing a demand could be created for something which did not exist.
The winner o f the wager had such a triumphant and unexpected
success that he was forced to manufacture something. He put away
a tidy sum as the result, and the product is still being sold.
The Children’s Bureau and also the State organizations have wisely
limited their work for the most part to the rural districts and the
smaller towns. In the larger cities health activities are so many and
varied that we really have to guard against overlapping rather than
to bring in new agencies. For that reason perhaps the city physician
might be supposed to fail to grasp the problem o f the sparsely settled
district. Yet I have a feeling sometimes that perhaps we really even
overestimate the difficulties in comparing them with the conditions
under which we work.
The points in preventive work which are probably the most
stressed by the health programs to-day are: First, prenatal care for
the m otherland second, the follow-up work for the babies, with all
the instructions as to care and feeding included therein. I believe
it is more my part to speak o f prenatal care and the way to bring
the necessity for it home to the physician. Work for babies has
made a more popular appeal and does not need so much further
emphasise As far as prenatal care is concerned, i f it is simply a
question o f putting the subject before the profession, preaching it,
I am not sure that we shall get ahead very fast. I do not know
how it is in the rural communities, but in most places where I have
been the physicians seem to be pretty well fed up—to use that over
worked term—on the subject o f prenatal care. The younger physi
cians have been duly trained, duly instructed along this line in the
medical colleges and hospitals, or at least in many or them. I believe
comparatively few o f even the older physicians entirely ignore pre
natal care; but o f course there are some who do, and to these we
must appeal in some way. Perhaps as good a method as any is to
bring forward a few impressive and unimpeachable statistics on
maternal mortality in this country and its causes, and then trace
clearly the relation between these sad figures and the lack o f proper
prenatal care. Few people can remain callous before such a pre
sentation o f the facts. After all, we physicians, even the worst o f
us, do not really wish to see our patients die; and I think that
almost any o f us would welcome aid in prolonging their lives.
I f it is further suggested to these physicians that their help will
be needed and greatly valued in the fight to improve conditions, I
think many will do their best to respond to the appeal, because,
after all, the first instinct o f most people is to help anyone who is
in trouble. I f a person stumbles and falls in the street, everyone
runs to his assistance, and I think criminals are just as likely as
philanthropists to be among such would-be helpers.
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
The physicians in the country districts may be fully alive to the
importance o f prenatal care yet unable to live up to their own stand
ards because o f the great distances which must be covered in their
practice. Moreover, on account of the small .fees paid for confine
ment cases, they may be actually unable to afford to give the requi
site amount o f care to their patients. I know that someone spoke
this morning about fees o f $200, $300, $500, $1,000, but I do not
think that these large fees are charged so frequently as might be^
suggested by that paper.
This matter o f small fees is not limited to the rural community;
it is a problem in the cities too. The sum o f $25 to $35 seems to be
the accepted fee for the earners o f small wages in the cities. I know
that in the Italian quarter of Philadelphia the families who are
living on a small though steady income almost never expect to pay
more than $25 for a confinement case. An Italian woman whom I
know brought her daughter to me the other day, to see i f I could
get a physician for her in her approaching confinement; I said con
servatively I thought I could find one for $35. She said she knew
a physician who would do it for $20 but thought maybe I would
know somebody nicer. I do not know whether “ nicer ” meant
cheaper or referred to personal qualifications only.
It is perfectly true that $25 or even $35 barely pays for the confine
ment and aftercare o f a patient. I think any o f you will admit that.
Just the wear and tear on the physician (or even the blowing out o f
a tire) will completely use up any profit there is in the case. When
we consider the number o f visits that are made $25 or $35 is really
not a large sum; and when the patients are unable— or unwilling—
to pay extra for prenatal visits we really must not blame too severely
the physicians who seem to grow lax in their care o f pregnant women.
The most skilled and conscientious obstetrician must falter before
the utter apathy and even antagonism o f a public who see in prenatal
visits only a waste o f time and a physician’s device for extracting
more money. I think that by gaining the interest o f the community
we shall indirectly make the physicians see the value o f prenatal
care.
I remember a paper that was presented before the Child Hygiene
Association about five years ago by Dr. Lottie Bigler o f Dakota, a
former student o f mine. In it she set forth in much picturesque
detail the discouragements and difficulties besetting- her attempts
to do conscientious obstetrical practice, difficulties which were due
not at all to the limitations o f the pocketbook o f the patients but
to their ignorance and prejudice. I f the Children’s Bureau and other
health agencies will put forth continued efforts until people realize
the value o f proper obstetrical care to the point o f demanding it and
paying for it, they will undoubtedly help the conscientious physician
to maintain his standard and will bring the careless one up to the
mark.
Many a physician would welcome the establishment of a clinic
under the care o f an outside physician, with nurses to visit in the
homes, which would help him in the oversight o f his cases and would
report to him any complications— always providing that no one in
that clinic casts reflections on his methods or weans his patients
away from him, Right here is a difficulty which is hard to combat,
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. INFORMING PHYSICIANS AS TO A PRENATAL PROGRAM
107
Quite unintentionally the health clinics may give the impression that
they are doing work in which the physician is not interested and that
he is to be consulted only in case of sickness; whereas many o f the
general practitioners o f the present day really care a great deal for
preventive medicine and object to having the opportunity for it taken
from them. I do not know just how this problem is to be met, but
I trust that you all have the solution. I f the health authorities could
go to the physician with a clear-cut plan for such a clinic as I have
mentioned and the assurance o f their desire to help him in obtaining
the best care for his patients, they should certainly stand a fair
chance o f winning his support.
Doctor Knox remarked that the health officers could urge upon
communities the importance o f routine examinations by their own
physicians. I think that if these physicians felt that the nurses
really would stir up their patients to come in for prenatal visits they
would be much more sympathetic as to the importance o f prenatal
care. I f we must appeal to the mercenary side let the representatives
of the health organizations take with them some o f those testimonials
that we heard about this morning, which tell of the increase in the
physicians’ practice after the health demonstrations and clinics.
That would be at any rate a practical appeal.
Moreover, suggestions from the profession should be sought and
welcomed. It is always flattering to be asked for advice and sug
gestions. One feels that after all he must be worth more than he had
thought. The representatives o f the organizations and the bureau
could do as Doctor Noble described this morning—visit the different
physicians, go over matters with them, and show them just what is
being done and how they can cooperate. Or small group meetings
could be held, such as the smaller county medical societies, or groups
o f physicians in the different communities. Frank, informal discus
sions, with no long speeches, on such simple topics as: What the
health organization can do for you; what you think it should do;
and how you can help; the presentation of mortality records and
other data, followed by requests for advice from those present as to
ways o f reducing mortality and improving untoward conditions—
all o f these ways are very practical. Comparisons, no matter how
odious, could be made between counties and States. In this way the
varying problems o f thé different localities could be attacked more
successfully, for nothing is more fatal than to try to force a uniform
plan o f action, however well conceived, upon communities which
differ widely in regard to the situation under which they must carry
out their problems. Races, nationalities, industry, occupations,
wages, conditions o f transportation—all these and many other things
enter into the calculations.
In some places, as was said this morning, regional conferences
might be the best thing for the community; in others, itinerant
clinics; in still others, permanent clinics. We shall have to work
out with the physicians in some way the best methods for the given
place. And if meetings o f small groups are not practicable, then, as
I said, calls can be made on the individual physicians, so as to talk
the matter over informally, get their views, and win their friendly
interest.
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
From my point o f view the questionnaire would be the last re
source to fall back on. That may be because I have an inherent
objection to filling out blanks. I have filled out so many that some
times it seems to me I could not bear to see another; and I think the
busy physician, overburdened with work, sometimes feels that the
questionnaire is the last straw.
To -repeat what you all know so well that it is almost idle to say it
again, much can be gained for health work by making friends o f
the individual physician and small medical society in this informal
way. I do not believe that the publicity obtained by bringing up
the subject at large meetings is as helpful—-for instance, at such
meetings as those o f the American Medical Association. The papers
at those gatherings are many, the time is short, free discussion is
limited, and those disadvantages largely outweigh the gain in the
numbers who might be reached at a given meeting. Furthermore,
I do not know whether it is yourvexperience, but it has certainly
impressed me that in State and national medical society meetings the
tendency is for the physicians to go to the meeting where the most
sensational, or let us say the most exciting, thing is being discussed.
I think it starts with the student. I know that when I was teaching
students the lecture which seemed to bring forth the greatest en
thusiasm was the one which to me was absolutely unpractical;
namely, the one on monstrosities. [Laughter.] The students would
look at every two-headed baby; whereas I always had great difficulty
in impressing them with the fine points o f the normal placenta, some
thing much more valuable for them to know. The rapt attention
with which they walked around those jars o f monstrosities always
remains in my mind.
O f course this does not mean that we should not try to get such
an organization as the American Medical Association interested.
But I think we must present clearly the plain, cold facts with
“ before and after ” pictures. W e have talked a great deal about
maternal mortality, b'ut I think we have not enough figures yet—
at least, I have not seen many—to show the maternal and infant
mortality before good prenatal care went into effect, and after.
W e have these figures in hospitals, but we can not judge by hospitals.
An actual demonstration is the thing that will appeal. When the
physicians in the different regions are made to feel that we are all
working together in this matter and when they realize how much
good comes out o f the combination I think they will wish to have
the subject brought up in the larger meetings. They will get it on
the program because it is wanted, and they will have some strong
support behind it; and then it will go.
As far as the nurses are concerned I really have no special sug
gestion as to the best ways o f bringing the importance of prenatal
care before them. Only one thing occurs to me, which perhaps may
have been brought out by others. Some training schools now provide
for their pupils work with patients in their homes, a few months
devoted to definite instruction in home riursing. I find in Philadel
phia that the nurses who have had this opportunity come out with
a far greater interest in health work o f all sorts and consequently
with more interest in prenatal care and the care o f the infant.
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INFORMING PHYSICIANS AS TO A PftENATAL PROGRAM
109
And finally, “ my brethren and sisteren,” as the old preacher said,
I should like to leave two thoughts with you. The first is: Be not
weary o f well-doing. And the second is : Continual dropping weareth
away a stone.
The C h a i r m a n . Mr. Chenery, who is editor o f Collier’s Yteekly
and also a newspaper man, and who in connection with the^ Chil
dren’s Year campaign learned a great deal about the subject in
which we are all interested, is going to speak next.
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HOW CAN POPULAR MAGAZINES AID IN CAMPAIGNS TO
REDUCE MATERNAL AND INFANT DEATH R A T E S.
By
W
il l ia m
L.
C henery, E
d it o r ,
C o l l ie r ’ s W
eekly
I have been told I may talk quite informally. The question is,
“ How can popular magazines aid m campaigns to reduce ink
and maternal death rate!? ” I will say quite honestly that the kind
of aid which the popular magazine can render depends wholly on
the nature of the campaign. I hope you do not mind my talkmto
V6When I was a newspaper reporter, a cub reporter, I had it in
mind that an editor could put anything he pleased “
nr mao-azine There is no greater illusion. The editor torms an
estimate of what people will read. I f he forms the correct estimate
he has a successful newspaper or successful magazine f he fo
an incorrect estimate his paper or m a g ^ e g o ^ mto b m t r u p t ^
or the potential readers stop reading it. So he is himseil edited
steadilv and constantly by his readers.
i
T
T mvsefi keep in mind the picture that I saw years ago when I
first reported a^ational political convention. I f you have ever seen
14,000 ot 15,000 people assembled, seen
Seonfehave
«•et un in front of them, you soon appreciate that tew people nave
the gift of arousing, seizing, and h o ld i n g the attention of a larg
mob^and the majority have not. In a political convention the crowd
is usually very Intolerant. They will give any speaker a minute
or two. yA woman is given perhaps a little l o n g e r I f
sneaker catches the attention of the ahdience m that time ne nas
a respectful and friendly hearing, often an
if he proves tedious or talks about something that the audience is
out of sympathy with, or merely not interested m, he has a listless
hearing ^atPfirst^ then a stam piig of feet, then^ even^more extreme
measures are taken, i f the gentleman does not sit d o w n .T h e ribtors
are confronted by exactly the same thing except that ‘ ^
mistakes
are revealed in red figures submitted by auditors, lx you print
stuff that people are not interested in, people stop read^
and pretty soon you have very large losses to r e p o r t — a thmg that
nobody wants. Now that is the compulsion under which every
newspaper^ and every magazine operates We mug, m te r^ i our
a'udience; we must on the whole give nothing that will not interest
alA m a p zin .e differs from a newspaper in this essentially, I think:
a newspaper can appeal to several audiences, whereas a magazine h
oMy^oneAudience. I am told that one of the most successful pub
lishers in the country says nothing must go into his paper that does
not interest 10 per cent o f the people. That means in his case that
it must be of interest to 50,000 people. I f you operated °n any such
principle in publishing a magazine you would go on the rocks.
p I should say that in the national popular magazine we can not
publish anything that is not pnma facie o f interest to 25 to 40 per
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H O W MAGAZINES CAN" AID IN REDUCING MORTALITY RATES
111
cent o f our readers. I know we print a great deal of stuff that is not
so interesting, but we do not do it consciously. That is one o f our
mistakes.
'
You must then relate your campaign for the reduction o f infant
mortality or maternal mortality to the interest o f very large groups
o f people. Now here is what we know about the interests o f very
large groups o f people. It can be put into a very few words. The
story o f one or two or three girls and one or two or three boys, in
fictional form, published in any popular magazine is assured o f prac
tically 80 to 100 per cent reader interest. Everybody who buys The
magazine, whatever his views on any particular subject, will be likely
to read one o f those stories. I should say that the same material
put in abstract form and sent out from any Governmental depart
ment could hardly hope to have more than 25 per cent reading even
though it were done in the best conceivable manner. The reason for
that is very’ simple. The thing that we are all interested in is first
of all ourselves; and secondly the fortunes or misfortunes o f some
body else with whom we feel a certain bond o f sympathy.
Everybody is interested in individual men, individual women, in
dividual children, and only a very few people are interested in hu
manity or womanhood or infancy or any other abstract term. To
the extent that you can make a campaign intelligible to people
through translating it into terms o f individuals, to that extent it is
extremely easy for any magazine or any newspaper to cooperate with
you.
'
_
Mr. Siddall, the late editor o f the American Magazine, put the
thing very graphically once when some one asked him to publish an
article about the Brooklyn Bridge. He said the Brooklyn Bridge
was interesting to engineers, although it was an old story; that the
only story that he knew about the Brooklyn Bridge now, or then,
that would be universally interesting would be the picture o f a man
or woman on that bridge doing some exciting act. A picture o f a
man on the Brooklyn Bridge in the act o f committing suicide would
have 100 per cent interest. Everybody in range would look at it and
almost everybody would read about it; but to the degree that you
toned down the activity o f the person on the bridge, or if you re
moved him completely, by so much you would diminish the interest
in anything you wrote or published about it. Now that is one of
the fundamentals upon which the popular magazines act. W e at
tempt in practically every case to translate everything into the per
sonal story o f some individual, not because it amuses us to do that
but because we know that people to whom we have to appeal m the
mass will respond to that kind o f stimulus only.
There is another quite different principle that some ot the maga
zines utilize—this is particularly the women’s magazines rather than
the men’s magazines, although to some extent it operates there. Tn
addition to the interest in stories- as such, which is, o f course, the
fictional appeal, and the interest in the dramatization ox any Kina
o f story— even a story o f abstract priiiciples people are m eres e
in things they can use themselves or things that have some relation
ship to their own lives.
. ■
,
•
From the magazine-publicity point o f view it seems to me that m
considering infant-mortality or maternal-mortality campaigns you
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
liave to translate the material into such shape that the average per
son could see something o f utility in it for himself. That is perhaps
a base view o f the reading public, but I believe that it is not a wholly
incorrect view. You will find that the women’s magazines espe
cially have all sorts o f departments in which they render “ service,”
so called. They get experts o f one kind and another who give ad
vice on all kinds o f subjects. So far as campaigns as to women and
children can be translated into these columns o f course they will
have a ready acceptance in that type o f magazine. O f course they
will not have anything like as wide a reading interest as they would
i f you put them in another way.
There is one other thing to consider: I f through statistical studies
or any other way you discover some new principle or general truth
which has genuine elements o f novelty in it, that, o f course, has pro
found influence. It is not referred to every day, but it operates
through the magazines and colors them. It determines social policies.
The sort o f thing that I have in mind is the conclusions arrived at
by Miss Lathrop’s series o f mortality studies made during the early
years o f the Children’s Bureau. A number o f conclusions were out
standing, but the thing that always appealed to me most strongly
was the fact that in some way poverty seemed to have a universal re
lationship with infant mortality; that i f people were o f a certain
income group a certain number o f children died; if they were o f an
other income group another number o f children died; that as you
rose in the scale o f prosperity the chance o f life was better. Now
that is one o f these big, statesmanlike conclusions which, o f course,
influence everybody; and to the extent that you have them, o f course
you have publicity o f primary importance.
Before you think that I have painted too contemptible a picture o f
our readers and o f humanity in general I should like to ask you just
to think back over the news o f last year. There were two stories that
stand out in my mind as peculiarly significant and revealing. You
probably remember that in Kentucky a mountaineer named Floyd
Collins was caught in a cave which he endeavored unsuccessfully to
explore. For a day or two this was a column story in one or two
papers. Pretty soon every newspaper in the country began to print
it on the first page. They had one page, two pages, even 16 to 20
columns about this man. You had in that news story all the interest
o f the most successful novel. You had the picture o f a man in dan
ger and imminent jeopardy o f death and always the possibility o f
saving him, although he finally died. There was the most acute sus
pense, and everybody in the country was interested in it. The papers
had no choice about printing it. I f they had refused to do it their
readers would have demanded that they do it, or else they would have
gone to other papers that did print it.
A t exactly the same time that Collins was dying in that cave a
large grouj) o f coal miners in Indiana, I think, were entombed.
They died in a day or two. The story that related their tragedy
was perhaps a half-column the first day, the second day perhaps an
inch, and the thiTd day it completely disappeared. Nobody was
especially interested in them, in their fate, in their catastrophe.
There was no class distinction between them. Floyd Collins was
himself o f the coal-miner group, but you had' in one case a vivid
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H O W MAGAZINES CAN AID IN REDUCING MORTALITY RATES
113
personal story. Everybody knew the man, everybody was moved
by the possibility o f escape. In other words, you had suspense. In
the other case there was no suspense, consequently there was no
interest.
Now that, as we in the magazines and newspapers have discov
ered, is the way the popular mind operates. I do not say “ popular ”
contemptuously; it is the way all our minds operate. That is what
we are like, and to the extent that we can help in these campaigns
we have got to recognize what we are. The campaigns that news
papers and magazines really succeed in putting over are the cam
paigns that they regard it as a great privilege to cooperate in. They
regard it as a privilege only if they know that the interest in the
thing is so great that they will at least keep up their circulation by
cooperating in it.
These are fairly hard tests for a body o f people who are con
strained by scientific methods and who have—as I used to have—a
very proper scorn for popularization; and yet they are vital tests
for successful publicity.
Mr. Slosson, o f Science Service, said the other day in a speech that
he thought i f a plebiscite were taken a very considerable majority
o f the people would be found to favor the view that the world is
flat. I do not know whether that is true or not, but I think a pretty
good case could be made for it. And the reason is, i f it is true, that
people who know have had to endure so much contempt from people
who do not know. As a consequence they would not bother to trans
late their conclusions into terms understandable and interesting to
the great public. A democracy can not operate on that basis. A
number o f us have been concerned at what is called the rise o f
ignorance. In my judgment the reason is that there was nothing
else to take its place. W e have assumed that a few people could
put over good work, and that as long as the things were for the
benefit o f the great majority the great majority would swallow
them. But the great majority will not swallow them; and often
they are very resentful of things that they do not understand, how
ever beneficial they may be.
. So it seems to me that there is a serious obligation to undertake,
so far as is compatible with the ends o f the campaign, to translate
your material into the kind o f words, language, and stories which
the magazines and newspapers have discovered will arouse and hold
the attention o f the general public, who must be influenced in any
campaign if that campaign is to succeed.
The C h a i r m a n . In 1921 there was started in Washington a news
service which was intended to take scientific facts and material to the
newspapers in just the popular fashion that Mr. Chenery has been
speaking of. This service is connected with the National Research
Council, and the managing editor is Mr. Watson Davis, who will tell
us something o f their success in their work and something o f what
they have learned about furnishing the newspapers with popularized
material on scientific subjects.
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SCIENCE AND THE NEWSPAPERS—rINFORMING THE PUB
LIC IN REGARD TO MATERNAL AND INFANT HYGIENE
By
W
atson
D
a v is ,
M
a n a g in g
E
d it o r ,
S c i e n c e S e r v ic e
I wish, that Doctor Slosson could have been here himself to talk
to you, because most o f the inspiration o f Science Service has come
from him.
It is a wonderful job you have. The fundamental facts with re
gard to the way in which the ordinary person looks at your job and
my job, that o f telling people about what is being done in the field
o f scientific research and medicine, in order that they may live better
and happier, have been very well summarized by Mr. Chenery.
There are certain things, however, that no magazine nor syndicate
such as ours can possibly do: There are things that must remain
the function o f the local daily newspaper, and it is in the contact
with the local daily newspaper that the really interesting publicity
work of the maternity and child hygiene and care movement can
arise.
It seems to me that i f I were, as I may some day be, in the posi
tion o f running a local paper—it is a good deal o f fun, a lot o f
work—I should like to get hold o f a reporter who is interested in the
job that you are doing. This reporter would necessarily know how
to write, and I would tell him to go down to the hospitals, to your
clinics, to your centers and keep in touch with you. I would give
him the assignment o f telling the human interest stories that are
continually reverberating through your work, just as they do in the
courts. Dozens o f the newspapers o f the country have a court re
porter who has that human touch that makes the scenes in court
alive for the reader. There is no reason why it can not be done in
your child-hygiene work. Yours is a happier work, it has a much
better light to it; it has not the shade o f trouble that is cast over
the courts and the police stations.
The fact that the ordinary person knows so little about the reason
why the body functions as it does— and it is amazing how little he
really does know—would only make more interesting the material
that this specialist in human emotion would produce for the news
papers. And it seems to me that without even the initiati ve coming
from the newspaper editor it might be possible through cooperation
with the individual reporters that you come in contact with, to get
one or two o f them started locally into doing just that sort o f thing.
Most o f the propaganda—the publicity—I hate to use the word
“ propaganda,” but that is what it is ; it is a word, that has been
dragged in the mud a good deal—most o f the publicity for the work
that you are doing can best be accomplished by personal contact after
all, by feeding interesting things to the competent reporters who do
exist on newspapers.
In our work in Science Service, and the work of the other press
associations, which I am glad to say are now taking a much more
vital interest than formerly in reporting the progress o f science and
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SCIENCE AND THE NEWSPAPERS
115
medicine, we must naturally, from the nature of our work and the
geographically large area we cover, be confined to providing back
ground material. We can put out the story o f those great funda
mental laws which Mr. Chenery mentioned, but it is very difficult for
us to report, as should be reported and could be reported, the arrival
o f triplets, for instance. I think every arrival o f triplets in any city
would be a good story; there is no reason why it should not be. Then
if you could get some modern sob sister to work with you it would
be quite possible to have the mother o f the triplets write a story on
how she takes care o f them or how she would like to take care o f
them. You have all the human interest there for a wonderful news
paper story, and there is no reason why the articles should not do a
great deal o f good. The probability is.that 90 per cent o f the people
would read that story, whereas perhaps 10 per cent would read the
cold, everyday hard facts about child care which are put into the
usual textbook style.
As I said, the function o f the syndicate is to provide the back
ground for local news and to cover news o f importance no matter
where read, be it Hongkong or Oshkosh. It is very hard to get the
human contact, the local human contacts into our work. There is
one thing, however, that can be done, although it is very difficult.
That is to make the average people thrill with science as the inves
tigators themselves do. Pasteur, for instance, was a wonderful old
man—young man at the time he did his work. He “ scrapped ” with
many; he was quite normal in his emotions and human reactions. He
was not a god although a genius. He did interesting work. He made
mistakes. It is the job o f such national publications as syndicates
have become, and as magazines are, to give the background that
makes Pasteur live. To-day we can tell the wonderful story o f how
Doctors Dick and Dick, husband and wife, at the Leander McCor
mick Institute o f Infectious Diseases conquered scarlet fever, and the
part that others are playing in the long struggle to overcome that
disease.
*
is the function o f national publications and organizations to get
into the public consciousness the idea that in science and research
there is material that can be applied to improve the public health and
welfare. Then with your work locally, in smaller geographical divi
sions, reinforced by the direct personal appeal of articles in the local
newspaper, you can finally put to practical application and effect
these great general laws o f science.
I do not want to talk very much about Science Service. The work
is a very large amount o f pleasure, really. W e have established a
syndicate which specializes in science. We have the happy coopera
tion o f the National Research Council, the National Academy of
Sciences, and the American' Association for the Advancement of
Science, and with such cooperation we do furnish material to news
papers which they are eager to get, which they wish to publish__I
will not say “ eager to get,” because no newspaper is ever eager to be
sold any material.
I want to make it clear here that we operate semicommercially,
that we are not a publicity organization. A job worth doing should
support itself 5and i f this can be put into effect in any scientific en
deavor, it is the best possible arrangement. O f course the work
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
must not become grossly materialistic. Science Service is a nonprofit-making concern, but we sell all our material and we pay for
what we use. Such a policy forces a very good practical test o f our
ability to operate satisfactorily and to provide what newspapers
want. Our principal activity is a general news service to newspapers,
in which we carry a great deal o f medical and health news. I made
a survey o f the stories we sent out, and I was rather astonished to
find that so many o f them, approximately 40 per cent o f them, were
related to hygiene, health, and medicine. Our unconscious judg
ment o f what should go into the service had reflected the interest
that everyone has in himself, and the way in which other people
operate.
We have other features—one on the weather, one on nature, an
other on the stars. W e have a very interesting little series o f baby
tests prepared from a psychological standpoint that we shall offer
shortly. So many individuals and libraries have become interested
in our work and desire to obtain a service directly from us that we
have established an unpretentious weekly magazine— The Science
News Letter— and I feel confident that as we grow, and as other
agencies see the need o f the field in which we are operating, our work
and the work o f others will reinforce the excellent work that you
are doing.
The C h a i r m a n . One o f the very interesting State exhibits that
has been set up in one of the exhibition rooms for the conference is
that o f Texas, and one o f the unique features o f that exhibit is an
invisible drawing board which will make anyone an artist. Mr.
A. C. Mitchell, who is illustrator for the Texas State Board o f
Health, is going to demonstrate for us this drawing board and the
lecture with which it is used.
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B y A. C.
M
it c h e l l ,
I llustrator, S t a t e B
o ar d o f
H
ealth,
T
exas
I can not agree with our chairman that publicity people should
not be seen and heard. M y job is that o f being seen and heard just
as much as possible. I can hold the attention o f any audience, be it
school children, politicians, or physicians, and I do it scientifically.
I f you do not agree with me after I have finished, I want you to tell
ine so.
O f course, I must tell you a little bit about myself. Public health
did not discover me. I discovered public health. I am a cartoonist.
F or a number o f years I earned my living by making political car
toons. I have worked on big papers from New York to New Orleans.
The last one I worked on was in New Orleans, about 15 years ago.
Then the president o f the Texas State Board o f Health requested
me to come over and do some cartoons for him, and I have had a job
there ever since. When I went there I found that they were using
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posters for which they were paying from 50 cents to $1 apiece—a
prohibitive price. _ Yet the need o f teachers to-day is posters. We
can not keep up with our orders now ; I suppose we are behind anv-P
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where from 3,000 to 4,000, always behind. We just can not keep
up with them. I informed our health officer that I could print these
posters very much cheaper than he could have them made by the
ordinary process o f printing. I did not invent, I simply used an
old system o f stenciling which sign painters had been using for 100
years. They block out their design on ordinary window screen, then
they paint through it on the paper, wood, tin, or whatever medium
they wish to use. Instead o f using wire screen I build frames and
stretch on them silk bolting cloth such as millers use in bolting
flour. I block out with a celluloid varnish everything that I do not
wish to print. By means o f an ordinary rubber squeegee o f the kind
you see men cleaning windows with we force the color through the
mesh o f the cloth upon the paper. In that way we print from 500
tt
vava
A
ttt
$10 a pound we use ordinary house paint costing about 7 cents a
pound.
I f you have not already seen our exhibits in the hall here and in
the other rooms I should be glad to have you notice them. When
you first look at them they look as if they were made by hand, and
for that reason possibly you would not pay quite as much attention
to them as ordinarily; however, if you find anything in there that
is not worth while we would like you to tell us about it and we will
throw it out. We have the “ health fa iry ’s house,” which is a health
game. We print an outline of a house. The teacher tells a pathetic
story about the old witch Ignorance who has burned the health
fa iry ’s house down. The health fairy wishes to enlist the help of
the school children to rebuild her house; and by observing the ordi117
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nary health rules (brushing the teeth in the morning, eating cereal,
drinking sweet milk) they are allowed to color a stone or color a
shingle, and in that way they rebuild the house.
I don’t wish to talk too long, but I do wish to draw some pictures.
I hold attention by drawing pictures. Anyone can hold the atten
tion of any audience by drawing pictures.
When I proposed to print this matter at a fraction of the cost o f
ordinary printing they thought I was just about crazy. After I
had made good on this I made another proposition; namely, that I
could teach anyone how to draw and to illustrate his own lectures.
Then, o f course, they thought I was beyond all hope; but X did it,
and I am sure that after I have finished this you are going to agree
with me—I have told you that I was an artist, and I want you to
remember that all along, because after I have finished you are going
to lose all respect for me in that line. [Laughter.]
These lectures we use in our engineering department for putting
over mosquito-control campaigns. We use them in the schools. We
now have under preparation several lectures for children on the d if
ferent diseases and things o f that kind. W e also use them for par
ent teacher associations and the like. This lecture that I am going
to give you now is for highbrows, lowbrows, or school children^ You
can gauge it to your audience. It runs anywhere from 10 minutes
to 1 hour and 50 minutes, but I am going to run mine just a little
less than 10 minutes [making a charcoal drawing on a large sheet of
paper.]
‘
%
, -.1 1.M.*
Now, we first ask the children—this talk is on malaria—-if they
can tell us how many catching diseases they have. They will men
tion measles, whooping cough, and others. Then we ask them,
“ Now, can you think o f any other catching diseases that we might
have ? ” Some little fellow will say “ chills and fever.” W e say,
“ Chills and fever is right; that is malarial fever. Can you think of
another one? ” Another child will say “ dengue fever.” That is one
that most o f you know nothing about, but those children do. One
name for it is “ dengue fever,” the other is “ chills and fever.” Then
we say, “ What do you call dengue fever ? ” “ Breakbone fever,” one
o f them will say. “ Do you know how you catch chills and fever and
breakbone fever ? ” They will tell you several different ways, from
sneezing, or rubbing against someone, or shaking hands, or putting
marbles in your mouth, or something o f the kind. Then we tell
them that the only way they can catch this disease is that a mosquito
bites someone who has the disease and afterwards bites them; and
in order to know how to destroy the mosquitoes that carry the catch
ing disease it is necessary to know something about their life histories.
O f course the first picture that I am going to draw for you is the
picture o f the fellow that does not believe the mosquito gives you
these two diseases [drawing a picture o f a donkey]. That is a por
trait of that fellow. And here is what I hope happens to him [draw
ing a picture o f a mosquito on the donkey’s nose]. I hope the biggest
kind o f a mosquito pops him right on the nose.
Now mosquitoes lay eggs on water just as a hen lays eggs, but a mos
quito lays many more eggs than a hen ever does. She will lay 300
or 400 at one time. She lays them on top o f the water [making an-
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119
other drawing]. That is the water line [indicating] ; that is the egg
raft o f one o f our mosquitoes. Their eggs are different, and this par
ticular mosquito lays about 300 eggs in each raft, and they are glued
together just like that. They are so tiny that with the naked eye
you can hardly see the whole raft o f eggs. Within three or four
days— all depending on whether the water is warm or not—the little
wiggle-tails begin to pop out o f the bottom of this raft, and then
they start out to look for food.
Now we have the two different mosquitoes, as I have said, in
Texas— I won’t go through this whole lecture, but I show the audience
how to distinguish between the different species o f mosquito, from
the wiggle-tail up, from the eggs up [drawing a wiggle-tail]. Even
the eggs are different. That is a wiggle-tail o f the culex mosquito,
which is harmless. He hangs under the surface of the water at an
angle o f 45°. This is his head down here [indicating]. He is now
in a breathing position. He breathes through his tail.
This is the chills-and-fever mosquito [making another drawing].
He breathes parallel with the surface o f the water. He lies right
under the surface, and if you disturb him he wiggles off along the
top o f the water; the other darts down to the bottom o f the water
i f you disturb him.
After three to seven days, depending on the warmth of the water,
he turns into a pupa, corresponding with the cocoon stage o f the
butterfly. He neither eats nor drinks during that time, and he
certainly is an ugly “ varmint.” This is what we call the “ tumbler,”
or the pupa stage o f the mosquito [making another drawing]. He
is now breathing through his ears instead o f his tail. The children
enjoy all those little things. This is his leg case here [indicating].
His legs are all folded up in there. This is the wing case [indi
cating]. This is the eye. This is the abdomen. This little thing
here is a paddle to tumble himself around in the water with. From
that stage now we go to the adult stage. O f course it would take a
little too long and I will skip that; but we now show the audience
where the disease, chills and fever, or dengue, is taken from one
man to the other. Mrs. Mosquito, not Mr. Mosquito, does the biting.
Mrs. Mosquito has bitten an old friend o f mine, and I want you to
tell me who the old fellow is. It looks like a mountain. It is not
going to be a mountain [drawing a picture o f Mutt]. This is my
old friend Mutt. He has been out with little Jeff, and Mrs. Mosquito
found him and he is now laid up with a case o f chills and fever.
Another Mrs, Mosquito comes along and gets a nice load o f blood
from Mr. Mutt, and now she is going out to look for another victim.
This is also a friend o f mine. He ran for the presidency, and is
still running [drawing a picture o f Andy Gump]. This is Mr. Andy
Gump. Now, this is why Andy has such an agonized expression
[drawing a mosquito on Andy Gump’s head]. Old Mutt’s mosquito
found him. This is what happened to Andy [drawing Andy Gump
in bed calling “ Min.” ]. I could go on and draw these pictures, but
I am going to tell you now how that is done. Every picture you
saw me draw there was already printed on that piece o f paper in a*
very light yellow invisible to you but very plain "to the lecturer.
