HANDBOOK FOR PHYSICIANS U. S.P.H. S. CHILDRENS BUREAU ADVISORY COMMITTEES COMMISSIONER DEPT. OF LABOR AND INDUSTRIES OlAOHOSTIC lASOAATOBY Vlado A.Getting, Commi»»toner. OCCUPATIONAL HYGIENE CANCER AND other] | CHRONIC DISEASES | CANCER CONTROL BERKSHIRE [cooperating] I CLINICS I MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH ORGANIZATION PERSONNEL RECORDS BIOLOGIC LABORATORIES BLOOD I PROCESSING [statistical] I RESEARCH | CONNECTICUT VALLEY JULY 1,1944 TO JUNE 30,1945 - EXPENDITURES $5,300,409.19 - EMPLOYEES 1,742. ADMINISTRATION [ HEALTH | INFORMATION | [antitoxin L 1 I VACCINE I V.O. CONTROL VENEREAL DISEASES NORTH CENTRAL HOSPITAL LICENSING SANITARY ENGINEERING I LAWRENCE | | EXP. STATION | SEWAGE DISPOSAL [as cooperating! I Cl'NICS I GOVERNOR AND EXECUTIVE COUNCIL FISCAL WATER [laboratory! SOUTH CENTRAL i DISTRICTS COMMISSIONER WATER SUPPLIES LOCAL HEALTH ADMINISTRATION NUTRITION SOCIAL SERVICE CRIPPLED CHILDREN ( MATERNAL, | PRESCHOOL [PUBLIC HEAUm| I NURSING [ I SANITATION | northeasternI HEALTH MATERNAL AND CHILD HEALTH C. H. I. C. SCHOOL HEALTH epidemiology COMMUNICABLE DISEASES NORTH | METROPOLITAN DEPUTY COMMISSIONER FOOD AND DRUGS [ WESTFIELD I [ labor atory| [ DIAGNOSTIC[ [laboratory! PONOVILLE HOSPITAL INSPECTION SERVICE WESTFIELD [sanatorium SOUTH METROPOLITAN |laboi^ltory[ TUBERCULOSIS CLINIC SERVICE RUTLAND [ sanatorium) SOUTHEASTERN DENTAL HEALTH [tuberculosis | I CONTROL | [mortm reading] [sanatorium I PUBLIC HEALTH COUNCIL I LAKEVILLE I [sanatoriuh| Handbook for PHYSICIANS COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH STATE HOUSE • BOSTON • MASSACHUSETTS 1947 tJfea/Ms sJ. J/Qi Qr&Jf June 28, 1946 Onited-Sexall Drug Company, Inc, 101 Tremont Street Boston 8, Massachusetts Gentlemen The Department of Public Health acknowledges with gratitude the contribution made by the United-Hexall Drug Company, Inc. in making the Physician's Handbook available to practicing physicians. This is indeed a worthwhile accomplishment in these trying postwar days of shortages. The new, attractive, and practical Handbook presents in condensed form the facts the physician should know concerning the practice of medicine in the Commonwealth, including the legal requirements and responsibilities, and the services offered to physicians by the Department of Public Health, Besides providing a ready reference for the practicing physician, the Handbook is suitable for the training of the medical student, intern, returning physician veteran and public health worker. It is of value, also, as a practical reference in other fields. The Department wishes to thank especially the Professional Relations Department of your organization for their valued assistance and research in compiling the Massachusetts statutes of interest to the medical profession. Very truly yours, Commissioner V DRUG COMPiOT 43 LEON STREET BOSTON,MASSACHUSETTS July 21+1 1946 Dr. Vlado A, Getting Commissioner Dept, of Public Health State House Boston, Massachusetts Dear doctor Getting? The pharmacists of the Dnited-Rexall Drug Com- pany throughout the Commonwealth consider it an honor and a privilege to have been of service to you, to your department and to the medical profession in the preparation and publication of "The Physician’s Handbook". May this excellent volume have every success you wish for it. 'Sincerely* W. A. SEAMAN TABLE OF CONTENTS Communicable Diseases 2 Page General information 2 Reporting 2 Isolation and Quarantine 3 Diagnostic Laboratories 9 Bacteriological Laboratory 9 Wassermann Laboratory 10 Approval of Bacteriological and Serological Laboratories 10 Approved Laboratories 11 Popular Pamphlets 15 Hospitalization 15 Communicable Disease Hospitals 15 The Physician’s Responsibility 16 Biologic Products 16 Regulations for Distribution of Biologic Products 19 Sensitivity 20 Recommended Immunization Schedules 23 Immunization of Travelers 24 Specific Diseases 26 Actinomycosis 26 Anthrax 26 Chancroid 26, 63 Chicken Pox (Varicella) 27 Cholera, Asiatic 27 Conjunctivitis, Suppurative 27 Diphtheria 28 Dog Bite 30 Dysentery, Amebic 33 Dysentery, Bacillary 33 Encephalitis, Infectious 34 German Measles (Rubella) 34 Gonorrhea 35, 63, 67 Granuloma Inguinale 35, 64 Hepatitis, Infectious 35 Leprosy 35 Lymphocytic Choriomeningitis 36 Lymphogranuloma Venereum 36, 64 Malaria 36 Measles (Rubeola) 37 Meningitis 38 Mumps 41 Ophthalmia Neonatorum 41, 69 Paratyphoid Fever 42 Plague 42 Pneumonia 43 Poliomyelitis 44 Respirators, Location of 44 Clinics, Services for Crippled Children 45 Harvard Infantile Paralysis Commission 45 Hospitals and Institutions 46 Psittacosis 46 Rabies 4 * Rocky Mountain Spotted Fever 4. Salmonellosis 48 Scarlet Fever 48 Septic Sore Throat 46 Smallpox 46 Syphilis 50, 63, 65 Tetanus 50 Trachoma 51 Trichinosis 51 Tuberculosis 52 Consultation Clinics 53 Tuberculosis Dispensaries 54 Tuberculosis Hospitals and Sanatoria 57 Tularemia 60 Typhoid Fever 60 Typhus Fever 62 Undulant Fever 62 Venereal Diseases 63 Syphilis 65 Gonorrhea 67 Clinics for the treatment of Syphilis and Gonorrhea 66 Weil’s Disease 4 Whooping Cough 75 Yellow Fever "5 Arthritis 76 Cancer 76 Clinics 77 Cancer Prevention Clinics 77 Tumor Diagnosis Service 78 Cancer Hospitals 78 Information Furnished Physicians 76 Chronic Disease Hospital 81 Dental Health 81 Maternal and Child Health 82 Prenatal Care 82 Premature Infant Care 82 Child Health 83 Vision and Hearing Tests 83 Paqe Services for Crippled Children . . 84 Massachusetts Rheumatic Disease Program 85 Payt Local Health Administration 86 District Health Oflices 86 Medical Social Services 86 Nutrition 87 Public Health Nursing 87 Sanitation 87 Environmental Sanitary Control 89 Sanitary Engineering 89 Food and Drugs 90 Industrial Accidents and Diseases 92 Industrial Diseases 92 Workmen’s Compensation 93 Vocational Rehabilitation 94 Mental Diseases 95 General Out-Patient Clinics 95 Child Guidance Clinics 96 Mental Hygiene Clinics 97 Clinics for Feebleminded 98 Juvenile Court Clinics 99 Neurological Clinic 99 Treatment, Insane Persons 99 Epileptics 102 Dipsomaniacs, Inebriates and Drug Addicts 103 Feebleminded 105 Division of Mental Deficiency 106 Public Welfare 108 Institutions 108 Registration in Medicine 109 Services for the Blind Ill Services and Facilities Ill Work with Children 112 Prevention of Blindness and Conservation of Vision 112 Services for the Deaf and Hard of Hearing 113 Schools for the Deaf 113 Assistance to the Hard of Hearing 113 Vocational Training for the Deaf and Hard of Hearing 113 Veterans’ Services 115 Veterans Administration 115 Soldiers’ Home and Hospital 115 Soldiers’ Relief 116 Vital Statistics 117 Reporting Births 117 Reporting Deaths 119 IX GENERAL LAWS OF INTEREST TO PHYSICIANS Page Births and Deaths 123 Return and Registry of 123 Report of Congenital Deformities and Other Crippling Conditions .... 124 Death of Soldier or Sailor 124 Cemeteries and Burials — Burial Permits 142 Counties and County Officers 122 Medical Examiners 122 Courts and Judicial Officers and Proceedings in Civil Cases .... 156 Court of Insolvency 156 Preferred Claims 156 Physician’s Rights 156 Clerks of Courts to Report Conviction of Registered Physicians or of Un- registered Practitioners to the Board of Registration in Medicine . . 157 Juries — Obligations to Serve — Qualifications and Exemptions 157 Crimes, Punishments and Proceedings in Criminal Cases 158 Crimes Against Public Health 158 Sale of Poison 158 Crimes Against Chastity, Morality, Decency and Good Order 158 Penalty for Advertising, etc., Means of Procuring Abortion 158 Other Offenses Against Decency — Contraception 159 Dissemination by Advertisement, etc., of Information Concerning Certain Diseases 159 Labor and Industries 151 Reports to Department by Physicians of Certain Ailments and Diseases . . 151 Employment Permits 151 Certificate by Family Physician 151 Marriage 155 Certificate of Pregnancy 155 Notice of Intention of Marriage — Medical Certificate as Prerequisite . . 155 Mental Health 143 Commitment and Care of the Insane and Other Mental Defectives .... 143 Voluntary Admissions of Certain Feebleminded Persons 143 Commitment of Insane Persons — Authority 143 Order of Commit ment 144 Qualifications of Third Physician Appointed for Additional Medical Testi- mony in Commitment of Persons Alleged to be Insane 144 Qualifications of Physicians Certifying to Insanity 144 Dipsomaniacs, etc., Commitment of 145 Feebleminded 145 Commitment to Schools 145 Commitment to Department of Mental Health 146 Insane Epileptics, Commitment of 146 Commitment for Observation 147 Temporary Care of Persons Violently Insane, etc., Without Court Order . . 147 X Temporary Care of Insane Persons Needing Immediate Care 147 Temporary Care of Persons Addicted to Intemperate Use of Narcotics .. 148 Voluntary Admissions 149 Monson Slate Hospital, Admission to 149 Conspirac y to Commit a Sane Person 149 Physician’s Certificate as to Mental Defective to be Filed in Certain Cases . 150 Public Health 132 Department to Furnish Free Remedies for Ophthalmia Neonatorum . . . 132 Extra-Pulmonary Tuberculosis and Poliomyelitis Treatment at Lakeville State Sanatorium 132 Rheumatic Heart Disease—Admission of Children to North Reading State Sanatorium 133 Cancer Pat ients — Admission to Pondville and West field Stale Sanatoria 133. 134 Lung Disease (other than recognizable tuberculosis) Admission to State Sanatoria 133 Lung Disease (other than pulmonary tuberculosis) Admission to Middlesex Sanatorium 133 Care and Transportation of Infants Prematurely Born 133, 134 Diseases Dangerous to the Public Health, Physician to Report 135 Vaccination Exemption 135 Public Safety and Good Order 150 Observance of the Lord’s Day 150 Intoxicating Liquors and Certain Non-Intoxicating Beverages and Prescrip- tions 150 Sale by Druggists 150 Registration of Certain Professions and Occupations 135 Examination and Regulation of Physicians 135 Board May Accept Certificate in Lieu of Examination 138 Examination by Board of Registration 138 Records, Annual Reports of Board 138 Investigation of Complaints by Board 138 Penalties 139 Application of Statute Limited 139 Certificate of Registration to be Recorded with City or Town Clerk before Practice 139 Hospital Internes, Limited Registration 140 Medical Students, Limited Registration 140 Medicine and its Practice to Apply to and Include Osteopathy and its Prac- tice 141 Certain Acts by Certain Registered Osteopaths Prohibited 141 Disclosure of Certain Information by Registered Physicians Not Slander or Libel 141 Bullet Wounds, etc., Report of Treatment to be made 141 Suspension, Revocation of License to Practice Medicine 141 Board Hearings 142 Page Pendency of Action before Criminal Court No Ground for Delay of Action by Board 142 Revision of Suspension, etc., of Certificate, etc., by Supreme Court .... 142 Penalty for Practicing While Certificate Suspended 142 Regulation of Trade 126 Sale and Distribution of Narcotit; Drugs 127 Physicians May Personally Administer Narcotic Drugs, When 128 Sales to Certain Persons and Institutions Regulated 128 Hypodermic Instruments — Patient’s Permit to Possess 130 Penalty for Unlawful Possession of Narcotic Drugs 131 Federal Narcotic Law 132 Schools, Public 125 Physical Examinations 125 Pupils Infected with Dangerous Disease 125 Vaccination Certificate 126 Statutes of Frauds and Limitations 157 Limitation of Actions — Two Years 157 Actions against Physicians 157 Wills, Estates of Deceased Persons and Absentees, Guardianship, Con- servatorship and Trusts 154 Insolvent Estates of Deceased Persons 154 Order of Payment of Debts 154 Physician’s Rights 154 Settlement of Claims by Receivers 154 Physician’s Rights 154 Workmen’s Compensation 152 Examination by Impartial Physician 152 Fees for Physicians Appearing before Department in Behalf of Injured Employees 153 Hospital Records Admissible as Evidence 153 Medical Service, Payments Under Act 153 Pay*' XII HANDBOOK FOR PHYSICIANS COMMUNICABLE DISEASES GENERAL INFORMATION REPORTING The following diseases are reportable in Massachusetts: Diseases Declared by the Department of Public Ileal/h of Massachusetts to be Dangerous to the Public Health and Reportable Under Provisions of Sections 6, 7, 109, 111 and 112 of Chapter 111 of the General Laws, Ter- centenary Edition, as Amended by Chapter 265 of the Acts of 1938. I. Reportable to Local Hoard of Health Actinomycosis Anthrax Chicken Pox Cholecystitis of Typhoid Origin Cholera, Asiatic Diphtheria Dog Rite Dysentery: a. Amebic b. Racillary Encephalitis, Infectious German Measles Glanders Hookworm Disease Infectious Diseases of the Eye: a. Ophthalmia Neonatorum b. Suppurative Conjunctivitis c. Trachoma Leprosy Lymphocytic Choriomeningitis Malaria Aleasles Meningitis: a. Meningococcal b. Other; Pfeiffer Racillus Pneumococcal Streptococcal, etc. Mumps Paratyphoid Fever and aM other Salmonella Infections Plague Pneumonia, Lobar Poliomyelitis: a. Paralytic b. Nonparalytic (preparalytic) Psittacosis Rabies Rocky Mountain Spoiled Fever Scarlet Fever Septic Sore Throat Smallpox Tetanus Trichinosis Tuberculosis (all forms) Tularemia Typhoid Fever Typhus Fever Undulant Fever Weil’s Disease (Leptospira icterohemorrhagiae) Whooping Cough Yellow Fever 2 II . Reportable Directly to Massachusetts Department of Public Health: Chancroid Gonorrhea Granuloma Inguinale Lymphogranuloma Venereum Syphilis All reports except of venereal diseases should he made to the board of health of the community of residence. Telephone reports should be con- firmed in writing. Cards for such reports can be obtained from most boards of health. Venereal diseases should be reported directly to the Massachusetts Department of Public Health, 546 State House, Boston, using special forms obtainable from the Department. (See under Venereal Diseases for details of reporting, p. 63.) ISOLATION AND QUARANTINE The Massachusetts Department of Public Health makes minimum isolation and quarantine regulations. These are given in the table which follows. Local boards of health may make stricter requirements if they so desire but many accept those of the State without modification. In case of doubt inquiry should be made from the board of health of the community in which the patient is ill. T he physician is not allowed to modify these requirements except with the special permission of the local board of health. NOTES 1. Definition of Adult: Any person who has reached his eighteenth birthday is considered to be an adult, for purposes of these regulations. 2. Schoolteachers, only as it applies to their school activities, shall be subject to the same restrictions as children. Food handlers and persons whose occupation brings them in contact with children have no restrictions if they live away from home. 3. Food handlers living in a household where a case of typhoid, cholera, bacillary dysentery or paratyphoid fever exists shall be excluded from their occupation as long as they continue to live in the same house in which the case exists, and there- after until freedom from infection, as judged by clinical and laboratory evidence, has been demonstrated to the satisfaction of the Department of Public Health. Food handlers living in a household with a recovered case which continues to excrete typhoid bacilli after convalescence shall be excluded from their occupations unless they have been inoculated with typhoid vaccine within two years. 4. Contacts shall be quarantined until three weeks have elapsed from the date of last exposure unless immunized by a previous attack, by a recent successful vac- cination, or showing the immune reaction. 5. Patients who have lesions of primary or secondary syphilis on exposed parts of the body or in the mouth, and are employed in any occupation requiring regular, direct contact with other persons, such as barber, hairdresser, manicurist, waiter, waitress, nursemaid, domestic, etc., shall be reported by name, address and occu- 3 pation, to the Massachusetts Department of Public Health, unless the physician will assume responsibility for seeing that the patient discontinues such occupation until the lesions are healed. 6. Patients with open tuberculosis should in most cases receive sanatorium treat- ment, both for the benefit of the individual and the protection of his family. Those who remain in their homes shall observe all precautions necessary to prevent in- fection of the members of their families and of others with whom they may come in contact. This shall include approved methods of collection and disposal of the sputum, the sterilization of any articles of clothing and of toilet articles which may become contaminated by the sputum, the use of separate dishes and eating utensils and proper sterilization of the same. The patient should sleep in a separate room. For details concerning precautions in home care a pamphlet of the Massachusetts De- partment of Public Health entitled “Home Care of Tuberculosis Patients” is available. As soon as a diagnosis of tuberculosis has been established, arrangements should be made for the examination, including an X-ray of the chest of all members of the immediate family and of other persons with whom the patient has been in close contact. If the family cannot afford X-ray examination by a private physician, fa- cilities are available through the various state, county and municipal sanatoria. Persons with suspicious findings and those who have had contact with a tuberculous patient should be kept under medical observation as long as advised by the physician. It is the responsibility of the local board of health to provide hospital care for cases of tuberculosis, when needed, and to see that contacts are examined where such examinations have not been made through a private physician. When a case is reported the public health nurse representing the board of health should visit the patient’s home. She should instruct the family in the sanitary pre- cautions described above, see that arrangements are made for the examination of contacts and, if necessary provide transportation to the place where they are to be X-rayed, and should aid the patient in obtaining admission to a sanatorium if this has been recommended by his physician. Thereafter, the nurse should make visits to the home at least once in six months to determine whether the patient has moved. Whether the above-mentioned pre- cautions are still being observed, and whether any new measures are needed to control the spread of the disease. If the patient has moved to another town or state, the Massachusetts Department of Public Health should be notified. In cases where the physician wishes to exercise complete supervision, the nurse should obtain such information from him. The only acceptable reasons for the board of health failing to exercise the super- vision outlined above are: refusal of the family physician to permit periodic visits by the nurse; or placing of the patient’s name on an “inactive list” as a result of exam- ination including X-ray. No person who has or has had tubercle bacilli in the sputum or other bodily dis- charges shall be allowed to engage in teaching, nursing, dairying, or occupations involving food handling or the care of children until he has received a certificate from the board of health stating that his employment would not be dangerous to the public health. 7. Persons living in a family in which a case of tuberculosis exists or has existed within two years, and whose occupations involve food handling or contact with children, shall be required to have an X-ray of the chest to determine whether they shall be allowed to continue in such occupations. 8. All of the above diseases except five should be reported to the local board of health. The live exceptions (chancroid, gonorrhea, granuloma inguinale, lympho- granuloma venereum and syphilis) should be reported directly to the Massachusetts Department of Public Health on special forms, provided upon request. 4 ISOLATION AND QUARANTINE REQUIREMENTS OF THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH Disease Minimum Period of Isolation of Patient Adults (Note 1) Minimum Period of Quarantine of Contacts Placard Immune Children Children Not Immune Actinomycosis No restrictions No restrictions No restrictions No restrictions No Anterior poliomyelitis (infantile paralysis) Two weeks from onset of dis- ease, and thereafter until acute symptoms have sub- sided. Note 2 Until two weeks have elapsed from date of last exposure. Until two weeks have elapsed from date of last exposure. Yes Anthrax Until lesions are healed. No restrictions No restrictions No restrictions No Asiatic cholera Same as typhoid fever. Seven days from last expos- sure, and until a negative stool is obtained. Note 3. Same as for adults Same as for adults Yes Chancroid (Note 8) No restrictions if under con- tinuous treatment. No restrictions if examina- tion demonstrates absence of infection. Same as for adults Same as for adults No Chicken pox One week from appearance of eruption and thereafter until crusts have disappeared, provided that total period of isolation shall not exceed 14 days. No restrictions No restrictions No restrictions No Cholecystitis of typhoid origin (typhoid carrier). See Regulation 4. Supervision by local board of health until released from the carrier list by the De- partment of Public Health. Food handlers living in a household with a typhoid carrier shall be excluded from their occupations unless they have been inoculated with typhoid vaccine within two years and agree to observe precautions prescribed by the board of health. Same as typhoid fever. Same as typhoid fever. No Diphtheria One week from date of onset and thereafter until two suc- cessive negative cultures, taken at least twenty-four hours apart, from both nose and throat, have been ob- tained. Food handlers, and persons whose occupation brings them into contact with children living in a family in which a case exists, shall be subject to the same restrictions as chil- dren only insofar as it applies to their occupation. If immune as shown by Schick test, no restrictions provided they live away from home or the case is hospitalized, and if two consecutive negative nose and throat cultures taken at an interval of not less than twenty-four hours have been obtained. Until child lives away from home one week and until two negative nose and throat cul- tures taken at an interval of not less than twenty-four hours have been obtained. No restrictions thereafter if child continues to live away from home. Yes Dog bite No restrictions No restrictions. No restrictions No restrictions No Dysentery, amebic No restrictions except for foodhandlers, who shall be kept from their occupations until three successive nega- tive stool examinations, se- cured at intervals of not less than three days apart, shall have been obtained. No restrictions except for foodhandlers, for whom re- strictions are same as for case. No restrictions No restrictions No Dysentery, bacillary Same as typhoid fever. Note 3 Same as typhoid fever. Same as typhoid fever. No Encephalitis, infectious One week after onset, in in- sect-free room. No restrictions No restrictions No restrictions No German measles Three days from appearance of rash. No restrictions No restrictions No restrictions No Glanders Until lesions are healed. No restrictions No restrictions No restrictions No Gonorrhea (Note 8) No restrictions if under con- tinuous treatment. No restrictions if examination demonstrates absence of in- fection. Same as for adults Same as for adults No Granuloma inguinale No restrictions if under con- No restrictions if examination Same as for adults Same as for adults No (Note 8) tinuous treatment. demonstrates absence of in- fection. Hookworm disease No restrictions No restrictions No restrictions No restrictions No Leprosy Until disease is arrested. No restrictions No restrictions No restrictions No Lymphocytic chorio- meningitis Until recovery No restrictions No restrictions No restrictions No Lymphogranuloma venereum (Note 8) No restrictions if under con- tinuous treatment. No restrictions if examination demonstrates absence of in- fection. Same as for adults Same as for adults No Malaria No restrictions No restrictions No restrictions No restrictions No Measles One week from appearance of rash. No restrictions No restrictions No restrictions No Meningitis, m eningococcal Two weeks from onset of dis- ease (five days in cases ade- quately treated with sulfona- mide drugs), and thereafter until all acute symptoms have subsided. Note 2 Until ten days from date of last exposure. Until ten days from date of last exposure. Yes Meningitis: Pfeiffer bacillus, pneumo- coccal, streptococcal, and other forms. Until recovery No restrictions No restrictions No restrictions No Disease Minimum Period of Isolation of Patient Adults (Note 1) Minimum Period of Quarantine of Contacts Placard Immune Children Children Not Immune Mumps One week from onset of di- sease, and thereafter until all swelling of salivary glands has disappeared. No restrictions No restrictions No restrictions No Ophthalmia neonatorum One week after subsidence of symptoms. In gonococcal ophthalmia, thereafter until two successive smears from each eye at an interval of not less than forty-eight hours are negative for gonococci. No restrictions No restrictions No restrictions No Paratyphoid fever and all other Salmonella infections Same as typhoid fever. Note 3 Same as typhoid fever. Same as typhoid fever. No Plague One week after subsidence of all symptoms. In pneumonic cases, until seven days and no restrictions thereafter provided patients are hospitalized or they live away from home. Same as for adults Same as for adults Yes Pneumonia, lobar Until recovery No restrictions No restrictions No restrictions No Psittacosis Until recovery No restrictions No restrictions No restrictions No Rabies During course of disease No restrictions No restrictions No restrictions No Rocky Mountain spotted fever No restrictions No restrictions No restrictions No restrictions No Scarlet fever Uncomplicated cases: Adults, two weeks; children, three weeks from date of appear- ance of rash. Examine nose, throat and ears to detect ex- istence of discharge or inflam- mation before considering case as uncomplicated. (If upper respiratory tract symp- toms appear during month after release from isolation, re-establish precautions.) Complicated cases: Four weeks and thereafter until abnormal discharge shall have ceased, swollen glands sub- sided, or three successive cul- tures of abnormal discharge shall have been found free of hemolytic streptococci. No restrictions except for milk handlers and schoolteachers who may continue their occu- pation only with special per- mission of the local board of health. If immune as shown by Dick test or on the basis of a previ- ous attack of the disease, no restrictions, provided they live away from home, or cases are hospitalized. Until child lives away from home one week, no restrictions thereafter, if child continues to live away from home. Quar- antined contacts living in a household with a case should be allowed to return to school at the same time as the pa- tient is released from isola- tion. Yes Septic sore throat Until cne week after onset and until recovery, except milk handlers, who shall be excluded from their occupa- tion until satisfactory evi- dence is obtained that the danger of conveying the di- sease has passed. No restrictions except for milk handlers. Same as for adults. Same as for adults. No Smallpox Three weeks from onset of di- sease and thereafter until all crusts have disappeared and skin has healed. Note 4 Note Note 4 Yes Suppurative conjuncti- vitis (acute epidemic conjunctivitis, pink eye) Exclusion from school and public gatherings until re- covery. No restrictions unless sus- pected of being infected. Same as for adults. Same as for adults. No Syphilis (Note 8) No restrictions if under con- tinuous treatment, except as given in Note 5. No restrictions if examination demonstrates absence of in- fection. Same as for adults. Same as for adults. No Tetanus No restrictions No restrictions No restrictions No restrictions No Trachoma Exclusion from general school classes during acute stage. No restrictions No restrictions No restrictions No Trichinosis No restrictions No restrictions No restrictions No restrictions No Tuberculosis (all forms) Note 6 Note 7 No restrictions No restrictions No Tularemia During acute stage. No restrictions No restrictions No restrictions No Typhoid fever (Typhoid carrier: see “Cholecystitis of typhoid origin.”) One week after subsidence of clinical symptoms. There- after may be released on special permission of and under the supervision of the local board of health, super- vision to continue until three successive negative stool and urine cultures, secured at in- tervals of at least one week apart, have been obtained. Note 3 No restrictions provided con- tacts can be relied upon to observe precautions outlined by board of health and pro- vided at least one satisfac- tory stool specimen is sub- mitted for examination. No restrictions provided con- tacts can be relied upon to observe precautions outlined by board of health and pro- vided at least one satisfac- tory stool specimen is sub- mitted for examination. No Typhus fever In vermin-free room until re- covery. In presence of lice, until four- teen days after last exposure. Same as for adults Same as for adults No Undulant fever Weils Disease (Infec- tious jaundice due to Leptospira ictero- hemorrhagiae) No restrictions Until recovery No restrictions No restrictions No restrictions No restrictions No restrictions No restrictions No No Whooping cough Yellow fever Three weeks from beginning of spasmodic cough. In mosquito-proof room first four days of fever. No restrictions No restrictions No restrictions No restrictions Until two weeks from last ex- posure. No restrictions No No ISOLATION AND QUARANTINE REQUIREMENTS OF THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH DIAGNOSTIC LABORATORIES Bacteriological Laboratory: The Alassachusetts Department of Public Health maintains a Bacteriological Diagnostic Laboratory at 281 South Street, Jamaica Plain, (Telephone, Arnold 5440). Containers for the shipment of specimens to the laboratory may be obtained through the local board of health. Directions for collecting and shipping the specimens are found inside the container and should be followed care- fully to obtain the best results. Specimens are accepted only from physicians, dentists, hospitals and recognized health agencies. All posi- tive diagnostic diphtheria cultures, positive diagnostic Widals, positive enteric cultures, positive spinal fluids and positive gonorrheal eye smears and cultures are reported by telephone at state expense and con- firmed by mail. Other reports are made by mail only. No charges are ever made for laboratory examinations. No chemical examinations are per- formed. The following bacteriological and serological examinations are made: Anthrax cultures Diphtheria cultures Dysentery, amebic: direct examinations cultures Dysentery, bacillary: cultures Food poisoning (Outbreaks of food poisoning should be reported immediately to local board of health and state district health officer in order that an in- vestigation may be made.) Gonorrhea: smears cultures Helminths: adults and ova Infectious Mononucleosis heterophile antibody agglutin- ations Malaria smears Meningitis — spinal fluid for; Meningococci Pfeiffer’s (influenza) bacillus Pneumococci Streptococci Tubercle bacilli Other organisms Pneumonia blood cultures sputum typing Rocky Mountain Spotted Fever Weil-Felix reaction Salmonellosis: agglutination cultures Streptococcus cultures Tuberculosis; fluids for culture sputum examination Typhoid: blood cultures stool cultures Widal reaction Typhus: Weil-Felix reaction Undulant fever: agglutination cultures Vincent’s Angina smears 9 w assermann Laboratory; This laboratory, located at 281 South Street, Jamaica Plain (Telephone, Arnold 1232), is maintained by the Massachusetts Department of Public Health. Specimens are accepted only from physicians, dentists, hospitals, and recognized health agencies. Special containers for blood samples should be obtained directly from the laboratory or through the local board of health. The following specimens are examined in this laboratory: 1. Blood for Hinton tests for syphilis and for quantitative serologic tests in connection with penicillin treatment of syphilis. 