Anyone who can hold a piece o f chalk can draw these pictures very
easily. I f you look closely now you can see the yellow line.
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The best way to do this work is to put in a plant to do the print
ing. A manufacturer of paint (whose name and address can be
obtained on application to the Children’s Bureau) will send you a
complete plan for a printing system costing from $50 to $5,000.
Our plant cost us about $2,500, and we print all o f our school games
and school posters, and sets o f these lectures. I have 3,000 sets
ready to send out in April. W e furnish the 14 pictures to this set
and 3 colors o f chalk with each set, also a mimeographed lecture
with marginal pictures explaining each picture that the lecturer
must draw. You sgb how oasy it is for anyone to do that work} and
the audience will always tell the story for itself by answering such
questions as I indicated that the lecturer can ask. W e are now pre
paring a lecture on the care of the teeth, to be delivered, like the
mosquito lecture, by teachers or any lecturers.
The actual material for one o f those lectures costs about 15 cents.
I print for all the bureaus ”o f the State board o f health, consequently
the expense for each department is not so great. Most o f my work
is done for the bureau o f child hygiene, and we charge nothing for
the school games we send out nor for any o f the material. W e send
it postpaid to anyone requesting it, and send out many thousands
each year. This is something that every State needs. It is surpris
ing to me that no philanthropist has come forward and perpetuatea
his name by putting up a few million dollars for poster work-—
school work—something that is badly needed in this country.
The C h a i r m a n . I want for a few min’utes to tell you a little bit
about what we are planning to do and are doing in the Children s
Bureau, and leave the question with you as to how we could cooperate
best in working together. W e recently sent out a questionnaire to
health organizations and social-welfare organizations and commer
cial exhibits and motion-picture companies to make a list o f all the
health publicity material that was available. W e sent it to some
thing like 500 organizations, and nearly all o f them replied. Nearly
all o f them sent very thick catalogues o f material; you will see a
number o f them in our display—in our exhibit office—but the im
pression one gets on looking over that material is that there is a
great deal o f waste motion in publicity and popular education, and
that if there was some profitable method o f cooperating in the get
ting out o f popular material, motion-picture films, and so forth, it
would be much more effective and much less expensive.
Some o f the things which the Children’s Bureau is doing which
may interest you are these:
In the first place, o f course we send out to the newspapers the
ordinary press releases based upon our reports.
In the second place we try to send out as often as possible our
general popular press releases which are based 'upon the care o f the
mother and the child, and other child-welfare topics.
One of the things which we have had to do this year is this: We
have taken several popular publications, notably “ Child Manage
ment,” by Doctor Thom (Children’s Bureau Publication No. 143)
•and also our little folder “ What Builds Babies,” by Doctor Menden
hall. Instead o f sending out a notice to the paper saying that we
have published this folder we have taken the folder itself, broken
it up into short articles o f about 350 words each, taken verbatim
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121
from the folder, given each a heading, beginning, and ending, so
that it stands alone, but sending the complete folder out broken *up
articles- For instance, we sent o'ut 15 articles entitled
. Child Management, by Doctor Thom,” each with a little subheadmg and a footnote saying that this was a publication o f the Chil
dren’s Bureau syndicated.
Those have proved rather popular. It is just one suggestion o f
the method o f getting something a little different from the ordinary
press statement. .A. number o f the States have asked for extra copies
o f those series and have sent them to their local papers. Maine
for instance, did that, and a number o f other States.
It would be perfectly possible for us, i f it would be helpful to
you, to have additional copies o f series like that when they relate
to maternity and infancy subjects sent to the States for local dis
tribution.
Some o f the other things that we are doing are: First, in the
held o f popular material. Writers o f popular articles often come to
us for material about the maternity and infancy act. Wre have not
just the sort o f material that they would like to have, and i f it were
possible to get it from the States it would be a great help. W e do not
have nearly enough pictures. W e have a great many pictures up here
on the walls, which you have sent in, but it is always helpful to have
more. We need especially the human-interest material about which
Mr. Chenery has told you.
That o f course we can not get here in
Washington sitting at a desk and making it up. It has to come in
to us.
In the exhibit line we have one or two things which may be o f
interest to you. Last year we had made the model o f the child-health
and prenatal center which you have probably seen in our reception
room. That model, which was worked out very carefully by an ex
pert sculptor under the direction o f the maternity and infancy divi
sion o f the Children’s Bureau, is available for loan for any exhibit
that any State may care to call for. It has already been in a number
o f States and in fact I think received a gold medal in one State
which pleased us very much.
We also have a miniature nursery which is available for loan.
That includes the walls of the nursery, which are collapsible and
can be sent flat ready to set up, and the equipment for the nursery—
table, bath, bed, play pen, toys, and two little dolls.
The child-health poster, which many o f you became familiar with
during Children’s Year, we have had reprinted without the Chil
dren s Year wording on it. That, I think, could be purchased
directly from the Superintendent of Documents should there be any
demand for it. I can not give you any price on that at present be
cause we should first have to estimate the demand there might be
for such a poster before they could give a price. The price would
probably be very low indeed since the initial cost has been met by
the Children’s Bureau.
In the motion-picture field you all know our two films, “ Our Chil
dren,” and “ Well Born.” We are also developing, or planning to
develop, one or two other things that may be helpful.
We have recently purchased two machines, which you have doubt
less seen in our exhibit rooms. These use film instead of the oldfashioned stereopticon slides. Our rickets film which consists of pic
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PROCEEDINGS,
m a t e r n it y
a n d in f a n c y
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tures taken by Doctor Eliot at the clinic has also been shown. We
have a film on the care of the baby, which has been made up from
pictures given by a number of the State bureaus and one or two
other associations. W e are also planning a film on prenatal care
and on nutrition.
These rolls o f film of course can be mailed very easily and shown
in any one o f these portable machines, and they will be available for
sale.
I do not wish, and I do not feel qualified, to give a talk on public
ity technique. You never know when you send out a story whether
it is going to carry or not— at least, you do not know until after it
appears in the paper. Yet I may mention one or two things that
our experience has shown in regard to the publicity fields repre
sented by newspapers, magazines, exhibits, motion pictures, and
radio.
As far as the newspaper is concerned the technique o f writing a
newspaper story is fairly obvious to most people. This seems to me
important—that in any community it is exceedingly worth while to
go to the editors o f the papers to discuss a program as a whole, not
only just when you want a story the next morning. In other words,
make friends with the editor, explaining the program, so that the
editors have some conception of the whole scope and philosophy o f
the thing.
It seems to me that the most influential paper in the country is
often neglected. That is undoubtedly the little county newspaper,
probably the only paper which is read from cover to cover in the
country. That paper can be reached, as you all know, I am sure, by
a “ boiler plate service” or directly. A number of the States have
been doing that. Maryland, for instance, had a most interesting
weekly series o f health talks sent out by such a source.
/'
I shall not presume to say anything about magazines because Mr. :/v
Chenery has covered that so well in his talk, and he is so much better
qualified than I am to speak about it. This little additional footnote
I should like to make to his speech, that one o f the types o f maga
zine that ought not to, be neglected is the bulletin o f the State; Fed
eration o f Women’s Clubs, what we might call the “ party organ,”
the bulletins o f the trade-unions, the bulletins o f the teachers’ fed
erations, and the like. These are small and they reach only their
own groups; but such groups are influential and sympathetic. It
pays for instance, as I know Miss Crough did recently, to send an
|
account o f what the State board is doing to the State bulletin of the
women’s clubs, and undoubtedly most o f the States are doing that.
The professional journals are equally important, as Doctor Tallant
pointed ou t; and as to exhibits the very interesting State displays in
this building speak for themselves.
The two most important factors in a successful exhibit are motion
and light—the two most important factors in attracting attention,
at least. It is interesting to go to State fairs, or to exhibits, and I
think it is very important for the people who are working along those
lines to do that, to stand around and see what sort o f thing the people
look at. The first thing that is noticed is something that moves; the
next is something that attracts attention by bright color or by light.
That is not enough, o f course. After you have attracted attention
you have to convince; and after you have convinced you have to
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persuade to action. But evidently nothing can be done unless atten
tion is attracted.
Another factor in the making o f an exhibit, which is possibly
worth handing on to you, was suggested to me by a publicity expert
111
York City. He pointed out that in any local community an
exhibit will be very much more interesting i f the people in that
community help in the actual making of it. So he suggested that
any State or National group which wished to send pictures around
quite generally shpuld hire some one especially qualified and skilled
to plan such an exhibit, and this person should plan it down to the
last detail, even possibly making sketches for posters and working
any model that is to be set up, taking pictures o f
other parts o f the exhibit. Then let these pictures and his directions
and estimates be sent to your local person in charge or given to the
nurse or whoever is going to take charge o f the local exhibit. But
leave the actual making in the hands o f the group in the commumty—the school, the women’s club, or other group.
. Just one more thing has seemed to me quite important. In additrym£ to Put ? ver the maternity and infancy program, the
publicity connected with the act should have one other object. It
seems to me that we have not only to meet the opposing factors o f
prejudice, perhaps, and indifference, and custom, and tradition but
that there has developed recently a still greater factor which must
be contended with. That is a factor o f opposition to Government
activity itself. By this I do not mean criticism o f governmental
organizations or agencies or governmental officials, which may be
necessary and wholesome; I mean something very much more serious
a np?^e un less direct and concerted attack at the Government itself.
I his point I can illustrate, perhaps, by one fairly typical quota
tion from an editorial in an influential paper. It describes the Gov
ernment o f the United States as an organization full of bureaus and
swivel chairs at the expense o f the tax-paying American people. It
seems to me that this should be met by publicity about the Government; that it is just as necessary and legitimate for the Government
itself to attempt to build up good will as it is for any business or
public or private organization o f any kind; and that it is very essen
tial that Government bureaus tell about themselves as well as about
their work; that they tell about the people who are in them, about
their salaries, and i f necessary about the cost o f the service; that
they also let their pictures go into the paper, which I know is some
thing that is hard to do sometimes.
Yhe sentiment o f the editorials in the papers o f the country is so
far as we can judge from the few clippings here, favorable to the
maternity and infancy work. We analyzed clippings coming in re
cently from a number o f States, and only one o f all the clippings
and editorials received was unfavorable. This would indicate that
the act itself is understood and appreciated.
I hope that you will let us know i f there is any way we can
cooperate with you in the publicity. We shall be very glad to help.
1 shall now turn over the meeting to Doctor Haines, who will take
charge o f the discussion.
[Dr. Blanche M. Haines took the chair];
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DISCUSSION OF PUBLICITY FOR MATERNITY AND CHILDHYGIENE WORK
The C h a ir m a n . We shall have a little time for general discus
sion o f publicity methods, and after that Mrs. Marsh will show you
some pictures. But they are not quite ready yet, and in the mean
time I will say that we have a distinguished visitor.
You all know what wonderful cooperation we have had from the
General Federation o f Women’s Clubs in promoting our program
under the Sheppard-Towner Act, and it gives me the very greatest
pleasure to introduce Mrs. Walter McNab Miller, o f St. Louis, Mo.,
the chairman o f the department o f public welfare, o f that federation.
Mrs. M iller . Madam Chairman, it is a great pleasure to be here
with you and tell you that the federation is certainly behind the
Sheppard-Towner bill. It certainly is behind the enactment, or
rather the appropriation o f money in the District, because we have
watched the work in the States and the chairman o f our child-wel
fare committee has been making a study which we are having pub
lished. We are hoping very much that through our official action we
will get it into the hands o f the President, showing that these 3,000,000 women o f the federation are behind this work. W e have
watched it. W e know what you are doing, and we are trying to help
in every way possible.
Miss A bbott. I wonder if I could say, just following Mrs. Miller’s
statement, that I have had a telephone message from Mrs. Sherman
inviting any o f you who would like to attend to-night a reception
that is being given for the women at the General Federation head
quarters on N Street—the address you can find in any telephone
book. There will be a short program and reception at 8 o’clock.
The C h a ir m a n . I s there anything, Miss Abbott, that you wish to
say about publicity?
Miss A bbott. No, because I do not dare say anything with Mrs.
Marsh here. But I will say I have always been afraid o f publicity.
1 have a great many doubts and uncertainties about everything we
do, and I am bewildered as to the way in which we sometimes suc
ceed. I do not know whether Mrs. Marsh remarked that the other
day, after a general press notice on Child Management had been
sent out, a New York newspaper carried an editorial which began
with the statement: “ This is a bulletin you will want to write for.”
In the next morning’s mail we had thousands o f requests, most o f
which came from W all Street and other business addresses. O f
course we knew that it was due to that opening sentence. Now I
want somebody to tell me how to get the same thing said about other
bulletins that we issue. I am perfectly sure that in this particular
case the motive back o f the requests was wholly selfish. Those men
wanted to know about their own children. I suspect that they wanted
to be able to take part in the evening conversation about what to do
with Mary or John [laughter] and contribute something that mother
did not know about.
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Mrs. M iller . May I suggest a way in whicli you can get some pub
licity ? When you get a new bulletin send it to our division chair
man, Miss Mary Murphy, o f Chicago, who is in charge o f child wel
fare, and ask her to write to the State chairmen and see that it gets
into the papers in the State. Thus it will come from an unofficial
source and will help, I am sure.
Miss A bbott. Miss Murphy gets all our news releases, as well as
all our bulletins and she has always been very helpful. I shall tell
her now that she has an additional duty to perform.
Mrs. M iller . And I will see that the public-health chairman does •
the same thing.
The C h a ir m a n . Is there any further discussion in regard to pub
licity? There is one thing which I wish to say; namely, that it
seems to me we should use our scientific journals, so far as we can
particularly our State journals, in telling what we are doing in the
State. W e can get into the columns o f the State medical journals,
and I strongly advise that as one way o f publicity in reaching the
professional group.
Doctor S chw eitzer . I might relate a little experience that we had
in Indiana. A fter making a report o f our activities one year I was
very much surprised to see a headline in the newspapers stating that
we had found m our examination o f children in Indiana several thou
sand— 15,000, I think—mental defectives. That was a misprint. It
should have been “ dental ” defectives, but it created a great deal o f
interest. [Laughter.] The newspapers disliked very much to re
tract, so in a few days we wrote another letter, a more popular story—
and probably more widely read—correcting the impression.
Doctor B arnett . There is one thing to remember about our pub
licity, especially in regard to the county. I believe that the publicity
we get in our local county papers (as Mrs. Marsh said a while ago)
is read from cover to cover; and I insist that the nurse is the one to
give that, to report her conference, if she has one, to the paper
herself. One o f the first things she should do when she goes into the
county is to make friends with the editor o f that paper. I f the nurse
does not do this, the newspapers may get the idea all wrong, as we.
had happen just recently m Texas when the secretary o f our State
medical society wrote us a letter saying he was very much surprised
that the State board was going into the practice of medicine through
its nurses. He referred to an article that had appeared about one of
the counties where we were going to have a nurse. In telling her
duties it said among other things that she was to take the place o f the
physician in all cases where they were not able to have a physician,
to supply treatment, etc. Instead o f getting it from the nurse or
from someone who knew what the nurses were going to do the
papers made up that item themselves; and we received the criti
cism for it. Therefore I think that one o f the nurse’s first duties
when she goes into a county is to get in close touch with the news
papers and give them their news items in the form in which she
wishes them to appear.
Miss O sborne. I think that the matter o f publicity should be very
carefully supervised. ,I know that unless we supervise it we are very
likely to encounter criticism.
The pamphlet Child Management has also been reprinted in our
local newspapers, and it has been quite widely circulated, I am sure,
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especially the part o f the pamphlet concerning habit forming, which
we used in our publicity last year for some special demonstration
work that we were doing. To illustrate it we used a human-interest
story. Each o f these 18 or 20 articles was given about two columns
of front-page space, about 5 or 6 inches long. This human-interest
story is about a little boy who was given a development test. He was
asked among other things, f What would you do if you were going
/
to go some place and missed your train?” He looked at the nurse in
some surprise and with a great deal of query in his eyes, and said, “ it. /
wouldn’t be possible for us to miss a train: My mother is always on
time.” [Laughter.] So we hung a little habit-forming story on that
and it really was very attractive.
Doctor K o e n ig . In Arkansas we are having more requests for pub
licity than we can take care of. The State papers and county papers
have been perfectly wonderful, and other papers that we have in
Arkansas. Even the medical journals, such as the State medical
journal, are willing to give us space. They wish something every
month, and our State papers give us fine write-ups. We do not go to
them; they come to us; they come to our child-hygiene bureau, and
we have clippings there concerning our work. In fact, the publicity
that the newspapers in general gave us has been one o f the outstand
ing features of this year’s work. The other outstanding feature is
the open-mindedness with which the people o f Arkansas are taking
our instruction.
Doctor G a r d in e r . W e had a peculiar experience in New York the
other day. We began to have a number o f requests for certain types
o f literature that we issue, and these followed close on one another
until we had about 100 or more. Although we do receive frequent
requests we do not always have 100 in one day for one type o f litera
/
ture; and finally we found one letter in which the writer said she
had seen this mentioned in a certain daily newspaper. We looked
in that day’s issue o f this paper and found in its question-and-answer
column a reference to a rather old, out-of-date type o f literature we
had gotten out some time ago. Yet all these answers had come in
in response to that; so this gave to me the suggestion that perhaps
all the papers that conduct a question-and-answer column would be
glad to have copies o f your literature or even that o f some other
State than your ow n; and they would be glad to send that literature
to the people in your State.
Another demonstration o f that has been made in connection with
a certain weekly for farmers’ wives. Such a publication wrote us
a while ago asking whether we would like to have the names o f the
people who had written to their question-and-answer column and
whether we cared to do anything about those cases that came up. A
good many inquiries were about nurses. We said we would like to
have that monthly list, so we receive it.
/
Now, about reaching the professional group: Doctor Dees, our /
obstetrician, came in after a week’s work the other day and said, “ In
all my experience in State work I have never seen such ill people as
are coming to me this week.” Then she mentioned different cases. !
There were four or five bad pelvises and numerous cases of high blood /
pressure, and other serious cases—a very remarkable week’s work. (
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DISCUSSION OF PUBLICITY METHODS
127
i
^ith 0uT publicity iiian about it, he said “ Give
me that stuff, and I Will put it in the State journal” He did so and
we have had quite a little comment on that. So that opens up another
avenue to publicity.
^
p
Doctor N o b l e . In Pennsylvania we have had I do not know how
many requests from colleges and high-school girls. They write in to
ask it we will send them everything we are doing about child welfare
as they are taking a special course in that work. We finally decided
i tha*
w,e ^ceived more than one request from a college we would
send half a dozen or a dozen sets o f the material desired and ask that
these be put in their libraries where they would be available for the
girls who were taking the course. I felt that we should never refuse
a request like that but should comply with it to the fullest possible
extent, because these young women who have learned about child
wealth are going to be our best friends later on.
Mrs. D illo n . The home-economics division in West Virginia does
that every year with its group o f home-making students. A set of
the material has been given to each one o f those girls for three years
now, and as the girls go out all over the State they will become a
wonderful group o f community workers behind this program
I was interested m what Miss Abbott said a little while ago about
her uncertainty in regard to newspaper publicity. We have had
some experiences that have made us feel the same way. We have
/ been trying to safeguard our publicity and have succeeded to a cer
tain extent m some o f our counties. That is true in counties where
we have only a public-health nurse, not a full unit, so that there is
\
I
tT o ^ Z t“
u nurse when sh-e goes in there e*cept the organiza
tion that we make a representative organization which we call the
county public-health association. One o f the standing committees o f
that organization is always a publicity committee, and those people
are made to feel that in their work they have the heaviest responsibilWf ole ^bmg next to that o f the nurse herself; and some o f
them have done very wonderful work. We try to choose our public
ity person very wisely, and we always put some newspaper men or
women on that committee i f we can get them. One stipulation is
always made, and we hope it is never broken— that the articles
prepared must be read by the nurse before they are given out to the
papers. In this way we have nearly always been able to safeguard
stories which might otherwise be sensational. O f course the newso o f X f 6 V6Iy X l 118 f ° r the k ^ n -in t e r e s t stories, and they do
not always arrange them as we should like.
y
Mrs. Reid. When Florida was faced with an influx o f people a
steady procession o f all sorts of vehicles loaded with t h f kitchen
otorTfiandi h? cMdreA commg int0 the State by thousands we were
i ° r *a Whlle as to h°w to let them know where they
could get help m an emergency—because it is always an emergency
with people on the road. Unfortunately they could not afways
the road esoaX f i I *161*6 X Can
help; but they stopped along
each commufitv
Yh ^
* questl°miaire to some organization in
each community, if there was an organization o f any kind in that
mmumty, asking that it be filled out and returned to us
The
a u t h o r X ^ t h i n n 118 SUCh ™for™ tion as ^ e name of tlJ chief
authority m that town, whether it be mayor or city commissioner
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MATERNITY AND INFANCY CONFERENCE
or what not, the names o f physicians, the churches, the schools,
principal hospitals, and all the general information about the town,
whether there were any health organizations, physicians, nurses,
and so on, so that the travelers “might know where to irnd them m
When these questionnaires were returned we were able to compile
a good deal of information which we thought we could turn over
to the nurses going into the district; but we found that we did not
get information to the people quickly enough in that way. bo we /
issued a small folder called Health Hints to Travelers, which con
tained only general information but named the one place from
which a 2-cent stamp would bring information and help. W e started
with 10,000 copies. They were gone almost immediately, and we had
to have a reprint. I really think, from the letters we have received
from all over the State—not just from the people in the counties
but from other people who have received these little fo ld e r s — our
work has received more publicity from this little Health Hints to
Travelers than could have been obtained in any other way.
The C h a ir m a n . N ow we must proceed to the moving pictures.
They will be shown in this room.
■_ . , ™
„
Mrs M arsh . The films to be shown are “ Tommy Tucker s Tooth,
“ Big Gains for Little Bodies,” and the New York State department
film, “ The Two-Family Stork.”
[Meeting adjourned. The audience remained seated to see the>
moving pictures.]
,
WEDNESDAY JANUARY 13—MORNING SESSION
DR. VIOLA RUSSELL ANDERSON, EXPERT IN IN FAN T HYGIENE, MATERNITY AND IN F AN T HYGIENE DIVISION, CHILDREN’ S BUREAU, PRESIDING
The C h a ir m a n . W e have this morning on our program Dr. D. A . j
Thom, the director o f the habit clinics o f the Community Health
Association o f Boston and director o f the division o f mental hygiene
in the Massachusetts Department o f Mental Diseases. Doctor Thom
has come to us because o f the request o f many directors who are
anxious to know i f the putting on o f a program o f mental hygiene
in a State is a feasible thing. As you know, he is the author o f our
Children’s Bureau pamphlets on Child Management and on Habit
Clinics for Preschool Children. I afti very much pleased to intro
duce Doctor Thom.
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THE PRACTICAL APPLICATION OF MENTAL HYGIENE TO
THE WELFARE OF THE CHILD
[
B y D . A. T h o m , M . D ., D irector of t h e H abit C lin ic s of B oston ;
D irector, D ivisio n of M en tal H yg ien e , M assachusetts D epart m e n t of M e n ta l D iseases
The first five years have an importance in the mental and physical
welfare o f the individual that no other period of life can possibly
assume. For years you have all been concerned with ways and means
o f preserving the physical health o f the child, but only within the
last half decade have you been turning your attention to some o f
the vital problems which concern his mental welfare.
It is my privilege this morning to discuss with you very infor
mally some o f the conditions that may arise during the early years
which are fundamentally related to the intellectual and emotional
life o f the child and which may lead to much unhappiness and ineffi
ciency m later life.
Perhaps I can best cover what I have to say by answering three
very general questions: W hy is this preschool period important?
\ Why is the mental health during this period so easily impaired?
Wherein lies the responsibility for the mental health o f the child of
preschool age, and how may we devise ways for disseminating the
knowledge that we already have relating to the preservation o f
mental health?
W e all know in a very general way why the preschool age is
important. It is the period when many physical and mental defects
l ca£ b.G diagnosed. It is the period when they first make themselves
f sufficiently obvious to be recognized not only by specialists but very
frequently by laymen. Take for example the mentally deficient
group. Nearly all cases o f mental defect can be diagnosed during
the first four years o f life. It is most important to recognize mental
limitations early, so that some intelligent plan may be outlined,
thus permitting the intellectual equipment, poor as it may be, to be
utilized and developed to its full capacity.
Massachusetts has a rather progressive law for the purpose o f
recognizing and recording those individuals who are mentally dev The law requires that all persons three or more years re
tarded in the public schools shall have a psychometric examination
and a further provision is made that where there are 10 or more
feeble-minded individuals o f school age in a community special
classes must be established. This means that the feeble-minded
recognized under this law at the earliest possible date will be 8 or 9
years o f age. I feel that when a disease or condition that can be
recognized usually during the first, second, or third year exists, and
a plan o f treatment might intelligently be put in operation, it is
futile to wait until five or six years later before instituting a pro
gram o f education.
r
Epilepsy, that chronic convulsive disorder which fills so many
y§ds lq our institutions throughout the country, has its beginning
129
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to a very large extent in early life. Studies pertaining to epileptics
in institutions caring for the chronic cases indicate that more than
one-half o f these cases had their first convulsion prior to the fourth
year o f life .1 It is equally important to note that the subsequent
history o f a large group o f children having convulsions prior to the
fourth year of life indicates that the convulsion was quite definitely
a criterion o f nervous instability; had it been so recognized many
o f the shoals upon which children become wrecked in later life
and which act as exciting causes o f convulsions might have been
avoided.'
.
„
. . ,
You are all familiar, I am sure, with the frequency with which
blindness, deafness, and speech defects occur during the preschool
period. Although many of these defects are due to organic condi
tions for which there is no absolute cure, much can be done by early
education and training to reduce the handicap. According to the
United States Bureau o f the Census there were on January 1, 1923,
more than 267,000 patients in State and other public hospitals and
private institutions caring for the mentally sick.2 This group alone
is occupying more beds than all other medical and surgical cases
combined— which would include all the hospitals for tuberculosis,
surgical and medical cases, and infectious diseases. It would be im
possible to measure the total cost to the country brought about by
mental diseases alone. "We do know that in Massachusetts 20
cents o f every dollar that the taxpayer turns in is being spent for
the care o f that type o f mental disease which needs institutional
treatment. But the great problem of mental health is not the care of
those individuals confined in institutions. The great problem is the
so-called psychoneurotic class o f individuals, persons who are emo
tionally unstable, who are unable to meet the ordinary problems o f
every-day life in an efficient way. There are thousands o f individuals
who have only a limited degree o f usefulness owing to the fact that
their intellectual capacities are handicapped by their emotional
conflicts.
,
.
.
_ , .
,
It is during the preschool years—that is, the first six years or
life— that many of the undesirable habits and personality deviations
first develop; and it is not long before they become so obvious and
so devastating to the personality that their ultimate effect on the
future usefulness o f the individual can easily be recognized even
by those who are untrained in either psychology or psychiatry.
It is interesting to note in getting statistics from our general hos
pitals, especially the out-patient departments, that about 60 per cent
o f the individuals who go for treatment have not physical disease
but are suffering from a state o f mind; and this state of mind alters
their conduct in a way that renders them inefficient—the so-called
“ neurotic.” So far as work is concerned, they are quite as incapaci
tated as the individual who has a physical ailment. So there is a
little relation between the actual organic incapacity and the amount
o f work these individuals are capable of doing. The point I wish to
make is that a large percentage of all these psychoneurotic mdividu^
1 See “ The relation between infantile convulsions and the chronic convulsive ^orders
of later life,” by D. A. Thom, M. D. (Archives of Neurology and Psychiatry, Vol. XI,
^^Report^of^Census of Institutions for MentaJ Disease, Unit;ecl States Bureau of the
(In press'.)
Census.
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131
als of adult life can be diagnosed during the preschool period, and
treatment can be rendered which will prevent this enormous waste
o f human energy.
Consider for the moment the underlying mental characteristics
o f a criminal. They are impulsivity, lack o f inhibitions, inability
to forego momentary pleasures and make sacrifices for a definite
end. After considerable experience with criminals in prisons and
reformatories we find that these dominating mental characteristics
have been life-long factors in the personality make-up o f this group
of individuals. In our clinics for the children o f preschool age we
see well marked in the uncontrolled, disobedient, asocial child these
same personality deviations which keep him in conflict with the
family and his immediate environment. I have made an attempt
to outline just a few o f the social problems that we meet in every
phase o f life from the cradle to the grave. Most o f them can be
diagnosed at a very early age, and much can be done, as experience
has shown, to eradicate or alter them, or perhaps substitute desirable
and social tendencies which will serve the individual in good stead in
later life. Another reason for impressing you with the importance
o f recognizing these personality deviations early might well be found
m the fact that certain mental characteristics which the child has
during these early years are more usable in altering undesirable
habits than at any other time in life. I refer to the general plasticity
o f the child’s mind, as shown by imitation, Suggestion, love o f appro
bation 5and one might add as another asset the ease with which one
can interpret conduct in early life as it is not altered by training,
education, and experience. Finally, in this plea for early recognition
and treatment o f undesirable habits, personality deviations, and
criminal tendencies, I would call your attention to the numerous
facilities that have been organized and developed during the past
20 years in the interest o f the child. I refer to the nursery schools,
the. kindergartens, special hospitals, nurses and physicians whose
training has been devoted entirely to the understanding o f the child;
books, plays, toys, and all sorts o f amusements in general have been
developed, not only to entertain but to educate and train along prac
tical lines and develop the nervous system o f the child.
There is a tendency to divide the life o f the child in a very arbi
trary way into its physical, intellectual, and emotional aspects; and
the minds o f lay people, and frequently those too highly specialized,
think o f processes working independently one o f the other. Obvi
ously this is a grave mistake. We all appreciate how closely these
three aspects o f child life are interwoven one with another, and
how important it is for the closest cooperation to be encouraged
among the psychiatrists, pediatricians, and psychologists. Intel
lectual processes are stimulated by good physical health and emo
tional stability, and the feeling side o f the child’s life is tremendously
altered if the physiology and biochemistry and general mechanics
o f the body are out o f adjustment.
Here is an example o f a physical problem which finds many o f its
manifestations in the intellectual and emotional side o f the child’s
life. A little girl 9 years o f age was brought to a clinic because she
was considered a nuisance in school. She had repeated the first and
second grades and was in the third grade doing poor work. The
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
physical examination, which must always be considered as o f pri
mary importance, showed this child to be poorly nourished and
poorly developed, with stooped shoulders, bent back, and a pale,
careworn expression. The important and outstanding physical
defect was deafness. It was revealed that the child was absolutely
deaf in the left ear and could hear the spoken voice at a distance o f
f> feet only. Three years before she had had a psychological exami
nation and was given an intelligence rating o f 63. Her present
psychological rating, taking into consideration her deafness, is much
higher; b'ut it seemed wise not to give her any definite relative
standing on the intellectual scale without much more detailed exami
nation than could be given at the time o f writing. It at least indi
cates that she is not mentally deficient. This physical defect had
prevented the child from demonstrating her real intellectual ability
in her school work. She soon began to be teased by the other chil
dren because o f her inadequacy in class work. Naturally she became
impressed with her own -failure, felt inferior, and found school
unpleasant. She became difficult to manage at home, played truant
from school, and developed certain destructive tendencies. There is
little doubt in my mind that this child’s failure in academic work
and the personality changes that followed are easily explainable by
the child’s deafness and the handicaps resulting therefrom. Mental
deficiency and delinquency were symptoms o f this underlying organic
defect and this conduct was simply the result o f her effort to keep
herself from being ignored, which, after all, is an expression o f the
instinct o f self-preservation, even though it results in asocial activity.
I recall a 9-year-old boy who was brought into my office by his
mother. The lad had been doing very mediocre academic work in the
third grade o f a private school. One o f the teachers had told the
mother that the boy had a brilliant mind and that his failure was
due entirely to his lack o f interest and concentration. After care
fully studying the entire situation, evaluating the lad’s intellectual
equipment in terms o f his past experience, his general ability to meet
the ordinary problems o f everyday life, and the psychological exami
nation, we found him to be of a very moderate mental equipment.
He had had convulsions in early life, which fact undoubtedly played
a large part in preventing normal intellectual development. His
intelligence quotient was 75, and, all things being considered, one
could come to no other conclusion than that the lad was doing very
good work with what he had to do with. It would be a great in
justice to push this child on and subject him to more mental stress
and strain than he was capable o f standing because the teacher en
tertained the belief that he had a brilliant mind. Unfortunately
we can not measure the emotional disturbances in children’s lives in
terms o f intellectual quotients, nor have we any such tests as can be
readily applied to measure both qualitatively and quantitively defec
tive hearing. The emotional stress has to be measured in terms o f
conduct, frequently in terms o f nonconformity or inefficiency and
unhappiness. Emotional stress and strain are in the background
o f almost all psychoneurotic symptoms.
The following case comes from a home o f no economic difficulties
where both parents are educated, both cooperating and in entire
agreement as to the training and care o f the child, and where the
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133
results o f their' training and care and supervision, up to a certain
point, have been considered not only satisfactory, but quite ideal:
A 5-year-old girl was taken to a clinic by her overwrought parents
because suddenly and quite unexpectedly she had refused to take
food or swallow. The morning that I was called to the office in consulation the father was anxiously but silently pacing the floor; the
mother was weeping and wringing her hands; and the little girl was
sitting quietly next to the physician wearing a mask-like expression.
The saliva was dribbling from her mouth to her frock, which was
soaked, and she seemed only casually interested. The physician stated
that three days ago for some unknown reason the child had refused to
take any food, and that she was constantly demanding that her
mother reassure her that it was all right to swallow. In spite o± the
many reassurances given she had refused to swallow and had drib
bled all day long. A brief interview revealed the following: i t
appeared that the mother had frequently told the child that she
should never allow anyone to kiss her, and in order to make her state
ment more impressive she informed the child that it caused miectioii
by germs, and that when the germs were swallowed the little girls
died. It happened that on the afternoon previous to the day her un
usual conduct began she had gone to her first dancing class, and some
man, she stated, stooped down, patted her on the head, and kissed
her on the mouth.