2. Spinal fluid for Davies-Hinlon and Wasserrnann tests. 3. Specimens submitted through the State Division of Livestock Disease Control for pathologic, bacteriologic, and serologic examinations; including animal heads for rabies. APPROVAL OF BACTERIOLOGICAL AND SEROLOGICAL LABOR ATORIES In accordance with Section 184A of Chapter III which was passed in 1939, the Department of Public Health may, at the request of a labora- tory, issue a certificate of approval for the performance of designated bacteriological and serological tests, which the Department finds the laboratory capable of performing satisfactorily. As the law is not man- datory, application is voluntary. The approval of a laboratory is determined essentially by the qualifica- tions of its personnel, the suitability of its quarters and equipment, the use of accepted methods, the satisfactory performance of its work, and the maintenance of adequate laboratory records. Accuracy of tests is ascertained by ability to maintain close agreement with other labora- tories on specimens periodically sent out to approved laboratories by the State Bacteriological and Wassermann Laboratories. It is the most important single method for evaluation of a laboratory. \ isits are made from lime to time by a member of the Department further to appraise the laboratory and to make suggestions when desired. A certificate of approval is granted for one year and renewal is dependent upon the continuance of a satisfactory standard. Chapter 135 of the Acts of 1946 extends the State laboratory approval program (o include ordinary blood grouping, Bh blood testing and cross matching of donors and recipients of blood transfusions. In addition it authorizes the issuance of certificates of approval for laboratory tests upon milk, foods, eating utensils, water and sewage. A list of laboratories approved for these additional tests will be available later. 10 The following is a list of the laboratories holding certificates as of May, 1946, and indicates the tests for which each was approved. (“A” indicates that the laboratory is approved for the test.) APPROVED LABORATORIES "So So Is 5 ~s ft. a 1 • 2 ,5C *5 •S s. c 5 c •1 "3 =0 t. H 0. so V t, J3 "3 3 c a *»< .H ”5 3o ■*s Laboratories holding certificates in State iMboralory Approval Program H Q y. d d d ,9 i S .£> c ft. 1 "a c .e 35 S’ js. 35 <0 h* O 03 ft, i 1 1 d Amesbury Amesbury Hospital A A A Arlington Symmes Hospital A A A A Ayer Community Hospital A A A A A A A Beverly Beverly Hospital A A A A A A Boston Beth Israel Hospital A A A A A A A A Boston Dispensary A A A A A A A A A A A A A Boston Lying-in Hospital A A A Boston State Hospital A A Children’s Hospital A A A A A A A A A A A A Clinical Laboratory A A A Faulkner Hospital A A A A A A A A A Health Department A A A A A A A A A A A A Leary Laboratory A A A A Mass. Eye & Ear Infirmary A A A A A Massachusetts General Hospital A A A A A A A A A A A Mass. Memorial Hospitals A A A A A A N. E. Baptist Hospital A A A A N. E. Deaconess Hospital A A A A A A A A A A N. E. Hospital for Women and Children A A A A A A A Pratt Diagnostic Hospital A A A A A A A A A A A Robert Breck Brigham Hospital A A A A A St. Elizabeth’s Hospital A A A Brockton Brockton Hospital A A A A A Health Department A A Brookline Board of Health A A A Corey Hill Hospital A 11 1 Laboratories holding certificates in State Laboratory Approval Program Diph. Cult. Enteric Path. G. C. Smears Malaria Meningitis Pn. typing Rapid Hinton Stand. Hinton Strep. Cult. 77L Smears TR. Cultures d c e ft, j Weil-Felix Und. Aggl. Cambridge Board of Health A A Cambridge City Hospital A A A A A Cambridge Hospital A A A A A A A A Chelsea Memorial Hospital A Clinton Clinton Hospital A A A A A A A Everett Whidden Memorial Hospital A A A A Fall River General Hospital A A St. Anne’s Hospital A A A Truesdale Hospital A A A A Union Hospital A A A A Fitchburg Burbank Hospital A A A A A A A Framingham Union Hospital A A Gardner Henry Heywood Memorial Hosp. A A A Gt. Barrington Fair view Hospital A A A A A A A Greenfield Franklin County Public Hospital A A Haverhill Hale Hospital A A A A A Holyoke Holyoke Hospital A A A A A A A Providence Hospital A A A A A A A A A A A A Hyannis Cape Cod Hospital A Ipswich B. S. Cable Hospital A A A A Lawrence Lawrence General Hospital A A A A A Leominster Leominster Hospital A A APPROVED LABORATORIES (Continued) 12 1 Laboratories holding certificates in Stale Laboratory Approval Program Diph. Cult. Enteric Path. G. C. Smears Malaria Meningitis Pn. typing Rapid Hinton Stand. Hinton Strep. Cull. TB. Smears TB. Cultures s a a. -d s Weil-Felix Und. Aggl. Lowell Lowell General Hospital A A A A A A A A A A A St. John’s Hospital A A A St. Joseph’s Hospital A A A A A A A A A Lynn Health Department A A A A Lynn Hospital A A A A A A A A A Union Hospital A A A Malden Malden Hospital A A A A A Marlboro Marlboro Hospital A Medfield Medfield State Hospital A A Medford Lawrence Memorial Hospital A A A A Melrose Melrose Hospital A A A A A A A A A A A Milford Milford Hospital A A A A Montague City Farren Memorial Hospital A A A A A A Natick Leonard Morse Hospital A A A New Bedford Clinical Laboratory A St. Luke’s Llospilal A A A A A A A A A A A A Newburyport Anna Jaques Hospital A A A A A A Newton Health Department A A A A Newton-Wellesley Hospital A A A A A A A North Adams North Adams Hospital A A A A A A A A Northampton Cooley Dickinson Hospital A A A A A A A A A A Norwood Norwood Hospital A A A APPROVED LABORATORIES (Continued) 13 os Laboratories holding certificates in Stale Laboratory Approval Program Diph. Cult. Enteric Path. G. C. Smears Malaria Meningitis Pn. typing Rapid Hinton Stand. IIinlon Strep. Cult. TB. Smears TB. Cultures a e. a ft. £ Weil-Felix £/nc/. Aggl. Oak Bluffs Martha’s Vineyard Hospital A A A Pittsfield House of Mercy Hospital A A A A A A**A A A A A Health Department A A A A St. Luke’s Hospital A A A A A A A A A A A A Pocasset Barnstable County Sanatorium A A A A A A A A Quincy City Hospital A A A A A A A Salem Salem Hospital A A A A A A A A A Somerville Somerville Hospital A Southbridge Harrington Memorial Hospital A A A Springfield Health Department Hospital A A Mercy Hospital A A A A A A A A Springfield Hospital A A A A A A A A A A A Wesson Memorial Hospital A A A Taunton Morton Hospital A A A A Tewksbury State Infirmary A A A A A A A W alpole Pondville Hospital A A A A Waltham Metropolitan State Hospital A A A Waltham Hospital A A A A A A Ware Mary Lane Hospital A A A Wareham Tobey Hospital A A Wellesley Board of Health A A A A **Kline Test APPROVED LABORATORIES (Continued) 14 as "a O "a a, •a Co 3 s s 20 .a •2 a> • S a .a •S J5 d "a O «C a. S I oc V &. .3 "a a c a a. .H a! a-. Laboratories holding certificates in State Laboratory Approval Program d d d -2 a "a C a. ."a s, ■2 ~e a a S' 35 20 CQ E»i O oq i "a c d Westfield Noble Hospital A A A A A A A A State Sanatorium A A Weymouth Weymouth Hospital A A A A A A Winchester Winchester Hospital A A Winthrop Community Hospital A A A A A A Worcester Health Department A A A A A A A A A A A A A Memorial Hospital A A A A A A A A A A St. Vincent Hospital A A A A A A Worcester City Hospital A A A A A A A A A A A APPROVED LABORATORIES (Continued POPULAR PAMPHLETS Popular pamphlets on various diseases are available through the Bureau of Health Information, Department of Public Health, 546 State House, Boston. HOSPITALIZATION The board of health may, if it sees fit, order hospitalization of any case of communicable disease. Before hospitalizing a case the physician should consult with the local board of health, in order to avoid subse- quent misunderstandings as to hospital charges. Care of cases of com- municable disease may be obtained in the following hospitals: COMMUNICABLE DISEASE HOSPITALS County or Municipal Boston Bourne Fall River Lowell City Hospital *Barnstable County Infirmary *Fall Biver General Hospital Lowell Isolation Hospital * Building or ward of a general hospital 15 COMMUNICABLE DISEASE HOSPITALS County or Municipal Lynn New Bedford Salem Lynn Isolation Hospital fNew Bedford Isolation Hospital Health Department Hospital for Conta- gious Disease Somerville Contagious Disease Hospital Health Department Hospital Belmont Hospital Somerville Springfield Worcester Private Boston Boston Greenfield Newton Pittsfield Plymouth Waltham Hospital Haynes Memorial Hospital *Franklin County Public Hospital *Newton-Wellesley Hospital *Sampson Memorial Hospital * Jordan Hospital * Walt ham Hospital In addition to these hospitals, many general hospitals accept cases of typhoid, infantile paralysis, and meningococcus meningitis. THE PHYSICIAN’S RESPONSIBILITY: 1. Report cases to the health agency. Laboratory and consultant services are available for the diagnosis of certain diseases. 2. Cooperate with the health agency in carrying out health regula- tions. (a) Isolation and quarantine. (See p. 3.) (b) Release cultures, when applicable. 3. Make full use of biologies, furnished without charge, for prophylaxis and for treatment. (See p. 18.) BIOLOGIC PRODUCTS: Biologic products are prepared by the Division of Biologic Labora- tories of the Massachusetts Department of Public Health and distributed without charge, under the regulations given below. The Division com- * Building or ward of a general hospital fin operation only during an epidemic 16 prises two laboratories, the Antitoxin and Vaccine Laboratory and the Hyams Blood Processing Laboratory located at 375 South Street, Jamaica Plain, The Antitoxin and Vaccine Laboratory was established in 1894 for the production of diphtheria antitoxin, and has since undertaken the preparation of a number of other biologic products of recognized merit. The policy of the Department recognizes the desirability of manufactur- ing and distributing products for which there is a need from the stand- point of public health, and which can be produced economically and efficiently. Some commonly used products which do not meet these criteria, as tetanus antitoxin and rabies vaccine, and some which are not often needed, as botulinus antitoxin, are not manufactured at the Antitoxin and Vaccine Laboratory. The Hyams Blood Processing Laboratory, completed in 1946, is a wing attached to the Antitoxin and Vaccine Laboratory. It is equipped to apply the most modern methods of processing to human plasma and other biologic products, and is the first state health department labora- tory of its kind in the world, it functions as a unit in the Department’s blood and blood derivatives program. This program comprises: 1. Procurement of voluntary blood donations by means of a mobile blood donor unit with the aid of the Red Cross and other agencies. 2. Processing of the donations to the products listed below. 3. Research on the development of new fractions of plasma or red cells. 4. Assistance to communities in procurement of blood donors, estab- lishment of blood depots, typing of donors, and other methods of facilitat- ing the acquisition and utilization of whole blood. The biologic products prepared by the Commonwealth are distributed without charge through the channels listed below. Physicians should learn from their local boards of health and hospitals where supplies are kept. As these are perishable products and their cost is borne by the tax levy, it is requested that due care be taken to avoid waste by over-stock- ing. All outdated products should be returned to the Division of Biologic Laboratories, either directly or through the local depot. Distribution of products derived from voluntary human blood dona- tions is limited to the communities participating in the program except when the supplies are more than adequate to cover their needs. Distribution of tetanus toxoid and pertussis vaccine will begin in 1947. 17 Products furnished by the Division are as follows: I. Furnished primarily through local boards of health Schick Test Outfits Old Tuberculin (undiluted) Serum Sensitivity Outfits Diphtheria Toxoid Typhoid Vaccine Smallpox Vaccine Sterile Needles for Vaccination Immune Serum Globulin Diphtheria Antitoxin, 1000 units Diphtheria Antitoxin, 10,000 units Silver Nitrate Solution Scarlet Fever Streptococcus Antitoxin 1 PRODUCTS FROM FRACTIONATION OF HUMAN BLOOD PLASMA 18 2. Available only from the Division of Biologic Laboratories: Pneumococcus Typing Serum Antipneurnococcic Serum, types 1-33 (obtained at the Bade riological Laboratory) Anti-Hemophilus Intluenzae, type B, Serum Blood Grouping Globulins (available June 1917) Normal Horse Serum Delibrinated Horse Blood Typhoid-paratyphoid A & B vaccine Pertussis Vaccine* Pertussis Vaccine-Diphtheria Toxoid* Tetanus-Diphtheria Toxoid* 3. To be furnished through hospitals as supplies become available: Normal Human Plasma Normal Serum Albumin (Human) Red Cell Residues Preserved Whole Blood Fibrin Foam (Human) Fibrin Film (Human) Dried Thrombin Antihemophilic Globulin Blood Grouping Globulins The drugs for the treatment of venereal diseases are distributed through the Division of Biologic Laboratories for the Division of Venereal Diseases (see pages 66 and 68). REGULATIONS FOR DISTRIBUTION OF BIOLOGIC PRODUCTS All biologic products are distributed under the following conditions; 1. Distributing stations must supply and use adequate refrigerating facilities for storage of products. 2. The delivery of diphtheria and scarlet fever antitoxin, smallpox vaccine, typhoid-paratyphoid vaccine, Schick test outfits, diphtheria toxoid, and tuberculin is limited to boards of health, except as noted below. 3. A board of health not equipped to act as a distributing station may designate a hospital or drug store as its agent, but may not designate more than one agency. * Now furnished only for immunization of infants cared for under Federal Emergency Maternity and Infant Care Program; to he available through local boards of health for general use in 1947. 19 4. A board of health may maintain more than one distributing station but products will be delivered by this Department to one place only in each town or city, unless needed for emergency use. 5. Hospitals of over 100 beds may obtain products by sending a messenger to the Antitoxin and Vaccine Laboratory for them. 6. Physicians may obtain prophylactic products and therapeutic products for immediate use by calling at or sending a messenger to the laboratory for them. 7. Delivery of products through channels other than those authorized above may be made if the Director of the Division of Biologic Labora- tories considers that the exigencies of the situation warrant it. 8. District health officers will inspect biologic products on hand at distributing stations at least twice a year and will report their inventory and findings to the Antitoxin and Vaccine Laboratory. 9. These regulations do not apply to state institutions. The possibility of reactions following injections of any foreign protein should be kept in mind. SENSITIVITY: PRECAUTIONS ADVISABLE IN THE ADMINISTRATION OF SERUMS AND ANTITOXINS. Serum therapy should be employed only when definitely indicated and only by those equipped to combat such reactions as may occur. This is because of the possibility of serious reactions in certain sensitive individ- uals. A. Acute Anaphylactic Type of Reaction. Severe and sometimes fatal reactions may occur in sensitive individuals following the injection of even minute amounts of serum by any route. The symptoms are dyspnea, cyanosis, urticaria, lumbar or abdominal pain, and collapse, any or all of which may begin within a few minutes to an hour or more after the injection. Such reactions may usually be avoided if the following precautions are observed before the serum is administered. I. History. Patients giving a history of asthma, vasomotor rhinitis or ot her allergic symptoms occurring on exposure to horses or rabbits may be dangerously sensitive to the corresponding serum and should not be given serum of this species except after consultation. A history of asthma or hay fever, eczema, urticaria, or angio-neurotic edema due to other causes is of importance only in suggesting the need for caution. Such individuals probably have an allergic tendency, and should preferably be given serum with the precautions outlined in section JI l-d below. 20 Patients who have previously received serum injections (diphtheria, tetanus, or other antitoxins, antimeningococcic or antipneumococcic serum, diphtheria toxin-antitoxin mixture, etc.) may have acquired a sensitiveness to serum of the corresponding species, which is usually most intense from about one week to three months after the injection. Repetition of the injection of serum of the same origin during this period or in the presence of serum disease may be dangerous and should not be attempted without due regard to the risk. A history of a reaction—or lack of reaction—to a previous injection of serum is not a reliable indi- cation of how a patient will respond to a subsequent injection of the same or any other serum. Note: Bacterial vaccines and diphtheria toxoid do not contain horse or rabbit serum. II. Tests for Sensitivity. An ophthalmic or skin test, or both, should he performed on any patient to whom serum may he administered. (Material for testing is available at places supplying other biological products.) These tests are not infallible, but they give the best information avail- able. Rarely, sensitive individuals will not react to either test. The ophthalmic test is considered a more reliable indicator of clinically significant hypersensiliveness than the skin test, and is usually considered sufficient in testing for sensitivity to refined rabbit serums. It is of little or no value in children (who may wash out the serum by crying) or in any one with marked injection of the conjunctivae. Tests should not he done, nor any serum administered, unless fresh epinephrine solution is at hand, preferably in a syringe. a. Ophthalmic Test. Examine both eyes for conjunctival inflam- mation, Then put a drop of homologous serum diluted 1:10 (if available; if not, use the serum it is planned to inject) in the conjunctival sac of one eye, leaving the other eye as a normal control. A positive reaction is indicated by itching, watering, and a diffuse reddening of the eye within 30 minutes. Severe reactions may be controlled by the instillation of a few drops of epinephrine, 1:1000 dilution. b. Skin Test. Make a control injection of 0.1 cc. of physiological saline into (not under) the skin of the flexor surface of the forearm, so as to raise a small wheal. Then inject 0.1 cc. of homologous serum diluted 1:100 into the skin of the other forearm. If the test is negative, the eleva- tions caused by the injections tend to disappear in a few minutes, the serum test sometimes persisting longer than the control. A positive test will exhibit rapid enlargement of the site of the serum injection within 5-20 minutes with urticaria, a surrounding erthyema, and in severe re- 21 actions, pseudopodial extensions of the central wheal. A general anaphy- lactic reaction has very rarely occurred. Reactions usually subside within an hour or two. a. Negative Test. Subject to the precautions outlined above (paragraph I—History) with respect to the history of allergy and of previous serum treatment, serum may be administered by any route to persons who do not react to these tests (or to either test, if only one is done). If serum is given intravenously, the first dose should not exceed 2 cc. Serum should always be given very slowly, taking several minutes to administer the first cubic centimeter and at least one minute more for each additional cubic centimeter. III. Use of Information Derived from Tests. 6. Positive Eye Test. In the presence of a positive ophthalmic test serum therapy is so definitely contra-indicated that it should prob- ably not be undertaken by any route except after consultation. In- travenous injection of serum is such patients may rapidly induce very severe or even fatal reactions, and should be considered only in the most pressing emergency, if at all. See also paragraph III d. The possibility of using serum from a different animal source should he explored. c. Positive Skin Test. The import of positive skin tests is probably less than that of positive eye tests, but the same precautions are ad- vised, particularly if the skin test is strongly positive. See also paragraph 111 d. d. Doubtful Tests. If the tests give doubtful reactions or if the administration of serum is decided upon in spite of positive tests, the subcutaneous injection of a dose of epinephrine (5-15 minims of 1:1000 dilution) given a measured six minutes before the serum, is a procedure which has been used with success and which appears to be rational. Smaller initial doses of serum than usual should be given at a very slow rate. IV. Desensitization. The practice of desensitizing sensitive patients by the administration of repeated graduated doses of serum, starting with minute amounts (0.005 cc. more or less), subcutaneously and giving increasing doses at intervals of approximately one-half hour, is no longer recommended. V. Observation. All patients receiving serum should be kept under close observation for at least 30 minutes and preferably 60 minutes, during which time a physician should be immediately available. YI. Treatment. Fresh epinephrine solution, ready for administra- tion, should be at hand in a syringe whenever serum is administered. 22 The dose is I ec. (15 minims) lor an adult, correspondingly less lor a child. It should be given if the patient complains of lumbar or abdominal pain or shows evidence of urticaria, dyspena, cyanosis or collapse. The dose may be repeated within a few minutes if necessary, and may be given intravenously. Artificial respiration may be required and measures to combat shock (the application of heat, etc.) instituted if collapse occurs. B. Thermal or “Chill'" Reactions. These rarely occur except after the intravenous administration of serum. Their frequency has been greatly reduced in recent years by improved methods of processing and testing. If the patient develops a chill, which when it appears at all usually begins within twenty minutes to one and one-half hours after any dose, the advent of hyperpyrexia should be watched for. Should hyperpyrexia develop, immediate treatment is essential. Epinephrine is of no use at such a time, but procedures advocated for the treatment of heat stroke are indicated, such as the use of ice packs, the application of sheets wrung from ice water, and ice water enemas. Venesection may be of use should pulmonary edema develop. C. Serum Sickness. This is characterized most often by urticaria, but fever, enlarged glands, and joint pains are other common signs. It may come on any time up to four weeks after serum therapy, most commonly between the fourth and tenth days. Although this complication is dis- agreeable for the patient, it is not serious. Epinephrine may be given to allay discomfort, but its effect is of short duration. Cold applications lessen the annoyance of the urticaria. Large doses of salicylate have also been recommended. D. Arthus Phenomenon. At the site of the subcutaneous or intra- muscular injection local reactions occasionally occur, not incited by infection but going on to necrosis. Serum injected about seven days to three months after a previous injection (see above—1. History), particu- larly if administered to a patient with serum sickness, appears most likely to cause such reactions. The possibility of such reactions should be kept in mind to avoid confusing them with local abscesses. RECOMMENDED IMMUNIZATION SCHEDULES Plan I. Age 6 months: Combined pertussis vaccine (Sauer or Kendrick and Eldering modification) and diphtheria toxoid. Booster dose of diphtheria 23 toxoid before entering school. Some physicians prefer to begin im- munizations at 3 months. Age 8 months; Smallpox vaccination, given at the time of the last dose of combined pertussis-diphtheria immunization. Revaccination before entering school. Age 9 months: Tetanus toxoid. Booster dose one year later and follow- ing external wounds. Plan II. Age 6 months: Pertussis vaccine (Sauer or Kendrick and Eldering modification). Some physicians prefer to begin immunizations at 3 months. Age 8 months: Smallpox vaccination, given at the time of the last dose of pertussis vaccine. Revaccination before entering school. Age 9 months; Combined diphtheria and tetanus toxoid. Booster dose of tetanus toxoid one year later and following external wounds. Booster dose of diphtheria toxoid. IMMUNIZATION OF TRAVELERS a. Usually required of all travelers in foreign countries. 1. Smallpox: Vaccine virus, an inoculation which results in a primary, accelerated or immune reaction. Furnished by the Department. 2. Typhoid Fever: Triple vaccine (typhoid-paratyphoid A & B), three doses at 7 to 10 day intervals, annual single doses of 0.5 cc. thereafter. Furnished by the Department upon special request. b. Advisable for travelers to foreign countries. 1. Tetanus: Tetanus toxoid, three doses at one to three month in- tervals; a recall or booster dose one year later or following external wounds. Toxoid available only from commercial manu- facturers until 1947, when the Department will begin to dis- tribute it. 2. Diphtheria: Diphtheria toxoid, three doses at three to four week intervals. Furnished by the Department. Adults should be Schick tested and only positive reactors immunized. See Diphtheria, Active Immunization on p. 29. 24 c. Required of all travelers entering certain areas. 1. Yellow Fever: A single dose of yellow fever vaccine. Obtain- able only at the principal ports of embarkation (New York, Miami, New Orleans, Los Angeles, etc.) through the U. S. Public Health Service. 2. Typhus Fever: Typhus vaccine, two or three doses of 1 cc. each at 7 to 10 day intervals. Vaccine not furnished by the Department of Public Health; obtainable from commercial manufacturers. 3. Plague: Plague vaccine, two doses of 0.5 cc. and 1.0 cc., 7 to 10 days apart. Revaccination every six to twelve months while in plague area. Vaccine not furnished by Department. Obtainable in 1946 at California, Oregon and Washington ports of embarka- tion through the U. S. Public Health Service or through the Cutter Laboratories, Rerkeley, California. 4. Cholera: Cholera vaccine, two doses of 0.5 cc. and 1.0 cc., 7 to 10 days apart; a booster dose every six months while in cholera areas. Vaccine not furnished by the Department of Public Health; obtainable from commercial manufacturers. 25 SPECIFIC DISEASES ACTINOMYCOSIS DIAGNOSIS Based on clinical findings confirmed by microscopic examination of discharges from lesions. TREATMENT Penicillin appears to be effective. ISOLATION AND QUARANTINE (See p. 5.) PREVENTION No method of immunization. Destruction of infected animals. DIAGNOSIS VNTHRAX Based on history of handling hides, wool, hair or bristles; clinical findings; and microscopic examination of lesions and discharges for anthrax bacillus. TREATMENT Neoarsphcnamine, sulfonamides and penicillin have all been found to be effective therapeutic agents. Serum is also available from commercial sources. ISOLATION AND QUARANTINE (See p. 5.) PREVENTION No method of active or passive immunization available. Disinfection of hides, adequate ventilation, use of gloves, careful handwashing, at- tention to abrasions of skin. CHANCROID (See pages 63 and 69.) 26 DIAGNOSIS CHICKEN POX (Varicella) Based on c linical findings. TREATMENT No specific treatment ISOLATION AND QUARANTINE (See page 5.) PREVENTION No method of active or passive immunization available. DIAGNOSIS CHOLERA, ASIATIC Based on clinical findings and bacteriological examination of stools. TREATMENT Administration of fluids parenterally; plasma and blood to combat shock is essential first. Sulfonamides may be of value. ISOLATION AND QUARANTINE (See p. 5.) PREVENTION Commercial vaccines, now available, give considerable protection for a limited period. Used only for persons traveling in areas where cholera is prevalent. CONJUNCTIVITIS, SUPPURATIVE DIAGNOSIS Based on clinical appearance. TREATMENT No specific treatment. Sulfonamides or penicillin instillations often useful. ISOLATION AND QUARANTINE (See p. 8.) PREVENTION Good hygiene, including avoidance of contact with those suffering from the disease. 