,
. A »
How much o f an impression this incident made upon the mind ot
the child is difiicult to evaluate at this time, but the important aspect
o f the problem seems quite obvious. The parents o f the child were
quite intelligent in handling most o f their problems, entertaining
some rather unusual ideas about bringing up a child on an intellec
tual basis. Their principle was that the child should not be spoiled
by attention, praise, or affection. I f things went well it was taken tor
granted; if otherwise, moralization and punishment followed. I he
child was never boisterous, her table manners were perfect, her
speech grammatically correct, she was never disobedient, she p ayc
only under supervision with most carefully selected playmates; her
neatness, punctuality, and general conformity to p a r e n ta l law wetfe
accepted as a matter o f course. The emotional upset which developed
after the child had been kissed would ordinarily have been eradicated after a little explanation had it not been for the fact that, quite
as unexpectedly as the symptoms had developed, the pare
£
to take notice o f the child. They not only gave her a httle attention,
but they became extremely worried and anxious. I he child Ior
first time in her life became the center o f attention. It was a new
experience and one which was so pleasing to her starved emotiona
life that it is not at all surprising that she clung to xt with great
tenacity and gave it up with considerable reluctance.
^,
another conclusion o f the home situation which occasionally produces
rather alarming symptoms in the child. , The oversolicitous parent
stuffs and overfeeds the emotional life o f the child, whereas the sterib
forbidding type o f parent starves it. These are two extremes o
treatment; neither o f which will promote strength and stability m
the emotional life o f the child.
.
nf
The three foregoing cases, I think, emphasize the nMesaty o f
studying the child as a composite unit, the reaction o f the individual
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
to the environment, and the manifold problems o f that environment
which the child has to meet.
The conduct of children is frequently more easily interpreted than
that o f adults, inasmuch as it is more spontaneous, less repressed, and
less colored by a social sense. It invariably centers around the child
since it is directly concerned with the preservation o f the child’s
own ego as well as his physical being and during the early life fails
to take into consideration the feelings and desires o f others within,
the same environment.
The neurotic tendencies in children, as with adults, are always
striving to serve some purpose, although occasionally they are so
vague and ill-defined that the objective is not perfectly clear. It may
be perfectly obvious, the motive o f temper tantrums," neurotic vomitmg, delinquency, or some other undesirable deed or habit, or it may
necessitate a long, careful study of the case; but all such conduct
has a motive which the child feels at least is working out to his im
mediate advantage. Asocial conduct is all too frequently utilized
to avoid the difficult situations in life? and the child who learns by
experience that such conduct aids in dodging reality on one occasion
is likely to practice it more or less continuously.
I t i s quite important to consider for a moment the incapacity that
n ^U v-ij01? a ^atber minor mental handicap in the life o f the child.
Ih e child that is incapacitated on account o f some undesirable habit
or personality defect or twist not only demands but gets a dispro
portionate share o f the mother’s time. The mother is invariably
more concerned about this one individual in the family whose
personality obliquities lead to asocial conduct than she is with the
other three or four children who may be considered normal; and it
is not surprising that these normal children will react in a normal
nieans resentment and rebellion toward the parent for
the disproportionate share o f her time which she is giving the delinquent. Keep m mind, if you will, that the incapacity for efficiency
a^'+1/ 1aPP1^ess brought about by an unhealthy state o f mind is one
-Ju iP-u cori?IPon as well as one o f the most important problems
with which social and medical organizations have to deal. It is o f
interest to note that the incapacity from mental handicaps, unlike
that o f physical origin, is out o f all proportion to what one is led to
, expect.
The question now arises—who should be held responsible for the
mental health o f the child o f preschool age? It is not practical,
^11
lt .(^e.sirable, to have all these children examined by a so^
do n0t dnd the Apartm ent o f Agriculture
nf W p f
arOUnd t0 ride on the back o f ^ e r y cart
SL“
- to ten.the farmer to put so much here and so much
J h W t f Pf ! erai instructions, I presume, are sent out to farmers
fh S kgm ^
aJLt0 h<iT best to fertilize certain lands. I
think our approach to the problems o f education and our approach
t h a t l f iF 0“ 6”18 ° t , 1i?.ay h.need>
handled in much the same*way;
n e c L lr ilv r e ^ ! l Slb y ^ t h e menial health o f the child must
dividuals w ^ . T
Parents, teachers, social workers, and those inwTn S r S
making daily contacts over long periods o f time
the
e n t a lt
fa 1 tTo;fMh
Z ° f the
6* d[®Cult
Problams
concerning
the m
mental
health
f children
are Tbrought
about
by environmental
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Ap p l ic a t io n o f 1 M e n t a l H y g i e n e
135
situations so obviously unhealthy that it does not take a trained
psychiatrist or psychologist, or any other specialist, in fact, to deter
mine what the defect is, and frequently to make intelligent recom
mendations to correct it. This does not mean, o f course, that there
are not innumerable problems concerning the mental health o f the
child that are very vague and ill-defined, in which it will take all
the skill and all the ingenuity t>i those best trained to comprehend
the underlying difficulty. Herein, o f course, lies a certain element
o f danger which is stressed and frequently, I believe, overstressed
by the specialist; that is, the parent, the teacher, and the untrained
individual must appreciate which problems lie within their province
and which ones present fundamental difficulties o f such a nature as
to need the services o f the expert.
A t the present time there is much valuable information concern
ing the mental health o f the child, rather well-defined ways o f
meeting certain problems and mechanisms that are not too compli
cated for the intelligent person to understand, which gives lay
people a much better understanding o f how asocial activity develops
and what it means to the child. It is extremely important that all
you individuals who are held responsible for the physical welfare o f
the child take advantage o f every opportunity to familiarize your
selves with the fundamental principles o f child psychology. Many
serious mistakes would be avoided if we all utilized the material that
is at hand and available. One o f the things that parents, teachers and
numerous other persons who come in daily contact with children fail
to recognize is that the child really has a mental life. I f we can get
the parents to appreciate that they are dealing with an individual,
regardless o f his chronological age ; an individual who has a mental
life capable o f experiencing many o f the same emotions at 3 years
o f age which he experiences at 30, much will be accomplished. These
children have hopes, ambitions, doubts, fears, aspirations, joys, and
sorrows that are thwarted and gratified in much the same way as
our own.
Parents tend to look upon the child as a rather mechanistic indi
vidual that responds physically to a certain situation and without
any relation to events o f the past. It is pathetic, I think, and a bit
discouraging that so few o f us, as adults, can remember in any
great detail what our emotional lives were prior to the sixth year.
But those who will take time to get close to the mental life o f the
child, taking conduct as a sort o f guide post and the mental content
o f the child’s mind as their objective—what is going on in the mind
o f the child, what he is thinking of, what he is hoping for, what he
is fearing—will find that this mental life is very well established, very
well organized.
In understanding the conduct o f the child it is o f great importance
to know what he is thinking, how he is planning, what he is attempt
ing to avoid and to attain, how he feels about things and people,
situations and events, which we, as adults, are prone to believe make
little or no impression upon him. We must bear in mind that the
mental attitude o f the child toward life is highly colored by the
personalities with which he comes in contact. We must become less
concerned with symptoms and more concerned with fundamental
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causes. From the environment and the personalities with which the
child has to deal we can expect to learn much regarding the basic
forces that are the causative factors o f asocial conduct.
There is nothing more important in dealing with children than
the psychiatrist’s attitude toward the parents. It is not sufficient in
most cases to point out parental defects and to lecture parents about
being domineering, oversolicitous, or whatever their fault may be.
It is quite essential that the parents be helped to understand why
they have developed this particular attitude toward the child. The
following briefly indicates this point: A boy o f 6 years was brought
to the clinic only yesterday morning by a mother who stated, “ This
child is stubborn, refuses to do anything I tell him, makes a terrible
fuss about his food. I have to coax, tease him, and finally feed him.
I f he takes a nap I have to lie down with him. He scratches and
kicks and pinches the smaller children. He is extremely cruel to
animals, sticks pins in the cats. When denied he screams and yells.”
During the questioning o f the mother a child was staging what I
considered a violent temper tantrum in an adjoining room. When
I inquired whether he was her child, she replied in a half-hearted
way, “ Yes, but that is a modest protest at my being away.” This
mother seemed to be a woman o f average intelligence. She had three
other children who were apparently getting along without great
difficulty, and on the whole she seemed to be handling most o f her
problems in a very sensible sort of way. In reply to inquiry re
garding her husband she stated, “ He is really quite a problem, so
far as managing the children is concerned. He resents my cor
recting them and frequently remarks, ‘ Oh, don’t bother the chil
dren, let them go, don’t be nagging them all the time. They are
going to be young only once. Give them a good time,’ and during
the hours that he is home he refuses to permit me to discipline them
in any way whatever.”
W e find that this man had been brought up in a very cold, for
bidding home. He had a tyrannical uncle whose treatment at times
was extremely cruel. He could not remember either his father or
mother. Childhood was an extremely difficult and unpleasant time
in this man’s life, and as he grew up he had carried in his own mind
the idea, perhaps at times only, in a rather vague sort o f a way,
that if he ever had any children they were going to have a different
childhood from what he had had. “ They are not going to be
nagged, picked on, and punished as I was when I was a kid.” Here
we see a very interesting example o f a man who is really overcom
pensating his own children for what he himself had to go through
as a boy. Now this overcompensation on his part can not be cor
rected by simply telling him that he is doing the wrong thing, that
he has got to change his attitude, that he is spoiling the boy, and
that he knows nothing about handling his own problems. His
whole attitude toward the child will be more permanently and hap
pily changed i f he can be made to understand exactly what he has
been doing and that there are certain dangers in permitting the child
to have a life o f license just as there are dangers in curbing, thwart
ing, and at times completely annihilating any initiative on the part
o f the child. I t may also be pointed out that his wife is trying to
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sail between these two shoals upon which so many children are
wrecked and that his cooperation is absolutely essential to the future
welfare o f the family.
I have pointed out many times that frequently the very love and
devotion that parents have toward children prevent them xrom meet
ing their problems o f child training on an intellectual level. People
who are perfectly stable about meeting the ordinary problems o f
everyday life become extremely panicky when dealing with some
o f difficulties in training children.
I might briefly summarize the thoughts that I wish to leave with
you this morning as follows r First, there is no more important period
in the life o f the individual than the first five years. During this
period many o f the physical and mental defects which handicap the
individual in adult life can be recognized, and it is during this
period that they can be most easily understood and treated. Fre
quently this will prevent the personality from becoming twisted and
distorted to the extent o f rendering the individual unhappy and in
efficient. By the very nature o f things as they exist to-day the re
sponsibility o f child training must be assumed by parents, teachers,
nurses, and general practitioners,,and not by specialists. The psy
chiatrists and psychologists have a very important function to per
form in presenting the knowledge at hand regarding mental hygiene
in such a way that it can be utilized by various groups with whom
the child comes in intimate contact. The problems o f mental health
are brought about frequently by undesirable factors in the environ
ment and by physical defects, both o f which can and should be
recognized by intelligent laymen as soon as they appreciate their
importance.
I would therefore urge upon you all to avail yourselves o f the
vast amount o f information already at hand concerning the mental
life o f the child and use it in your daily contacts with your patients,
whether you meet them in the clinic, in the home, the nursery school;
whether they be found in the congested districts o f New York City
or in some o f the sparsely populated hamlets with which many o f
you are so intimately concerned.
DISCUSSION
The C h a ir m a n . Doctor Thom’s paper is now open for discus
sion. I shall ask Doctor Haines to take charge o f the discussion.
[Dr. Blanche M. Haines, of the Children's Bureau, took the chair]
The C h a ir m a n . Are there any questions you wish to ask Doctor
Thom, or has any one something to say? We have just a little while
for discussion.
Doctor B rydon . A ll o f us who conduct child-welfare conferences
throughout our States, are constantly confronted by mothers who
ask questions, and we know that we may never see some o f these
mothers again. They live in the rural districts and have no facili
ties such as people have in Boston, where they can go to Doctor
Thom’s clinic. W e know that a mother is speaking from her heart
when she brings in her problem child and asks certain questions.
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Are there any specific instructions that can be given to such a mother,
that will cover these phases of the child’s life: The physical, the
mental, the intellectual, and emotional— just something that we can
pass on to this mother that may help her ?
A D irector. I should like to ask Doctor Thom how he handled
this bad boy 4 years old in regard to the control o f the father. He
did not give us the treatment, and I should like to know a little bit
about that.
j
Miss O sborne. I should like to ask i f Doctor Thom thinks it would
be a good idea to have the county nurse follow a textbook to help in
classes with mothers, to help in one particular phase o f bringing up
children, such as habit. Do you think that she could do that?
I have in mind that particular difficulty that Doctor Brydon spoke
of, that we do not know how to tell these mothers at just one visit
how to take care o f their children. It is a very hard thing to do, but
I thought perhaps the nurses might help mothers’ classes with some
sort o f instruction.
Doctor L a k e m a n . I should like to have Doctor Thom repeat for
the benefit o f some o f us at the back o f the room the results of the
survey made o f patients that entered the hospital 20 years pre
viously.
'
Doctor B l a c h l y . I should like to know more about the child who
was upset by being kissed.
■■■■’ (
The C h a ir m a n . Does anyone wish to know about the feasibility o f
habit clinics as a State piece o f work?
Doctor G ardiner . I should like to know that.
Doctor T h o m . On the first question, regarding one visit to a clinic,
I do not know whether there is anything that you can put into the
hands o f the mother at the present time to cover all problems that
might arise in the succeeding months between visits. I think such
statements would have to be very general. The point that I made
might be stressed, that the mother should appreciate that the child
has a mental life, that the child’s conduct is simply a reaction between
his particular personality and the environment in which he is
placed— common, simple, everyday examples given. For example, let
us consider jealousy: I f a newborn baby comes into the family, it is
a natural reaction for a youngster 3 or 4 years old, who has been hav
ing all the time o f the mother, to be a bit rebellious when some other
individual is introduced into the family. Frequently mothers look
upon this reaction as simply naughtiness or badness on the part o f the
child, because this youngster at 4 years o f age would have a ten
dency to push the other youngster away. Naturally the mother feels
that the 1 -year-old child has more demands upon her time and is en
titled to it. Now there is a problem that the mother can understand
and a common problem in many homes. Something might well be
gotten out, I suppose, on these everyday problems with which moth
ers have to deal; but I do not know o f anything you can give to a
mother that is going to cover all problems at the present time. I f a
child came to a physician with a question o f a medical or a physical
diagnosis you could advise her on that particular condition, but it
would be very difficult to anticipate what was going to happen in the
physical life o f that child. You might sit down and say, %Now if
the child has rickets, do this; i f the child has croup, do that.” You
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might cover many things if time permitted, and yet you might omit
the very thing that was going to happen two or three days after the
mother left the clinic.
So I do not see that we have any way o f covering all the things
that might happen. I think we might perhaps present to parents
in a rather more general way something about the mental life o f the
child and its interrelation to the emotional and physical.
Now, the treatment o f this bad boy, whom I saw only yesterday
morning—saw only once. The treatment o f this boy is the treatment
o f the father. It consists in getting the father to appreciate that the
mother must live with this boy 10 hours or 12 hours a day and that
he sees the boy for only a couple o f hours, that in spite o f all the ^
interest and the efforts that the mother puts into this problem he can
undo her work in the 2 hours that he is at home; and furthermore to
make him understand the reason for his particular reaction—that
he is overcompensating for unpleasant experiences that he had in his
early life, and although that is generous and human it is going to
work a hardship on the child. Another important thing is to make
this father see that if he has a child just under 4 years of age, as this
child was, the family can not control, even in this padded environment
where everything is fitted up, so to speak, to adjust to this difficult
situation— what is going to happen to the child when he gets out in
the world when he is 5 or 6 years old and meets school problems,
where he is going to be considered just one o f the group and there
will be no adjustment o f environment. Is he the one who is going
to take the adjustment? So I think the problem there is dealing en
tirely with the father.
In regard to textbooks for nurses I do not know o f any textbooks
written on this subject o f psychiatry and the mental life o f the child
that deal with problems specifically enough to be o f any great value.
I do believe very strongly that mental hygiene should be introduced
into the nurse’s curriculum, so that she may appreciate the inter
relationship between the physical and mental side o f the individual’s
life. But there are a great number o f nurses who have not had
that opportunity; and it seems to me that courses, wherever possible,
of even two weeks’ duration should be established in relation to de
partments o f health and private organizations, as has been done in
Boston, for example, where the Community Health Association has
provided for its nurses some lectures on this subject o f mental
hygiene which the director feels have been of real value.
It is extremely important, to my mind, that the nurse have this
mental-hygiene point o f view. There are in Boston three nursing
organizations that go into 3,000 homes a day. I do not believe that
all the psychiatrists in Boston could have anywhere near the influence
on the mental health o f the children o f the city o f Boston that this
group o f nurses has, going into 3,000 homes, picking up these prob
lems o f temper tantrums, undesirable sex habits, feeding habits, that
are well within the realm o f the nurse’s ability to handle.
The survey o f chronic convulsive disorders to which I referred
was taken from the records of Munson State Hospital. There we
found that about 52 per cent, I believe, o f all the cases that had
good histories showed the first convulsion to have come on prior to the
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fourth year o f age; and the other material was taken from the
Massachusetts General Hospital, the Children’s Hospital, and the
Infants’ Hospital. These children were sent there with acute in
fections, such as whooping cough, gastrointestinal upsets, and the
like. A ll cases were excluded where there was any possibility o f a
meningitis or an encephalitis, a brain tumor, a brain hemorrhage,
or anything directly associated with the nervous system, so that the
convulsion was secondary to the acute infection. The cases were di
vided into three groups: First, children that died o f convulsions;
second, children that became feeble-minded, many o f whom were in
institutions; and third, a group that did not become feeble-minded
but developed epilepsy. Some o f them were in institutions, and some
o f them were occasionally having recurring spells; and some one
o f these grave things had happened to a little more than 50 per
cent o f that group. Now I think that is perhaps large; I mean that
i f you consider all the children who have.convulsive disorders I
think that percentage is high. I found that in a large group—
5,000 cases— about 1 child in every 14 has convulsions; that is, about
7 per cent o f all children. This is the figure for a group of 5,200
children from 1,000 families.
But the point I was trying to make is that an infantile convulsion
is a serious thing. Yet pediatricians as a group—those that I have
consulted— felt that it was not serious, that perhaps most children
did have convulsions, and it was not anything to worry about. To
me a convulsion in a child is an indication o f the instability o f the
nervous system; and for that particular type o f child a special
plan should be laid out. That child should be looked over often and
a little bit more carefully. In the first place every effort should be
made to ascertain why the child has convulsions. A very careful
physical examination should be made to determine that; and then
a path should be laid out to evade the ordinary shoals upon which
many children are wrecked.
The next question is on the kissing. That is quite important. I
failed to mention what the little girl told me when I took her up
stairs for the 20-minute examination. I immediately gave her a
glass o f water, which she drank without comment. Then I said,
“ Martha, why have you not been swallowing? W hy have you not
been drinking water and taking food ?” Then the child told me
about going to the dance and a man stooping down and kissing her.
“ W ell,” I said, “that is nothing serious, is it? ” She replied, “ My
mother told me I should never let anybody do that.” I asked her
why. She said, “ She told me I would get germs, and i f I got germs
I would die.”
Well, I think that did cause the temporary upset—I mean it got
her to thinking along those lines. But I believe that could have been
handled very easily and passed over without any difficulty. The
important thing was that when this child got sick (for the first
time, apparently) both the parents stopped and got tremendously
concerned; and the child for the first time saw herself just the center
o f the stage and everybody running around trying to do something
for her and teasing her to do this and teasing her to do that when
Qrdinarily she just did it without any fuss.
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So far as habit clinics themselves are concerned I should not
recommend the establishment o f clinics quite independent of the
clinics that have to do with the physical health of the child; I be
lieve that any individual who has intelligence enough to operate a
clinic looking after the physical welfare o f the child can incorporate
into that fund o f knowledge what we know about mental hygiene
and render to parents information o f great importance. It would
not be wise for undertrained workers to set up a special clinic for
the mental health o f children. I think it should be incorporated
in the welfare work itself. The two should go hand in hand. Sup
pose the mother brings in a child for a feeding problem: Many
mothers bring children to me and say, “ This youngster does not eat
anything. I don’t remember when this child has had anything
to eat.” You look at the youngster and see that he is fat and plum p;
and her assertion does not seem entirely plausible. You find the
problem to be not the amount o f food the child eats; but when he
eats, what he eats, and the way he eats it. His intake is all right
but he will not take it in unless the mother gives it to him; he will
not take it when the mother wishes him to, because he knows he
can get it when he wants it; and perhaps he refuses vegetables if
he can get meat or ice cream.
I think those problems are so closely interwoven that the mental
hygiene should be dispensed at a clinic that is doing the health work.
Doctor S c hw eitzer . Would it be a good thing to have a psychia
trist visit the various clinics and help to take care o f the problem
children ?
Doctor T h o m . Yes. I think the principal value o f having a
psychiatrist visiting clinics would be his having conferences with
those who are running the clinic, to point, out in a very general way
how to meet the problems at hand. Each time he should leave with
the persons running the clinics such information as he had.
Doctor
S c hw eitzer .
Y ou think he should act as a consultant?
Doctor T h o m . Yes, a consultant and an educator in that field.
Doctor S ch w eitzer . I would like to say one thing more. I wish
to say that we have found Doctor Thom’s book on hatpt training
in childhood 3 very good to use in regard to child management. We
have found it very helpful not only for physicians and nurses but
also for the mothers themselves.
Doctor B rydon . I wish to know how early—or whether you go
into the subject with the parents—one can teach the child to over
come jealousy, for instance, or personality twists. Can the young
child be taught responsibility to others, service to others, and the
golden rule? How early can one teach these, and do you employ
these things in overcoming personality twists?
Doctor T h o m . I wish I had some o f the copies that I have made
o f the conversations just as they are held with mothers. In dealing
with the type o f mothers that come to my clinic one must get things
over in a very practical sort o f way. I always try to project into
the future the problem with which I am dealing. Thus, if I am
3 “ Habit Clinics for Children of Preschool Age,” by D. A. Thom, M. D., Mental
Hygiene, Vol. VI, July, 1922, pp. 463-470. The National Mental Hygiene Association,
370 Seventh Avenue, New York City. (Reprints obtainable.) The Children’s Bureau
has published a report by Doctor Thom on this subject entitled “ Habit Clinics for the
Child of Preschool Age; their organization and practical value ” (Publication No. 135,
Washington, 1924).
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AND INFANCY CONFERENCE
dealing with a child whose mother is concerned about jealousy or
who has brought the child in and we find that the difficulty is one
o f jealousy, I say to her, “ Now, Mrs. Smith, you know all this stuff
I am going to tell you, but undoubtedly you are familiar with
certain people that just hate to see other people get ahead. You
live in an apartment house, or you live in a tenement house, and
you know a lot o f people that are what we c a ll 4jealous,’ don’t you? ”
She will immediately think o f half a dozen right off that she knows,
and she certainly would not want to be like that! Then I try to
point out to her that this is just what her youngster is heading fo r;
and what she is actually trying to do is not merely to bring up a
child that can live in this household o f hers, capable only o f adjust
ing itself to this environment where everything is constantly being
shifted and changed to suit the child, but she is trying to bring up
a child that in fact is going out to live in the world at large. The
first problem on leaving the home is the school, maybe the kinder
garten, possibly the nursery school, or the first grade in school; and
I try to point out to her that this environment o f the child is going
to be rigid ; it serves 30 or 40 children, and it is going to serve the
majority o f those children. I f any child has such a personality
twist that is marked, such as jealousy, so that the child is making
assaults upon a little brother or sister, the mother can protect and
look after that thing in the home; but i f it happens in school that
youngster is going to be ostracized.
In other words, I accomplish more with the mother by taking the
problem at hand and projecting it into the future, trying to make
her visualize the type of child she is going to have at 8 or 9 years of
age, or 10 or 15. And as far as the golden rule goes, that adjust
ment to life— adjustment to these problems which individuals have
to meet, whether in the nursery, in the school or in the high school,
or whether in industry—is the application o f the golden rule. I
think that the attitude we take toward parents is very important.
I mean that our conversations should not make them believe the
child’s condition due to any inferiority on their own part. So fre
quently we are apt to make parents feel that they are inadequate,
that they are inferior, that they do not know; and they go away
with rather a hopeless attitude toward life. Hence, regardless of
what you actually feel about it, you are going to accomplish a great
deal more i f you can give them the knowledge and still protect their
self-respect; and I think projecting these problems into the future
does that.
The C h a i r m a n . We shall now turn the meeting back to Doctor
Anderson.
[Dr. Viola Russell Anderson, of the Children’s Bureau, took the chair]
The C h a i r m a n . Dr. Nina Simmonds, professor o f chemical hygi
ene in the School o f Hygiene and Public Health o f Johns Hopkins
University, and coauthor with Doctor McCollum of The Newer
Knowledge o f Nutrition, is to be our next speaker.
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NUTRITION IN RELATION TO REPRODUCTION AND
VITALITY OF THE OFFSPRING
B y N i n a S im m o n d s , S c. D ., A ssociate P rofessor of C h e m ica l
H yg ie n e , S chool of H yg ien e an d P ublic H e a l t h , J ohns H op
k in s U niversity
\
The student of nutrition to-day knows that dietetics occupies a very
important place in the field o f preventive medicine. More progress
has been made in the subject since 1915 than in all the years before,
owing to the understanding o f the great importance which the un
identified factors or vitamins play in nutrition .1 Since we have come
to understand the significance o f the vitamin hypothesis it has been
possible to plan experimental diets with definite objectives in view.
Investigators before 1915 planned many experimental diets appar
ently having the same dietary properties, but they could not explain
why animals grew in some cases and not in others. Loss o f appetite
in the experimental animals was a most discouraging factor in the
early experiments. The early studies which cleared up this confus
ing problem have been discussed elsewhere.2
It is now possible with the knowledge available o f the dietary
properties o f the natural foodstuffs and their manufactured prod
ucts, as cornmeal and white flour, to appraise very accurately a
dietary formula. W e know that an adequate diet must contain the
following dietary factors: 18 to 20 amino acids which result from
the digestion o f complete proteins; a source o f energy in the form
o f fat and the carbohydrate glucose, or sugars or starches which are
convertible into glucose ; 9 inorganic elements in the form o f suitable
compounds (potassium, sodium, calcium, magnésium, phosphorus,
iron, chlorine, sulphur, and iodine) ; and for certain species 4 and
possibly 5 as yet unidentified dietary factors known as vitamins. It
is still an open question whether fat as such is required in the diet,
vit has not been possible up to the present time to put into the diet two
and possibly three o f the vitamins without adding fat.
The vitamins are known by the letters o f the alphabet, as vita
mins A , B, C, D. Evans and Bishop, o f the University o f California,
have presented evidence which is very suggestive that there is an
other fat-soluble vitamin associated with reproduction which they
now call vitamin E.^ Since we do not know the chemical nature o f the
vitamins nor the rôle which they play in the animal organism we
describe the gross appearance o f the symptoms which appear when
the animal is deprived o f a single one o f them in its diet, which is
made adequate in other respects.
McCollum, Elmer V., and Marguerite Davis: “ The nature of dietary deficiencies
of rice. The essential factors in the diet during growth.” Journal of Biological Chem
istry [Baltimore], Vol. XXIII (1915), pp. 181-247.
^McCollum, Elmer V., and Nina Simmonds: The Newer Knowledge of Nutrition (third
edition, The MacMillan Co., New York, 1925, 675 pp.) ; Sherman, Henry C. and Sybil L. :
) The Vitamins (The Chemical Catalog Co., New York, 1922, 273 pp.) ; Funk, Casimir : The
\ Vitamins (authorized translation from second German edition by Harry E. Dubin, Wil
liams & Wilkins Co., Baltimore, 1922, 502 pp.).
143
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Vitamin A is present in abundance in cod-liver oil, butter fat, the
leaves o f plants, liver, kidney, and egg yolk. The seeds o f plants, as
wheat, corn, rye, and barley, although not devoid o f it, are not rich
sources o f it. The absence o f vitamin A from the diet leads to the
development o f a peculiar condition o f the eyes. Mori has described
the condition as xerosis conjunctivae or xerosis corneae (xerophthal
mia ).8 Xerosis or dryness is the essential change. The ulcers o f the
corne'a (keratomalacia) are secondary and are due to infection by
microorganisms. The lacrimal gland, the Meibomian gland, the
Harderian gland, and the salivary glands undergo marked alteration
when vitamin A is not present in the diet. These glands cease to
function, and bacteria gain a foothold. Mori states: 4
4It is neces
sary to consider the clinical picture o f xerophthalmia as a series o f
secondary symptoms which are indicative o f the hypofunction o f a
certain part o f the secretory apparatus o f the organism.” In other
words, xerophthalmia is the specific manifestation o f a specific
glandular lesion. It is one o f a chain o f symptoms, the other links
o f which, in children, are hoarseness, cough, lack o f saliva, and
general malnutrition. There is also a purulent discharge in nose
and ears.
Evans and Bishop 4 have described a recurrence o f the ovulation
cycle in adult rats when their diet was deficient in vitamin A. They
found that there was a prolongation o f the oestrus desquamative
change in the vaginal epithelium, the smear consisting chiefly, if
not exclusively, o f the cornified cells which in normal rats charac
terize the actual period o f oestrus and ovulation only. These females
continue to ovulate and to form corpora lutea irregularly or at
intervals approximating the normal.
Vitamin B is much more abundant in nature than is vitamin A.
It is present in nearly all natural foods. It is not present in any
fats o f animal or vegetable origin. It is absent from or present in
very small quantities in manufactured products, as bolted flour,
degerminated cornmeal, or polished rice. A lack o f this vitamin in
the diet leads to the development o f a disease known as beriberi in
man or polyneuritis in birds and mammals. We are not familiar
with the exact changes which result in the body from a lack o f this
substance. The work o f McCarrison, however, indicates that the
entire digestive tract is debilitated and then the nervous symptoms
develop. It has been suggested that the absence of this factor causes
a breakdown in the mechanism which controls the nervous system.5
Evans and Bishop deprived adult rats o f vitamin B and found
that there was a complete cessation o f the ovarian function .4
When certain species o f animals, man, monkey, and guinea pig
are given a diet lacking in the antiscorbutic substance, or vitamin C,
8Mori, Shinnosuke : “ The changes in the para-ocular glands which follow the admin
istration of diets low in fat-soluble A ; with notes of the effect of the same diets on
the salivary glands and mucosa of the larynx and trachea.” Johns Hopkins Hospital
Bulletin [Baltimore], Vol. XXXIII (October, 1922), pp. 357-362.
„„ , ^
* See the following articles by Herbert M. Evans and Katherine S. Bishop:
Exist
ence of a hitherto unknown dietary factor essential for reproduction,” in the Journal
of the American Medical Association (Chicago), vol. 81, no. 11 (Sept. 5, 1923), pp.
889—893 ; “ The ovulation rhythym in the rat on inadequate nutritional régimes, in the
Journal Of Metabolic Research [Morristown, N. J.], vol. 1 (1922), pp. 334—356; “ The
production of sterility with nutritional régimes adequate for growth and its care with
other foodstuffs,” in the Journal of Metabolic Research, vol. 3 (1923), pp. 233—31o.
5McCarrison, Robert : Studies in Deficiency Disease. Hodder & Stoughton, London,
1921. 270 pp.
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scurvy develops. The rat is apparently immune to scurvy and does
not require this vitamin in its diet. Vitamin C is present in abun
dance in orange juice and lemon juice. Certain vegetable juices, as
those o f tomato, turnip, potato, and cabbage, are fairly good anti
scorbutic substances.
J
The onset o f scurvy in those species which are susceptible to it
\ because
o f their inability to synthesize the vitamin C is sufficiently
rapid to make it difficult to carry out experiments on the effect o f
lack o f the antiscorbutic substance on fertility. As yet no relation
has been shown to exist between vitamin C and the functioning o f
the reproductive organs. Doubtless the occurrence o f scurvy would
cause damage to these structures since the hemorrhages in scurvy
occur in every tissue in the body.
It has been demonstrated that a vitamin is associated with bone
growth. Rickets in the rat has been shown to be the result o f a
faulty combination o f three factors in the diet; namely, calcium,
phosphorus, and vitamin D, or that vitamin which influences the
growth o f bone. This unidentified substance is present in abundance
in cod-liver oil. It is also present in certain fish oils, in butter fat,
and in coconut oil. It has been demonstrated that it is not the same
substance which is associated with xerophthalmia, although its dis
tribution is similar. Coconut oil contains a small amount o f vitamin
D but does not Contain vitamin A.
When the diet o f a young animal contains unfavorable ratios
between calcium and phosphorus and is lacking in a sufficient amount
o f vitamin D the bones do not develop normally. Our experience
leads us to believe that a rat thrives best when the diet contains
about one and one-half times as much calcium by weight as phos
phorus. The optimal content o f calcium for the rat appears to be
not far from 0.65 gram and o f phosphorus 0.41 gram per 100 grams
o f food mixture. It is possible to obtain essentially normal skeletal
development with less o f these elements in the diet provided the
animals are illuminated with sunlight or ultra-violet light, or are
given certain fish-liver oils. For this reason it may not be possible
\
to determine with great accuracy the exact amounts o f calcium and
phosphorus needed in the diet. When the diet is low in phosphorus
and rich in calcium, or poor in calcium and rich in phosphorus,
and is lacking in the vitamin D, the organic structures in the osseous
tissues grow abnormally and do not calcify satisfactorily .7 The
resulting condition is known as rickets. Animals do not develop
the characteristic lesion o f rickets in the absence o f vitamin D if
their diet contains appropriate amounts o f calcium and phosphorus.
A condition o f osteoporosis develops which has no resemblance to
rickets.8 There must be unfavorable ratios between calcium and
phosphorus and a lack o f vitamin D before rickets can develop in
the rat.
l
Evspis and Bishop have presented evidence which is very sug
/
gestive o f the existence o f a new vitamin intimately connected with
7 Shipley, P. G., E. A. Park, E. V. McCollum, and N. Simmonds : “ Is there more
than one kind of rickets?” American Journal of Diseases of Children [Chicago], vol.
23, no. 2 (February, 1922), pp. 91-107.
8 Shipley, P. G., E. A. Park, E. V. McCollum, and N. Simmonds : “A pathological con
dition bearing fundamental resemblances to rickets of the human being resulting from
diets low in phosphorus and fat-soluble A : The phosphate ion in its prevention.” Johns
Hopkins Hospital Bulletin [Baltimore]. Vol. XXXII, no. 363 (May, 1921), pp. 160-171.