27 DIAGNOSIS DIPHTHERIA If clinically diphtheria, do not delay antitoxin pending laboratory report. Nose and throat cultures for diagnosis should be sent to local labora- tories (see p. 11), or to the Bacteriological Laboratory, 281 South Street, Jamaica Plain; outfits obtainable at local boards of health. Positive diagnostic reports telephoned. (See p. 9). TREATMENT In all cases known to be or suspected of being diphtheria, and in cases of membranous “croup,” antitoxin should be administered at once, and a culture taken immediately for bacteriological diagnosis. Dosage: Antitoxin is ineffective against toxin already absorbed in the tissues. Therefore, to be effective, antitoxin treatment must be adequate and prompt. (See Wesselhoeft, C., Med. Clin, of N. A., Mar., 1936.) The schedule given below is suggested as a guide to adequate therapy but each case should be treated according to the individual problems it presents. Doses larger than those noted may sometimes be necessary. The dose should be adjusted to the extent of the inflammatory membrane and the general condition of the patient. AMOUNT OF ANTITOXIN IN THE TREATMENT OF A CASE OF DIPHTHERIA Mild Cases Moderate Severe* Malignant Membrane limited Both tonsils in- Extension of mem- Extensive mem- to one tonsil or to volved or one tonsil brane to uvula, soft brane, extreme tox- the nares and adjacent pil- palate or naso- icity, hemorrhages lars pharynx in mucous mem- branes, skin, etc. UNITS UNITS** UNITS** UNITS** 5,000-10,000 10,000-20,000 30,000-50,000 50,000-100,000 The total amount of antitoxin needed should be administered in the first dose; but if, at the time of the next visit, a spread of the inflamma- tory process or an increase in toxic symptoms is noted, the question of giving additional antitoxin should be considered. Administration—Route and Technique: In mild and early moderate cases the antitoxin should be injected by means of a sterile *Cases of laryngeal and naso-pharyngeal diphtheria, moderate cases still active hut seen late at the time of the first injection, and moderate cases of diphtheria occurring as a complication of another communicable disease should be treated as “severe cases.” . **The larger amount should be used if antitoxin is given intramuscularly. Intravenous administra- tion of part of the dose is recommended in severe and malignant cases. 28 hypodermic syringe into a suitable muscle instead of merely under the skin, since absorption takes place about three times as rapidly from muscles. For intravenous administration, the injection may be given into the vein on the flexor surface of the elbow. Always test a patient for sensitivity before administering serum. Antitoxin for intravenous use should show no sediment or turbidity. It must be warmed to room temperature and given slowly. Before the antitoxin is administered wash the skin at the point of injection with soap and water followed with alcohol. When dry, paint with tincture of iodine. ISOLATION AND QUARANTINE (See p. 5.) PREVENTION Passive Immunization: Passive protection of contacts against diphtheria may be obtained by the subcutaneous injection of 1,000 units of antitoxin. The immunity thus established is of short duration, lasting only ten days to two weeks. Serum sickness and sensitization to horse serum may result from such an injection of antitoxin. This method of immunization is not recommended for contacts who can be kept under daily observation so that treatment may be given immediately if they show signs of the disease, particularly if active immunization is in progress. Active Immunization liecoin men da tion s a. All children between six months and high school age should be immunized with diphtheria toxoid. The Schick test need not be performed on them before immunization, since the majority of children of this age group are susceptible to diphtheria. b. The Schick test should be performed on all persons of high school age or over who are exposed to diphtheria or who are likely to come in contact with it. Interpretation of the test will indicate treatment as follows: 1. Schick positive, control negative: susceptible. Administer diphtheria toxoid. 2. Schick positive, control positive but smaller; often sus- ceptible, and sensitive to proteins of the diphtheria bacillus. Where individual handling of patient is possible, administer diphtheria toxoid with caution in small divided doses. Where this is not feasible, administer diphtheria toxin-antitoxin mixture. 29 3. Schick and control show approximately equal reactions: immune but sensitive to diphtheria bacillus proteins (“pseudo- reaction”). No immunization indicated. 4. Schick and control tests both negative: immune. No immunization indicated. Dosage of Toxoid: Three doses of 0.5,1.0 and 1.0 cc. given respec- tively at intervals of three or four weeks are advised. Fewer doses or administration at shorter intervals may fail to produce immunity. In- jections should be made subcutaneously after painting the skin at the site of injection with tincture of iodine. Do not inject more than 1.0 cc. Discard remaining contents of used vials at end of clinic session. The standard dosage schedule given above may cause moderate or oc- casional marked reactions in adults. For this reason the first dose in adults should be 0.1 cc. If no marked reaction follows, the second and third doses should be 0.5 and 1.0 cc. respectively. If a marked reaction oc- curs, the dosage can be adjusted in accordance with the severity of the reaction, and the interval between doses shortened, provided a total of 2.5 cc. is administered. The Schick Test. Schick test outfits furnished by the Department of Public Healt h through local boards of health. Inject 0.1 cc. of toxin on right arm, and 0.1 cc. heated toxin for control on left arm, all injections into but not through the skin. Observe reactions on fourth day. REPORTING DOG BITE All cases of dog bite, whether requiring antirabic treatment or not must be reported to the local board of health. (See p. 2.) RECOMMENDED PROCEDURE The dog: a. Do not permit anyone to kill the dog\ if it is killed at once, it may be impossible to determine promptly whether or not it was rabid. b. Keep the dog under observation for two iveeks. When the case is re- ported to the board of health, the animal inspector will quarantine the dog. If the dog is well at the end of two weeks, the possibility of trans- mission of rabies at the time of the bite may be dismissed. c. If the dog becomes sick have it examined by a veterinarian. d. If the dog dies have the head sent to the Wassermann Laboratory, 281 South Street, Jamaica Plain, (Telephone, Arnold 1232). This is a State laboratory, examination being made without charge. 30 The patient: a. Cauterize wound, if possible, with fuming nitric acid. Iodine, mercurochrome, and similar antiseptics do not cauterize, nor are other cauterizing agents effective. b. Antirabic treatment: Acting under authority of Chapter 375 of the Acts of Ih37 (amending Chapter 1 TO, section 145A of the General Laws), the Department of Public Health has adopted the following rules and regulations in accordance with which boards of health are required to furnish antirabic vaccine and treatment. These regulations should not be interpreted as a flat recommendation that all persons so bitten by or exposed to dogs should be given treatment, but rather as the conditions under which boards of health are required to furnish the vaccine and treatment if the clinical circumstances surrounding the case indicate to the physician that the patient is in need of treatment. The board of health is under no obligation to furnish vaccine and treatment regardless of the opinion of the attending physician, unless the case is covered by one of the following regulations. 1. Antirabic vaccine and antirabic treatment shall be furnished by the board of health for all persons bitten by or intimately exposed to the saliva of: (a) A clinically rabid animal. (b) An animal the head of which was found positive for rabies on laboratory examination. (c) An animal the head of which was found suspicious for rabies on laboratory examination. (d) An animal the head of which was in such condition on reaching the laboratory that it could not be examined, and was therefore classified as unsatisfactory for examination. (e) An animal which could not be restrained for a clinical observa- tion period of fourteen days after the date of biting or exposure. (f) An animal which was killed without being held for observation and without subsequent laboratory examination of the head. 2. Antirabic vaccine and antirabic treatment shall be furnished by the board of health for all persons bitten on the head. Treatment shall be discontinued at the end of seven days if the dog by which the patient was bitten is still well and is kept under observation for seven additional days; treatment to be resumed if the dog shows signs of rabies during this second seven-day period. 3. Before antirabic vaccine is furnished to a physician for the treat- ment of a patient, said physician shall certify in writing to the board of health the name and address of the patient to be treated, the severity of 31 the bite or degree of exposure, the place where the bite or exposure oc- curred and the identity of the animal responsible for the biting if said is obtainable. 4. If antirabic vaccine and antirabic treatment are given because of a bite or exposure occurring in a community other than the one in which the patient resides, notice of said facts shall be forw arded by the board of health to the board of health and animal inspector of the community where said biting or exposure occurred and to the county commissioners of the county, other than Suffolk, in which said latter community is located. 5. No charges shall be paid for services other than for the administra- tion of the vaccine. 6. A physician shall be entitled to twenty-one doses of antirabic vaccine for the treatment of head bites or severe multiple lacerations on other parts of the body, and to fourteen doses for the treatment of all other bites or exposures. 7. The board of health may require a statement made under penalty of perjury and signed by the patient to be treated, or, in the case of a minor, by his parent or guardian or person immediately responsible for his supervision, stating the place where said person was bitten or exposed and the identity of the dog if obtained. Attention; Before beginning antirabic treatment, vaccine should be obtained from the board of health. Vaccine should not be purchased directly as the board of health is not responsible for the cost of vaccine which it has not purchased. To avoid the possibility of subsequent dis- pute as to costs of treatment, obtain authorization from the board of health. The State does not furnish antirabic vaccine. Antirabic Vaccine: The vaccine at present recommended by the Department of Public Health is that prepared according to the Semple method (phenolized virus). Fourteen injections are usually adequate for simple bites on the trunk and extremities. When the bite is on the head or neck, or where there are severe multiple lacerations, twenty-one injections are desirable. All injections are given subcutaneously, pref- erably in a different site each day to avoid local soreness; the abdominal wall is a frequent site for the injections. In making decisions in regard to treatment when actual exposure to the virus is doubtful, the slight but very definite danger of paralysis resulting from the use of the vaccine should be taken into consideration. 32 DIAGNOSIS DYSENTERY, AMEBIC Based on clinical findings with laboratory confirmation through examination of fecal specimens. Vegetative stale of amebae: For best results it is necessary to examine unpreserved, freshly passed specimens, which must reach the laboratory within two or three hours and must be kept warm in transit. This may be done by wrapping the container in several layers of paper. If distance from the laboratory prohibits sending fresh specimens, the less satisfactory fixed smear method may be used. Special con- tainers for this purpose are available through local boards of health. (See p. 9.) For satisfactory results, directions as to mailing and fixing of smears must be followed carefully. Patients should not be sent to the State laboratory. Encysted stage of amebae: Stool specimens in 10% formalin may be sent to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. Special containers for this purpose are available through local boards of health. TREATMENT Several specific amebicidal drugs available, ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No method of immunization available. Prevention depends on good sanitation and personal hygiene. DIAGNOSIS DYSENTERY, BACILLARY Based on clinical findings with laboratory confirmation. Some strains of dysentery bacilli cause merely a transient diarrhea in healthy adults, or in children over twelve years of age. Stool specimens may be sent in typhoid culture outfits to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. For best results specimen should be taken early in the disease and from a diarrheal specimen, including mucous if present. Local laboratories approved for making examinations for enteric organisms are listed on p. 11. 33 TREATMENT Sulfonamides hasten clinical recovery. In Shiga type (rare in Massa- chusetts), antitoxin may be of use. Not furnished by the State. ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No practical method of active or passive immunization available. Prevention depends upon good sanitat ion, the protection of food supplies, pasteurization of milk and good personal hygiene. ENCEPHALITIS, INFECTIOUS DIAGNOSIS Based on clinical findings. Confirmation by rising titer of neutralizing antibodies or complement fixation for the virus (eastern or western equine, St. Louis, Japanese B, etc.) during convalescence, or by isolation of virus from brain post-mortem. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No method of immunization available. Prevention of some varieties by protection from bites of mosquitoes and by mosquito control. GERMAN MEASLES (Rubella) DIAGNOSIS Based on clinical findings. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No practical method of immunization available. 31 (See pages 63 and 67.) GONORRHEA GRANULOMA INGUINALE (See pages 63 and 69.) HEPATITIS, INFECTIOUS DIAGNOSIS Based on clinical, laboratory and epidemiological findings. Often oc- curs as multiple cases or in epidemics. TREATMENT Supportive plus a high protein, high carbohydrate and low fat diet, plus high vitamin intake with maintenance of fluid balance. Prolonged rest during convalescence has greatly decreased the incidence of re- lapses. PREVENTION The two established mechanisms of infection are (1) contaminated food and water supplies and (2) transfusion of blood or plasma from a donor with actual or latent infection. Many persons acquire immunity through latent, unrecognized infections. Use of food and water supplies of known safety, avoidance of unnecessary transfusions, and great care in avoiding blood donors having had any association with known cases of jaundice, are the primary preventive measures to be followed. In cases known to have been exposed to infection by the oral or contact routes, protection may be achieved by the injection of 0.1 cc. per pound of immune serum globulin. References: 1) Stokes, J. J. and Neefe, J. R.: J.A.M.A. 127,144, Jan. 20, 1945. The Prevention and Alleviation of Infectious Hepatitis by Gamma Globulin. 2) Havens, W.P. Jr. and Paul, J.R.; J.A.M.A. 129,270, Sept. 22, 1945. Prevention of Infectious Hepatitis with Gamma Globulin. LEPROSY DIAGNOSIS Based on clinical findings, confirmed by demonstration of leprosy bacilli in smears from lesions. Call Division of Communicable Diseases, Massachusetts Department of Public Health, for assistance in diagnosis. 35 TREATMENT Send to U. S. Leprosy Hospital at Carvilie, Louisiana. Application is made through the board of health to U. S. Public Health Service. ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No method of immunization available. Prevention by avoidance of prolonged contact with a case. LYMPHOCYTIC CHORIOMENINGITIS DIAGNOSIS Based on clinical findings confirmed by rise in titer of neutralizing antibodies late in convalescence. Serological tests available at National Institute of Health, Bethesda, Maryland. TREATMENT No specific treatment ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No method of immunization available. No evidence of person to person transmission. Eradication of house mice. LYMPHOGRANULOMA VENEREUM (See pages 61 and 69.) MALARIA DIAGNOSIS Based on clinical condition with laboratory confirmation. Smears for diagnosis may be sent to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. Special containers available through local boards of health. (See p. 9.) Thick and thin films should be sent, conveniently upon the same slide. Recommended Procedure: Finger should be cleansed with alcohol and dried before pricking. To make thick smear, place three drops on one end of the slide and quickly spread into a homogeneous 36 area about the size of a dime, with the blood lancet or corner of a clean slide. Allow to dry thoroughly in the air in a horizontal position. In veterans returning from malarious areas, coma or symptoms resembling meningitis and encephalitis may he due to cerebral malaria (aestivo-autumnal, due to P. falciparum). TREATMENT Quinine and atrabrine relieve clinical symptoms. In coma due to aestivo-autumnal malaria, intravenous quinine hydrochloride is im- perative. ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No practical method of active or passive immunization available. In endemic areas prevention depends upon control of malaria mosquitoes, personal protection from bites, and suppressive quinine or atabrine. MEASLES (Rubeola) DIAGNOSIS Based on clinical findings. TREATMENT No specific treatment after symptoms appear ISOLATION AND QUARANTINE (See p. 6.) PREVENTION Passive Immunization Prevention: In infants under 3 years, in older children who are tuberculous, debilitated or otherwise chronically ill, or in groups of children in institutions, hospital wards, etc., prevention of measles in exposed susceptible patients is indicated. It may be obtained in most instances by administration of a sufficient dose of immune globulin within 6 days after the actual dale of exposure. The protection so ob- tained is of the passive type and does not last more than three weeks. Dose: 0.1 cc. per pound of body weight. Modification: If the properly selected dosage of immune globulin is given to exposed susceptible individuals (preferably about 4 5 days 37 following exposure) the disease will usually occur in mild or ‘'modified” form. In normal healthy children over 3 years of age this mild form of the disease is advantageous inasmuch as it results in an active, and more or less permanent, immunity. If modification is thus obtained, the incuba- tion period is occasionally prolonged to 17-21 days; catarrhal symptoms are usually slight; temperature is lower; Koplik’s spots may be absent, and rash may be mild and transient. “Modified” measles is probably as infectious as the unmodified form; therefore, if a quarantine is for any reason to be imposed, it must be extended to 3 weeks after exposure. Dose: 0.025 cc. per pound of body weight. References: Janeway, C. A.: J.A.M.A. 126, 678-680, Nov. 11, 1944. Clinical Use of Products of Human Plasma Fractionation: II. Gamma Globulin in Measles. 1. Immune Serum Globulin—For prevention, give during first four days after exposure*; for modification, four to ten days. Furnished by the Department of Public Health directly or through certain local boards of health. Given by intramuscular injection; do not give intra- venously. May be obtained through: 2. Convalescent Serum—Usually not obtainable except in cer- tain hospitals. For prevention, 3 cc. during first four days after exposure*; for modification, four to seven days. Inject intramuscularly in buttocks, lateral aspect of thigh, or between scapulae. Active Immunization; No practical method available. MENINGITIS DIAGNOSIS Based on clinical findings supplemented by lumbar puncture and spinal fluid examination. The possibility of the meningitis being due to the Pfeiffer bacillus, pneumococcus, etc. (see p. 39) should be borne in mind. Specimens of spinal fluid should be examined by direct smear and by culture before starting chemotherapy. If local facilities for such examination are not available, spinal fluid may be sent to the Bacteri- ological Laboratory, 281 South Street, Jamaica Plain. Positive reports are telephoned. (See p. 9.) If a meningococcus, pneumococcus or Pfeiffer bacillus is isolated, it should be typed as soon as possible. Typing is essential, if serum therapy is to be considered, and must be per- * Determination of date of exposure. Measles is communicable t hree days before the appearance of the rash. Therefore, the date of appearance of the rash in the patient being known, the dale of first possible exposure of the contact is three days earlier. 38 formed at the beginning, since identification of type may become im- possible later. Cerebral malaria (due to P. falciparum) should not be overlooked in persons returning from tropical areas. (See Malaria, p. 36.) TREATMENT General: Immediate and adequate sulfonamide therapy is indicated in all types of purulent meningitis and should be instituted pending determination of the infecting organism. Upon positive identification of the organism, therapy according to some such scheme as the following is recommended. Sulfonamide drugs are listed in the probable order of their effectiveness, in case sensitivity to the drug of choice requires changing to some other drug. Causative Organism Therapy Meningococcus: Sulfadiazine, sulfathiazole or sulfanil- amide; penicillin; and/or anti-rneningo- coccic serum if sulfonamide therapy fails or is not tolerated. Pfeiffer (Influenza) Bacillus: Sulfadiazine or sulfathiazole and specific serum; streptomycin if obtainable. Pneumococcus: Sulfadiazine or sulfathiazole, and penicil- lin; anti-pneurnococcic serum if drug is not tolerated or is not effective. Streptococcus: Sulfadiazine or sulfanilamide or sulfathi- azole and penicillin. Drug Therapy: Because patients with meningitis are usually de- hydrated as a result of vomiting, fever, sweating, and failure to take fluids, it is essential to precede the first administration of any sulfonamide drug by the administration of fluids, given preferably by the intravenous or the subcutaneous routes and in sufficient amounts to overcome the dehydration. Regardless of the sulfonamide drug selected or route of ad- ministration, ample fluid output should be insured by whatever means is most effective, and an adequate blood sulfonamide level (at least 10-15 mg. per 100 cc.) must be achieved and maintained. Where penicillin or streptomycin are indicated, maintenance of adequate dosage for suf- ficient periods of time is equally essential. Serum Therapy; Antisera are furnished by the Department for the treatment of infection due to pneumococcus (types 1-33), and H. 39 influenzae (type B). Caul ion: See “Precautions Advisable in the Ad- ministration of Serums and Antitoxins.” (p. 20.) Serum should be warmed gently to room temperature before use. Never Heat Serum Above 98°F. (body temperature). Always test patient for sensitivity before administering serum. AIeningococcus Infection: Studies reported to date indicate that recovery from meningococcus meningitis is apparently as frequent following sulfonamide therapy alone as following combined serum and drug therapy. Since penicillin is also fairly effective, serum is now rarely used or needed. Serum therapy, however, is indicated in the treatment of meningococcus infections in a patient unable to tolerate effective doses of sulfonamide or penicillin. Pneumococcus Meningitis: Intrathecal and intramuscular penicillin combined with oral sul- fonamides, have lowered the average mortality in this condition to about 50% Although definite evidence that combined drug and serum therapy results in a still lower mortality is lacking, the use of serum ap- pears strongly indicated in a disease having such a serious prognosis. Serum should be given ini ravenously whenever possible. The type of pneumococcus must be determined and serum for that particular type used. II. Influenzae (Pfeiffer bacillus) Meningitis: Meningitis caused by H. influenzae (usually the serologic type B) is particularly common in children and infants. Penicillin is usually inef- fective, and sulfonamides alone are undependable. Combined sul- fonamide and serum therapy results in recovery in over 75% of cases. Streptomycin is apparently the most effective therapeutic agent yet discovered but until it is generally obtainable, combined serum and sulfonamide therapy is indicated, employing not less than 100,000 units (100 mg. of antibody nitrogen) of serum as the minimum dose. ISOLATION AND QUARANTINE (See p. 6.) PREVENTION No active or passive immunization for any variety of meningitis. Susceptibility is slight and general measures are not applicable. Because of the high incidence of carriers, sulfonamides are given to contacts of meningococcus meningitis under certain rare circumstances. 40 MUMPS DIAGNOSIS Based on clinical findings. TREATMENT No specific treatment ISOLATION AND QUARANTINE (See p. 7.) PREVENTION No practical method of active or passive immunization available OPHTHALMIA NEONATORUM REPORTING All cases showing inflammation, swelling, redness or abnormal dis- charge of the eyes within two weeks of birth must be reported to the board of health. “If either eye of an infant becomes inflamed, swollen and red, or shows an unnatural discharge within two weeks after birth, the nurse, relative or other attendant having charge of such infant shall report in writing within six hours thereafter, to the board of health of the town where the infant is, the fact that such inflammation, swelling and redness of the eyes or unnatural discharge exists.” (G.L. Ch. ill, Sec. 110. (See p. 134.)) Also“if either eye of an infant whom or whose mother a physician, or a hospital medical officer registered under section nine of chapter one hundred and twelve, visits becomes inflamed, swollen and red, or shows an unnatural discharge within two weeks after birth, he shall immediately give written notice thereof, over his own signature, to the board of health of the town ...” (G.L., Ch. Ill, Sec. 111. (See p. 135.)) DIAGNOSIS Smears to be examined for gonoccocci should be obtained. May be examined in the local laboratory (seep. 11) or sent to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. The usual gonorrhea outfits, obtainable through local boards of health, should be used for this purpose. Positive results are telephoned. (See p. 9.) TREATMENT The General Laws of the Commonwealth require that the local board of health upon receipt of a report of a discharging eye as above described 41 “shall lake such immediate aclion as it may deem necessary, including, so far as may be possible, consultation with an oculist and the employ- ment of a trained nurse, in order that blindness may be prevented.” (G.L., Ch. Ill, Sec. 110. (See p. 134.)) Sulfonamides and penicillin are effective in the treatment of gonococcal ophthalmia. ISOLATION AND QUARANTINE Aseptic nursing precautions to prevent spread of possible infection to the other eye or to the eyes of attendants. PREVENTION Silver nitrate solution for instillation in the eye at time of birth is furnished in wax ampoules by the Department of Public Health and obtainable through hospitals and boards of health. Under authority granted by the General Laws, Ch. Ill, Sec. 109A (see p. 134), the Department has ruled that only one per cent silver nitrate put up in individual doses in wax ampoules can be used as a prophylactic in the newborn. (See Gonococcal Ophthalmia Neonatorum, p. 69.) The recording of the use of the prophylactic on the birth certificate is required by law. (See pages 69 and 134.) PARATYPHOID FEVER (See Salmonellosis, p. 48.) DIAGNOSIS PLAGUE Based on clinical and bacteriological findings, and history TREATMENT Serum may be of some value. ISOLATION AND QUARANTINE (See p. 7.) PREVENTION Active Immunization: Commercial vaccines, now available, give considerable protection for a limited period. Used only for persons traveling in areas where plague is prevalent. 42 DIAGNOSIS PNEUMONIA Epidemiological, clinical, X-ray and bacteriological findings may be required for determination of the etiology, treatment and prognosis of a case of pneumonia. Causative agents may be pneumococcus, streptococ- cus, staphylococcus, Friedlander’s bacillus, etc., or various virus agents (e.g. those responsible for ornithosis and “atypical pneumonia”). Pneumococci are the commonest cause, and the most responsive to specific treatment. Samples of sputum, and of blood for culture should be collected and sent to the nearest approved laboratory or to the Bacteri- ological Laboratory, 281 South Street, Jamaica Plain, at the onset of the disease, since the nature and type of the infecting organism fre- quently cannot be determined after drug treatment has been instituted. No generally available facilities for the diagnosis of virus pneumonia exist in Massachusetts. The etiological agent, particularly the type of pneumococcus, may usually be determined from a sputum specimen. If no sputum is raised, a throat swab and a blood specimen should be taken since they may pro- vide cultures which can be typed. Select freshly raised sputum; do not be content with saliva as oral cavity may contain pneumococci of a type different from that causing the pneumonia. Send sputum in special containers available through boards of health, or in any sterile container. Do not use tuberculosis sputum outfits as these contain carbolic acid which destroys the pneumococci, making typing impossible. TREATMENT Sulfonamides or penicillin are usually effective. It may be necessary to use type specific anti-pneumococcic serum in some cases. Drug therapy should be based on adequate dosage and should be maintained for at least 3-4 days after recovery has set in, to avoid relapses. Type specific anti-pneumococcic serum is now rarely em- ployed except in cases unable to tolerate the drugs, or showing no response after 48 hours of adequately maintained drug therapy. Specific anti-pneumococcic serum, types 1-33, is furnished by the Department for treatment of cases of pneumonia in which the type of infecting pneumococcus has been determined. All cases should be tested for serum sensitivity before serum is administered. (See p. 20.) ISOLATION AND QUARANTINE (See p. 7.) 