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the reproductive function. They state that when female rats are
fed a diet consisting o f purified foodstuffs and the known vitamins
but are deprived o f the dietary factor which is said to be found most
abundantly in wheat-germ oil, lettuce, oats, wheat, and muscle meats,
there result the appearance of normal oestrus and ovulation and the
fertilization and implanting o f the ova; but invariably disease and
resorption o f the products o f conception take place. They find that
when they add any o f the above substances to the diet normal young
are born.
With an understanding of the importance of these unidentified
factors in the diet and with the knowledge o f the differences in the
biological values of the proteins and o f the importance o f the mineral
composition o f the diet, it has been possible to make much progress
in the subject o f nutrition during the past few years.
One o f the problems which has been o f great interest has been
that of the relation o f the diet of the mother to reproduction, vitality
o f the offspring, and milk production. The first experiment to be
systematically planned from these points o f view was conducted
at the Wisconsin Experiment Station during the years 1906 to
1909.9 The object was to determine whether rations for young
heifer calves so made up as to be alike so far as could be determined
by chemical analysis but derived each from a single plant would
prove o f equal nutritive value for growth and thé' maintenance of
vigor.
The ration given to one group o f animals was derived solely from
the wheat plant and consisted of wheat straw, wheat gluten, and
the entire wheat grain. Another group was fed a diet composed of
the entire corn plant, which included the kernel, stalk, and leaf,
together with a portion o f corn gluten. The third group was fed
the entire oat plant ; that is, rolled oats, oat straw, and leaf. A fourth
group, which it was thought would serve as controls, were fed a
ration having the same chemical composition but derived from equal
portions o f wheat, oat, and corn products. The animals were re
stricted absolutely to the experimental diets but were given all the
salt (NaCl) they cared to eat. A ll the groups ate practically the
same amount of food; and digestion experiments showed that there
were no differences in the digestibility o f the four rations. The
reproduction records o f these animals are o f special interest. The
corn-fed heifers invariably carried their young to full term. The
young showed remarkable vigor, were normal in size (73 to 75
pounds each), and were able to stand and nurse within an hour
after birth, as is the rule with vigorous calves. A ll lived and de
veloped in a normal manner. The young o f the wheat-fed mothers
were the reverse in all respects. They were born three to four weeks
too soon and were small, weighing on an average 46 pounds. These
young were either dead when born or died within a few hours after
birth. The young of the mothers which had been fed the oat-plant
ration were nearly as large as those from the corn-fed mothers,
the average being 71 pounds. A ll the cows in this group produced
their young about two weeks too soon. One o f the four calves was
8 Hart, E. B., E. V. McCollum, H. Steenbock, and G. C. Humphrey: Physiological
Effect on Growth and Reproduction of Rations Balanced from Restricted Sources. Wis
consin Agricultural Experiment Station Research Bulletin No. 14. 1911.
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born dead; two were very weak and died within a day or two after
birth; and the fourth was weak, but with care it was kept alive.
Most o f the young o f the cows which were fed the mixture of the three
plant products were weak. The-mothers were kept on the experi
mental rations, and the following year they repeated in all essential
details the reproduction records obtained in the first gestation period.
Records were kept o f the milk production during the first 30 days
o f the first lactation period. The average production per day per
individual o f the corn-fed group was 24.03 pounds; for the wheatfed group, 8.04 pounds; for the oat-fed animals, 19.39 pounds; for
the group fed a mixture o f the three plants, 19.82 pounds.
It was not possible through autopsy and analysis o f the tissues o f
these young and analysis o f the feeds and excreta of the animals o f
the different groups to determine what caused the marked differentia
tion o f the animals on the different experimental rations. It was
not possible by any means known to biological chemistry to discover
the cause o f the pronounced differences in the physiological well
being o f the different lots o f cows. Doctor McCollum has told me
many times about this experiment, and how it convinced him that
the only way in which the problems of nutrition could be solved
was to solve the problem o f the successful feeding o f the simplified
diet. He believed that if this were accomplished it would be possible
to proceed from the simplest to the complex diets employed in prac
tical nutrition. The story o f his researches with Miss Davis in
solving the problem o f feeding the purified diet have been discussed
elsewhere.10
Since many laboratory experiments had demonstrated that young
rats could not synthesize the dietary factors vitamins A and B but
must derive them from their diet before growth could take place the
question arose as to whether the mammary gland could synthesize
these essentials for the nursing young when the diet o f the mother
did not contain them. The extent to which the mammary gland can
serve as a factor of safety for the nursing young is now fairly well
understood. It is well known that the proteins of milk are o f dis
tinctly higher quality for the promotion o f growth than are those
o f the vegetable foods generally. The nursing mother takes her
large supply o f plant proteins of low biological value and puts into
her milk a smaller quantity o f protein o f high biological value.
In order to discover whether the mammary gland can synthesize
vitamins A and B we carried out a series o f experiments with lactating rats the diets o f which were faulty in known respects. The
rats were kept on a diet of natural foodstuffs until the young were
born. The results showed clearly that the milk of the mothers did
not contain either vitamin A or vitamin B unless these were con
tained in the food .11
. .
Since the rat does not need vitamin C for normal development it
was necessary/to use another species of animal to study whether or
not this, factor could be synthesized by the mammary gland, j It has
been demonstrated by several investigations that when a cow is fed a
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ration low in the antiscorbutic factor her milk is a very poor source
o f it. Cows fed on green pasture produce milk rich in vitamin C.
Doctor McCollum and I carried out many experiments designed to
show how far a mother can produce, while subsisting on a diet o f
natural foods deficient in one or more respects, a milk which will
make good the deficiencies o f the diet o f the mother as food for her
nursing young. The results show that her milk under such conditions
is much better constituted than the food from which she formed it,
and that this milk, taken by the young while they are eating o f the
same faulty diet as their mother, makes her deficiencies good in a
surprising manner and enables them to make some growth when
without the milk the rest of the food would not support any growth.
The details o f these experiments are too complex for presentation
here but are described fully elsewhere.12
The accompanying table shows how weights o f young at compar
able ages vary according to the diet o f the mother. Diet 3026 had
the following composition: Wheat, 25; maize, 19.5; polished rice
(cooked), 9.5; rolled oats, 8.5; peas (cooked), 8.5; navy beans
(cooked), 8.5; casein, 10; whole-milk powder, 5; NaCl, 1 ; C aC 03,
1.5; butter fat, 3. The protein content was about 21.7 per cent and
o f high biological value. Diet 2193 contained: Wheat, 60; cooked
dried beef kidney, 4.2; NaCl, 1 ; CaCO 3, 1.5; dextrin, 30.3; and
butter fat, 3. This diet contained 9 per cent o f protein (6 per cent
from wheat and 3 per cent from kidney). The proteins were o f
good quality, but the content was evidently too low to induce
optimal growth in nursing young.
Ration number
Number Age
of young (days)
3 0 2 6 .......................
2193......... ................
3026...... ...................
2193........................
3026..........................
2193........................
4
4
6
6
8
8
18
19
17
17
12
17
Weight Number Age
(grams) of young (days)
120
90
161
130
153
127
4
4
6
6
8
8
27
26
26
31
21
31
Weight Number Age
(grams) of young (days)
205
131
280
230
234
232
Weight
(grams)
4
32
177
8
8
28
42
348
362
It is clear from the weights o f the young in this table that the
diet o f the mother determines the quality o f the milk which she
will produce. She sacrifices from her own tissues to a certain extent
and also calls upon the reserve which she has stored in her tissues,
but this is seldom sufficient to enable her to promote normal growth
in her young. One o f the most striking illustrations o f this point
was brought to light in some work which we did when studying the
value o f cod-liver oil for calcium utilization.13 The diets used were
very low in calcium but about normal in phosphorus. The females
receiving the cod-liver oil and low-calcium diet did not present any
marked abnormal appearance, as is frequently seen on low-calcium
diets; ^but they were nevertheless in a state o f great nutritional
instability. Their weakness was shown in a spectacular manner
12 McCollum, E. J.. and Nina Simmonds : “ The nursing mother as a factor of safety
in the nutrition of the young.” American Journal of Physiology [Baltimore], vol. 46,
HO. 1 (1 9 l o ) , pp. 275—313.
18 McCollum, E. V., N. Simmonds, P. G. Shipley, and E. A. Park : “ Is there a sub
stance other than fat-soluble A, associated with certain fats, which plays an important
rôle in bone development?” Journal of Biological Chemistry [New York], Vol. iT No. 1
(January, 1922), pp. 1-27.
- ~
-
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during the nursing of the young. They showed very characteristic
histones. They were nervous and apprehensive and walked with a
peculiar gait. When at rest they had difficulty in rising to their
feet. The condition did not usually appear when the rats were
nursing their first litters, but as a rule, after the second litter had
been nursed about 15 days the mother would die. The skeletons of
these rats were very fragile; many o f the bones broke into small
pieces as soon as they were touched. It was evident that the mother
had sacrificed much o f her skeleton for the young. The young
remained undersized, since sufficient calcium was not available for
them to make normal growth.
A point in which we have been much interested is that milk is
produced under faulty dietary conditions. Andrews 14 tried to
nourish pups with the milk o f Filipino mothers whose infants had
died of beriberi. A ll o f these developed the paralysis o f the pos
terior extremities which is one o f the characteristics of the disease.
Dr. E. Roxas, o f the Philippine Islands, and Dr. A. do Amaral, o f
Brazil, have stated 16 that mothers suffering from beriberi produce
considerable quantities of milk. A point which I should like to
emphasize is that although a mother may be producing much milk
it is not necessarily good milk. Unless the mother is taking a satis
factory diet her milk will be o f inferior quality. The findings o f
Kaupe on mothers’ milk during the Great War are o f special interest
in this connection.16 He states that although the mothers produced
sufficient milk for the infants to make normal gains they did not do
so. The protein, fat, or carbohydrate content did not seem to be
altered; and Kaupe raised the question as to whether, on account o f
the war, the mothers’ milk was undergoing changes which they did
not know about. It seems very probable that, owing to the food
shortage, the milk was too low in vitamins.
We know from laboratory experiments that when female rats are
on unsatisfactory diets the vitality of the offspring is impaired, just
as the vitality o f the calves was low under similar circumstances.
A striking instance o f the effect o f antenatal conditions upon the
development o f rickets was made by Doctors Dalyell and Mackay
m Vienna in 1920.17 Two infants were observed. The first was
born o f a healthy peasant girl and the second o f one suffering from
osteomalacia. The healthy mother nursed her own baby and also
acted as foster mother to the other baby. Except in the earlier weeks
o f life, when both were nourished by their own mothers, they re
ceived identical food, consisting o f breast milk from the healthy
woman supplemented by one or two bottles o f cow’s milk daily. One
child was born in July and the other in August. By the middle of
December severe rickets was observed in the infant o f poor inher
itance. Cod-liver oil was then given, but in spite of this treatment
the stigmata of rickets persisted until the following March, when the
child was about 9 months old. The healthy mother’s own child
14 Andrews, V. L. : “ Infantile beri-beri.” Philippine Journal of Science, sériés B, 1912,
Vol. VII, p. 67.
15 In personal communication.
10Kaupe, Walther: “ Muttermilch und Krieg.” Monatsschrift für Kinderheilkunde
(orig. 1918-19), lLeipzig and Vienna], Vol. XV, pp. 83-92.
17 Studles of Rickets in Vienna 1919—1922, Medical Research Council, p. 122. Special
Senes iVo. 77. London, 1923. (Also personal communication from Dr. Vladimir
Korenchevsky.)
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remained healthy and developed normally. It appears that the child
born from the mother suffering from osteomalacia was physically
inferior because o f the condition o f the mother.
The investigation of rickets in children which Doctor E lio t 18 and
her coworkers have been carrying on in New Haven shows that nearly
all children whom they have observed have some rickets during early
life : “ Large, rapidly growing breast-fed infants and very fat
infants show definite evidence of rickets. It is an uncommon thing
to find a healthy, vigorous breast-fed infant who does not show
rickets by roentgen-ray examination. Premature babies, who grow
exceedingly rapidly, are notoriously rachitic.” It will be o f great
interest to know what the mothers o f these children were eating
during pregnancy and lactation. Doctor Eliot has not yet pub
lished her records on this phase o f the study. The work of Hess and
U nger 19 in New Y ork is o f interest in this connection. The negro
child is very subject to rickets. The tendency is so marked that
Hess and Unger found more than 90 per cent o f the negro babies to
have rickets; a majority of even those who were breast fed showed
some signs o f the disorder. They made’ a study of the diet o f 75
negro women, ascertaining the dietary for at least two or three days,
being careful not to include Sunday or Monday. In this way they
obtained dietaries of 75 mothers for 179 days.
The data show that the women ate meat or fish on 172 days out of
179, rice 100 times, potatoes 128 times, eggs 52 times, fruit 58 times,
vegetables 53 times, vegetables in stew 32 times, milk as a beverage
47 times, milk with cereal 59 times, with tea and coffee 81 times,
and in cocoa 38 times. The study was made in the fall and winter
months. The vegetables were seldom fresh; they were either canned
or dried. Fresh vegetables were taken only 21 times during the 179
days, and the lack o f fresh vegetables was not compensated for by a
larger supply o f fresh fruit. It is clear from these studies that the
larger part o f the diet Was composed o f meat, potatoes, and rice,
with tea or coffee. This diet would not keep one in good condition,
nor would it supply good milk for the young, and it is not strange
that the children o f these mothers suffered from rickets. It is
surprising that breast feeding was recommended for so long without
the giving o f attention to the diet o f the mother. It was apparently
believed that milk would be o f good quality because it came from the
mammary gland. We know that this is not the case.
Another phase o f nutrition in relation to the health of the mother
is discussed by Maxwell in connection with osteomalacia in China.
(Hess and Unger do not mention the occurrence o f this disease
among the negro women whom they observed.) Maxwell says o f
osteomalacia in China: “ It is a peculiar and widespread disease,
as a rule affecting adults, though cases in children about the age o f
puberty are not very rare. As regards adults it is a disease o f the
female, and o f pregnant women, though occasionally a stray case may
18 Eliot, Martha M .: “ The control of rickets.” Journal of the American Medical
Association [Chicago], vol. 85, no. 9 (Aug. 29, 1925), pp. 656-663.
19 Hess, Alfred F., and Lester J. Unger: “ Prophylactic therapy for rickets in a negro
community.” Journal of the American Medical Association, Vol. LXIX, no. 19 (Nov. 10.
1917), pp. 900—903; “ The diet of the negro mother in New York City, Vol. LXX, no. 13
(Mar. 30, 1918), pp. 1583-1585.
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be found amongst males.” 20 It corresponds in certain respects to
rickets in children, to cage paralysis in animals, and to osteoporosis.
In osteoporosis the bones are very fragile, but this is not the case in
osteomalacia, in which an osteoid tissue lacking calcium salts re
places the normal osseous tissue. The bones become very soft and
flexible, and in extreme cases they can be bent as if they were rubber.
I f a cure results the bones harden with the deposition o f lime salts,
and the deformities which have developed during the softened period
become permanent. There is much osteomalacia in the Shansi
Province and also in Manchuria. It seems to occur more in the
northern part o f China than elsewhere. According to Maxwell the
diet o f the people in the Shansi Province consists largely o f wheat
meal, oatmeal, kaoliang flour, bean flour, and millet, with a little
white cabbage, bean leaves, and gourds. During the winter the diet
is limited in most places in the country to millet gruel, sometimes
supplemented with a little cabbage or salted vegetable. We pointed
out several years ago that millet contains fairly liberal amounts o f
vitamin A. It also contains vitamin B, as do a few o f the other
things which they eat. Thé cabbage would protect them from scurvv
provided it was raw. There is no mention o f the occurrence o f
sclfv y - Their diet is therefore not conducive to the development of
ophthalmia, beriberi, or scurvy. The mineral content and vitamin
D content are very low, and these must be factors contributing to
the occurrence o f osteomalacia.
What is the etiology o f osteomalacia ? McCrudden. a student of
calcium metabolism, says :
Just as the subcutaneous fatty tissue acts as a store of fat and the liver
glycogen as a store of carbohydrate, so the skeleton acts as a store o f calcium
salts to be called on in time of need. During the later months o f pregnancy
and during lactation the need for calcium salts is great, greater than the
intake in the food, and it becomes necessary to draw upon the calcium supply in
the bones. The result is that the new bony tissue laid down to replace old bone
as it disappears is poorer in lime salts than the normal. Ordinarily the quanti
tative change in the composition of the bones is not great enough to produce
symptoms. A t the end of gestation and lactation when the extra need for
calcium has ceased, normal bone is again laid down.21
Maxwell says that this theory o f calcium assimilation covers only
one-half o f the truth. I f it were as simple as this one would need
only to make good the calcium deficiency and the patient would be
cured. He says that in practical treatment the addition o f calcium
is not sufficient, but that when given cod-liver oil, good- food, and
sunlight the majority o f patients recover. The work o f the last few
years on rickets demonstrates that the need of cod-liver oil or light
rays is to aid in the assimilation o f the calcium. Without one o f
these the calcium apparently can not be utilized.
Maxwell and his coworkers find that there are three periods in a
woman’s life at which osteomalacia is prone to appear: Puberty,
when there begins to be a disturbance o f the calcium balance with the
establishment o f the monthly drain o f calcium in the menses; pregnancy, when the demands o f the growing fetus begin to drain cal: “ Osteomalacia in China.” The China Medical Journal
LS^&Hgka1], Vol. XXXVII, no. 8 (August, 1923), pp. 625-642.
McCrudden, Francis H .: Endocrinology and Metabolism [Clinical Diagnosis of Inter
nal Diseases, Vol. IV, edited by H. L. Barker], D. Appleton & Co., New York, 1916.
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cium from the mother; and the period o f lactation, when the
demands o f the newborn child require calcium in the milk supply.
By far the largest quantitative demand for calcium is made during
lactation.
According to Maxwell a typical history is as follows: First preg
nancy, normal; second pregnancy, pain during the last few months,
normal labor; third pregnancy, pain beginning about the third month
in pregnancy, labor difficult, requiring forceps or even craniotomy;
fourth pregnancy, pain as already described but more severe, a dif
ficult craniotomy or a Cesarean section needed, natural birth im
possible. The disease may appear in the first pregnancy and progress
so fast that a Cesarean section may be hecessary at the time o f the
first labor. As a rule the disease clears up after lactation is complete,
but it may recur again and again. In the minority o f cases the dis
ease steadily progresses, making the patients bedridden invalids till
they die o f asthenia or intercurrent infection;
The question may be asked: What is the condition o f the fetus
when the mother suffers from osteomalacia? Maxwell says that
the evidence all shows that the fetus also suffers but to a less degree.
This may be an extreme example o f what can occur when the
dietary conditions and living conditions are both unsatisfactory.
The living conditions o f these people aggravate the condition brought
about by faulty diet. When the disease begins to develop they stay
in the house away from sunlight, and their condition goes from bad
to worse.
A ll experimental data are in agreement that the diet o f the preg
nant and nursing mother is o f the utmost importance for the well
being o f the child. But it is shortsighted to wait until a woman is
pregnant before she takes note o f her diet. As Doctor Mendenhall
has well stated: “ Maternity should be prepared for. Not every
woman or a woman in every year o f her child-bearing period is in
the proper condition to give the right prenatal environment or to
furnish the proper nutriment to a child .” 22
The following statement is taken from the proceedings o f a recent
congress on child welfare held at Geneva, Switzerland: “ With
regard to infants the First General Congress on Child Welfare
considers breast feeding the only proper method o f nourishment
except where medical advice is opposed to this course. No woman
should be employed as a wet nurse unless she has nursed her own
child for five months.” 23 No mention is made o f what the mother
should eat while nursing.
, From what has been said it will be apparent that a faulty diet may
interfere in a marked degree with fertility, with the prenatal
development o f the young, with the secretion o f milk o f satisfactory
quality, and with the development o f the skeletal tissues o f the nursyouRg j and it may cause in the mother nutritional disturbances
which induce profound damage o f one kind or another. Child
bearing by women living on diets deficient in vitamin B may cause
them to have beriberi when otherwise they would escape. Child
bearing by women taking a diet faulty in its content and relationship
o f calcium and phosphorus not infrequently results in so great a
2 Mendenhall, Dorothy R .: “ Preventive feeding for mothers and infants” Journal
0f J ^ me ^fnomics [Baltimore], vol. 16, no-. 10 (October, 1924), pp. 570-578
23Proceedings of First General Congress on Child Welfare, Geneva, Switzerland 1925
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depletion o f the mineral salts of the skeleton as to cause extreme
and permanent injury. The studies o f American dietaries made by
’ ~rierman u ^
24s^ow that the average calcium content is less
than one-half o f the average phosphorus content. Our studies indi
cate that these are unsatisfactory quantitative relationships between
these two elements.
• F ° i m°Le than ? decade doctor McCollum and I have been studym g the effects o f nutrition in its relation to fertility and to the
vitality o f both mother and young. We have gathered a great
amount or information concerning the diets o f people in different
? al
the worJ. 5a ndl t Permits some very interesting deductions.
I shall here mention only that Americans and some Europeans hare
been trying for several decades an experiment in human nutrition
on a nation-wide scale, which involves the consumption o f a dietary
composed largely o f refined cereal products, refined sugar, muscle
meats, and tubers. Such a list o f foods as ordinarily appear in the
any menus in this country is_ incomplete for laboratory animals and
tends to interfere not only with growth but also with fertility, and
it furthermore tends to undermine the vitality o f the mother. In
vestigators have been able to produce experimentally, with the
operation o f no other than faulty nutrition, all the deficiency dis
eases which occur in man. Many o f the difficulties in parturition,
exhaustion due to lactation, resorption of the bones, frequently
seen m women have been observed in female rats.
J
Doctor De G aris2* has emphasized that pain in every other body
function (menstruation, micturation, defecation) is accepted as due
to some fault in the process and inquires why this is not true also
o f labor. Yet pam m labor is so usual that the several definitions o f
this function accept the existence o f pain as a concomitant o f the
normal process. The results o f observations o f laboratory and
domestic animals all support the view that any difficulty in delivery
is generally directly traceable to some fault in the female’s diet. The
insults o f nutrition studies on animals probably justify Doctor De
Garis m saying that at present a safe labor can confidently be prom
ised to the mother if proper care is given in the prenatal period.
It seems highly probable that i f we had all the facts many o f the
difficulties o f labor could be traced to nutritional causes! In some
cases these may be the result of faulty nutrition during infancy or
childhood, resulting m a small pelvis; in others the trouble may
nave arisen from the woman’s having brought herself in adult life
into a condition o f nutritional instability which unfits her for the
strain o f childbearing. We have emphasized many times the serious
ness o f the border-line condition o f malnutrition in which the
evidences are obscure.
, J t r “ ’ildf be,bey°!idi he s,c °Pe. o f thf PaPer to discuss in detail the
„ “ , c o f roods and the planning o f menus which promote health
po^uT aSS
fUlly “
fgSEJS,
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re “
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
DISCUSSION
The C h a i r m a n . I am sure you wish to ask Professor Simmonds
some questions. The neonatal deaths are a big factor, and yet we have
not touched upon this in any conference we have ever had. I have
felt that neonatal death is tied up with nutrition to a very great
extent. I have no figures; I have nothing to prove that; and one
reason I wanted Professor Simmonds to come was because she had
made these experiments with rats. She did not tell you very much
about vitamin E, and 1 do not know that she will feel like expanding
that subject very much now, but if you wish to ask her some ques
tions please do so. W e shall have about 20 minutes’ discussion.
Doctor G a r d in e r . It occurred to me when Professor Simmonds was
talking that we might begin with several States and make some
sort o f study o f breast feeding.
O f course we do recommend
breast feeding. W e have got to go on recommending it, and I think
everyone who has recommended it has realized that there was some
thing in the quality o f the milk. Yet after all you put one foot
forward at a time, and I think that is perhaps the stage at which
we are now in regard to breast feeding. But I do think that perhaps
it would be perfectly possible to select 100 or 500 or 1,000 cases of
lactating mothers and study the food they are taking just as they
take it. Take an average community, perhaps, having a sprinkling
o f the foreign element, and so on; have another State do likewise,
and have someone line up a schedule for the study. I should be very
glad to make such a study.
I think one of the griefs of our work is that so much detail and
administrative work lies at hand that we have not time to think oyer
things and meditate on them as we would like to, and make studies
when we have such an abundance o f raw material at our disposal.
Doctor B r y d o n . I should like to ask Doctor Simmonds about
canned-tomato juice. That is universally used everywhere, and in the
country districts we can not get oranges. Is there any particular
brand o f tomatoes that you advise, or is there any particular pro
cedure in preparing canned tomatoes that could be issued? I also
wish to ask whether prune juice or pineapple juice would be good
substitutes;
_
.
.
Professor S i m m o n d s . The question o f tomato ]uice as a substitute
for orange juice is very important. Doctor Kohman, o f the National
Canners Association, is perfecting a new type o l canning procedure.
Whether that is going to make every can o f tomatoes contain its
original content o f vitamin C I do not know. It is said that toma
toes ripened artificially, such as those picked green and sold in the
wintertime, contain less vitamin C than those picked ripe from the
vines in summer. I do not know of any criticism o f the tomato juice
which has been used in this country. Possibly the tomatoes canned
in England may have been overprocessed. W e know that vitamin
C is destroyed by oxidation. I f the tomatoes are canned quickly
and not boiled very much, and not stirred when they are boiled,
more vitamin C would be retained. I have not heard o f a child’s
developing scurvy in this country when given a liberal amount o f
tomato juice. A child receiving plenty of orange juice will not
develop scurvy. The vitamin C content o f California oranges differs
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f r°m that o f Florida oranges. Oranges differ at different seasons
ox the year in vitamin C content. The same is without doubt true
or tomatoes.
I think home-canned tomatoes, or any good commercial brand
ot tomatoes, will probably serve as a source o f vitamin C i f not
given in very small amounts.
Doctor B rydon . Would it make any difference whether they were
canned in tm or jars? Would glass jars be different?
S i m m o n d s . Canning in tin or glass jars does not make
any difference unless copper comes in contact with the product,
xiaw-turmp juice, raw-potato juice, and raw-cabbage juice are all
good antiscurvy remedies. The Indians knew the symptoms o f
scurvy and knew how to prevent this disease. They did it by giv
ing an infusion o f spruce needles. Eskimos eat raw glandular organs as well as other meat. Raw liver is a good source o f vitamin C.
I he C h a ir m a n . We have been looking up these vitamins for a
woman who has asked us, and we are getting information—-for the
Arctic Circle, I should say.
A D irector. What about the relative value o f pineapple juice?
• j 0 lessor o i m m o n d s . Canned-pineapple juice would be a very
contain^t;6 S° UrCe
y^ am^n C. Raw pineapple would probably
A A ^ ™ ^
should we state to the mothers as to the value
or the different berries ?
Professor S im m o n d s . They are not potent sources o f vitamin C.
Doctor Hojer found the whortleberry to contain a small amount o f
this vitamin. I think canned-tomato juice will be the best source
ot any o f the canned juices.
A D irector. Is that true o f blueberry ?
blueberrie°r SlMM0NDS‘
1
do not know °* any experimental data on
potatoes1? ^ LLEN* 1 Wlsh to ask
P r°fessor Simmonds said raw
Professor S im m o n d s . Raw turnip is really better than raw potato
years^ ^ g'1V6S m° re *|mce' Raw Potatoes have been used for many
b e ^ i ? e n ? CT0R* T ° h° W y ° Ung a cl^ d m ay raw turniP and potato
Professor S im m o n d s . Very few cases o f scurvy in babies under
o f age have been reported. We do not know whether
or not this is due to a protective substance which the child carries
over from prenatal life. Raw-turnip juice or raw-potato juice
probably could be given. Orange juice is frequently given to in
fants 4 weeks o f age. One can not make statements which would
apply to all bafoios,
Doctor KoEMo. How would it do for the mothers in the country
districts in Arkansas who are too poor to buy canned tomatoes to
eat a raw potato, carrot, or turnip every day during the first few
months when they are nursing the babies? Would that put into
the mothers milk what the baby ought to have?
Professor S im m o n d s . I do not know enough about it to make a
statement on that. I should think that the raw vegetables would in
crease the vitamin-C content o f the mother’s milk.
8 months
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Doctor K oenig . Even babies only one year old like to chew on a
raw onion.
Professor S im m o n d s . I should not think that children ought to be
given raw onion. I should ask a physician about this. Raw onions
are a good source o f vitamin C.
Doctor G ardiner . I should like to ask about those cows that were
fed on corn. Was that whole corn?
Professor S im m o n d s . It was the whole corn plant, i. e., the leaves,
stalk, and corn kernel. W e know that the leaf has a marked die
tary property as compared with the seed. That is why we include
leafy vegetables as one of the protective foods. Leafy vegetables
such as spinach, lettuce, cabbage, beet tops, and the like are protec
tive foods, and we wish to encourage mothers to eat them.
Doctor B rydon . Couldn’t you cook turnips, onions, and potatoes
and not hurt the vitamins ?
Professor S im m o n s . I f you cooked them a short time the vitamin
C would not all be destroyed; vitamins A and B would not be injured
much.
Doctor B rydon . About how long ?
Professor S im m o n d s . One can not make a definite answer to this
question, since it is not heat but oxidation which destroys vitamin
C, and the amount of oxidation taking place would depend upon
the method o f cooking. Something raw should be included in the
diet each day.
Doctor B rydon . Then mealy potatoes do not have much vitamin
content ?
Professor S im m o n d s . Cooked potatoes would not be so potent in
the vitamin C as raw ones. I do not know o f any experiments on
baked potatoes.
The C h a ir m a n . A major part o f the program o f Indiana is the
work that Doctor Schweitzer is doing in mothers’ classes. She has
found that in this State the problem o f informing the mother con
cerning prenatal care and the hygiene o f infancy works out very well
through the instruction given in the mothers’ classes. Doctor
Schweitzer will tell us about that now.
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B y A da E . S c hw eitzer , M . D ., D irector, D ivisio n of I n f a n t an d
C h ild H yg ien e , S tate B oard of H e a l t h , I n d ia n a
rimp16 w atT ient made
tbe ciiairman is correct for the present
^
W
however, with child-health conferences.
We have held them in every county in Indiana, working through
each county by townships, so that m every county we have had from
i h 4 co^ ere?lces- This nearly always preceded the work done
m the mothers classes. In the child-health conferences we not
examine children but also consider, as far as we are able, the
n o^„T T t,Pr° bleT w,lth reference to diet and behavior, such as
I f l l '
il Sp° ke about, tllls morning. Our service to the mothers
l
has concerned not only the physical condition o f each
S S , ™
examined but also its growth and development and
t o c b e h l ° reactions. We had many cases in the conferences where
the behavior reaction seemed to be the chief thing worrying the
mother. One instance may be given:
-> s
r
° f agu T aS Presented with » baby brother.
affect the chiui 4 ? ? th6 neW !-aby ™ s not a normal child did not
aflect the child s behavior reaction. But the baby took a great deal
o f the mother’s attention, and the little girl, who had been quite no?mal in every respect up to that time, developed an unwillingness to
eat. ohe was jealous o f the new baby, and she found that by not
eating she could get her mother’s attention, m e n the child w S
brought for examination, her mother said, “ I have been devoting
four hours every morning to getting this child to take her cereal,
^ is given.afrald
1
am neglecting the baby-”
The ad™ e indicated
with 6them f,0lmid that after, child-health conferences, or coincident
with them perhaps not wholly as a result o f them—the infant
mortahty rate was going down. The maternal mortality rate which
HHe^fe” g? m?n c?w.n very slowl3b or not at all, Showed a percepall 1the TTtoLl Tb/ S, ImP.rove“ ent, which p reva il throughout almost
Ch;m h • 4 d St,ates’ 1S Partly due t0 the intensive activities o f
dren’i ^ ene w‘f kers> and P,ar% to ‘ he interest created by Chil’ and Partl7 i ° tbe results o f the draft examinations,
m o i-^
° Ui , 1arli infant mortality rate did not go down very
markedly, as will be shown by our charts, and because our mortality
elt f W * w Under 1
month,o f aSe had not g°ne down perceptibly^
we felt that we were not doing as much as we should when we
and gave “ Others advice concerning them,
aitb” gb ,e d!d dlscover a great many defects or a great many cases
h!tP
n0n’was
whl?h
we aseribed to the condition o f the meaner
mother
before i!?Utn
the baby
born.
Whenever we found that a child had markedly defective teeth
we inquired especially into his early history—as to any previous
diseases, as to his nutrition, and as to the nutrition o f toe mother
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
before that child was born. Often the condition o f the child could
be traced to the condition o f the mother before the birth o f the baby.
This interested a great many mothers in prenatal care, so that when
we were ready to start our mothers’ classes we were met in almost
every place with interest in the type o f instruction given. I shall
review briefly the outline o f the work as it is given. You will be.
able to see very clearly from the outlines just about what is pre
sented. The plan of work is adapted to each community.
At first we had special organizers. We found later that it was
better to let the persons who are going to do the work do the or
ganizing—that is, the physician and the nurse. W e started with
one physician and one nurse in a county working out various plans
nnt.il finally we reached the one plan which we are now working,
and the physician and the nurse in adjoining counties organized
alternating schedules.
.
*
,
The nurse does most o f the organizing. The physician is'expected
to make the contact with the medical profession as early as possible,
and to have time enough during the period when the classes are in
progress to make additional contacts.
Before the organizing begins the division sends a letter to every
physician in the county, and to a few other prominent people, an
nouncing organization o f the county for mothers classes, and asking
the physicians about their own methods o f procedure in maternity
cases, also requesting suggestions as to the type o f information
needed by the mothers in their county. W e believe the physicians
who are in the field know better than we what type o f information
should be given. W e have received a great many valuable sugges
tions. A copy o f the State bulletin which has in it a summary o f
the replies that we have received will be left on the table.
The nurse interviews local officials and gets committees organized.
W e do not work with any one organization, but with all organiza
tions that are interested. After the committees are organized in the
county seat they are organized also in the larger and smaller towns
throughout the county. As many groups as seem to be interested,
up to about 14, are organized for classes in each county. The
physician gives the first week’s lectures while the nurse is organiz
ing or finishing organization in the adjoining county. The lectures
deal with the usual subjects in regard to pregnancy and to the need
for prenatal care, and include the growth and development o f the
embryo, usually from the standpoint of nutrition and o f the possi
bilities o f normal labor.
While the physician starts the series in the second county the
nurse goes into the first one with a very practical demonstration of
the care o f the expectant mother, using the prenatal charts pub
lished by the National Child Welfare Association. She shows the
mother how to prepare for a confinement case in the home; she
has a maternity room set-up that we have here to illustrate what
she is telling. She actually makes the various dressings in the pres
ence o f the mother, showing how they should be prepared and steri
lized. The use o f a clinical thermometer, blood-pressure apparatus,
and other procedures are demonstrated before these mothers, so
there will be no fear in their minds when the physician asks to do
these things. The importance o f the physical examination o f the
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mother is also emphasized, and the physician explains-, with anatomical charts, the character o f the physical examination, including
the pelvic measurements.
,, Y5e_physician’s second lecture has to do with the actual birth o f
the baby and the care o f the newborn child and o f the mother. The
third lecture, m the fifth week o f the course, discusses the preven
tion o f infectious diseases, especially those o f childhood. A t this
time are shown motion pictures which review the entire course.
1*1
^
Well Born, and two films on embryology, one
called L ife’s Beginning, and the other The G ift o f Life. The
film selected depends upon the type o f audience expected. I f we
are to have a mixed audience, we use L ife’s Beginning, which
does not contain so much maternal anatomy. I f we have just the
mothers who are in the class, with perhaps the husbands, we use
either one. In order to emphasize the necessity o f proper nutrition
and proper care o f the teeth we use the film Tommy Tucker’s
looth which you saw yesterday. We use other films also. We
find the one called Better Babies very helpful. It depicts the
growth and development o f the child o f preschool age, his behavior,
reactions, and mental development and training.
The nurse s second demonstration is the establishment o f ma
ternal nursing and the care o f the young infant, and the development o f the child of preschool age, the child-welfare charts being
used to assist in the demonstration. We find that even when we are
busy setting up the motion-picture machines or doing various things
these charts are being read; and they are read at intervals between
the lectures, impressing visually the oral lessons taught.
much has been said about interesting the medical profession in
the work that I put statistical charts up. I find that a talk based on
this group o f charts is interesting to the physicians, showing why
the work is needed. W e usually explain that whereas work has been
done tor the protection o f mothers and babies for some years and
whereas we have been able to reduce certain types o f mortality and
certain types o f morbidity a great field still remains almost un
touched. We can show what that field is by the relative causes o f
death as seen on these charts.
You can see in the older chart, which was finished about 1919, and
newer one? finished about 19239 just about how much progress
we have made with relative causes o f death. One chart shows the
causes o f mothers deaths; another shows the causes o f death in very
early infancy.
J
Another chart shows that our reduction in infant mortality has
been mostly along the line o f intestinal infections, largely by a con
sideration o f diet and o f the care o f the child. We have still other
problems that we have not solved, and we are trying to meet some
o f those by this mothers’ class work.
We have also charts on mental hygiene and physical health.
/ - f j ? jflci an.s an(*
nurses5too, are prepared to present in de
tail the facts demonstrated on these charts. We have in our library
the latest pamphlets and books on these subjects, such as Doctor
Lucass book on the Runabout Child; Doctor Gesell’s book, Doctor
White s, and others on maternal care and infant feeding for the use
o f our physicians and nurses. They supplement them with the
reading o f these pamphlets and present the pamphlets to the mothers.
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I have here for your inspection a complete package o f the pam
phlets which are used in our mothers’ classes and which are also sent
out on request. As has been mentioned, they have been asked for
by persons who teach science, home economics, and ■physical educa
tion in colleges. The home-economics people especially want pam
phlets on diet. We were very fortunate several years ago in hay
ing Doctor McCollum, o f Johns Hopkins University, lecture ill
Indianapolis. The young woman who took notes on his lecture
wrote it up, and with a few changes her report was printed as “ The
Elusive Vitamin.” W e have an illustrative vitamin chart to go with
it that was printed in the book and reproduced in a suitable form
available for teachers who wish to place it on the wall. #
_ .
More recently Doctor McCollum came again for our national dairy
show and supervised the placing o f all o f the exhibits which had to
do with nutrition. This was a great educational demonstration in
Indiana. The practical application o f earlier instruction given to
mothers leads us to hope that these lessons concerning prenatal care,
and the talks concerning the care during pregnancy, must o f neces
sity bear fruit later on.
Recently we sent questionnaires to heads o f committees and to
mothers, asking reports on benefits to children who were examined
in child-health conferences and definite questions about personal
and community results. A short summary o f replies will be avail
able soon.
.
W e took from our correspondence at random, as a part or our
present campaign for acquainting people more fully with the work,
notes from physicians, nurses, school authorities, parents, and people
in general concerning the work o f the division. These reports have
been classified by kinds o f persons writing, by counties, and by
congressional districts. The maps on display we have prepared
for presentation to persons interested in the organization and m
what is being done with Sheppard-Towner money. This gives every
one a definite picture o f the parts of the State we have worked and
the types o f work done in each district.
Our statistician compiles the information contained on the exami
nation charts and assembles statistical data concerning the condition
o f children in all counties/ The prevalence o f whooping cough and
the presence o f infectious diseases by ages are shown. This chart
showing that the teeth begin to develop in the seventeenth week o f
embryo life emphasizes the importance o f prenatal nutrition. When
mothers realize that what they eat is responsible in a large measure
for the kind o f teeth that children have they begin to understand
that it is important to give attention to these things before the baby
is born. Doctor Brady, o f Kansas City, has a complete set o f these
pictures, showing the development o f the teeth from the seven
teenth week o f embryo life to the fifteenth year. This shows the
normal development o f the teeth so that comparisons can be made at
any stage o f the child’s development to ascertain whether his teeth
are developing normally or not.
One chart shows a little survey that we made concerning the ex
tent o f prenatal care which this group o f mothers received two or
three years ago. Now 5many o f our mothers are asking for early
prenatal care 5in fact, we have reports from a large percentage o f
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our classes, that women who are expectant mothers go immediately
to their physicians after they have heard the first lecture and as£
for prenatal care.
Our activities maps have been worked out by congressional districts. A member of our League o f Women Voters suggested that,
fehe said: Congressmen and others want to know what is being
done with Sheppard-Towner money and also want to know what is
being done m any particular section o f the State.” Our map shows
that we have worked with our mothers’ classes since February 1924
coF*?^ies5leaving 33 counties for the next year.
I he child health conference map shows the number o f babies ex
amined m each county o f the State. This map and the key have
been made in colors, showing the number o f children who were
examined under State funds before we had Sheppard-Towner money
an(ii.Sh10^ ing ,how. greatly we were able to extend the work after
we had those funds.
Another chart shows other types o f work that have been done,
lectures, exhibits, and demonstrations. In large exhibits all types
projects are COrrelated as a model demonstration o f community
The most complete demonstrations are the State fair exhibit and
our exhibit or program at Winona Lake Chautauqua for a week
each year m July. On each program we have child examination,
mothers class demonstration, motion pictures, and exhibits. The
people attending are responsive to this work.
A t the State fair we have four demonstrations under supervision__
a baby contest through which we have opportunity to teach health
standards by a series o f newspaper articles and to give a public
demonstration o f the results o f good care. The paper would not be
willing to print many long preliminary articles on child care if
it were not interested in our baby contests. The State board o f
agriculture provides at the State fair a room 40 by 90 feet in size for
a y contests and has fitted it up exactly as we requested. They
also have a better babies building,” where noncontest babies are
exammed and a day nursery is conducted. This is the only “ better
babies building m the United States built by the State board o f
agriculture m the interest o f the babies. A playground has been
provided and equipped by the State board o f agriculture, the Indian
apolis Lark Board, and a commercial firm interested in displaying
playground apparatus. An addition to our baby building' is
promised which will care for all o f our child-health activities at the
State fair.
There are many other very valuable ways o f presenting standards
o f maternal and infant care. We believe that although the major
activity is teaching in rural communities, “ it pays to advertise ”
through state-wide groups when suitable opportunities are offered.
DISCUSSION
Doctor B l a c h l y . I s it Doctor Schweitzer’s plan to continue doing
this work herself until she covers the entire State, or is she trying to
i(rave;
the minds o f the people the impression that they themselves
should take up this type o f work and finance it themselves as soon
as possible ?
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PROCEEDINGS, MATERNITY AND IN FAN CY CONFERENCE
f\
Mrs. D i l l o n . Do they go with this itinerant teaching service into
counties where work has already been started or only into counties
where there are no other workers to do it ?
Miss O s b o r n e . D o the counties pay for their own equipment ?
Doctor S m i t h . I should like to ask Doctor Schweitzer whether
she worked up any prenatal clinics to wind up the mothers’ classes.
Doctor S c h w e i t z e r . I think there are public-health nurses in
|
more than one-third o f the counties in the State. There are health
officers in every county. Some public-health work is being done
through the county and township health officers in every county.
j
So I can answer that question by saying yes, we do go into the
counties where work is already established; but I imagine you mean
to ask whether work in maternal and infant hygiene in these counties
was already established. In a few counties it was—in the larger
towns; but as a rule there is none in the small towns, and we do go
into any county, regardless o f whether this work has already been
established or not. However, in the larger towns where the work
is well established and under way, we ask the persons who are doing
this work whether they wish any additional work to be done. In
some towns they do and in some they do not. For example, Elkhart,
which started the child health center work with our help and with
our initial examination o f children, has progressed to the point
where it has four permanent child-health centers. Yet they feel that
they always want more work from the clinics whenever they can get
it— anything in the way o f stimulating greater interest o f people
in the work. South Bend, however, does not care for it. A very
good baby clinic is functioning there, splendidly conducted by the
best physicians in the city; and they have a fine visiting nurses’ association, consequently they do not care very much for work from the
J
State. But we do work out in that county because they have no
county organization except county nurses doing the work,, and
usually the nurses are very glad to have any assistance to enable
them to reach additional families or to bring the work before the
people from a different point of view so as to create greater interest.
The counties do not pay. W e carry our own equipment. The
only thing they furnish is the room, and occasionally we have been
asked for rental for the room. I have added to our organization
sheet, “ We do not pay any rent.”
W e have no prenatal clinics in Indiana because the State board
o f health does not approve of the making of examinations by the
State workers. I f any examinations are made at all they must be
made by local physicians. However, as I said this morning, we do
illustrate how some o f the things are done, so the women feel no
hesitancy in following the physician’s suggestions along these lines.
{
At the close of our mothers’ classes we have quite frequently a
follow-up child-health conference. Women throughout the county
1
are invited to bring their babies to the county seat for examination
if they care to, and through the instrumentality of these classes in the j
county from 60 to 80 babies are brought in.
Doctor B l a o h l t . D o you intend to continue the work yourself ?
Doctor S c h w e i t z e r . We have three physicians and three nurses '»
doing this work, and*We hope to be able to continue until we have
covered the entire State with mothers’ classes. Our idea now is to
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keep each physician in a certain part o f the State. While she is
conducting her mothers’ classes during these five weeks she is also
organizing child-health centers.
. There are certain times in the year when we can not work in the
river counties because o f the difficult going, but we plan to go back into
unfj i erritories w^ere we worked last summer and continue our
child health center work, supervising these centers, obtaining as
much assistance as we can from local physicians, and trying to en
courage the local people to take over the centers, with periodic super
vision from the State department. I think that is going to be the
crux o f the whole situation, namely, getting these taken over by the
i. P®®ple and carried on with just occasional supervision from
the health department; but we expect to give monthly or bimonthly
supervision for a time at least. We believe that a good many people
will welcome these clinics. We have tried this and kept them up
tor some time, but for various reasons most o f them have been disT o fw w rti
towns like Elkhart and places with a population
ot oOjOOO to 50,000 people, which have facilities for carrying on this
work. A t first that work in Elkhart was supported entirely by
volunteer contributions, but it is a permanent part o f the city’s public-weliare work now, maintained by community funds.
Doctor S tadtmtjller. Have you an outline o f work, or do vour
physicians all follow a set form o f lectures ?
Doctor S qhw eitzer . Yes. I shall be glad to let you have an
outline.
17
Doctor S tadtmuller . I should be very glad to have it.
Doctor S c hw eitzer . A ll our physicians have general outlines that
they tollow, but each one works out the individual lecture to suit
herself. We have here a complete set o f things that we distribute,
including the Children s Bureau publications. There is an outline
o± our fanance plan and our general plan o f work, then on the next
page a tabulated statement o f the money that we have spent, the
helpers that we have had in our division, and a few o f its accom
plishments. 1 hese have been distributed to workers throughout the
fetate, to medical people, and whoever is interested in SheppardTowner work. They have been distributed to persons in our State
UFj?an ^^.° comriiittees who had charge o f the appropriation.
We have round it very helpful to have a concise statement o f what
we have accomplished. I have a number o f these if you care to
look them over. There is just a little publicity attached that we use,
and the basis for publicity is mothers’ class work.
The C h a ir m a n . Our next speaker is Mrs. Gertrude S. Hasbrouck,
o f Wisconsin, who organized the infant-hygiene courses in that State.
She is particularly interested in having the instruction in infant
care and prenatal care given through the schools. The Wisconsin
.board or Education has taken over, almost as a mandatory pro
ceeding the instruction o f little mothers’ classes. The work has
gone also into the normal schools, the teachers and the normalschool students receiving this instruction through Mrs. Hasbrouck’s
organization.
•
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LITTLE MOTHERS’ CLASSES
M rs. G ertrude S. H asbrouck , O rganizer of I n f a n t -H yg ien e
C ourses i n t h e P ublic S chools of W isconsin
I have been asked this morning to tell you o f a phase o f maternity
and infancy work which Wisconsin is finding most satisfactory,
not only because the State anticipates immediate returns for values
expended but also because it is strong in the belief that a splendid
foundation is being laid for any phase of maternity and infancy
work which it may wish to develop in the future.
I was much interested at the morning session on Monday to note
the general agreement o f the speakers that to develop a more
widely appreciated and used prenatal service it- will be necessary
to promote in the public a more receptive attitude o f mind, and that
this can be accomplished only by the “ education o f the laity.” Edu
cation is generally conceded to be a slow process, not something
that can be acquired at one sitting or one hearing; and I waited
anxiously for a suggestion as to the most favorable psychological
and chronological time to begin this education o f the laity.
But it would seem that the privilege o f offering the suggestion is
to be accorded Wisconsin or, because o f the strength of its conviction
that it has the solution o f the problem, it will, with your permission,
assume the privilege. This solution is epitomized in its slogan,
“ Every Wisconsin girl educated for intelligent motherhood.”
Before presenting the outstanding phases o f our work, may I ex
plain that at no time am I referring to the familiar “ little mothers’
classes ” ? W e are not advocating “ little mothers’ classes” in W is
consin because we are convinced that we have a better and more
inclusive project for popularizing this phase o f education. This
project fundamentally aims to reduce infant mortality and morbid
ity, to lessen the number o f physically defective and deficient chil
dren, to develop in the mothers of the future a keen appreciation of
the importance of health in babyhood, and to induce a receptive
attitude o f mind toward any and all opportunities that make for
better health.
I f this education is desirable for a few, it is desirable for all. It
takes no more time nor money to reach a hundred than to reach a
handful. Our first work, therefore, was to find the way to make
our teaching universal, to reach every potential mother in the State.
This could only be done through cooperation with the State depart
ments o f education. W ith this cooperation assured, the first step
o f our project was accomplished. A course in infant hygiene as
an integral part o f the State educational system was indorsed and
forcefully recommended by the State department o f public instruc
tion and the State board o f vocational education, and was recom
mended as a definite part o f all normal-school training by the State
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board o f normal regents. The bureau o f child welfare prepared
the course o f study, provided a full-time organizer and instructor,
and m cooperation with the three boards mapped out the pioneer
The first consideration was to decide where in the school system
this study should be placed. It was a foregone conclusion that it
must b e ,sufficiently early to guard against loss by the premature
termination o f school life, as girls who leave school early usually
marry young and have larger families and the loss o f this instruc
tion would, to them, be irremediable.
Psychological factors also enter into the placement o f this course
m tne lower grades. The egoism o f adolescence is ever prone to
apply personal measurement to each new fact and theory, with the
result that a reactionary or indifferent attitude toward this study is
sometimes met in the older adolescent girl, whereas to the younger
girl it is quite the most delightful phase o f education she has yet
encountered in her school life. This enthusiastic enjoyment will be
the strongest factor to fix the instruction in her mind against a
ne<?d' ^ or tliese r?asons ^ was agreed that the course
t
in. the prehigh-school grades, anywhere above the
kttn. It may be given as a part o f the home-economics, physicaleducation, or physiology and hygiene course as it can best be adapted
m each school system, <with the exception of the rural schools,
where its place is definitely determined by the State department.
. th e second consideration was the preparation o f a course o f study,
with a thought to the future when it should be authorized and
standardized and *made an integral part o f the public-school cur
riculum. This need was met by a textbook which covers the fun
damental, basic principles o f the care o f the average normal baby
ihe first year o f life. It is, in fact, so simple that no teacher
should hnd it too difficult to present. It is concise, direct, compre
hensive, and arranged in logical sequence; it is sufficiently adaptable
to meet the exigencies attendant upon the adjustment o f a new study
into the curriculum.
The minimum time required for the course is 10 hours. This is
a very short time for the work we wish to accomplish, but if we
demanded more than that we should work hardship in the rural
schools. However, as we anticipated, appreciation o f the work has
extended the time given to it, and the majority o f the schools are
giving much longer courses.
A little handbook o f helps and suggestions was also prepared for
the use ot the teachers. ^ Tim textbook is not divided into lessons
because o i the great variance in the time given to the course in the
different schools. But in the handbook outlines o f lessons are pre
pared so that the teacher is provided with a guide to help her in
apportioning the time allotted the course in ratio to the importance
o± the subjects. Among other helps in the book is a model lesson
with problems, test questions and answers for examinations, sug
gestions for related work, and a list o f equipment for demonstration
purposes. These books are provided for the schools, free o f cost:
t e manual m numbers sufficient for class use, the handbook for
teachers. To each school, as it takes up the work, are sent patterns
o. the recommended open-front layette, blanks to use for securing the
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PROCEEDINGS, MATERNITY AND IN EAN CY CONFERENCE
certificates, letters of special instruction, and other helps as the
school or the teacher may seem to require them. The books go to
the schools stamped “ School property ” Personal, unstamped copies
may be purchased for 5 cents each.
m
'
The State board o f health also gives a formal certificate embel
lished with a large gilt seal. The use o f the certificates is in no way
obligatory, but if they are used the girls must qualify. Each must
have seen the baby bathed, must have seen a bottle formula put up,
and must have made a passing grade in a written or oral test. W e
send definite instructions with our blanks, which the teachers fill out
and return with the list of pupils who have qualified. The cer
tificates are then prepared and sent from our office.
In the past it has been customary to have this teaching done by
nurses. While it is apparent that the underlying principles govern
ing what is taught must be authorized by the medical profession,
the actual presentation o f the subject is best done by those trained m
the methods o f teaching. In no sense is the subject matter so pro
fessional as to bar the teacher from its presentation. Our aim is
to educate all women in mothercraft; this includes teachers. What
the sixth-grade girl can comprehend surely the mature and quali
fied teacher can present. However, i f a public-health or school nurse
is available, the teacher is at liberty to call upon her for the demon
strations; but it is the teacher’s responsibility that the text o f the
book advocated by the State department o f public instruction is
adhered to. Uniform and authorized methods of procedure are
thus insured«
We advocate that every part o f every lesson be demonstrated so
far as possible. Equipment is therefore a necessary adjunct in the
work. The articles on this table [indicating] compose the standard
equipment which we recommend for use in the schools. As you
see, it includes a doll, preferably the Chase hospital doll o f the size
o f a 2-months-old baby; an open-front layette; all articles used for
giving a bath and for preparing a bottle feeding; a basket bed and
its accessories. I should like to have a whole hour to talk about
this equipment, to show you just what we have and why it was
selected. There is not an article that has not been tested with the
words: Sanitation, hygiene, utility, and economy. W e have given
thought to the selection o f each article, and we feel that, up to the
present time, we have the best possible choice. To-morrow we may
see something that we think is very much better than anything we
have here. I f so, we shall change, but to-day this is the standard
equipment for our schools. It may be necessary for some o f the
schools to substitute and to borrow for a time, but we expect that
ultimately every school with grades eligible for this work will own
a set o f this standard equipment as a part o f its school property.
The problem o f securing equipments has not been a difficult one.
Very generally there are school funds available. When this is not
the case, the parent-teacher association or some o f the women s
organizations give a helping hand, and sometimes the girls earn
the money. I find, too, that the men’s organizations are most
enthusiastic about this work and generous with their help. You
know, these men o f ours have sung and written a great deal about
“ The hand that rocks the cradle” being “ the hand that rules the
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w orld ” [laughter]. It is strange, is it not, that they should be so
late ,in realizing that to do this rocking safely, education and
instruction are needed ?
I have been asked especially to speak o f our method o f approach
to these results. The first thing we did was to learn how much o f
this type o f instruction was already being given in the schools.
Naturally we could only expect to find it where home economics or
domestic science was taught. A questionnaire was prepared cover
ing such points as: W ho gave the instruction, nurse or teacher?
How much time was given ? What books were used ? What equip
ment ? How was equipment secured ? Permission was obtained to
send the questionnaires and the accompanying letters to the homeeconomics teachers o f the State in the name o f the superintendent o f
public instruction. They were promptly returned, and the teachers
were divided into three classes: Those doing the work, those who
would at least make a beginning that year, and those who could not
do anything before another year. This questionnaire proved that
while much instruction was being given it was lacking in complete
ness, that it was without standards or accepted authority as to meth
ods and text, and that most o f the work was being done in the high
schools— an irreparable loss to the girls who left school prematurely.
A fter a careful study had been made o f the school system and
the State courses o f study to learn where the course in infant hygiene
could best be incorporated into the curriculum, the project was pre
pared. It dealt with each class o f schools in the system and sug
gested where the course could be introduced, by whom it could be
taught, and how the books and necessary equipment could be pro
vided. The project was submitted to the department o f public in
struction, the State board o f vocational education, and the State
board o f normal regents, and with a few minor changes received
their sanction. The State department o f public instruction referred
the project to a senior supervisor, and together we worked out the*
details.
The rural schools were our greatest difficulty. In order to meet
the problem, we revised the eighth and ninth months o f physiology
and hygiene for the eighth grade and prepared definite instructions
for the presentation o f the course. The details are carefully worked
out so that the teachers will know just how much they must cover
in those two months, how they are to do it, how they are to secure
the extra time for demonstrations, and what disposition may be made
o f the boys when the teacher does not wish to include them. Copies
o f this revision are given to the rural teachers in training, and,
upon personal request or the request o f the county superintendent,
to the rural teachers in service.
The next step was to get to the teachers the information that this
course was to be installed. Letters were sent from the various State
departments and boards to their particular schools announcing the
new course, strongly recommending its immediate adoption, in
troducing the State organizer, and giving her general authority to
inaugurate the course. These letters were sent to the city and county
superintendents o f schools, to high-school principals, to grade
principals, to institutions training teachers, and to summer schools
and institutes.
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
The field was then ready for the State organizer. That honor is
mine. My time is divided about equally between teachers in serv
ice and teachers in training.
In the State normal schools, o f which there are 11, the work is
given usually in the home-economics course, but it may be given in
the physical-education or the physiology and hygiene course; it is
given also in the rural departments. There are 31 county rural
normal schools and 27 high schools with teacher-training depart
ments. When working in these schools I usually give an entire day
and include the boys for part o f the work.
No attempt is made to visit these schools each year. A fter my
visit the teachers are expected to finish the course, and to repeat the
entire course each year thereafter. I f, however, the teacher feels
inadequate for the task or there is a change o f personnel, effort is
made to repeat the instruction until they are able to handle the
course for themselves. As a result o f questions from the girls or
definite requests from the teachers it is often possible to give much
prenatal instruction.
While the primary purpose of my service is to train and assist
grade teachers I also work in the high schools. The work o f in
stalling the course in the city schools is often done at the request
o f the city superintendent. Next year will see the course in infant
hygiene taught in the school system o f every city in the State.
As we anticipated, with the foundation infant-hygiene course
in the grades there has been a consistent demand for an advanced
course in the high schools. These requests have not as yet been
met by our department, but many high schools are working out
individual courses. The city o f Madison is particularly progres
sive. It is giving a 36-hour home-making course to the senior and
junior high school girls. Child management is studied—methods
o f dealing with the obstinate child, the stubborn child, and the child
who is finicky about food—along the lines we have listened to
this morning but by methods adapted to the understanding o f the
girls. Prenatal instruction is given by a woman physician—how
the food and health habits o f the mother affect the child, why the
mother should have supervision during pregnancy, labor, and the
aftercare o f the baby and mother. Lastly, two lectures are given
on our national problem: The loss and waste o f life in maternity
and infancy.
Additional contacts with teachers in service are made at institutes,
summer schools, and teachers’ conventions.
Wisconsin has a wonderfully developed vocational and continua
tion school system, as you probably know. The law reads that
every city o f 5,000 inhabitants must have a vocational school,1 and
every city o f less than 5,000 may have one. Many o f these schools
were giving a very satisfactory course in child care before the
infant-hygiene course was authorized. Now it is a definite part
o f the curriculum. In the Vocational School in Milwaukee, which
has an enrollment o f 12,000, it has for some years been the policy
that each girl in attendance must take a home-making course. W e
hope a like rule will be made to apply to the boys. W hy should,
they also not have education and training in home making ? Surely
1Wis., Stat. 1923, sec. 41.15, subsec. (1) ; sec. 41.17, subsec. (1).
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they will be better citizens and better fathers for a knowledge,
even a superficial one, of eugenics, nutrition, health, and child train
ing. How many times in the home do we see the superior health
knowledge o f the mother set aside or rendered nil by the wellintentioned but more ignorant father? Our next step (and may we
take it soon!) is to train our boys as well as our girls for more
intelligent parenthood.
When presenting this work to a class I usually demonstrate han
dling, dressing, and bathing the baby, because o f the opportunity
to illustrate the difficult technique involved. However, I never let
the girls lose sight of the fact that the most important thing that
can be done for a baby is to give him the right food; that more
of his future happiness and success in life depends upon the food
that he has during the first year than on any other health factor
in any other one year of his life. The second most important thing
is the regularity with which the baby is fed; a baby may have the
very best possible food for his particular needs, but if his care
takers have not a sufficient amount of intelligence or self-control to
feed him by the clock, his whole health morale may be seriously im
paired. The third most important thing is sleep; the fourth, sun
shine and fresh a ir; and the fifth, comfort. As a subheading under
comfort comes handling, bathing, and clothing.
When working with a class o f teachers I do my best to stimulate
and inspire them to vitalize their teaching and humanize their
interests, and to impress them that, if they would realize results
in teaching health, they must keep away from cut-and-dried methods.
True, we still have to teach many nonessentials, for example, the
names o f the 280 bones in the human body (I think that is the correct
number), when it would be much more intelligent and profitable to
spend that time in teaching what to eat to make good bones; but
little by little we are moving on to better things and better ways.
I have great sympathy for the boy, a conscientious little chap, who
went to his teacher at the close o f a dry-as-dust course in physiology
and said, “ Teacher, I know where my liver is, but I don’t know
where my bacon is.” [Laughter.]
In normal schools at least one period is devoted to methods and
procedure. A variable but definite time is given to presenting the
fact that this course of study has become a definite part o f our school
system to meet a great national problem; that our high infant death
rate, high infant morbidity rate, with its aftermath o f physically
defective children, are facts that threaten the strength of the Ameri
can Nation; that dead babies, sick babies, and physically defective
children are the heritage o f ignorance; that education is the solu
tion; and that the full value o f this education can be realized only
when it is given in time and given to all; that there is no public
institution where all can be reached and intelligently prepared for
the supreme obligation of life, parenthood, but the public schools.
DISCUSSION
Doctor B l a c h l y . I should like to know how much training the
teachers have had in child care and child training before they start
to work?
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Mrs. H a s b r o u c k . They are expected to have some training in the
normal schools at the teachers’ institute or some other teachers’ club.
However, the superintendent o f public instruction definitely states
that with the handbook and manual o f infant hygiene no other spe
cial training is necessary to do this work acceptably. W e are teach
ing only the simple, fundamental principles o f the care o f the average
normal baby. Such information should be the educational equipment
o f every woman if she is intelligently trained for motherhood. The
course is worked out in detail and is complete in these two little
books. When the teachers master these we feel that they are quite
competent to teach all that we request them at the present time.
Miss M a r r in e r . Are you going to send those to a ll o f us ?
Mrs. H a s b r o u c k . Yes; I shall be very glad to. I have a few
envelopes o f the material that we are using left here. I brought
enough, I think, for everybody.
Doctor S t a d t m u l l e r . I should like to have you tell us how you
persuaded the State board o f education to let you introduce this into
the curriculum. I have not been able to do that in California. They
say they have had so many things crammed into the curriculum that
they are taking subjects out instead o f putting them in.
Mrs. H a s b r o u c k . Where this goes into the home-economics work
it is not additional; it simply displaces some other work; for instance,
cooking and sewing. Where it goes into physiology and hygiene it
does not add a number o f hours o f work for the teacher; it merely
displaces something else, and the same is true if it is put with
physical education. I presented to our State superintendent of pub
lic instruction my argument that the infant death rate is a national
problem and that the only way we can ever meet it is by educating the
children o f the State so that the knowledge would become the com
mon property o f all the people; and I evidently convinced him,
because he has been most cooperative.
I think you would be interested to know that in the vocational
schools we are able to give quite a little instruction in prenatal care.
Where I have met the teachers and feel that they are ready for this
advanced work, I send material from the State bureau and the
United States Children’s Bureau. Often I am able to give prenatal
instruction in these schools when I am there to present the infanthygiene work. In the county normal schools and the high school
teacher training classes I always try to give some work along this
line also, just enough to make those girls comprehend that there
is something which they as intelligent women should know about
themselves. When I go before the State normal schools and have
the assembly period, as I do usually both in the summer school and
in the regular school session, or when I have my groups o f boys and
girls in the county normal schools, I try to make the boys feel that
they too have a part in this, that it is something that can not be left
entirely to womanhood, that the supreme obligation o f life , the
gravest responsibility and the highest duty that ever comes to a
human being is that o f parenthood, and unless we are prepared
to meet that obligation intelligently we can not feel that we are doing
our duty to ourselves, to our country, or to future generations.
The reaction from the boys is very wonderful. I have yet to meet
a gro'up o f boys that in any way have shown the least embarrass-
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ment. They seem to take these thoughts very seriously. I can not
say always that the girls have shown the same seriousness when boys
are present, but I have yet to meet a group o f boys who show the
least bit o f levity. In the high schools also I often include the boys
in the work that precedes actual demonstration work. I believe
that in so doing I perhaps lessen the possibility o f levity that might
come from the girls having this “ baby work.” I remember in one
high school where I had a class o f about 300 (I had grade children
also) there were more than 80 high-school boys. The principal
helped me bring in my equipment. When he brought in the doll
he held it high, and o f course it aroused a shout, which was all
right— I try to have the children have as good a time as possible.
But I felt that he had struck the wrong note, and that if I left the
matter .there, the course would be the butt o f a great deal o f levity.
I asked the principal if he wo'uld leave his boys for half an hour,
adding that I wbuld dismiss them when I was ready. He agreed
o f course and I presented to those high-school boys the problem o f
our infant death rate. I gave them some o f our State statistics and
those o f other States, by comparison and facts arousing their inter
est and their pride. Then I went on with a good deal o f the talk
that I usually give to normal-school students. When those young
boys got up to file out, I watched them carefully; not one o f those
80 boys gave any side glances or showed that they felt the least bit
o f embarrassment.
Another instance I like to remember was with a group that in
cluded a rival normal school and a State school o f agriculture and
domestic science. There were an unusual number o f rather young
boys in the school o f agriculture—probably 14 or 15 years old. It
was the last o f the year, and the superintendent said I might keep
them as long as I desired and dismiss them for the day when I had
finished. They seemed much interested in the work, and I kept
them almost two hours. When I had the baby at the point where
she was ready to be put into the tub I thought perhaps it was well
to dismiss the boys. I said that I had enjoyed very much having
them in the class but that they were now excused for the rest o f the
day; however, if they wished to stay I would be glad to have them.
I never dreamed that they would remain. The boys sat in their
seats looking straight to the front. Not a boy looked right or left to
see whether any other boy in the class was going or not. I repeated
the permission to go for the day because I thought they had not
understood. Then one o f the teachers tried to make them Under
stand that they were excused for the day if they wished to go. Not
a boy moved. They sat with faces to the front, determined to see it
through, and see it through they did. I omitted none o f the details
I am accustomed to give to normal-school girls. Later in the day
?
one ° i
° ^ er boys in the hall. He came up to me and said,
Madam, that was a mighty fine talk you gave us.”
Q j^ e often I find in county normal schools that in mixed groups
the boys ask questions and the girls do not. Now in our one-room
rural schools where we have men teachers the problem arises, who is
going to teach this course ? I have asked this o f our State superin
tendent and other school men. The general opinion seems to be that
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if a man takes a position and infant care is one o f the things to be
taught, he would be expected to teach it. Just how he is going to get
by when it comes to bathing the baby I don’t know. But that is
his problem.
[Meeting adjourned.]
,
WEDNESDAY JANUARY 13—AFTERNOON SESSION
DR. BLANCHE
M.
H AIN ES, DIRECTOR, MATERNITY AND IN FAN T-H YGIEN E DIVISION,
TH E CHILDREN’ S BUREAU, PRESIDING
The C h a ir m a n . Doctor Abercrombie, o f the Georgia Board o f
Health, will read to us the paper prepared by Doctor Bowdoin, who
could not come to the conference on account o f sickness in his family.
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THE USE OF COUNTY UNITS IN RELATION TO COUNTY
ORGANIZATION FOR WORK UNDER THE MATERNITY
AND INFANCY LAW
B
y
J oe P . B
o w d o in ,
D
B
ir e c t o r ,
o ar d o f
H
D
of C h il d H
G e o r g ia
iv is io n
ealth,
y g ie n e ,
S tate
[Read by Dr. T. F. Abercrombie]
With a credit o f $29,530.55 in the United States Treasury for work
in Georgia and with nothing to match it, we faced a necessity for
finding a like sum. We felt that Georgia, with her 3,000,000 people
and estimated 6,000midwives, faced a responsibility that must be met
in some way. W e could not match the sum with State board o f
health funds for the very good reason that we have not received an
increase in appropriation for six years, and there is none in prospect
for the next two years in spite o f a constantly increasing demand and
expansion o f the routine work. In this extremity we appealed t o '
different communities and offered to match their money for a full
time maternity and infancy nurse—reserving the right to reject
or accept such a nurse and to supervise her work and direct it—this
•nurse to be under the local supervision o f the county board o f health
or some agency that was mutually agreeable.