43 PREVENTION No accepted method of active or passive immunization available. POLIOMYELITIS (infantile Paralysis) DIAGNOSIS Preparalylic Cases: Based on clinical findings, supplemented by lumbar puncture and spinal fluid examination. Paralytic Cases: Based on clinical findings. TREATMENT Preparalytic Cases: No specific treatment Paralytic Cases: a. During acute stages: symptomatic and supportive with special reference to prevention of contractures. Advice in regard to orthopedic treatment to accomplish this end may be obtained through the Services for Crippled Children by applying directly to the Depart- ment of Public Health. In cases of respiratory paralysis, placing patient in a respirator may be of life-saving value. Respirators are located in the following hospitals: Number of Respirators Beverly Beverly Hospital 2 Boston Children’s Hospital several Boston City Hospital 8 Boston Haynes Memorial Hospital 3 Boston Massachusetts General Hospital.... 4 Boston Peter Bent Brigham Hospital 3 Cambridge Cambridge City Hospital 1 Fall River Fall River General Hospital 1 Fall River Union Hospital 1 Fitchburg Burbank Hospital 1 Greenfield Greenfield Isolation Hospital 1 Haverhill Haverhill Municipal Hospital (Hale) 1 H olyoke 1 lolyoke Hospital 1 Lawrence Lawrence General Hospital 2 Leominster Leominster Hospital 2 Malden Malden Hospital 1 New Bedford St. Luke's Hospital 1 44 Number oj Respirators Newton Newton-Wellesley Hospital 1 Pittsfield House of Mercy Hospital 1 Quincy Quincy City Hospital 2 Salem Salem Hospital 2 Springfield Health Dept. Hospital 1 Worcester Belmont Hospital 1 Worcester Memorial Hospital 1 Worcester Worcester City Hospital 3 b. After acute stages: 1. Care available through the Services for Crippled Children. Special consultation service is provided by the Department of Public Health on the request of the attending physician, for paralyzed cases of poliomyelitis on condition that the family is unable to pay for the services of an orthopedic surgeon. Applications for this service should be made directly to the District Health Officer. 1 f necessary, a consultant will visit the patient, with the attending physician, but the facilities of the nearest Clinic for Crippled Children should be utilized, if the patient is able to attend. These clinics are described on page 81. 2. Harvard Infantile Paralysis Commission Clinics The Central Clinics of the Harvard Infantile Paralysis Com- mission are in the Children's Hospital building, Boston, where special facilities exist for the treatment of infantile paralysis in all stages of the disease. Facilities are available for patients of all ages. The Commis- sion conducts, in conjunction with the Central Clinics, treatment clinics in 11 cities and towns of the Commonwealth: City or Town location Time Arlington 5 Court Street Tuesday afternoons Beverly Beverly Hospital Alternate Wednesdays Dedham 82 Court Street Friday afternoons Haverhill 42 Fleet Street Wednesdays Lawrence Child Welfare Rooms, City Hall Mondays Lowell 150 Middlesex Street Wednesdays Malden 351 Main Street Saturday mornings Medford Old Tufts School, Tufls Square Quincy Dispensary, High School Avenue Mondays Somerville Old Bow Street Police Station Thursday afternoons Waltham Waltham Baby Hospital Tuesday afternoons 45 3. Hospitals and institutions admitting paralyzed cases for special care are: City or Town Name of Institution Restrictions Baldwinsville Hospital Cottages for Children Under 14 years Boston Industrial School for Crippled Day School Children Canton Massachusetts Hospital School for Between 5 and 15 years Crippled Children Egypt (Scituate) Children’s Sunlight Hospital Children 2-6 years Adults 16-35 years Lakeville Lakeville State Sanatorium Over 3 years Newton Center New England Peabody Home for Under 12 years Crippled Children North Dartmouth Sol-E-Mar Under 14 years Springfield Shriner’s Hospital for Crippled Under 14 years Children Applications for admission to most of these hospitals should be made directly to the Superintendent. Admissions to Lakeville are made through the local boards of health or the Alassachusetts Department of Public Health and to Sol-E-Mar through St. Luke’s Hospital, New Bedford. ISOLATION AND QUARANTINE (See p. 5.) PREVENTION Passive Immunization: No method of proven value. Active Immunization; No method available. Prevention of exposure is almost impossible due to subclinical cases and carriers, but avoidance of travel and crowds during epidemics is advisable. Tonsillectomy should be postponed. DIAGNOSIS PSITTACOSIS Based on clinical and laboratory findings. Laboratory tests not per- formed by the Department of Public Health but the Division of Com- municable Diseases should be consulted for directions regarding spec- imens. TREATMENT No specific treatment. 46 ISOLATION AND QUARANTINE (See p. 7.) PREVENTION No method of active or passive immunization available. Regulation of sale of parrots and other psittacine birds. Avoidance of contact with sick birds. Note: Ornithosis, a term including psittacosis, refers also to infections with a related virus, contracted from pigeons, domestic fowl and other birds. RABIES (See Dog Bite, p. 30.) Other animals are occasionally found to be rabid. The possibility of contracting the disease by bites of animals other than dogs should al- ways be considered. ROCKY MOUNTAIN SPOTTED FEVER DIAGNOSIS Based on clinical findings with confirmation by Weil-Felix reaction and complement fixation test. For these tests 5 cc. of blood should be sent in a sterile test tube to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. (See p. 9.) Blood should be drawn early in the disease and at weekly intervals in order that a rising titer may be detected. TREATMENT Hyper-immune rabbit serum useful if given before or about the time of the appearance of the eruption. ISOLATION AND QUARANTINE (See p. 7.) PREVENTION Vaccination for those in heavily-infested areas; avoidance of tick bites. Commercial vaccines, now available, give considerable protection for a limited period. Used only for persons traveling in areas where Rocky Mountain spotted fever is prevalent. 47 SALMONELLOSIS DIAGNOSIS Based on two principal clinical varieties: (1) Cases with typhoid-like symptoms with bacteremia, usually due to S. paratyphi A (Paratyphoid A) or S. paratyphi B (Paratyphoid B), rarely to other types; (2) Cases with gastroenteritis, usually due to S. typhimurium (B. aertrycke) or to one of the other numerous types. Typhoid-like cases may be diagnosed bacteriologically by blood and stool cultures. Cases of salmonella gastroenteritis are diagnosed bacte- riologically by stool cultures only. Subclinical infections in contacts often occur. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 7.) PREVENTION Active immunization available for Paratyphoid A and Paratyphoid B only. Travelers to foreign areas should receive the Triple Vaccine (Typhoid-Paratyphoid A & B) which is available from the Department upon request. Prevention of infections causing gastroenteritis is made difficult by the occurrence of unrecognized subclinical infections, which spread the disease. Stools of contacts should be cultured to discover such sub- clinical cases. Good sanitation and personal hygiene are essential in the control of all forms of Salmonellosis. DIAGNOSIS SCARLET FEVER Based on clinical findings. Throat cultures of no practical value except in epidemiological studies. TREATMENT General medical care is adequate for the usual mild case. Complica- tions may be greatly reduced by penicillin therapy, and to a lesser extent, by sulfonamides. Scarlet fever streptococcus antitoxin may be indicated in toxic cases, and is furnished by the Department of Public Health in 9000 unit vials through local boards of health. All cases should 48 be tested tor horse serum sensitivity before giving antitoxin. Serum re- actions follow scarlet fever antitoxin more frequently than diphtheria antitoxin. (See p. 20.) The dose is 9.000 to 27,000 units depending on the severity of the case and the weight of the patient. ISOLATION AND QUARANTINE (See p. 7.) PREVENTION Passive Immunization: Use of antitoxin for this purpose not generally recommended, owing to the mildness of the prevailing disease and the frequency of serum reactions. If emergency prevention is essen- tial and the patient gives no evidence of sensitivity to horse serum by history or by sensitivity test (see p. 2L), 3,000 to 4,500 units of antitoxin may be given intramuscularly. Active Immunization: Dick toxin given in five subcutaneous in- jections at one week intervals produces a high level of protection, but in customary doses causes a fairly high incidence of untoward reactions. Dick toxin is not furnished by the Department of Public Health or by local health departments. SUSCEPTIBILITY May be determined by Dick test. Inject exactly 0.1 cc. into the skin; observe 20-24 hours. Any redness 1 cm. or more in any diameter indi- cates susceptibility. Dick test material is not furnished by the State or local health departments. SEPTIC SORE THROAT Septic sore throat is probably not a definite disease entity. The term usually includes severe sore throats of streptococcal origin. An abnormal incidence of sore throats in the practice of any physician should be re- ported to the local board of health for investigation as to its possible spread through milk. Persons with sore throats should not be permitted to work around milk supplies. SMALLPOX (Variola) DIAGNOSIS Based on clinical findings. TREATMENT No specific treatment. 49 ISOLATION AND QUARANTINE PREVENTION (See p. 8.) Passive Immunization: No satisfactory method available. Active Immunization: Smallpox vaccine virus furnished by the State through local boards of health. (See p. 19.) Virus must be kept in a refrigerator freezing compartment until used (do not carry it in coat pocket). Multiple pressure method advised instead of scarification. (See directions accompanying vaccine.) Acetone or alcohol is preferable for cleansing the skin; avoid medicated alcohols. Do not cover site of vaccina- tion with a dressing or shield. Failure to obtain successful “takes” may arise from use of out-dated or improperly stored vaccine; from use of non-volatile antiseptics in preparation of the site; or from failure to penetrate the epidermis (al- though visible oozing of blood should be avoided). Successful primary “takes” are self-evident, but in revaccination it is essential to make sure that a genuine immune or accelerated reaction is observed, before re- garding the vaccination as successful. When to vaccinate: The first year of life is the ideal time in which to perform a vaccination, as reactions are less severe and complications at a minimum. The child should be re-vaccinated prior to entering school. Any person who has never been vaccinated should have it done at once. Massachusetts law requires that “an unvaccinated child shall not be admitted to a public school except upon presentation of a certificate . . . signed by a registered physician designated by the parent or guardian, that the physician has at the time of giving the certificate personally examined the child and that he is of the opinion that the physical condi- tion of the child is such that his health will be endangered by vaccina- tion.” The supreme court has ruled that a school committee may re- quire renewal of such a certificate as often as every two months. SYPHILIS (See pages 63 and 65.) TETANUS DIAGNOSIS Based on clinical findings. No bacteriological test available. TREATMENT Tetanus antitoxin, not furnished by State. 50 ISOLATION AND QUARANTINE (See p. 8.) PREVENTION Passive Immunization: Where possible exposure to tetanus has oc- curred, protection may be obtained in most instances by administration of 1,500-3,000 units of tetanus antitoxin, after testing patients for sensitivity to horse serum (see p. 20). Protection furnished by antitoxin is transitory, and therefore not wholly dependable, and is prone to induce serum sickness and sensitization to horse serum. Active Immunization: Tetanus toxoid, properly administered, provides a long lasting protection, causes few reactions, and is recom- mended for those persons who are likely to be exposed to tetanus, (children, hostlers, farmers, veterinarians, etc.) and for all allergic subjects, in whom sensitivity to horse serum is relatively frequent. Tetanus toxoid will be furnished by the Department of Public Health in 1947. DIAGNOSIS TRACHOMA Based on clinical symptoms. (Laboratory examination to exclude other infections.) TREATMENT No specific treatment. Penicillin very useful locally, ISOLATION AND QUARANTINE (See p. 8.) PREVENTION Avoidance of contact with suspected or actual cases. General hygienic measures. No method of immunization. DIAGNOSIS TRICHINOSIS Based on clinical findings, eosinophilia, muscle biopsy, skin test (antigen available from commercial houses), and precipitin tests (send 5 cc. of serum to National Institute of Health, Belhesda, Maryland). TREATMENT No specific treatment. 51 ISOLATION AND QUARANTINE (See p. 8.) PREVENTION No method of immunization. Trichinosis may be avoided by eating only thoroughly cooked hog meat. TUBERCULOSIS Diagnosis in early stages usually based on X-ray findings, with or without laboratory data, and upon symptoms or physical signs. DIAGNOSIS 1. Sputum: Sputum may be sent to local laboratories (seep. 11) or to the Bacteriological Laboratory, 28 L South Street, Jamaica Plain. Outfits obtainable through local boards of health. (See 9.) Specimens should be adequate in amount and coughed up from the lungs. The first sputum raised in the morning is preferable. a. Laboratory examinations: 2. Itody fluids for culturing: Body fluids should be sent to an approved laboratory (see p. 9) or to the Bacteriological Laboratory in special outfits. (Do not use tuberculosis sputum outfit which contains phenol.) b. Tuberculin Test: Old Tuberculin for diagnostic purposes only is furnished by the State through the local boards of health, in capillary lubes for the Von Pirquet test, and in ampoules lor making dilutions for the Mantoux test. (See p. 18.) Directions for performing tests are in- cluded in each package. Saline solution for making dilutions not fur- nished by the State. Positive tuberculin reaction implies tuberculous infection, but gives no indication as to the activity of the process. c. X-ray Services: Patients unable to afford private X-ray service may be referred by their family physicians to State and county tubercu- losis hospitals or to clinics staffed by such hospitals (see a, below and pages 57 and 58). Reports made only to referring physician. d. Diagnostic Out-Patient Departments: Such departments are maintained at all State, county and municipal sanatoria. (See pages 57 and 58.) e. Pholofbiorograpbic units have been furnished by the Depart- ment to several large general hospitals in Massachusetts for the routine chest examination of all patients admitted to the hospital and all out- patients. 