We succeeded in getting $27,290 through this source and a small
appropriation from the State funds to take care of the expense o f
the healthmobile, leaving us a balance o f unmatched funds o f
$2,240.55, or a total budget o f $54,580. In addition to this the State
paid for printing and furnished quarters, accounting, and other
incidentals.
This method o f county units under supervision gave us unified
work. The programs were all arranged by the division, and the
midwives’ classes began and finished at the same time, as also the
mothers’ classes and little mothers’ leagues. The work was coordi
nated throughout the State; the units were all doing the same thing.
We had the reports coming into the office along the same lines each
week. These reports are made on forms furnished by the division,
and each nurse in addition to her statistical reports gives a narra
tive report. Thus the director keeps in touch with all nurses, not
only those in our employ but all public-health nurses. The director
issues a monthly letter discussing various questions, making sug
gestions, keeping the work o f the nurses coordinated along the same
lines for the same period. The supervising nurse makes regular
trips o f inspection and special trips where and when necessary,
keeping the entire nursing force in close touch with the central office.
We also have regular conferences; all nurses report to the central
office twice a year, the summer convocation lasting several days. It
is really an institute; we arrange the course and invite especially
qualified physicians and nurses to give addresses. This gives us
unity o f thought, coordination, and cooperation.
173
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PROCEEDINGS, M ATERNITY AND IN FAN CY CONFERENCE
The county unit does the State and local health work a vast amount
o f good for the reason that it brings us in close contact with the
people. It places the Children’s Bureau, the State board of health,
and the people in copartnership. The local unit does this as nothing
else will. The nurse visiting the expectant mother, assisting her
physician in keeping her well, making the details o f the expected
event easy for the mother, visiting her and then her baby and keeping
up with the baby until it is in school establishes the strongest tie that
we can conceive of. The spirit o f cooperation, partnership, 1 you
please, ripens into the closest relationship. Perhaps this plan o f
copartnership with a smoothly working program and a nurse who
has a genial, friendly disposition is the strongest influence that we
could have to bring about the appointment o f a full-time commissioner o f health.
.
, . ,
■,
-yi
The counties contiguous to the one m which the nurse works will
be inspired to give attention to sanitation o f the home and public
buildings. She should be able to arouse enthusiasm m the persons
with whom she comes in contact and to convince them of their re
sponsibility, thereby causing them to have a higher sense o f their
duty toward their fellow man. I f her work is good, true work, her
example will spread, and other communities will want like service.
In our organization we have three itinerant nurses who go into a
county and spend about a month or six weefe teaching midwives,
mothers’ classes, and little mothers’ leagues. They make it a point
to become acquainted with all the physicians, civic and religious or
ganizations, and officials, the latter including most o f the politicians.
They travel by automobile, each furnishing her own car. They go
into the remote counties and to the backwoods districts o f each
county. They hunt up midwives and get them to come to classes.
This brings them into contact with the masses and especially with
the local registrar o f vital statistics, who is generally the justice o±
the peace in his section.
,
T«
This gives a splendid opportunity for contact o f the best type. In
addition to these nurses we have at present the cooperation or t e
physician who is loaned by the United States Children s Bureau to
aid us in the instruction o f the negro midwives. She is doing most
excellent and thorough work among her people; her services are of
great benefit to us. It might be well to mention that all our mid
wives are negroes, and in each county where the work is completed
we make a permanent county unit by organizing them into a midwife
club with a president, vice president, and secretary. They meet once
a month and have a regular program. A ll are expected to keep up
their study, as our certificate of registration is good tor only one
year. Keexamination keeps up interest and in time will attord us
the opportunity gradually to improve the personnel o f the midwives
o f the State. These clubs also help us to get the unlicensed midwife
in line. W e require physical examination and a negative Wassermann. This examination brings the midwife class in closer touch
with the physician, another binder for the county unit.
In short, without the county unit plan in Georgia the SheppardTowner Act would be a complete failure; with it, we are doing untold
good.
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COUNTY ORGANIZATION FOE SHEPPARD-TOWNER WORK
175
DISCUSSION
Doctor A b e r c r o m b ie . I do not know whether you all know the
Georgia law or not. We have on our statute books a law creating a
county board o f health m every county in the State, and upon two
successive recommendations o f a grand jury it becomes obligatory
upon them to employ a full-time commissioner o f health.
It might be well to repeat that all our midwives in Georgia are
negroes. In 1924 the Georgia Medical Association passed a resolu
tion calling on the State board o f health to draw up rules and regula
tions that would in some measure supervise and control the midwives
111 °ur ktate, and that was begun on January 1 , 1925.
i
We t ^ n k you very much, Doctor Abercrombie.
If
**a^ ered that the health officer comes to give the report himDoctor
It is a pleasure to be with you.
I think you will like at this time to hear from the
Chief o f the Children’s Bureau.
Miss A b b o t t . I do not know that I have anything especial to say
except to express my great gratification at the development o f the
Sheppard-Towner work as shown in the discussions here at this
j ren(Se
in the exhibits and your reports. Those o f us in the
Childrens Bureau have watched with great interest the way in
which the plans have developed in the States from year to year and
the activities that you are engaged in become better established in the
local communities with the different methods in different States.
As you may have heard, either through the group at home or since
you have been here, the question o f the extension o f the Sheppard1 owner Act is up at this session o f Congress. The authorized ap
propriation was for a five-year period which expires June 30, 1927,
and we are asking for an extension o f that authorized period— asking
!t now because we think the legislatures that meet next January
ought to know what will be available and because we need the same
information in making up our next year’s budget.
I am very eager to see any o f you who have questions you wish
to ask me. Doctor Haines knows a great deal more about your work
than I do, but I do appreciate very much having the chance to meet
and know you, and I hope to be able to get out into the States next
year more than I have during the past year or two.
The C h a i r m a n . I wish to clarify one thing. I have written to
you about all sorts o f reports, and I may have confused you. When
1 was a State director the two semiannual reports that we had to
get out for the Children’s Bureau always seemed to me two extra
repQrts, because I had to get out one annual report for mv health
officer. When I came here I saw the semiannual report from this
side o f it, and realized how difficult the compiling o f it is. Conse
quently , it has seemed to me that the simplest way was to have one
annual report which would coincide with the Government year, and
that closes always on June 30. But i f you are getting out a certain
monthly report, or a quarterly report, or whatever you are sending to
your State chief, just let us have a carbon copy o f it, so that we can
keep in touch with you and also have some items for our news letter.
In addition to these you prepare your financial report; that one we
need twice a year, just as we have been having it.
A
b e r c r o m b ie .
C h a ir m a n .
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PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
I find that some of you are getting out very complicated monthly
reports, and a few States said they were “ struggling ” with the re
port. Because I had struggled so hard in my own State and had
arrived at what I thought was a fairly good report, I have had copies
o f two types o f reports typed for distribution. The first is a very
simple little one that comes from Texas. You see, we had something
very good yesterday from Texas, and this very simple little report
they print every month in their “ Gleaner ” [indicating]. This other
report [indicating] is my own, which has the cumulative figures
from the beginning of the Sheppard-Towner work. I foujid this
important because somebody was always asking me “ How many
conferences have you had? How many this or that have you had?
How many children have been enrolled in the little mothers’ league ? ”
and so on. So I am sending this to you not as a form for you to copy
but simply for you to see; and on the back o f this pink sheet is a
device we have for checking up on defects noted in conferences ( 1 )
by age groups, (2) by sex groups, and (3) by defects. There is one
copy for each o f you, and you may take them and look at them
afterwards.
I think we are ready to proceed with the afternoon program. Each
speaker has been requested to limit the talks on cooperation and
organization o f groups to 10 minutes each. I feel very apologetic
about this program. It is too full, and yet we must have some of
these things brought out at this time.
Mrs. Mathews, o f Colorado, will discuss the cooperation o f
physicians. She is o f the laity, yet she seems to have been able to
get the cooperation o f physicians. W e who are physicians think it
takes a physician to handle a physician, but evidently sometimes they
are very well handled by a lay worker.
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THE COOPERATION OF PHYSICIANS IN MATERNITY AND
INFANCY WORK
M rs. E . N . M a t h e w s , E xecutive S ecretary , C hild W elfare
B u reau , D epartm ent of P ublic I nstruction , C olorado
I am glad that the chairman has spoken about my being a lay
worker. W e are in the department o f education. W e are not in the
State board o f health at all, and Colorado has no department o f child
14 has a dePartment o f child welfare, and since this is part
ot the department o f education, it is recognized as educational, and
no physicians fear that we are coming to take their business away
from them.
J
Possibly the most important factor in the success o f the traveling
child-health conference is the personnel o f the working unit. In
Colorado we have been most fortunate in having a group of workers
^"O appreciate that this entire work is founded on a medical basis
and that without the whole-hearted support o f the medical profession
it not only will fail to progress but will absolutely fail in the end.
in Colorado the workers in the child-welfare bureau speak grate
fully o f the cooperation o f the physicians with the Sheppard1 owner work, for that cooperation has been o f such a high stand
ard and o f such generous proportions that we are deeply appreciative
and truly thankful for the spirit that has prompted it.
During the years the Sheppard-Towner bill was fought through
Congress we heard a great deal about paternalism and about “ State
medicine.
The American Medical Association was not backing the
bill, the physicians in our State were none too friendly, and there
was considerable talk locally and nationally about the part which
old-maid social workers and nurses would play in telling mothers
how to raise their babies.
Fortunately for Colorado a group of pediatricians was alive to
the need for the maternity and infancy work. They were strong
advocates o f public health and heartily approved the Colorado outIme o f activities for maternity and infancy. They ranked with the
eadmg men in the medical profession in Colorado and were accepted
throughout the State as authorities. These men were, in very truth
responsible for the success in our work. Their professional prestige
and our position m the department of public instruction marked our
whole endeavor as educational. It was something we could teach
the people; something the parents could learn; something the knowl
edge o f which would benefit the little ones. There were no paternallsm, no State medicine,” no compulsory corrections, no invasion o f
the local physicians rights, no interference with the sanctity o f the
home. There was simply the spreading o f health education.
Since it was an educational measure the University o f Colorado
^ ^00 an mterest
the work, and through its extension division
the department o f organization cooperated with the bureau o f child
welfare to the extent that all the child-health conferences are organ177
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17S
PROCEEDINGS, M ATERNITY AND IN FAN C Y CONFERENCE
ized by the university organizer. His first effort on entering a com
munity is to get in touch with the local physicians and dentists. I f
they are favorable to the work, the organization o f a conference con
tinues; but if the local physicians object, the work in that community
is withdrawn, because we feel that no conference is complete unless
the local physician is among the working group. Several amusing
incidents have arisen from these withdrawals. , Wfien the conference
would be in adjoining towns some physicians in the town which had
declined the demonstration would be curious or else suspect that some
o f their patients might be attending the conference seeking advice.
They would drop in at the examination, look on for a while, then
offer their assistance, and finally make every endeavor to prevail
upon the conference to stop in their own town.
It has been customary in each town to ask the attending physicians
to dinner after the conference. Here different cases are discussed,
future work is outlined, and the local physicians assist in planning
the follow-up work to be done in their communities. In counties
having county medical associations a meeting o f the association is
usually called for dinner, and our conference physicians are asked
to talk. After this dinner in some counties arrangement was made
to hold clinics to which the physicians brought their special cases for
consultation.
.
In one county all the county medical and dental groups assisted at
the child-health conference in relays o f one hour each, and one
evening they all attended the dinner. They had voted that 2 physi
cians should look after the practice o f the entire group o f 22 in order
that the rest might be free for the conference and for the lectures.
The most appreciated cooperation is that where physicians in adjoin
ing localities drive for miles to assist in the conference or to relieve
the local physician that he may assist. This has been the custom in
small communities in the dry-lands district as well as in the more
distant communities in the mountains.
In Colorado, as in all States, we have the old-time physician, who
has lived in one community the greater part o f his life and looks
askance at preventive medicine. No greater success has been
achieved by our entire group than to convert some o f these men o f
the old school to the point where they will undertake a graduate
course or “ run into Denver to look in on the new ideas ” expressed
in our new State medical school.
The medical profession has responded beyond our highest hopes
in every part o f Colorado. Since the beginning o f the work only 3
physicians have absolutely refused to consider a conference in their
community, whereas 263 physicians and dentists have given from
one to three days o f their time assisting in the actual work o f exam
ining the children. Their greatest service is in continuing this health
work in their community after the State help has been withdrawn.
They work as volunteers. When the follow-up nurse arranges her
clinics after one o f the child-health conferences a meeting o f all
local doctors and dentists is called and they decide how many opera
tions each will be responsible for. For instance, in one town we
examined 243 children. A t this place was a good throat man, who
was delegated to perform all the tonsil and adenoid operations (o f
which there were 22). These children were cared for at the local
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COOPERATION OF PHYSICIANS IN SHEPPARD-TOWNER WORK
179
hospital, and the county physician acted as the anesthetist. Six eye
corrections were made also, eight minor operations performed, and
dental defects corrected for 107 children. The nurse arrange«! for
the payments for the operations and divided among the physicians
the amount collected. The dentists gave a flat rate for filling and a
nummum charge on all other work, and this was paid to the dentists
Another instance was in a town somewhat isolated in summer and
almost completely isolated in winter, where we examined 106 chil
dren. I here was only one physician in this whole district. After
the nurse worked up a general interest, the local physician brought
in a specialist and his assistant to make the corrections for the children in that community and surrounding district. This same medi
cal adventure has occurred in several other places; and in one small
community the situation was cared for in the same way by the fol
low-up nurse, except that she had to arrange for all professional
services, as there was no physician within a radius o f 50 miles,
lhree physicians and a hygienist drove 93 miles Saturday afternoon,
and on Sunday morning performed 23 operations, assisted by the
bureau nurse, who had prepared in the schoolhouse an operating
24°Cursb0yS Ward and a girlS’ Ward’ where the children were kept
i^ e
f^tempted to keep in touch with the members o f the medi
cal and «iental associations at all times. Besides contributing several
articles to the State medical journal in the past year, we gave a
demonstration rural clinic at the annual meeting of the State medical
society, and one o f the bureau consultants spoke before the annual
fetate dental society meeting, explaining the work and the value o f
the cooperation o f their society in furnishing a hygienist for State
demonstrations m connection with the traveling health clinic
Bast June the bureau held the first o f its annual institutes on
maternity and infancy Physicians answered the call to act as instructors and came m from various cities to serve us. This institute
lasted three days from 9 a. m. to 9 p. m. We had lectures on prenatal, infant, and child care by the State’s leading obstetrician and
pediatrician, and lectures on prevention o f tuberculosis by nationally
known men There were lectures on teeth and on feeding the infant and child. A t night the lectures were for parents—on cancer
and tuberculosis, an«! on the care o f the eyes. " These physicians
were training the chairwomen in regard to the value o f child-health
conferences, the necessity of holding them at least once a month, and
the mdispensability o f a nurse; and at the same time they were
bringing them to feel that a permanent child-health center is a comfinand faiiyP0I1Slblllty Which the women should shoulder morally and
°inei ° f i t 6gre^ esi servic.es rendered to the maternity and infancy
work by the medical men in Colorado was in the matter o f legis
lation. It was the physicians o f the State who backed the work
i u j P?,
where
,received our appropriation. The legislature
slashe«! the appropriations for the other bureaus in the State, and
we waite«! m fear an«! trembling for what would happen to us; but
the physicians rallied to our cause and we were given the same
amount as m the previous administration, I f I had the time to go
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180
PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
into details regarding our legislative experience you would see that
our $5,000 appropriation was an outstanding victory.
Let me add that in Colorado there are only 1,700 physicians regis
tered, and 800 o f them are in Denver proper, which contains onethird o f our population. Nearly 300 are in Pueblo, and 143 are in
Colorado Springs. So you see that outside o f these three large cities
there are not more than 400 or 500 physicians in the State.
The C h a ir m a n . The next subject is the cooperation o f the publichealth nurses. Miss Anderson, o f New Mexico, who is herself a
nurse, will discuss this feature o f the use o f groups.
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W H Y N EW MEXICO N U R SE S CO O PERATE IN M A T E R N IT Y
AND IN F A N C Y WORK
B
D o r o t h y R. A n d e r s o n , R. N., D
P u b l ic - H e a l t h N u r s in g , B u r e a u
P u b l ic W e l f a r e , N e w M e x ic o
y
iv is io n of
of
P
u b l ic
C h il d H y g ie n e a n d
H e a l t h , B o ar d o f
New Mexico apparently gets an unusual amount of maternity and
infancy work done by nurses outside o f the bureau o f child hygiene.
I think one o f the main reasons for this is the fact that our whole
State department o f health is comparatively new. It was inaugu
rated in July, 1919— only six and one-half years ago. Since then
the communities and counties establishing nursing services have
looked to us for guidance in planning their programs and in help
ing them select a well-qualified nurse. W e have not hesitated to
suggest what we felt was the best plan o f work for them, and the
State supervising nurse has made visits to the nurses when she was
in their territory, even though they were not directly under her
supervision.
The nurses themselves feel the need o f a general program includ
ing maternity and infancy work, because o f the physical character
istics o f the counties in which they work. When a nurse has to drive
anywhere from 20 to 235 miles to reach a school in her county it
would be foolish for her not to try to reach every family in the
community visited. Thu nurse usually inspects the school children
in the morning, holds a child-health conference and mothers’ meeting
in the afternoon, and then visits any people who may be sick in that
town. She may be called upon to pull teeth or to prescribe simple
remedies. O f course, we know this is not according to medical
ethics, but when people live 50 to 100 miles away from a physician
and are too poor to have one come to them (because the physicians
charge a dollar a m ile), or have no conveyance in which to get to
a physician, the nurse simply goes ahead and does the best she can.
I f the case seems very serious she reports it to the county health
officer, who is usually the county physician as well, and he visits
the case.
When you compare New Mexico with its population o f only 360,000
(and I believe this includes the Indians on the reservations) with
Washington, D. C., which has about 500,000 inhabitants, you can
begin to appreciate how very scattered our people are. For this
very reason a strong community spirit exists throughout the State,
and everyone works more for the good o f the State than for the
individual good o f his local community.
The State has had severe financial reverses the last few years, due
to the drop in the cattle market, severe droughts, and the drop in the
price o f copper—which was the cause o f closing up several mining
towns o f 4:,000 to 5,000 inhabitants. It has been a real struggle for
the counties that have nurses to get enough money to pay them, so
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
the nurses feel they must give o f their best to compensate the counties
for their sacrifice. Another difficulty arises from the fact that we
have no hospital or clinic facilities to which to refer cases. The
physicians are usually generous about donating their services in
emergency cases if the nurse will bring the patients to their offices.
In some places the local physicians will go with the nurse and health
officer and hold a corrective clinic in a schoolhouse. A t one such
clinic held 68 miles away from the county seat they removed tonsils
and adenoids for 10 youngsters, made several examinations o f eyes,
and gave children glasses if the people were too poor to pay for
them. They also reset a fractured arm that was growing very
crooked, as the parents were too poor to take the child to a physician.
We understand that Denver, Colo., is to have a new orthopedic
hospital supported by a fraternal organization, and we are very
much thrilled over the prospect, as we shall be able to get some o f
our crippled children in there for treatment. W e have no orthopedic
specialist in New Mexico; many o f our children are becoming per
manent cripples from lack o f care.
There are 16 nurses doing public-health nursing in the State, and
all except 1 now come up to the standards o f the National Organiza
tion for Public-Health Nursing. Two are staff nurses, paid with
Sheppard-Towner funds; five are county nurses, paid partly with
Sheppard-Towner funds; and the rest are regular county nurses,
community school nurses, and nurses in the Indian pueblos. The
State school auditor has promised not to approve the budget for a
school nurse unless she comes up to the State department o f health
standards, which are the same as the standards o f the National
Organization for Public-Health Nursing. I have visited all o f the
school nurses but one this year, and each is doing some maternity
and infancy work. They say, “ W hy, we can’t let it go when there
is no one else in the community to do it ! ” Almost all except the
Indian pueblo nurses send monthly statistical and narrative reports
to our office. (We have no jurisdiction over the Indian Service as
that is under Federal management.)
In order to make the nurses’ work more effective the State bureau
sends out supplies to any nurse who requests them regardless o f
whether she comes under our jurisdiction or not.
Since we have a very limited appropriation we have borrowed
material and ideas for our little mothers’ classes from other States.
Little mothers’ classes are being systematically introduced into the
schools for the first time this year. As the State has a very large
Spanish-American population we are training in infant care many
girls who would never learn it otherwise, because comparatively few
o f them ever reach high school. The girls enjoy the work; and at
the completion o f the course their graduating exercises are held, and
the mothers are invited to watch some demonstration in child care.
Three girls give the demonstration, one doing the practical work,
one telling in English what is being done, and the third telling
about it in Spanish.
I might say in passing that we have the only legislature in the
country held in both English and Spanish, and this is done accord
ing to State law. However, English is being spoken more and more,
and as it is also a State law that the schools must be taught in
Engish the coming generations will be English speaking.
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WHY NEW MEXICO NURSES COOPERATE
183
Besides supplies for little mothers’ classes we furnish midwife
certificates to midwives who have completed the bureau’s approved
course o f midwifery and have passed a physical examination. We
also furnish the nurses with layette patterns, literature on prenatal,
infant, and child care, and diet cards for preschool children.
W e have a film-slide projector and films and a daylight screen that
we loan to the nurses, and a stereopticon machine with slides, and also
several regular health films that the nurses often get some publicspirited motion-picture manager to show in connection with his
regular program.
You may wonder why any nurse would choose to work in a State
with so few facilities at hand to make her work really effective.
Her efforts are worth while because of the great need for the work
and the fact that even the most ignorant try to follow her directions,
although in doing it they may have to give up some age-old supersti
tion. Many o f our native people still believe in the power o f the evil
eye; and they believe in their medicine women rather than in modern
methods. T o the nurse who is endowed with the pioneer spirit and
the spirit o f adventure, coupled with self-reliance and common sense,
our State offers the most wonderful opportunity for real service that
can be found anywhere.
In conclusion I will say that I believe one o f the main reasons for
the close cooperation the nurses give us in maternity and infancy
work is the real spirit o f comradeship that exists between the State
bureau o f health and the individual nurse. We rejoice with her
when she has started some mother or baby on the road to health, and
we make our appreciation known through our nurses’ news-letter that
is issued at irregular intervals.
Here is an incident which shows how much the maternity and
infancy work means to the State: About six weeks ago I was with
one o f my nurses up in a mountain district, and we came to a home
where an eight-months-old baby had just died. The family were
Spanish-American people who spoke very good English, so while
I was laying out the baby, the other nurse and the mother examined
an older child o f 18 months to see that it was all right.
The C h a i r m a n . The next topic under organization and use o f
groups will be the use o f men’s and women’s organizations. This
will be presented by Doctor Richards, director of the bureau o f child
hygiene o f Utah. I think there are some unique features in his plan.
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Federal Reserve Bank of St. Louis
COOPERATION O F L A Y O RGANIZATIO NS IN M A T E R N IT Y
AND IN F A N C Y WORK
B
y
H. Y. R
ic h a r d s ,
M . D . , D ir e c t o r , B u r e a u of C h i l d H
S t a t e B o ar d o f H e a l t h , U t a h
y g ie n e ,
In discussing the use of lay men’s and women’s clubs in maternity
and infancy welfare work m Utah the short time allotted me will
permit but a very brief outline of our methods.
Since the beginning of our activities under the gheppard-Towner
Act we have extended its benefits to every part o f the State.. I
believe that our method of organization has been somewhat different
from that o f most other States. We have considered every com
munity of the State as one where a child-health center could be
established. We learned early that if we wish to reach the greatest
number o f people we must take the work to them, they would be slow
in. coming to us.
lc&rncd} too? that people h&ve & kind o f community spirit which causes them to feel slighted or offended when we
ask them to go to a neighboring town to attend a health conference.
They feel that their town is just as good as any other. The transpor
tation problem also had to be considered. People resented the neces
sity of going 4 or 5 miles to attend a conference unless they really
believed that something was wrong with their children. W e would
therefore see only the sick ones, while the supposedly well ones were
still neglected. Since these were the children we wished most to see
it was apparent that we must go to them.
.
. In order to accomplish this a health survey o f each community
was made, the various men’s and women’s clubs were visited, and
the prominent local people were interviewed. It was made plain
to these clubs and societies that we were very desirous o f obtaining
their cooperation. Their interest was usually easily obtainable.
Many o f them expressed a wish to make^ the organization ox the
child-welfare program a part o f their activities. They were, inva
riably given to understand that the work was state-wide, and could
not be considered the special work o f any society or club. However,
the State was anxious to have them give the bureau o f child hygiene
their support and to assist where necessary with the finances ox a
child-health conference in their locality. The small funds needed
were easily obtainable by this means. Many health centers, when
organized from local lay people, were thus able to obtain scales,
sheets, napkins, measuring boards, towels, basins, and other articles.
A t a public meeting the work was explained fully, and the ne
cessity o f forming an organization was discussed. A t this time the
advantage o f having a community organization representing all
clubs, societies, and factions was made clear. As a result the com
mittee thus formed usually had upon it one or more members ot
each society or club. These representatives were then m a position
to keep their club members informed as to the activities and needs
o f the health center, and thus they anchored our work to the local
community. W e could then go to all organizations for what finan
cial or lay help we needed. A ll seemed to have a direct personal
184
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Federal Reserve Bank of St. Louis
COOPERATION OF LAY ORGANIZATIONS
185
interest, and were the more desirous to have it succeed. Various re
ligious organizations were treated in the same way in order to avoid
all prejudices.
The relief society o f the Mormon Church has given a great deal
o f aid to the Sheppard-Towner work. This organization has a repre
sentative branch in every hamlet o f the State. It was developed for
the purpose o f caring for the sick and poor who live in the State
or wherever help is needed. Through contributions it has been
financially quite strong. Health work has always interested this
organization, and when the Sheppard-Towner law became effective
the women o f this group used their influence to the utmost to obtain
tne benefits o f this law for their State. Maternity and child-welfare
work likewise became a part o f their program. Each local associa
tion was instructed to do everything in its power to assist the State
board o f health in this field. In many o f the localities o f the State
almost all o f the population belonged to the Mormon Church, and
its relief society was the only one in the neighborhood. The members have proffered their assistance unselfishly, and have given o f
their funds. Where they have owned small buildings they have
permitted the use o f these for the holding o f health conferences.
«applying the maternity bundles under the direction o f
the State board o f health. We have furnished a list o f articles to
be placed in these bundles, and have given instructions as to how
they should be arranged handily and compactly. The method o f
sterilization is supervised, and the proper care o f the bundle is
described. These bundles are then loaned to people who are unable
to pay tor their use, providing that the materials are returned in
good, clean condition. Where possible a small fee is charged to cover
the loss and depreciation. This rental fee varies from $1 to $2.50,
depending upon the locality. It is not the aim of this society to
make a profit from these bundles, but only to obtain sufficient funds
to replace worn and destroyed material. Many of the physicians,
especially those o f the most scattered sections, are finding that these
bundles meet their every need; and some have gone so far as to
require that all their confinement cases obtain them.
In some instances the farm-bureau organization has served as a
means o f stimulating local interest. Diets, health, and home eco
nomics demand a great deal o f its attention. Through these its
a2 ?5^ . i S dra7 n ^ the children, then to the establishment o f a
c dd-health center. It too has offered its assistance in many ways.
-By such use o f these clubs and societies we have had a very
sympathetic associate in every community o f the State, some one who
would carry on in our absence when possible, and some one with
w om we cou d plan and ^finally act. In every case, however, we
ave made it plain that this was Federal and State work and could
n no way be considered that o f any individual or group. We feel
RUCCel S i i he Pr?_sent time is due largely to the cooperation
that we have had from these lay men’s and women’s clubs.
here that we have not fostered the idea o f using
f
h buildings or homes or anything o f that nature for confer^
not do otherwise. We have felt, as others have
n
*5 “ ? the.b?s* Place for health conferences is some
! S unleSS
c° uJd
,anl m vap a b ly wherever possible we have 'used—
the publiG-school buildings. In the winter they
at least preferred
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Federal Reserve Bank of St. Louis
186
PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
were usually warmed and cared fo r; in the summer we had plenty
o f room so that we could spread out over the building, using three
or four rooms if necessary.
A large number o f our communities can do absolutely nothing but
assist an itinerant conference—and I might state here that our
entire program *o f organization has been on the plan o f itinerant
conferences. W e have but three organized health centers in the State
under the definition, probably, that you directors give o f an organ
ized health center— and by that I mean holding a conference once a
week throughout the entire year with local assistance. W e have but
three o f those, one in Salt Lake, one in Ogden, and one in Murray;
a suburb o f Salt Lake, just south o f it. Those in Ogden and Murray
are more or less under the supervision o f the State board of health.
The one in Salt Lake is not at all under our jurisdiction; it functions
quite independently.
The rest o f our State is handled entirely by an itinerant con
ference.
We are not wholly satisfied with what the future holds for us in
our child-welfare work. We have not entirely developed our future
plans. As I have said, we have gone about organizing every section
and corner o f the State; and from now on it is going to be a problem
o f continuing the work. W e have felt that possibly the best way o f
handling our future problem is going to be through the county health
unit, but we find that we are meeting with difficulties in getting
health units established.
I don’t know how it is with the rest o f you, but we go into one
county and propose to them the organization o f a county health unit
with a full-time health officer, giving what help he needs, offering
to finance the program partly; and the suggestion is not accepted.
In some districts we feel that the health units would solve many of
the health problems but where the people are so scattered and their
resources are so small that they can not do it by counties, we have
tried to establish health districts. But we have been totally dis
appointed in the establishment o f health units in co'unties or dis
tricts so far. We have at present three county health units in the
State o f Utah. I know that many o f you are going to gasp at the
number. I have gasped at some o f the remarks that you have made.
You have talked during the last two or three days about your rural
sections and your programs and your problems, and you seem to be
worrying about them, when I have thought, “ Well, if I could ever
reach that in Utah, I wofild have reached Utopia, and there would
be nothing more to gain! ” Our problems in the W est—and I say
“ W est” because I mean beyond the Mississippi River, not beyond
Chicago— are certainly different from any problems you have in
the East. I do not think that they are harder to handle, but they
have got to be met and handled in a different way; and while we
are rather proud, I might say, o f what little we have done in Utah
since the Sheppard-Towner Act came into effect, we still have a lot
to accomplish, and we are only hoping that the Federal Government
will see fit to assist us at least for another five-year period.
The C h a ir m a n . The next group that we shall speak about is the
use o f the farm group or home demonstration agents. Doctor Lauer,
o f Iowa, will speak on this.
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T H E COOPERATION O F FA R M GRO U PS AND HOME DEM
ONSTRATION A G EN T S IN M A T E R N IT Y AND IN FAN C Y
WORK
E.
EL
L a u e r , P h . D . , D ir e c t o r , D i v i s i o n
I n f a n t H y g ie n e , S t a t e U n iv e r s it y
of
of
M a t e r n it y
I owa
and
I construed this invitation to present the matter o f the utilization
o f the farm groups as a request to come and speak very informally
regarding this matter. I feel I owe you an apology, after sitting
here and hearmg three very good papers read, to say that I have not
my paper written out, and I shall have to talk informally. I may
say, however, I thought o f writing it this morning, but I spent this
morning over at the House Office Building, and I should like to say
in that connection that I think a good many o f you will find it very
delightful to meet some o f your State representatives while you are
here. I had one o f the most delightful mornings I think I have
ever put in, because everywhere I was asked why I was here, and
then I could explain why I am here, and it led to a very interesting
conversation in each case.
The utilization o f the farm bureau has been touched upon by Doc
tor Richards; and in Iowa this was our main problem. When the
Sheppard-Towner law was accepted in Iowa it seemed necessary to
create a body o f public opinion behind it and to create it in a hurry.
Public opinion usually is not created overnight, but this thing needed
support and it needed it at once.
I think most o f you know Iowa well enough to realize that when
we say “ Iowa public opinion” we mean farm opinion. The ques
tion in Iowa resolved itself into getting the active support o f the
farm interests, and that was possible through the farm bureau. A l
though the physicians o f the State expressed approval and the
medical society unanimously voted support, it was necessary to have
popular support also.
The farm bureau took up the matter o f the child-health confer
ences, which constitute the program very largely in Iowa, as in most
o f the other States. There is a very ironical situation, however, in
that. The Medical Society said through its field-activities commit
tee that although it was in favor o f this work it did not feel that it
could actively hold these conferences but would be very glad to
indorse them if they were sponsored by any other organization.
They felt that i f they sponsored them it would seem that they were
drumming up business. Their saying that they did not care to
sponsor it directly compelled the bureau to find some one who would
sponsor it directly; and the approval o f the farm bureau influenced
public opinion to a degree that was very fortunate when the matter
came up in the legislature.
Now the point is, however, what have we gained besides that?
We have established ourselves, I think, but how about the actual
work which is to be done? I think you see that utilizing the farm
bureau meant rather a double task, namely, to have a certain specific
101848°— 26-----13
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Federal Reserve Bank of St. Louis
187
188
PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
type o f work done while leaders were being trained to do it. Now
that in itself, as it seems to me, is a very complicated procedure;
but having the farm bureau sponsor our conferences almost en
tirely has caused every one o f the county units of the farm bureau
in Iowa at the present time to have health as one o f its major
proiects. It would seem a foregone conclusion that this would, be
the case; but it was not true five years ago, it was not true three
years ago. But now, as I say, if you take the projects or.the farm
bureau and see what they have chosen as the work they want
to do, you find that health is one o f those things, and it is usually
given a great deal of prominence. Health conferences appear along
side o f instruction in regard to clothing or alongside p f nutrition
work, which o f course is a matter of health; but in addition 1 find
health (and very often some mention o f the Sheppard-Towner con
ferences as such) put down as one o f the projects, together with
bovine-tuberculosis eradication, hog-serum problems, windbreaks
o f the farm, and things o f that kind. This certainly speaks well
for what may be done in the future.
There is another point with regard to working with the farm
bureau. That is, we have tried to show how our Sheppard-Towner
program has a connection with other things that are going on 111
the State, how it is merely one phase o f a larger question. You
have all done it, I am quite sure, but I think we have had the oppor
tunity o f emphasizing it a bit more in Iowa.
,
Two other projects are being carried on now-y-or at least are
planned and b e g u n -in Iowa that I consider very significant for us.
One o f these is the fact that we now have a State children s com
mission, or a State bureau as a result o f a commission, with a State
commissioner o f child welfare. That bureau is going to depend tor
its success on how thoroughly it can organize the various counties
o f the State into some sort o f working machinery to take care ot
the manifold problems o f child welfare. The other thing which is
going on is a project o f the child-welfare research station at the State
University o f Iowa. Through a grant o f money from the Laura
Spelman Rockefeller Fund it has been possible to organize a pro
gram o f what we call “ parent training,’ which is largely a pre
school matter. The success o f this parent-training project and the
success o f this child-welfare bureau will depend absolutely on how
far the farm element intelligently get behind them and do the wor .
Through the organization o f the Sheppard-Towner work we have
created a public interest in these matters. The R e c to r o f the
children’s bureau tells me that in counties where the SheppardTowner work has been done for two or three years he finds an en
thusiasm, an interest, and an intelligence m regard to child welfare
which makes it very easy for him, for instance, to organize his
committee, or his commission, or whatever it is called. I hat did
not happen simply because a child conference went into that com
munity and examined 25 or 30 babies; but these people have become
interested, and they read, and they ask, and they look up things.
They no longer turn over the page o f the paper that says something
about these matters and look at other things. There is a growing
body o f intelligent opinion on the subject ot child welfare.
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Federal Reserve Bank of St. Louis
FARM-GROUP COOPERATION IN SHEPPARD-TOWNER WORK
189
A t the last meeting o f the State conference o f social work the con
ference recognized the fact that there is a spirit o f unrest in Iowa.
1 am an Iowan, and we are not at all ashamed of this unrest. You
can not overestimate it. The more you go up and down that State
the more you are impressed by its seriousness. But at this State
conference a man talked on the relation o f farm prices to matters
o f social progress; and he said, o f course, the thing which you all
know, namely, that the solution of the farm question lies not in
getting better prices nor in regulating production but in better
living on the farm.
I f we can get the organized efforts, such as the Sheppard-Towner,
to make a direct contribution in a specific field to better living in the
larger aspect, it seems to me we are building on a foundation which
is certainly not o f sand and which is going to make it possible to
rear an edifice that will stand through the ages. That is why this
matter o f cooperation with the farm bureau, which was more or
less thrust upon us by the situation, has been, it seems to me, a very
happy contingency and one which I believe will insure the per
manency o f the work.
The question o f health centers in rural districts is baffling, but I
am not so much concerned about how that work is going to be or
ganized if I can feel sure that in one o f these rural districts o f
Iowa— any one o f thousands which you may consider, with one
physician for a tremendous radius o f territory—the men and women
wish their children cared for.
C hahiman-. We shall have the discussion on this symposium
a little later. The next topic will be the methods o f determining
the amount o f time spent in maternity and infancy work when
matchmg other funds. This will be presented by Miss Marriner
o f Alabama.
’
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Federal Reserve Bank of St. Louis
MPTWOrm OF DETERMINING THE AMOUNT OF TIME
SPENT IN^ M ATERNITY AND INFANCY WORK WHEN
MATCHING OTHER FUNDS
B
y
J e s s ie L . M
P u b l ic - H
and
a r r in e r ,
ealth
N
R . N ., D
u r s in g ,
ir e c t o r ,
S tate B
B
u r e a u of
oar d o f
H
C h il d H y g ie n e
A labam a
ealth,
When it was decided that our program o f matemai and infant
hygiene activities should be coordinated with the general health ac
tivities of our county health units and that the r e s p o ^ b i i y
carrying out the aims and purposes o f the Sheppard-Towner Act
should be delegated to the county health officers, these administrators
were confronted.by a problem for which there-wa^ no
solution. When a county has only one public-health nurse who is
expected to apportion her time to maternal and infant hygiene
school hygiene, and communicable-disease control, how shall the
administrator guard against the giving o f undue attention to activi
ties for which there is an immediate and pressing demand or which
may especially interest the nurses? How can he be sure that the
maternal and infant hygiene program to which Federal and State
aid has been allotted is getting a square deal and that the funds so
allotted are not being diverted to other uses than those for wh c
thev were intended?
.
n • ,i
When health officers have appealed to us for advice or help m tn
solution of this problem our answer has been m the form o f a
challenge rather than a formula: “ Use your common sense and
k t youf conscience be your guide. You will be required to keep
accurate and complete records o f all your activities and t o ™
monthly progress reports which are based on these records. Ihe re
ports and the individual record cards on file m your office will be
open to inspection for purposes of analysis and study at all times.
Your local public has a right to know what you are doing. It is
obligatory that the State board o f health be informed with regard to
' your activities. I f you succeed in setting up and maintaining a wellbalanced urogram you will unquestionably win the applause of your
pubhc dFurBi^more the headquarters office will study and analyze
your records in order to acquire something tangible, something more
nearly approaching a formula o f administration for county health
work to set before those health officers whose records do not compare
favorably with yours. I f you do not succeed m making these hne
adjustments satisfactorily you will drift into the position of a
follower instead o f a leader while the achievements o f your more
successful colleagues will be set before you for your emulation.
From the first it has seemed to us that the most we can hope to do
is to provide a system o f record keeping and forms for reporting
activities which will tend to maintain a desirable degree o f clarity
and provide us with the means o f evaluating accomplishments. A
schedule for making these evaluations will need to be worked out,
190
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Federal Reserve Bank of St. Louis
ALLOTTING TIM E TO MATERNITY AND IN FAN C Y WORK
191
and before it can be successfully applied it must have the under
standing and approval o f the county health officers as well as o f the
State board o f health forces. This sounds perfectly simple and
very easy, but in actual practice it has proved to be about as easy as
measuring the energy expended by Atlas in bearing the world upon
his head, and perhaps as simple as reducing to a formula the por
trayal o f a sunset on canvas.
The staff o f the State board o f health includes a corps of regional
directors whose duty it is to provide stimulating contact and con
tinuous educative supervision o f the county health officer’s work.
One o f the first achievements o f the maternal and infant hygiene
program must be enlisting the interest o f the regional directors
(as well as that o f the State health officer) in this program and
convincing them o f its vital significance when successfully carried
out as a part o f the general plain.
Our first objective was a uniform blank for reporting all county
health activities in order to permit comparison o f results and to
eliminate the use o f a supplementary maternal and infant hygiene
report (such as had been required during the first year’s operation).
These blanks must carry items adequately covering maternity sub
jects without unnecessary details which would increase the labor
without increasing the value o f the report. It seemed advisable
to include a statement o f the estimated number o f miles traveled and
the number o f hours devoted to maternal and infant hygiene work.
It is a policy o f the State board o f health that efforts toward
standardization ^o f method shall grow so far as possible out of
actual practice in the field and not be arbitrarily designed and ap
plied to the field by the headquarters office. As a result of this
policy and o f the important part which custom plays in the ques
tion o f reporting public-health activities three years elapsed before
a uniform report was brought into use throughout the State.
Case record cards were selected and supplied, the use o f which
provides official evidence of the facts reported. Explanatory defini
tions o f the items occurring in the report form were put in the
hands o f the county health officers. The county health officers
adopted this blank for reporting activities in its present form at
their 1925 conference. Two systems o f evaluating county health
work have been put before the conference and have been taken under
consideration.
One is the well-known cost-credit' system originated by Doctor
Rankin, o f North Carolina. The other is a schedule o f ratings or
points assigned to the various phases o f public-health activity, known
as the Toledo schedule. About all that can be said of either o f
these is that they offer a suggested system o f rating public-health
work. They have been tested tentatively and in a limited way in
Alabama. The cost-credit system has been found useful in convinc
ing appropriating bodies o f the money value o f health work. Rat
ings achieved according to the Toledo schedule greatly interest and
stimulate technical workers and lay people who take an intelligent
interest in health conservation. The points allowed in this schedule
for various types of work are arbitrarily fixed. The present schedule
is under test, and at some future conference o f health officers there
may be set up a system o f credits which meets the approval o f the
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Federal Reserve Bank of St. Louis
19 2
PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
combined State and county health forces. This will provide a basis
upon which it will be perfectly fair to rate health administration.
I have been trying to lead up to the statement that the amount o f
time to be spent may be determined by properly balancing the pro
gram and going after results in this most vital and fundamental
field. I believe it a mistake deliberately to start to divide time when
an eminently more inspiring motive for the day’s work is to be
found in furthering a vital feature of the program. When the day s
work is done the workers should record on its appropriate card every
item o f service rendered. Those items which are included in the
field o f maternal and infant hygiene should receive a notation o f the
estimated period o f time occupied by them, and to this should be
added a proportionate allowance of the time devoted to travel.
When the office secretary checks up all items for the monthly report
she has only to add the hours devoted to maternity and infancy for
inclusion in the report. That this record is likely to fall far short
o f accuracy is admitted without argument, but it seems to us that, in
any attempt to make a division of time the primary object in plan
ning the day’s work would itself defeat the purpose of the days
work.
. ■
■
We are not unmindful o f the serious defects which occur in the
recording and reporting o f activities. Many o f our most enthusiastic
and tireless workers are slow to acquire the habit of keeping an ade
quate record o f their activities; few have learned to analyze the rec
ords of their office and draw from them significant deductions. Yet
in spite of the many difficulties connected with record keeping and
report making we are convinced that the only criterion by which a
piece of work should be judged is that o f tangible results or definite
accomplishments. Every claim o f this sort set forth in a report
should be soundly supported by individual and case records in our
files. We further contend that the time element enters into this
project only incidentally and is worthy o f study only in the interest
o f administrative efficiency.
Since I was asked to present this subject at our conference I have
made a supervisory visit to three health units, and in each o f these
I asked the health officer to show me how he attempted to determine
the amount o f time spent in maternal and infant hygiene work, and
how, when planning his program, he attempted to determine the
amount o f time to be spent in this phase of work. In all three of
these the nurse recording her work at the end of the day made a
notation o f the time which she spent in maternal and infant hygiene;
and the health officer intended to do this also but stated that it was
sometimes overlooked. In one o f the counties the health officer in
planning his program had made a fairly clear division of the nurse’s
time between major, minor, and incidental duties; and these were
set down in tabular form opposite the calendar months. The duties
set down in major and minor columns were maternal and infant
hygiene, school hygiene, tuberculosis control, and antityphoid inocu
lations. No attempt was made to designate incidental duties. The
two months at the beginning o f the school year showed_ school work
in the major column with a combination o f the others in the minor
column; two months o f the early spring showed typhoid inoculations
in the major column; and in the other eight months it was planned
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ALLOTTING TIM E TO MATERNITY AND IN FAN C Y WORK
193
that maternal and infant hygiene work should be the major activity
o f the nurse with school follow-up and tuberculosis calls combined as
minors with it.
I will sum up by saying that our county health forces need the
stimulus o f a logical evaluation o f the work th ej are doing, partic
ularly o f the maternal and infant hygiene work. In this evaluation
the question o f time spent and miles traveled should receive due
consideration; but because these mechanical considerations seem to
have a dispiriting effect on the health workers their importance
should not be overemphasized.
Only work intelligently planned, conscientiously performed, and
accurately recorded is worthy o f the profound analysis and study
which leads to convincing presentation o f matters reported. Future
progress in the development o f satisfactory technique in publichealth work depends upon the amassing of trustworthy and signifi
cant records and the establishment o f recognized measuring rods by
which comparative values may be reckoned.
Alabama is struggling slowly toward such a system o f evaluation
for county health work but feels very much alone and unaided in
the task. I believe that our policy of trying to build upon the
basis o f actual experience in the field is sound and that any system
to be successfully operated must have the approval and concurrence
o f the workers whose success is to be measured by it. I suggest,
however, that the Chief o f the Children’s Bureau be asked to appoint
a committee to give further study to this important question and to
present if possible some definite recommendations concerning it at
our next conference.
The C h a i r m a n . The next subject to be considered is the cost o f
separate items o f work. Doctor Gardiner o f New York will talk to
us about this.
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COST O F S E P A R A T E IT EM S OF WORK IN A M A T E R N IT Y
AND IN F A N C Y PROGRAM
By
E l i z a b e t h M. G a r d in e r , M. D., A
M a t e r n it y , I n f a n c y , a n d
C h il d
H e a lth , N e w Y ork
c t in g
H
D
ir e c t o r ,
y g ie n e ,
D
D
iv is io n
epartm ent
of
of
In the few minutes assigned for this subject I shall not dwell at
any great length on the reasons for needing to know the rate o f
expenditure for different types of work. Suffice it to say that one
or two circumstances arising o f late have seemed to sharpen our
interest in it greatly. One was the question arising in our division
o f administration as to whether a certain piece o f work was in fact
worth what it was costing; and the other was an eleventh-hour noti
fication that we were spending several thousand dollars too much
for another phase o f work and at the same time being committed in
such a way that we can not gracefully or even wisely withdraw.
Such a disturbing situation would not have arisen had we been con
stantly informed as to the rate of expenditure and the balances on
hand out o f the budget allowance for that item.
Cost accounting is a highly valued asset in any business, and we
should by now be in position to compare costs for the same types of.
work in different parts o f the country. Therefore some parallel
cost system, I believe, should be instituted in order that our findings
may be comparable.
It is only in the hope that such action may be taken by this con
ference and that a committee may be appointed by the Chief o f the
Children’s Bureau to deal with this need that I have consented to
attempt a presentation o f this subject, which I do not feel that we
in New York State have dealt with at all adequately thus far.
However, our attempt to secure cost figures has already brought
about two good results. The auditing department has assigned a
full-time accountant to our work alone and has evolved a plan for
giving us the information we need. You have been handed some
sheets showing cogt o f different activities for the past six months.1
Those are estimates, not actual figures. To have ascertained actual
cost for even six months under our present system, particularly at
this season o f the year, would have imposed too great a burden on
our already overtaxed auditing department. Consequently these
figures are not actual computation, although they are, I think,
fairly accurate.
On the first three sheets you will notice the 10 items according to
which we budget to the bureau. The only item which needs analysis
is that o f salaries. Those have been classified as “ administration ”
and “ field.” W e have several more office clerks and stenographers
than are shown under administration, but they are included under
field because their work has to do entirely with certain field activities.
1 Copies of the tabulations discussed in this paper can be obtained from the division
of maternity, infancy, and child hygiene, department of health, Albany, N. Y.
194
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COST OF ITEMS IN A MATERNITY AND IN FAN C Y PROGRAM
195
Several o f these groups have duties contributing to various kinds o f
work; for instance, consultant nursing service. These nurses deal
with five services or activities: ( 1 ) Supervision o f Sheppard-Towner
nurses; ( 2) inspection and supervision o f local child-health centers;
(3) conducting maternity-hygiene classes for nurses; ( 4) the or
ganizing and teaching of mothers’ health clubs; and ( 5) general
promotion o f maternity and child hygiene. Consequently, where we
have under the item o f salaries a means o f estimating the cost o f
consultant nursing service as a whole we also find that service dis
tributed among special activities o f the division. The same holds
true o f general-duty nursing service, so that we must get right down
to activities and determine those for which we need specific cost in
formation and decide just what elements enter into that cost.
You will find listed our activities and the items entering into their
cost. Let us consider those activities and the items about which there
might be a question:
1. M idwife regulation.— This is the only activity to which is
properly chargeable any large amount for printing and postage
because we do not use the frank and there is much special-delivery
and registered mail. Occasionally supplementary nursing service is
added because new plans for the year involve part-time assistance
from general-duty nurses, so that salary and travel should be
reckoned here proportionately.
2. GMid-health conferences or consultations.— The only unusual
item here is follow-up service—this also out o f general-duty nursing.
In the last six months 115 working-days were given to this activity.
Two cars here are needed, one for the unit itself and one for the ad
vance agent; and probably in 1926 part-time car expenses for the
follow-up nurses will be added.
3. Prenatal conferences or consultations.—Here, too, is additional
nursing service for follow-up or demonstrations.
L Demonstrations. We hope to get here, in the case o f Fulton and
Tioga, not only the cost o f operating but also the cost o f establishing
the demonstration. General-duty nurses will be assigned from time
to time to each o f these two demonstrations and their salary and
expenses charged to them. If, however, their visits are for the pur
pose o f instruction—that is, to shape them up for field d u t y then such cost should be charged to observation visits, which we will
touch upon later.
For the Tioga demonstration we have the added cost o f direction
by the Maternity Center Association.
h. Oormrmmty whole-time 'public health nursing demonstrations
( Wheatland, Easthampton, La Salle, and N orfolk} .—Here the travel
expense is not local (which is assumed by the community), but refers
to that incurred through coming to Albany for conference or attend
ance at the Sanitary Officers’ Conference once a year.
6. Gormmu/riity part-time public health nursing demonstration.—
x*-^11,®1really includes 24 demonstrations. In this case the cost would
be bunched ; but note “consultant nursing service ” travel and
expense.
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
7. Gomrmmity demonstrations.— Child-health conferences, 21 dem
onstrations. This also is “ bunched.” These conferences are held
regularly twice a month and the cost estimated collectively.
8. Convrrmnity demonstrations.— Child-health conferences, twice
yearly— so-called “ Type C ” plan; 13 of these figured collectively.
9. Community demonstrations.— Child-health conferences, Type C,
county-wide, 66 communities. These are a class by themselves and are
sponsored by county medical societies who appoint the physicians
and determine the places where the conferences are to be held. They
represent a new development and a very important one to continue,
and because they were undertaken much more readily than antici
pated they caused us to overspend our budget allowance.
10. M aternity-hygiene courses amd mothers’ health clubs. Here
we have the proportionate salary and travel o f consultant nurses
and a portion o f demonstration material cost charged.
11. Observation visits.—Although we engage^ as highly trained
personnel as possible they must have opportunity to keep abreast
with the newest and best practices. On the other hand, estimating
cost o f this term will show whether we are expending too much for
educating individuals already well qualified.
Exhibit material is an item to be estimated as a whole separately
and then distributed among maternity-hygiene classes, mothers’
health clubs, fairs, and loan service to local nurses.
A word as to the use and abuse of cost figures. The question we
meet from the outside is not merely “ What does it cost?” but Is
it worth what it costs?” The cost in dollars or per capita in dollars
alone does not tell this. This is a matter for real judgment into
which must enter the factors of distances traveled, the type of
population dealt with, the newness of the work, the receptivity to
ward it, the degree of popular ignorance or knowledge concerning
it, or the attitude o f the “medical profession toward it. The need
o f the work is the first consideration. Often in the face o f a seem
ingly high per capita cost there is a consistently progressive growth
o f such factors as appreciation o f and demand for the service by the
public, an increasing use of the service by patients and physicians,
better cooperation on the part o f the recipients of the service, and
evidence o f penetration o f the educational phase of the work.
It would be an abuse o f cost figures to give them out to the general
public without informing that public as to the underlying factors
involved; therefore, if we do engage in a careful estimation o f costs
o f different types o f work, such figures should be used publicly only
when due value is accorded to the difficulties encountered in under
taking any piece o f public-health work.
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DISCUSSION OF TH E P A P E R S OF T H E AFTERN O O N
SESSIO N
Doctor R i c h a r d s . I notice in Doctor Gardiner’s budget that in
some places she has allowed $15 per day for a local physician to
on child-health conferences. Does that in any way avoid the
difficulty o f having a local physician volunteer his seryices? In
Utah we have considerable difficulty in getting local physicians to
carry on these child-health conferences themselves, and we are not
offering, or have not offered, any compensation. I wonder whether
the giving o f a small fee o f that kind does solve some o f those
problems.
Doctor G a r d in e r . I think it is the general feeling, particularly in
ik ¡Fast, ^ a t physicians should be paid for their work i f you have
the funds. I could not say whether paying the physicians lessens their
willingness to do the work free. There is in New York State quite
a feeling against so-called “ State medicine” ; and I think if any
thing has served to abolish it, perhaps it is the organizing of these
type C consultations on a county-wide basis. That is a new de
velopment. It started at a suggestion from the office in Yates
County. I think they held 10 or 12 consultations in various parts
o f that county. There was a question o f local competition coming up
m that particular community, and in order to obviate that the
medical society appointed men to work in other towns or villages
than those where they resided. Those consultations have been re
peated on the twice-yearly plan, and just before I came away they
invited me to come to an annual meeting in Yates County, where
we were to hold a symposium on the defects found among the children examined. That is a real advance. Perhaps the $15 enters into
the willingness o f the physicians to serve; but once they have gotten
into the habit o f doing it I believe they would not stop if thev did
not receive the $15 per day.
Another county which previously had not been cooperative or
ganized 23 consultations during August and September, and the
nurse who reported on that work was very much impressed with the
conscientious and careful examinations that were made. She said
the physicians showed entire willingness to do the work according
to the standards we had suggested.
We send around in advance of these consultations a little set o f
suggested standards, and they carried out the technique o f our own
State unit just as far as it was possible under rural conditions. I
believe you would find those men working again next year to repeat
^ a®6 consultations, whether they received $15 a day or not.
Mrs. R e i d . I should like to ask Doctor Gardiner if they use local
physicians for those conferences and how they select the physicians?
Doctor R i c h a r d s . T o guard against possible confusion—my ques
tion was the same, except that I also ask whether you did not ask the
medical societies to appoint your physicians ?
Doctor G a r d in e r . Do not confuse these with our own units. We
have a unit for consultation, for child-health conferences; these
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PROCEEDINGS, M ATERNITY AND IN FAN CY CONFERENCE
others are appointed in various ways. Most of the regular ones are
held twice a month, which we call type A and type B. The physi
cians for these are appointed by the mayor or the local health officer,
supposedly with our approval as to their qualifications. I do not
know that we have ever signified our approval in any case, and I do
not know that it has ever been asked. They just appointed them
anyway. But the county-wide consultation is sponsored by the
county medical society. They appoint the physicians and indicate
places where the consultations are to be held, and only on that basis
will we give a county an allotment. For instance, our district State
health officer may say, “ I believe I can accomplish this with such
and such a county society. How much could you let us have ? ” I
say, “ W e can let you have to the extent o f $800 for the first con
ferences. You can not spend any more than that, and it should be
spent at the rate o f $15 a day for the examiners.” We figure that
the examining physicians ought to examine at least 10 children
apiece. A t one time we gave a $15 allotment grant to a community,
and they happened to have only 49 children to examine and 7 physi
cians had been engaged. That, of course, was ridiculous. So now
we specify a four-hour clinic period, and the examination o f at
least 10 children by each physician.
Doctor M o C o r n a c k . Just a point about holding these clinics. I
think the itinerant clinics are extremely important, but we found
that people do not wish to be examined by their own physicians.
You know a “ specialist” is just an ordinary man 10 miles away
from home, but people do not wish the local physician to look over
their babies at a child-health conference. He can look them over any
time; whereas I can go into a community 100 miles away from home,
or even less, and have 75 babies come into the clinic in one day. Then,
with the local physician working at one table and myself working
at the other, I examine 50 o f those babies, and he will get about
15 o f them. That is not because I do the work any better than he
does but because the parents almost* always prefer some physician
from outside.
We have our State divided into the east side and the west side, and
we have tried as nearly as possible to get the pediatricians on the
west side (Seattle and Tacoma) to come over to the east side and do
our examinations and let the west-side men go over there. That
does two things. It gives the people some one away from home,
and it helps the local physicians tremendously. I f I travel 400 miles
to conduct a clinic the local physician knows that I am not doing
it from the standpoint o f working up private business for myself,
and I think that is important.
A point in regard to the length o f time given to the clinic was
brought out this morning. A t first we had a feeling that the more
babies we examined, the wider our work, and the greater thing we
were doing. I went into one town that was very well organized, and
in three days I personally examined 300 babies. That was entirely too
much. It was not only pretty hard on me, but if you examine 100
babies a day the confusion is too great, and the mother is rushed
through too rapidly. Although I think the physician’s trained eye
will see everything that should be noted in those babies—I do not
think I missed anything— it is done so rapidly that the mother is
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DISCUSSION OF THE PAPERS
199
not well satisfied. Now at our clinics one physician has two nurses
working with him. One nurse sits at a table writing on the record
sheet every word he utters; the other nurse works between the dress
ing room and the table, keeping them going and coming; and with
this aid one physician can really examine 50 babies thoroughly. This
assumes that he works from 8 a. m. until 5.30 p. m., doing it well and
during that time giving^ the mother a little personal instruction.
What she wants in the clinic is for you to tell her that this baby is
or is not all right and talk to her in a very confidential way for
just^ a few minutes. Even i f it is only two or three minutes she
realizes that she is really getting something more than being told
as the baby goes off the table, “ Baby is all right.” She is not satis
fied with that. I am sure that if we go in and stay two days we do
very much better work than i f we go into a town and do 100 babies
in one day.
Mrs. R e i d . May I ask if the cost then should be the cost o f travel
plus $15 a day? It would be travel and maintenance then, would
it not?
’
Doctor McCornack. I guess we have been pretty liberal. In our
office there are two o f us, who have been helping the State depart
ment. W e have gone over the State for two or three years now and
have not charged anything at all for our time. Our traveling ex
penses are paid. W e figure in our office that this is part o f our
contribution to the community chest, and we owe it to the community; and so far we have not demanded anything for our time ex
cept our traveling expenses.
Doctor N o b l e . I should like to ask if that rate, 50 babies a day per
examining physician, can be kept up day after day.
Doctor R i c h a r d s . I am going to say no. I have tried just about
such a program, and I believe I am pretty well able to say. As
I have already said, our work is entirely itinerant, and we have
planned holding these conferences with the local committee making
arrangements two or three weeks ahead. Many communities in which
we have held conferences are very small—we will say 200 or 300
population with no physician within 25 or 30 miles. I may mention
one little experience:
We had a day that we could spare, for which we had made no
definite plans, and there were two nurses with me. W e told a
neighboring community, just a little village—if any o f you go
to Zion Canyon you will pass right through it— called Rockville.
We told them that we would spend a day with them; and, not know
ing exactly what we were going to run into, we went to the little
village church at 9 a. m. I sat down in front o f the table with a
sheet oyer it, with two nurses making out records and weighing and
measuring. I worked from 9. a. m. until noon, then had a bite to
eat, and worked until 5. p. m.; and I had examined 80 children. I
want to tell you now it was one o f the hardest jobs that I have ever
done in my life, and i f I am out on these itinerant trips for two or
three weeks, carrying on a program not so rigid as that, yet making
from 25 to 40 examinations a day, I simply must go on the shelf
for repairs. 1 can not keep it up. One gets so tired o f a stetho
scope in Jus ears, so tired o f the din o f hearing those children cry,
and so tired o f the same questions and o f telling the mothers the
same thing that—well? i f I were not a man I would get hysterical!
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
The C h a i r m a n . That is the reason we have so many women pedi
atricians. [Laughter.] I don’t know how Doctor McCornack stands
quite so many. I might tell you a little experience of Doctor Smith’s.
When she came to Michigan, the first afternoon they rushed 75 babies
in to her, yet she lived through it. But there is a question whether
there should be a limitation on the number o f babies to be examined
in one day in the clinic or in a conference.
Miss O s b o r n e . May I bring out one point, that the more people
you get to help you work, the less you will have to do? We enlist
the aid o f committees such as have been mentioned to register and do
the other clerical work, get supplies, clean the rooms, and leave the
place in order. In most instances the county health officer, who is
the director o f the unit, i f there is a unit, invites every physician in
the county. I f there is no unit, we send a letter to every physician
in the county referring him to the part-time, health officer, and then
the nurse or whoever may go there calls upon him. That helps a
great deal. Perhaps at the conference we have four physicians and
a dentist, and the children go through a piggly-wiggly. A t the last
moment either the nurse or a physician will talk to them, and two
other people help to make out the slips.
Doctor N o b l e . D o you not think that if we try to work with num
bers and feel the rush of the crowd behind us we are going to lower
our standards very materially and that it is a great deal better to keep
our standards up and make fewer examinations?
Doctor M c C o r n a c k . But when you go into a community with 150
babies registered and have only two days in which to examine them,
what are you going to do ?
Doctor
N
oble.
Do it by appointment.
Doctor M c C o r n a c k . Yes, but they have already made 150 appoint
ments for two days.
Doctor S m i t h . May I answer that? We have itinerant clinics in
Michigan also, and when we attend our clinic we send a requirement
sheet ahead in response to the call for the clinic. That sheet states
that 30 babies a day is the maximum we can take care of, and al
though they may have more than the 30 registered we will take only
the first 30. Occasionally we do run over to possibly 35, but we think
30 babies a day is all that one physician can handle well.
Doctor G a r d i n e r . We feel that they can not handle that many.
W e were handling 40 children with two pediatricians working from
9 a. m. to 6 p. m. almost every day, and they asked to have the num
ber reduced. W e have reduced it to 16 or 17 examinations apiece,
because they felt they could not examine more than that satisfacto
rily. I think part o f our aim in consultations o f any kind is to teach
what constitutes a good physical examination for the children. That
is the thing that is going to awaken public demand for the work;
and that is exactly what the physicians want to know, too. I do not
see how you can examine 80 children.
Doctor B l a c h l y . In Oklahoma I started out by stating em
phatically that I would examine 20 children per day. I got that
suggestion from Doctor McKay at Albany, N. Y., and we have made
it distinctly understood that we do not want quantity but we do
want careful, thorough physical examinations. I believe that the
average o f 20 minutes spent in talking with the mother has been well
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DISCUSSION- OF THE PAPERS
201
worth the time. The mothers’ criticism that comes to me from all
over Oklahoma when the other physicians are making the examina
tions is always that they took too little time and. hurried it over too
much; the pediatricians that examine for me and take more time
always win the hearty support and cooperation of the mothers.
Doctor Gardiner is right.
* -M-iss O sborne. I think the aim o f these child-health conferences
is to get the people to go to their family physicians. Is it not there
fore important to have the family physician present?
Doctor G ardiner . Yes; if we can get him.
Doctor S c hw eitzer . I have one suggestion that we found helpful.
In a community where we found the people mumbling under their
breath about what physician was going to examine their respective
children we worked out a relay system. The State physician would
take a certain part o f the examination, and if we could locate a man
who had given special attention to eye, ear, nose, and throat work,
we said, He will examine all the eyes, and the next man will make
all the ear, nose, and throat examinations, and we shall take general
physical.
That gave us a chance to talk to the mother about diet
or anything else. She was perfectly satisfied, and by having the
workers relay the babies, i f the weighing and measuring was all
done beforehand, we examined a large number o f children very
easily.
J
Doctor R ichards . I think we are talking about two different
t mgs. One o f us is talking about the ideal, and the other is talking
about what we actually have to do.
Now I think all are absolutely willing to say that no physician
can examme and do justice to parent and child if he takes less than
ZO to 25 minutes to do i t ; but in regard to my situation and in that
o f dozens o f the others also, I am asking the same question—what
are you going to do ? I had 75 children. I f I turned away 50 o f those
children and went out o f that community somebody was going to be
angry about it; after you get accustomed to making those exam«
inations it is surprising how rapidly you are able to go over a child
for the, say, self-evident defects—and you can not do much more. It
has been my observation in my work that if you can sit down then
and talk to the mother a minute or. two about her child she is more
satisfied than if you spend half an hour examining her child That
may not be the general thing, but I think that you must take into
consideration the circumstances you have to face. I am the only one
doing this itinerant work throughout the State o f Utah, and i f I
put a limit o f 20 children on my activities— well, I know what would
happen to m e!
Doctor K oenig . In Arkansas we have had the same experience that
Doctor Richards has had. We have mothers bringing their children
10, 20, and so*metimes 30 miles, and we have from 150 to 400 people
at our conferences. Sometimes they take it as a carnival affair, and
the way we have done then is to try to get over a large group. We
would take one child from the family, letting the mother select
the cmld that she wanted examined. In taking the family history
one o f our three nurses can give the mother a great deal o f informat11^ theT\ W
^,e?1 ^ baby comes to my table and I examine the
child 1 can take chiefly the medical part. I think the greatest num-
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
bor o f children I have ever done in that way was 65, but that in
volves working long hours.
One thing we have done in the communities having only a oneroom school where we have to hold our conferences ^in this one
room. We have a table in one corner, a history table in the other,
and then have our sanitary exhibit occupy almost one whole corner
o f the room. This we carry along with us, and our chauffeur puts
it up. Our nurses alternate in explaining that exhibit while X am
going on with the history and talking to the mothers. In numerous
instances we have had to give what we call “ group demonstrations
because, you know, those country people are inquisitive. When we
take a child into the examination room we can not send the people
outdoors; sometimes we nearly have to lock the door to keep
them out so we can do our work. So we have them sit around and
see a group demonstration, the small children being sent outside.
In that way we can give quite a little instruction to the community,
and when we have just one day we want to give those mothers all
that we can. I know I can examine all the way from 30 to 50 chil
dren a day, and average 32 to 35. We have the child right there in
front o f the whole group—we protect the child carefully with a
towel. The farm and home demonstration agents undress^ the chil
dren and take them back and forth and dress them again, so we
do not lose very much time.
.
.
Doctor K r a ij s e . I am going to tell you how Missouri does it. It
is not much different from the West. We have about the same
problems. Our first day’s clinic is pretty well packed, and we have
to work fast, but we do this one thing: Where we find a child really
in need o f examination, in that little rural community, we schedule a
time for that child the next day. In other words, we allow two days
where we used to allow one. We tell that mother: “ You may bring
this child in tomorrow at 9 a. m.” We schedule nothing else for
that time.
For the next one we pick up that we feel shows a real complica
tion or is in need o f a more complete physical examination we say,
“ You come in at 10 or 10.30 a. m.” We have two physicians work on
the clinic—that is, two from the staff and two nurses— and o f
course we handle an average o f about 80 to 90 children through the
first day’s clinic 5but we do not handle more than 15 the second day
and some days not even that many.
_
We use that second-day clinic for another purpose too, in addition
to trying to render a real service by complete diagnosis. W e ask
the mother who the family physician is. There may be one or two
physicians in that community. I f there is only one we have him
there with us, but if there are two and their business is such that
we can’t have them there all the time, we go around and see the
physician again and tell him, “ We ran on to one o f your cases to
day, little Johnny Jones. We went down the line and examined
him to-day, and we think we may have found a heart complication.
W ill you come over and help us?” When he comes over he learns
the value o f consultation service. W e have very little opposition
from our physicians and usually have them there assisting us the
first day.
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DISCUSSION" OF THE PAPERS
20 3
But we can not get away from running a vast number through
our average first-day clinic. When we first started the work we
would allot a week to a county with six clinics for the county We
have the same number o f clinics now, but we allot two weeks to the
county; m other words, we give the county a little more, spending
a longer time; and instead o f trying to scatter the work over 114
counties in one year maybe we can do only 20 counties this year, or
25 counties this year. We are trying to pick more o f the rural tvpe,
because we have good physicians in St. Louis, Kansas City, St.
Joseph, Springfield, and other places where they can get special
service if they want it; but in about 60 counties in the State there
are very few physicians, and that is where we give our complete
physical examination in our second-day clinic. It is the real diag
nostic clinic. O f course we miss cases—we are bound to miss them,
running through so fast; but we do the best we can, and that is what
we want to do.
The C h a ir m a n , T wo recommendations have been made this after
noon. One was that the Chief o f the Children’s Bureau appoint a
committee to determine the amount o f time spent in maternity and
work when matching funds used in a generalized program:
and the other that a committee be appointed to map out some way o f
the cost o f separate items o f work. What is your pleasure
with regard to these two recommendations?
Miss M arriner . I move that the Chief o f the Children’s Bureau be
asked to appoint a committee to take under consideration the question
o f evaluating the maternity and infancy work o f the generalized
program.
®
Doctor Gardiner . I second the motion.
[The motion was put and carried.]
Doctor G ardiner . I move that the chief o f the Children’s Bureau
be requested to appoint a committee to take under consideration the
evolving o f a proper accounting system to give figures on separate
items o f work.
r
Miss M arriner . I second the motion.
[The motion was put and carried.]
The C h a ir m a n . We still have the report o f a committee on the
cooperation o f physicians, o f which Doctor Veech was chairman
Doctor V e ec h . This committee was appointed last year to look into
the cooperation o f the medical profession with the work under the
maternity and infancy act. In going over the reports that came from
the various members o f the committee before I came here I found
their response most heartening. They showed a better understanding
on the part o f the medical profession in their own States and those
they knew o f m regard to what we are trying to do under the act,
and full approval o f the work undertaken in most places. The reports from the various States here have indicated full cooperation
o f the medical profession, as you have heard. It seems to me there is
little else to be said about it.
The C h a ir m a n . What will you do with this report ?
Doctor B l a c h l y . I move that the report be accepted and the com
mittee discharged.
[The motion was seconded, put, and carried.]
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PROCEEDINGS, MATERNITY AND IN FAN C Y CONFERENCE
Doctor L a g e r . There is one thing I would like to mention as
probably expressing the sentiments o f this gathering. I find when
I come here every year that in looking at the exhibits and seeing the
things which have been published I always discover any number
o f things that are o f supreme interest and value to me, that I, o f
course, had not seen. I should like to present in a resolution that it
is the sense o f this gathering that the various State divisions be
urged to obtain a mailing list o f the other divisions and to send their
printed matter and publications (at their discretion) to all the other
divisions. I realize they would not care to send certain confidential
matters, but sometimes they do not send things because they think
they are insignificant. Now I found two very small things—I am
quite sure that the directors never thought o f sending them—that
were o f immense value to me. I think that i f we could get the
divisions to do this it would be very helpful. The divisions should
be careful to have the correct addresses to which to send such mate
rial. I fear I lose a good deal because it is sent to the State depart
ment o f health, which is at Des Moines, whereas the office o f the
director o f the division o f maternity and infant hygiene is at the
State University at Iowa City.
Doctor B l a c h l y . I second the motion.
The C h a i r m a n . Doctor Blachly seconds the motion that it is the
sense o f the conference that we should have an interchange o f your
literature and other material and that a proper mailing list should
be obtained. I will say for the Children’s Bureau that we will see
that each State receives a correct mailing list.
[The motion was put and carried.]
Is there any other business ? I may add that you had a program
committee last year, and that committee is partly responsible for the
program that you have had at this conference. It has made sugges
tions, and you yo'urselves have made suggestions. A t the very last
your chairman was not with us, nevertheless we have profited by the
criticisms o f last year, and I am sure we should like to profit by them
for next year. I have one criticism myself. We have been just a
little bit hurried; we had perhaps too full a program. Yet there
is much to consider, and we meet only once a year.
It seemed to me this morning that Doctor Schweitzer opened one
question that we have not touched, and that is whether we wish to
have something next year on embryology and biology in relation to
neonatal deaths, and something on nutrition in relation to neonatal
deaths—because I feel that we shall not get entirely away from the
neonatal deaths until we realize that the baby who dies in the first
month o f life dies, as Doctor Knox said yesterday, from inanition
and debility, according to the death certificate.
We have a guest with us, Dr. Taliaferro Clark, director o f the
division o f child hygiene o f the United States Public Health Service.
I wonder i f Doctor Clark will say a word to us ?
Doctor C l a r k . Ladies and gentlemen, it is a very great privilege
for me to be with yo'u. I have not been able to attend as many o f
these meetings as I would like to have attended.
It would be superfluous for me to attempt to tell those o f you o f
such vast experience in the field something about child hygiene and
how to do the work, because no one realizes better than I do that
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DISCUSSION OF THE PAPERS
205
t o b f rnU
rVpTni +dKVidUal P 7 blemsTpeculiar to your States that have
T¿ ,
S
b y I ° Y r.Se?ves; ^ is a matter o f evolution. Bht
I do want to tell you that it is o f great value to those o f us in adminibpr tnVe au.thoriy
Washington to have you gathered here from
how you S
them 6 COmpass’ dlscussing your problems and telling
I am not going to make you a speech. I am going to make iust
one announcement, namely, that I have been relieved f r Z cldldhygiene work (effective on the 19th o f this month) to go to Europe
for a three-year detail, where I shall have charge of th f supervision
of the United States Public-Health Service activities onT h e con
1JTbp pld the British lsles, and tbls 1S in the nature of a farewell,
in e c h a i r m a n . Is there anything else that you wish to talk about
Z ’ or^ ould y ° u rather talk to one another?
Mrs. K eid. I should like to make a motion that I am sure is the
¡SPS 0p i b1^ me?tlSg : T hat we offer our sincere thanks to the Chief
o f the Children s Bureau, the director o f the maternity and infancy
division, and the others in the bureau who have made this conferencl
and-everything pertaining to it possible for us.
sine dfe ?udience rose’ wlth aPPlause. The meeting then adjohrned
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A P P E N D IX
L IS T O F PE R S O N S W H O A T T E N D E D T H E T H IR D A N N U A L C O N F ER E N CE O F S T A T E
D IR E C TO R S O F T H E A D M IN IS T R A T IO N O F T H E A C T OF CON GRESS O F N O V E M
B E R 23, 1921, F O R TH E P R O M O TIO N O P T H E W E L F A R E A N D H Y G IE N E O F M A T E R
N IT Y A N D IN F A N C Y .
Alabama
Jessie L. Marriner, R. N., director, bureau o f child-hygiene and public-health
nursing, State board o f health.
Arizona
Mrs. O. R. Howe, director, child-hygiene division, State board o f health.
Arkansas
Margaret Koenig, M. D., associate director, bureau o f child hygiene, State
board of health.
California
Ellen S. Stadtmuller, M. D ., director, bureau o f child hygiene, State board o f
health.
Colorado
Mrs. E. N. Mathews, executive secretary, child-welfare bureau, department o f
public instruction.
Connecticut
Elizabeth A. Ingraham, M. D., director, bureau of child hygiene, department
of health.
Delaware
Marie T. Lockwood, R. N., supervisor o f nurses, State board of health.
District of Columbia
Watson Davis, manager, Science Service.
Florida
Laurie Jean Reid, R. N, director, bureau of child welfare and public-health
nursing, State board of health.
Georgia
T. F. Abercrombie, M. D., State health officer, State board of health.
Idaho
Mrs. S. J. Ewen, supervising nurse, bureau of child hygiene, department of
public welfare.
Indiana
Ada E. Schweitzer, M. D., director, division of infant and child hygiene, State
board of health.
Iowa
E. H. Lauer, Ph. D., director, division of maternity and infant hygiene, State
University o f Iowa.
206
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APPENDIX
Kentucky
207
•
Annie S. Veech, M. D., director, bureau o f maternal and child health, State
board o f health .
Maine
Edith L. Soule, R. N., director, division o f public-health nursing and child
hygiene, department o f health.
Maryland
Gertrude Knipp, chief, division of public-health education, State department of
health.
J. H. Mason Knox, jr., M. D., chief, bureau o f child hygiene, department of
health.
Nina Simmonds, D. Sc., associate professor of ehemical hygiene, School of
Hygiene and Public Health, Johns Hopkins University.
Massachusetts
Robert L. D e Normandie, M. D., instructor in obstetrics, Harvard Medical
School.
Mary R. Lakeman, M. D., assistant director, division of hygiene, State de
partment o f public health.
D. A. Thom, M. D., director of the habit clinics of the Community Health A s
sociation of B oston; director, division o f mental hygiene, Massachusetts
Department o f Mental Diseases.
Michigan
Lillian R. Smith, M. D., director, bureau o f child hygiene and public-health
nursing, department of health.
Minnesota
Ruth E. Boynton, M. D ., director, division o f child hygiene, State department
o f health.
Mississippi
F. J. Underwood, M. D., acting director, bureau o f child welfare and publichealth nursing, State board of health.
Mary D . Osborne, R. N., supervising nurse, bureau of child welfare and publichealth nursing, State board of health.
Mrs. W alter McNab Miller, chairman, department of public welfare, general
Federation of W om en’s Clubs.
Missouri
Irl Brown Krause, M. D ., director, division o f child hygiene, State board o f
health.
Montana
Hazel Dell Bonness, M. D ., director, division o f child welfare, State board of
• health.
Nebraska
Louise M. Murphy, R . N., director, division o f child hygiene, department of
public welfare.
Nevada
Mrs. S. H. Wheeler, executive secretary, child welfare division, State board
o f health.
New Hampshire
Elena M. Crough, R. N., director, division of maternity, infancy, and child
hygiene, State board o f health.
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PROCEEDINGS, M ATERNITY AND IN FA N C Y CONFERENCE
New Jersey
Julius Levy, M. D ., consultant, bureau o f child hygiene, department o f health.
Neu> Mexico
Dorothy R. Anderson, R. N., director, division o f child hygiene and publichealth nursing, bureau of public health, department of public welfare.
New York
W illiam L. Chenery, editor, Collier’s Weekly.
Carolyn Conant Van Blarcom, R. N.
S. J. Crumbine, M. D., general director, American Child Health Association.
Elizabeth M. Gardiner, M. D., acting director, division o f maternity, infancy,
and child hygiene, department of health.
North Carolina,
H . A . Taylor, M. D ., director, bureau of maternity and infancy, State board o f
health.
North Dakota
Maysil M. W illiam s, M. D., director, division of child hygiene and public-health
nursing, department o f public health.
Ohio
H . E. Kleinschmidt, M. D ., director, division of hygiene, State department o f
health.
Oklahoma
Lucile Spire Blachly, M. D ., director, bureau o f maternity and infancy, State
board of health.
Pennsylvania
Mary Riggs Noble, M. D., chief, preschool division, bureau o f child health,
department of health.
Alice W eld Tallant, M. D ., gynecologist and obstetrician, Philadelphia General
Hospital.
Rhode Island,
Marion L. Gleason, M. D., director, division o f child welfare, State board o f
health.
South Carolina
Ada Taylor Graham, R. N., director, bureau of child hygiene and public-health
nursing, State board of health.
South Dakota
Clara Edna Hayes, M. D., director, division o f child hygiene, State board o f
health.
Tennessee
Dorothy L. Heller, M. D., associate director, division of maternal and infant
hygiene, department of public health.
Texas
H . N. Barnett, M. D., director, bureau o f child hygiene, State board o f health.
A . C. Mitchell, illustrator, State board o f health.
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APPENDIX
209
Utah
H . T. Richards, M . D „ director, bureau o f child hygiene, State board o f h e m ,
Vermont
Harriet M. Gardiner, R. N., field nurse, State board o f health.
Virginia
l
Mary E. Brydon, M. D „ director, bureau o f child welfare, State board o f h eel»,
Washington
P o f ' h S h rnaCk> M * D " assistant director, division o f child hygiene, department
W est Virginia
nursing, departm en?'o?heaftht0r’ dlvis,° n o f chiId hygiene and public-health
Wisconsin
nursing, Stete b S r d ^ h e a l t ^ 0^ bureau o f child welfare and public-health
Mchild Welfare "an^ p^bfic-^alt^^rsin^State 11b o /i^ o f health68’
°f
Wyoming
“ d
maternal and infant welfare
Federal Government
Viola6 Russell* Andereon^^MflD 8 (^p ert^’n ^nfalrt w
Health Service
f
Depaf tment <* Labor.
r’ dlV1Slon o f chlld hygiene, United States Public
statistics> Bureau of the
United States Depar t ment '
A
g n ^ K
divisi° n’ Childr^ «
^ ^ ^ ^
Bureau,
division, Chil-
fa n t-h y gien e^V isio n ^C M ld ^en ^s^i^ea ^^n ited
maternity and
Eleanor T. Marsh, specialist in n n h i i n S U , .ted S*ates Department o f Labor.
“ “
°n’ *“
fant-hygiene division,' Children's B urem f'thiited^^flt " V T ’ matel'riit5’ and inHenry Schultz,1 director
Uni,ted States Department o f Labor
Department o f L a t o
stetIstIcaI dl™ ™ . OhUdren’s Bureau, United States
1 Resigned Jan. 15, 1926.
o
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£.0 ', A ? ? 7
J
l
___________________________
U. S. DEPARTMENT OF LABOR
JAM ES J. D A V IS . Secretary
CHILDREN’S BUREAU
G R A C E A B B O T T . Chief
THE PRACTICAL APPLICATION
OF MENTAL HYGIENE TO THE WELFARE
OF THE CHILD
By
D. A . TH O M , M . D.
U 'N IV E H S F * OF B K L A H O A "
LIBRARY
S ep a ra te N o . 6 from P ro c e e d in g s o f the T h ir d A n n u a l C o n fe re n c e o f
S tate D irectors in C h a r g e o f th e L o c a l A dm in istration o f the M aternity
a n d In fan cy A c t , 1 9 2 6 .
P u b lic a tio n N o . 1 5 7
W ASH IN GTON
G O V E R N M E N T PR IN TIN G OFFICE
1926
FROM
I
T .
U N IT E D
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Federal Reserve Bank of St. Louis
P . Ö O H E
S T A T E S SENATOR
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THE PRACTICAL APPLICATION OF MENTAL HYGIENE TO
THE WELFARE OF THE CHILD
B y D. A.
D
T
, M. D., D ir e c t o r o f t h e H a b i t C l i n i c s o f B o s t o n ;
D iv is io n of M e n t a l H y g ie n e , M a s sa c h u s e t t s D e p a r t
M e n t a l D is e a s e s
hom
ir e c t o r ,
m e n t of
The first five years have an importance in the mental and physical
welfare o f the individual that no other period o f life can possibly
assume. For years you have all been concerned with ways and means
o f preserving the physical health o f the child, but only within the
last half decade have you been turning your attention to some o f
the vital problems which concern his mental welfare.
It is my privilege this morning to discuss with you very infor
mally some o f the conditions that may arise during the early years
which are fundamentally related to the intellectual and emotional
life o f the child and which may lead to much unhappiness and ineffi
ciency in later life.
Perhaps I can best cover what I have to say by answering three
very general questions: W hy is this preschool period important?
W hy is the mental health during this period so easily impaired?
Wherein lies the responsibility for the mental health o f the child o f
preschool age, and how may we devise ways for disseminating the
knowledge that we already have relating to the preservation o f
mental health?
We all know in a very general way why the preschool age is
important. It is the period when many physical and mental defects
can be diagnosed. It is the period when they first make themselves
sufficiently obvious to be recognized not only by specialists but very
frequently by laymen. Take for example the mentally deficient
group. Nearly all cases o f mental defect can be diagnosed during
the first four years o f life. It is most important to recognize mental
limitations early, so that some intelligent plan may be outlined,
thus permitting the intellectual equipment, poor as it may be, to be
utilized and developed to its full capacity.
Massachusetts has a rather progressive law for the purpose o f
recognizing and recording those individuals who are mentally de
ficient. The law requires that all persons three or more years re
tarded in the public schools shall have a psychometric examination,
and a further provision is made that where there are 10 or more
feeble-minded individuals o f school age in a community special
classes must be established. This means that the feeble-minded
recognized under this law at the earliest possible date will be 8 or 9
years o f age. I feel that when a disease or condition that can be
recognized usually during the first, second, or third year exists, and
a plan o f treatment might intelligently be put in operation, it is
futile to wait until five or six years later before instituting a pro
gram o f education.
Epilepsy, that chronic convulsive disorder which fills so many
beds in our institutions throughout the country, has its beginning
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
to a very large extent in early life. Studies pertaining to epileptics
in institutions caring for the chronic cases indicate that more than
one-half o f these cases had their first convulsion prior to the fourth
year o f life .1 It is equally important to note that the subsequent
history o f a large group o f children having convulsions prior to the
fourth year o f life indicates that the convulsion was quite definitely
a criterion o f nervous instability; had it been so recognized many
o f the shoals upon which children become wrecked in later life
and which act as exciting causes o f convulsions might have been
aVy o u are all familiar, I am sure, with the frequency with which
blindness, deafness, and speech defects occur during the preschool
period. Although many o f these defects are due to organic condi
tions for which there is no absolute cure, much can be done by early
education and training to reduce the handicap. According to the
United States Bureau of the Census there were on January 1 , IV¿6,
more than 267,000 patients in State and other public hospitals and
private institutions caring for the mentally sick.2 This group alone
is occupying more beds than all other medical and surgical cases
combined— which would include all the hospitals for tuberculosis,
surgical and medical cases, and infectious diseases. It would be im
possible to measure the total cost to the country brought about by
mental diseases alone. We do know that in ^Massachusetts 20
cents of every dollar that the taxpayer turns in is being spent tor
the care o f that type o f mental disease which needs institutional
treatment. But the great problem o f mental health is not the care of
those individuals confined in institutions. The great problem is the
so-called psychoneurotic class of individuals, persons who are emo
tionally unstable, who are unable to meet the ordinary problems o f
every-day life in an efficient way. There are thousands o f individuals
who have only a limited degree o f usefulness owing to the tact that
their intellectual capacities are handicapped by their emotional
conflicts.
,, , •
. *
It is during the preschool years—that is, the first six years o f
life__that many o f the undesirable habits and personality deviations
first develop; and it is not long before they become so obvious and
so devastating to the personality that their ultimate effect on the
future usefulness o f the individual can easily be recognized even
by those who are untrained in either psychology or psychiatry.
It is interesting to note in getting statistics from our general hos
pitals, especially the out-patient departments, that about 60 per cent
o f the individuals who go for treatment have not physical disease
but are suffering from a state o f m ind; and this state of mind alters
their conduct in a way that renders them inefficient—the so-called
“ neurotic.” So far as work is concerned, they are quite as incapaci
tated as the individual who has a physical ailment. So there is a
little relation between the actual organic incapacity and the amount
o f work these individuals are capable o f doing. The point 1 wish to
make is that a large percentage o f all these psychoneurotic mdividui See “ The relation between infantile convulsions and the chronic
^ I T 't x r
of later life /’ by D. A. Thom, M. D. (Archives of Neurology and Psychiatry, Vol. x i ,
JU°R e p o r fk PCensut'6o6f8 InstitutionS for Mental Disease, United States Bureau of the
Census. (In press.)
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PRACTICAL APPLICATION OF MENTAL HYGIENE
131
als o f adult life can be diagnosed during the preschool period, and
treatment can be rendered which will prevent this enormous waste
o f human energy.
Consider for the moment the underlying mental characteristics
o± a criminal. They are lmp'ulsivity, lack o f inhibitions, inability
to ±orego momentary pleasures and make sacrifices for a definite
end. After considerable experience with criminals in prisons and
reformatories we find that these dominating mental characteristics
"fY e been life-long factors in the personality make-up o f this group
o f individuals. In our clinics for the children o f preschool age we
see well marked m the uncontrolled, disobedient, asocial child these
same personality deviations which keep him in conflict with the
family and his immediate environment. I have made an attempt
to outline just a few o f the social problems that we meet in every
phase o f life from the cradle to the grave. Most o f them can be
diagnosed at a very early age, and much can be done, as experience
has shown to eradicate or alter them, or perhaps substitute desirable
and social tendencies which will serve the individual in good stead in
later life. Another reason for impressing you with the importance
o f recognizing these personality deviations early might well be found
nr the fact that certain mental characteristics which the child has
id T ? gi heSe. earlj J ears. arG. m.ore usable in altering undesirable
habits than at any other time m life. I refer to the general plasticity
o f the child s mind, as shown by imitation, Suggestion, love o f appro
bation; and one might add as another asset the ease with which one
can interpret conduct in early life as it is not altered by training
education and experience.. Finally, in this plea for early recognition
and treatment o f undesirable habits, personality deviations, and
criminal tendencies, I would call your attention to the numerous
facilities that have been organized and developed during the past
20 years m the interest o f the child. I refer to the nursery schools
the kindergartens special hospitals, nurses and physicians whose
training has been devoted entirely to the understanding of the child •
books, plays, toys, and all sorts o f amusements in general have been
developed, not only to entertain but to educate and train along practical fines and develop the nervous system o f the child
Ihere is a tendency to divide the life o f the child in a verv arbirary way into its physical, intellectual, and emotional aspects; and
i b L t 111* 8 ° f lay PeoPl€j?,and frequently those too highly specialized,
thmk o f processes working independently one o f the other. ObviihlS
a
We a11 appreciate how closely these
three aspects o f child life are interwoven one with another, and
how important it is for the closest cooperation to be encouraged
among the psychiatrists, pediatricians, and psychologists. Intelectual processes a_re stimulated by good physical health and emotional stability, and the feeling side o f the child’s life is tremendously
l
Phy f° l° g y and biochemistry and general mechanics
o f the body are out of adjustment.
Here is an example o f a physical problem which finds many o f its
manifestations in the intellectual and emotional side o f the child’s
Jite. A little girl 9 years o f age was brought to a clinic because she
was considered a nuisance in school. She had repeated the first and
second grades and was in the third grade doing poor work. The
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
physical examination, which must always be considered as o f Pri~
mary importance, showed this child to be poorly nourished and
poorly developed, with stooped shoulders, bent back, and a pale,
careworn expression. The important and outstanding physical
defect was deafness. It was revealed that the child was absolutely
deaf in the left ear and could hear the spoken voice at a distance o f
5 feet only. Three years before she had had a psychological exami
nation and was given an intelligence rating o f 63. Her present
psychological rating, taking into consideration her deafness, is mucn
higher; b'ut it seemed wise not to give her any definite relative
standing on the intellectual scale without much more detailed exami
nation than could be given at the time o f writing. It at least indi
cates that she is not mentally deficient. This physical defect had
prevented the child from demonstrating her real intellectual ability
m her school work. She soon began to be teased by the other chil
dren because o f her inadequacy in class work. Naturally she became
impressed with her own failure, felt inferior, and found school
unpleasant. She became difficult to manage at home, played truant
from school, and developed certain destructive tendencies. I here is
little doubt in my mind that this child’s failure m academic work
and the personality changes that followed are easily explainable by
the child’s deafness and the handicaps resulting therefrom. Mental
deficiency and delinquency were symptoms o f this underlying organic
defect and this conduct was simply the result o f her effort to keep
herself from being ignored, which, after all, is an expression o f the
instinct o f self-preservation, even though it results in asocial activity.
I recall a 9-year-old boy who was brought into my office by his
mother. The lad had been doing very mediocre academic work m the
third grade of a private school. One of the teachers had told the
mother that the boy had a brilliant mind and that his failure was
due entirely to his lack o f interest and concentration After care
fully studying the entire situation, evaluating the lad s^ intellectual
equipment in terms o f his past experience, his general ability to meet
the ordinary problems o f everyday life, and the psychological exami
nation, we found him to be o f a very moderate mental equipment.
He had had convulsions in early life, which fact undoubtedly played
a large part in preventing normal intellectual development. His
intelligence quotient was 75, and, all things being considered, one
could come to no other conclusion than that the lad was doing very
good work with what he had to do with. It would be a great in
justice to push this child on and subject him to more mental stress
and strain than he was capable of standing because the teacher en
tertained the belief that he had a brilliant mind. Unfortunately
we can not measure the emotional disturbances in children s lives in
terms o f intellectual quotients, nor have we any such tests as can be
readily applied to measure both qualitatively and quantitively defec
tive hearing. The emotional stress has ter be measured in terms o f
conduct, frequently in terms o f nonconformity or inefficiency and
unhappiness. Emotional stress and strain are in the background
o f almost all psychoneurotic symptoms.
.
...
The following case comes from a home o f no economic difficulties
where both parents are educated, both cooperating and in entire
agreement as to the training and care o f the child, and where the
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PRACTICAL APPLICATION OF MENTAL HYGIENE
133
results o f their- training and care and supervision, up to a certain
P01.n ”! have been considered not only satisfactory, but quite ideal:
A 5-year-old girl was taken to a clinic by her overwrought parents
because suddenly and quite unexpectedly she had refused to take
food or swallow. The morning that I was called to the office in consulation the father tvas anxiously but silently pacing the floor; the
mother was weeping and wringing her hands; and the little girl was
&Lttmg quietly next to the physician wearing a mask-like expression.
1 i sf llva1 ^ as dribbling from her mouth to her frock, which was
soaked, and she seemed only casually interested. The physician stated
that three days ago for some unknown reason the child had refused to
any
an(l that she was constantly demanding that her
mother reassure her that it was all right to swallow. In spite o f the
many reassurances given she had refused to swallow and had drib
bled all day long. A brief interview revealed the following: It
aPpeiai
that the mother had frequently told the child that she
should never allow anyone to kiss her, and in order to make her state
ment more impressive she informed the child that it caused infection
by germs, and that when the germs were swallowed the little girls
died. It happened that on the afternoon previous to the day her un
usual conduct began she had gone to her first dancing class, and some
man, she stated, stooped down, patted her on the head, and kissed
her on the mouth.
an imPression this incident made upon the mind o f
the child is difficult to evaluate at this time, but the important aspect
o f the problem seems quite obvious. The parents o f the child were
quite intelligent in handling most o f their problems, entertaining
some rather unusual ideas about bringing up a child on an intellec
tual basis. Their principle was that the child should not be spoiled
by attention, praise, or affection. I f things went well it was taken for
granted; if otherwise, moralization and punishment followed. The
child was never boisterous, her table manners were perfect, her
speech grammatically correct, she was never disobedient, she played
only under supervision with most carefully selected playmates; her
neatness, punctuality, and general conformity to parental law were
accepted as a matter o f course. The emotional upset which developed
after the child had been kissed would ordinarily have been eradi
cated after a little explanation had it not been for the fact that, quite
as unexpectedly as the^ symptoms had developed, the parents began
to take notice o f the child. They not only gave her a little attention,
but they became extremely worried and anxious. The child for the
first time in her life became the center o f attention. It was a new
experience and one which was so pleasing to her starved emotional
life that it is not at all surprising that she clung to it with great
tenacity and gave it up with considerable reluctance. This is just
another conclusion o f the home situation which occasionally produces
rather alarming symptoms in the child. The oversolicitous parent
stuffs and overfeeds the emotional life o f the child, whereas the stern,
forbidding type o f parent starves it. These are two extremes of
treatment, neither o f which will promote strength and stability in
the emotional life o f the child.
The three foregoing cases, I think, emphasize the necessity of
studying the child as a composite unit, the reaction o f the individual
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PROCEEDINGS, MATERNITY AND INFANCY CONFERENCE
to the environment, and the manifold problems of that environment
which the child has to meet.
The conduct o f children is frequently more easily interpreted than
that of adults, inasmuch as it is more spontaneous, less repressed, and
less colored by a social sense. It invariably centers around the child
since it is directly concerned with the preservation o f the child’s
own ego as well as his physical being and during the early life fails
to take into consideration the feelings and desires o f others within
the same environment.
The neurotic tendencies in children, as with adults, are always
striving to serve some purpose, although occasionally they are so
vague and ill-defined that the objective is not perfectly clear. It may
be perfectly obvious, the motive o f temper tantrums, neurotic vomit
ing, delinquency, or some other undesirable deed or habit, or it may
necessitate a long, careful study o f the case; but all such conduct
has a motive which the child feels at least is working out to his im
mediate advantage. Asocial conduct is all too frequently utilized
to avoid the difficult situations in life, and the child who learns by
experience that such conduct aids in dodging reality on one occasionis likely to practice it more or less continuously.
It is quite important to consider for a moment the incapacity that
results from a rather minor mental handicap in the life o f the child.
The child that is incapacitated on account o f some undesirable habit
or personality defect or twist not only demands but gets a dispro
portionate share o f the mother’s time. The mother is invariably
more concerned about this one individual in the family whose
personality obliquities lead to asocial conduct than she is with the
other three or four children who may be considered normal; and it
is not surprising that these normal children will react in a normal
way— which means resentment and rebellion toward the parent for
the disproportionate share o f her time which she is giving the delin
quent. Keep in mind, if you will, that the incapacity for efficiency
and happiness brought about by an unhealthy state o f mind is one
o f the most common as well as one o f the most important problems
with which social and medical organizations have to deal. It is o f
interest to note that the incapacity from mental handicaps, unlike
that o f physical origin, is out o f all proportion to what one is led to
expect.
The question now arises—who should be held responsible for the
mental health o f the child o f preschool age? It is not practical,
neither is it desirable, to have all these children examined by a socalled “ specialist.” W e do not find the Department o f Agriculture
sending a trained chemist around to ride on the back o f every cart
o f fertilizer to tell the farmer to put so much here and so much
there; but general instructions, I presume, are sent out to farmers
giving them an idea as to how best to fertilize certain lands. I
think our approach to the problems o f education and our approach
to these problems o f health need be handled in much the same w ay;
that is, the responsibility for the mental health o f the child must
necessarily rest upon parents, teachers, social workers, and those in
dividuals who are making daily contacts over long periods o f time
with these children. Many o f the most difficult problems concerning
the mental health o f children are brought about by environmental
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13 5
situations so obviously unhealthy that it does not take a trained
psychiatrist or psychologist, or any other specialist, in fact, to determme what the defect is, and frequently to make intelligent recom
mendations to correct it This does not mean, of course, that there
1? nUmerable Problems concerning the mental health of the
child that are very vague and ill-defined, in which it will take all
the skill and all the ingenuity of those best trained to comprehend
the underlying difficulty. Herein, of course, lies a certain element
i flan^’er y7blcb I® stressed and frequently, I believe, overstressed
by .the, specialist,; that is, the parent, the teacher, and the untrained
individual must appreciate which problems lie within their province
and which ones present fundamental difficulties of such a nature as
to need the services of the expert.
. At, *he Prreent time there is much valuable information concern
ing the mental health o f the child, rather well-defined wavs o f
meetmg certain problems and mechanisms that are not too compli
cated for the intelligent person to understand, which gives lav
people a much better understanding of how asocial activity develops
niean^ to th® cblldis extremely important that all
fi
T h° are held responsible for the physical welfare of
the child take advantage of every opportunity to familiarize your
selves with the fundamental principles of child psychology. Many
serious mistakes would be avoided if we all utilized the material that
is at hand and available. One of the things that parents, teachers and
numerous other persons who come in daily contact with children fail
to recognize is that the child really has a mental life. I f we can get
t?iat1 they are dealing with an individual,
regardless o f his chronological age; an individual who has a mental
1 ±e capable o f experiencing many of the same emotions at 3 years
o± age which he experiences at 30, much will be accomplished. These
children have hopes, ambitions, doubts, fears, aspirations, -joys, and
sorrows that are thwarted and gratified in ¿u c h the s a i£ way as
our own.
J
i end
dook uP<>n the child as a rather mechanistic indi
vidual that responds physically to a certain situation and without
any relation to evepts o f the past. It is pathetic, I think, and a bit
discouraging that so few o f us, qs adults, can remember in any
great detail what our emotional lives were prior to the sixth year.
.But those who will take time to get close to the mental life o f the
coildyct a® a sort of g uide Post and the mental content
o± the child s mind as their objective—what is going on in the mind
o f he child, what he is thinking of, what he is hoping for, what he
is fearing—-will find that this mental life is very well established, very
well organized.
’
J
In understanding the conduct o f the child it is of great importance
to know what he is thinking, how he is planning, what he is attemptt? ay0ld and to attain, how he feels about things and people
situations and events, which we, as adults, are prone to believe make
little or no impression upon him. We must bear in mind that the
mental attitude of the child toward life is highly colored by the
personalities with which he comes in contact. We must become less
concerned with symptoms and more concerned with fundamental
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i0 There 'is
d e a fe ? w ith children than
Iu fq u ite ^ tS lS
i g
h e lp e d to° ™ dere‘ !^d
s s s i
considered a\iolent temper tantrum m an admming room. W h
I inquired whether he was her child, she replied in a half-hearted
1 mqmrea ^ ^ .g a modesf. protest at my being away. ih is
mother seemed to be a woman o f average intelligence. She had th
other children who were apparently getting along wi o
gr
»ud on the whole she seemed to be handhng most of her
r e e l i n g T S SS fd frequently remarks ‘ Oh^don’t bcrther
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S
sjs^ffius a w ®
l a g ^ i c t e T o n T and plnished as I waswhen^l ^ ^ M d j ^ H e r e
pensatinglns o w T * l l d f e r f o r Pwh°at he himself had to go through
5
he has Jot to change his attitude, that he is spoiling the boy, and
that L S toows n o t W about handling his own problems His
whole attitude toward fire child .will be more f r"
‘I ?
nilv changed if he can be made to understand exactly what he nas
Len doing and that there are certain dangers m permitting the child
tohave a life of license just as there are dangers m curbing thwart
ing and at times completely annihilating any initiative on the^pa
o /th e child. It may also be pointed out that his wife is trying to
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PRACTICAL APPLICATION OP M ENTAL H YG IEN E
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137
i dc mcky when deaiin* with —
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are brought about frequently by undesbrabk f a X r i i w n
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