52 CLINICS a. Consultation Clinics: Consultation Clinics to which physicians may refer patients for examination are maintained by Slate and county hospitals in many communities. Patients accepted only on reference of physician, board of health, or other health agency. Reports made only to referring physician or agency. Consultation clinics are maintained at present as follows: CONSULTATION CLIN ICS City or Town Location Time Auspices Athol Town Hall 4lh Wed., 1-3 P.M. Rutland State Sanatorium Ayer Nashoba Health Fourth Thurs., Alter Middlesex County Assoc. Bldg. nate months Sanatorium Brockton Board of Health Fridays, 4-5:30 P.M. Plymouth County Sanatorium Chelsea City Hall 2nd Mon., 2 P.M. North Reading State Sanatorium Chicopee City Hall Annex 1st Mon., 2-4 P.M. Westfield State Sanatorium Everett Whidden Memorial 2nd and 4th Mon. Middlesex County Sanatorium Framingham . . Framingham Union 2nd and 4th Tues. Middlesex County Sanatorium Franklin District Court Rooms Last Wed., 2 P.M. Norfolk County Hospital Gardner Board of Health 1st Wed., 1:30- Rutland State Offices 3 P.M. Sanatorium Gt. Barrington Russell House, 3rd Thurs. Westfield State 54 Castle Street Sanatorium Greenfield Franklin County Tues. following 1st W estfield State Hospital Mon., 1 P.M. Sanatorium Holyoke City Hall 1st Fri. following 1st W estfield State Mon., 12:30-4 Sanatorium P.M. Hyannis Cape Cod Hospital 3rd Tues., 1:30 P.M. Barnstable County Sanatorium Lawrence City Hall, Room 203 2nd Tues., 1-3 P.M. North Reading State Sanatorium Malden Malden Hospital 1st and 3rd Wed., Middlesex County 1:30-4 P.M. Sanatorium Martha’s Vine- Martha’s Vineyard Last Friday, 9:35 Barnstable County yard Hospital, Oak Bluffs A.M. Sanatorium Medford Lawrence Memorial 1st and 3rd Tues. Middlesex County Hospital Sanatorium Milford 129 Main Street 2nd Wed., 1-3 P.M. Rutland State Sanatorium 53 CONSULTATION CLINICS City or Town Location Time Auspices Nantucket Cottage Hospital Last Thurs., every Barnstable County other month, 3 P.M. Sanatorium Newton Newton-Wellesley 2nd and 4th Thurs. Middlesex County Hospital Sanatorium North Adams . North Adams 3rd Wed., 9 A.M. Westfield State Hospital Sanatorium Northampton . Memorial Hall 1st Wed., 9:30 A.M. Hampshire County Sanatorium Peabody 47 Lowell Street 4th Fri., 1-4 P.M. Essex Sanatorium Pittsfield Goodrich Hall, West 3rd Wed. Westfield Slate Street Sanatorium Provincetown . Town Hall 3rd Fri., 1 P.M. Barnstable County Sanatorium Revere City Hall 4th Mon. North Reading State Sanatorium Salem 5 St. Peter Street 2nd Tues., 2-5 P.M. Essex Sanatorium Somerville 379 Broadway* 2nd and 4th Fri., Middlesex County 6:30-8 P.M. Sanatorium Southbridge. . . Town Hall, Elm St. 3rd Wed., 1-3 P.M. Rutland State Sanatorium Stoughton Chicatauhut Club 1st Wed., 2 P.M. Norfolk County Hospital Ware Mary Lane Hospital 1st Tues., 3-4:30 Hampshire County P.M. every month Sanatorium and Hampshire County Health Assoc. b. Tuberculosis Dispensaries: Tuberculosis diagnostic clinics, in- dependent of State or county sanatoria, are maintained by local boards of health at present as follows: TUBERCULOSIS DISPENS A KIES City or Town Location Time Auspices Adams Board of Health Every other Mon., Board of Health Office, 20 Center 6-7 P.M. Street Beverly 84 Cabot Street Tues., 3-5 P.M. Board of Health Brookline 55 Prospect Street Tues., 2 P.M., Fri., Board of Health 7 P.M. Cambridge Cambridge Sanato- Tues., Thurs., and Board of Health rium, 799 Concord Sat., 9-11 A.M. Avenue * This clinic is planning to move in the near future to 154 Highland Avenue, Somerville. 54 TUBERCULOSIS DISPENSARIES City or Town Location Time Auspices Canton. 473 Washington St. 3rd Fri., every other Canton Hospital and month, 5-6 P.M. Nursing Assoc. Dedham 369 Washington St. 2nd and 4th Fri., 5-6 Board of Health P.M. Everett City Hall Annex, 379 Tues., 8-9 P.M., Fri., Board of Health Ferry Street 4-5 P.M. Fall River City Hall Annex Tues., 7-8 P.M. for Board of Health adults; Sat., 11-12 A.M., for children Fitchburg Burbank Hospital, Tues., 2-4 P.M., Fri., Board of Health Nichols Avenue 11-12:30 P.M. Gloucester City Hall Mon., 8-9 P.M., Board of Health Thurs., 4-5 P.M. Haverhill Gale Building, 471 Mon., 7-8 P.M., Fri., Board of Health Main Street 4-5 P.M., 3rd Sat., 9-11 A.M. (X-ray clinic) Holyoke City Hall Annex Mon., 6-7 P.M., Fri., Board of Health 3-5 P.M. Lawrence City Hall, Room 203 Daily 1-2 P.M., ex- Board of Health cept Wed. and Sat. Lowell Health Centre, Tues., 2-4 P.M., Health Department 63 Kirk Street Thurs., 5-8 P.M. Lynn 58 Andrew Street Every morning 9- Health Department 10:30 A.M. Marlboro City Hall, Main St. Mon., 4-5 P.M., Fri., Board of Health 6-7 P.M. Milton 101 Blue Hills Park- 1st Wed., 4-6 P.M. Board of Health way New Bedford. . Olympia Building Mon., 2-3 P.M., Sat., Board of Health 2-3 P.M. Norwood Municipal Building Thurs., 5-6 P.M. Board of Health Quincy 32 High School Ave. Tues., 6-7 P.M., for Health Department adults; Sat., 9-11 A.M. for children Revere City Hall Appt. through the North Reading State board of health Sanatorium Salem 5 St. Peter Street 2nd Tues., 2-5 P.M. Salem Association for Prevention of Tu- berculosis Springfield Health Department, Mon., 2-5 P.M. and Health Department Isolation Hospital 5:30 P.M. Taunton City Hall Daily 11-12 Noon Board of Health Worcester Belmont Hospital Wed., 9-11 A.M. Department of Pub- lic Health 55 c. Mass Examinations in Industry and in the Community: The Massachusetts Department of Health maintains three mobile photo- fluorographic units for the mass examination of workers in industry, the inmates of public institutions and, where feasible, the adult population of certain communities. This is a cooperative campaign shared by the Massachusetts Department of Public Health, the local health depart- ment, and the Massachusetts Tuberculosis League, and financed to a large extent by grants from the United States Public Health Service. The service is free and on a voluntary basis. The purpose of the program is the detection of undiagnosed tubercu- losis and the placing of such persons under medical treatment or super- vision in order to prevent the spread of infection to families and fellow- workers. The X-ray equipment is available to all industrial groups on the invita- tion of the plant management. As the X-ray unit is mobile and goes directly to the plant, little time is lost from work by the employees. Significant pulmonary findings are reported to the physicians named by the employees on the registration blanks, the persons concerned being invited by mail to consult them. The findings are confidential. No individual reports are made either to the plant management or to the plant physician. Upon receipt of such a report the attending physician should make careful clinical and laboratory, as well as additional X-ray studies, in order to confirm or deny the suspicion raised by the industrial X-ray examination. If the individual is found to have active pulmonary tuberculosis, he should be reported to the local board of health. The follow-up of significant pulmonary tuberculosis is the responsibil- ity of the local board of health and the District Health Officer. If a person who is advised to report to his physician fails to do so, the physi- cian should notify the District Health Officer who will take the neces- sary action in order to place such an individual under proper supervision. d. High School and College Clinics; Routine chest X-ray examina- tions are held for the detection of unsuspected pulmonary tuberculosis in high school and college students. Examinations are made on written request of the parents of the students and of the college authorities. When possible a photofluorographic unit of the Department is used. If it is necessary to use 14" x 17" film, the films are supplied either by the school, college, or voluntary health association. The grades selected in the high schools are usually grades 10 and 12. In the colleges the freshman and senior classes are X-rayed annually. Reports of findings are mailed to the physicians designated by the 56 parents, to the boards of health, or to the school medical departments. If active pulmonary tuberculosis is confirmed by the attending physician, the case should be reported to the board of health in the usual manner. TREATMENT Cities and towns are financially responsible for providing sanatorium treatment for patients unable to pay for the same. Pulmonary Tuberculosis—Adult: Patients having a legal settle- ment and unable to pay for care are referable to State, county or city sanatoria. Individuals able to pay, may be hospitalized in private sanatoria, or in county or State sanatoria. Tuberculosis—Children; Provision is made for hospitalization of children up to seventeen years of age at North Reading for either the primary or reinfection type of pulmonary tuberculosis. Extra-Pulmonary Tuberculosis; All types of extra-pulmonary tuberculosis (bone, gland, kidney, intestinal, skin, eye, etc.) are accept- able at Lakeville State Sanatorium. TUBERCULOSIS HOSPITALS AND SANATORIA FEDERAL HOSPITAL Number Name of Institution Location of Beds Bales per Week Superintendent United States Rutland 497 For Veterans only Dr. J. N. Wilson Veterans Admin- Heights istration (Manager) Number Name of Institution Location of Bedt t Rates per Week Superintendent Lakeville State Sanatorium (for extrapulmonary forms of tubercu- losis; adults and children) Middleboro 304 Patient (children or adults) $7.00 City or town; Children.... $7.00 Adults $10.50 Dr. L. A. Alley North Reading State Sanatorium (for children under 17 years) North Wilmington 280 Patient, city or town $7.00 Dr. C. W. Twinam Rutland State Sanatorium (for adults) Rutland 365 Patient $7.00 City or town $10.50 Dr. Paul Dufault Westfield State Sanatorium (for adults) Westfield 189 Patient $7.00 City or town $10.50 Dr. Donald A. Martin STATE SANATORIA 57 Procedure for admission to State sanatoria; Application blanks ob- tainable from local boards of health or from Department of Public Health, Room 546, State House, Boston, should be made out and signed by attending physician, and forwarded to the Department at the above address. The Department will arrange for approval of local board of health as to financial responsibility for those unable to pay. COUNTY SANATORIA Number Name of Inst itul ion Local ion of Beds Bates per Week Superintendent Barnstable County Pocasset Sanatorium (Bourne) 66 $10.50 Dr. J. G. Kelley Bristol County Attleboro Tuberculosis Hospital 60 $10.50 Dr. G. P. Smith Essex Sanatorium Middleton 350 $10.50 Dr. 0. S. Pettingill Hampshire Haydenville County (Northampb Sanatorium 60 an) $10.50 Dr. F. E. O’Brien Middlesex County Waltham Sanatorium 380 $10.50 Dr. S. H. Rernick Norfolk County South Hospital Braintree 160 $10.50 Dr. N. R. Pillshury Plymouth County Hanson Hospital 130 $10.50 Dr. B. H. Peirce Worcester County Worcester Sanatorium (Greendale Station) 128 $10.50 Dr. E. W. Glidden Procedure for admission: Special application blanks obtainable through local boards of health or directly from sanatoria, should be filled out by attending physician, approved by the local board of health and forwarded to the superintendent of the sanatorium. MUNICIPAL SANATORIA Name of Institution location Number of Beds Bates per Week Superintendent Boston 249 River St. , 573 According to ability Dr. J. W. Manary Sanatorium Mattapan to pay Board of Health Brookline 30 According to ability Miss E. A. McMahon Hospital to pay Cambridge Cambridge 100 According to ability Dr. Wm. P. McHugh Sanatorium to pay 58 MUNICIPAL SANATORIA Number Name of Institution Location of Beds Rates per Week Superintendent Fall River Tuber- culosis Hospital Fall River 110 According to ability Dr. A. J. Ledoux to pay (Health Com’r.) Burbank Hospital (Tuberculosis Unit) Fitchburg 34 $35.00 Mr. R. Bullock (Dir. Trustees) Lowell Isolation Hospital Lowell 60 $15.00 Sassaquin Sana- torium Now Bedford 124 $27.50 Dr. Hubert A. Boyle Health Depart- ment Hospi al (Tuberculosis Wards) Springfield 50 $15.00 and $25.00 Dr. L. J. Smith (Health Com’r.) Belmont Hospital (Tuberculosis Division) Worcester 150 According to ability to pay Dr. H. K. Spragler Procedure for admission: Application blanks obtainable from and re- turnable to local city health department. PRIVATE SANATORIA Number Name of Institution Location of Beds Rates per Week Superintendent Channing Home 198 Pilgrim 27 Patient sliding Miss E. Pelton, R.N. (women only) Rd., Boston scale up to $35.00, city or town $35.00 Jewish Tuberculo- Rutland 30 Free or according to Dr. M. J. Stone sis Sanatorium ability to pay 520 Beacon St. of New England Boston Pittsfield Anti- West Pitts- 14 Patient $5.00-$15.00, Miss E. Salford Tuberculosis field city or town $12.00 Hospital Procedure for admission: Application to be made directly to sanato- rium. ISOLATION AND QUARANTINE (See p. 8 and notes 6 and 7, p. 4.) PREVENTION The discovery and treatment of early cases and the separation of contacts (especially children) from open cases of tuberculosis are the most effective means of limiting spread. No practical method of im- munization available. 59 TULAREMIA DIAGNOSIS Based on history of tick bite or of handling wild rabbits or other possibly infected animals; clinical and laboratory findings (send 5 cc. of serum to National Institute of Health, Bethesda, Maryland for agglu- tination test). Repeat after a week if negative. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 8.) PREVENTION Avoidance of tick bites; wear gloves when handling wild rabbits, etc. Thorough cooking of meat of wild rabbits. DIAGNOSIS TYPHOID FEVER Based on clinical condition with laboratory confirmation. Laboratory tests: 1. Blood culture—Usually positive in the first week; sometimes as late as fifth week in severe cases. 2. Widal reaction — May be positive by the end of first week; usually not until end of second week. Repeat after a week as an increase in strength of reaction is of diagnostic significance. 3. Stool culture—If negative, repeat as it may not be positive until later in disease. 4. Urine culture—May be positive in the second week in a small percentage of cases. Specimens for above tests may be sent to local laboratories (see p. 11), or to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. Special outfits obtainable through local boards of health. (See p. 9.) Positive diagnostic reports telephoned. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 8.) 60 PREVENTION Active Immunization: Vaccine containing killed typhoid bacilli supplied by the Department of Public Health through local boards of health. Three subcutaneous injections (0.5 cc., 1.0 cc., 1.0 cc.) at inter- vals of seven to ten days or longer. Children in proportion to their weight; those under fifty pounds, one-half the adult dosage. Injection of 0.5 cc. subcutaneously or 0.1 cc. intradermally each year may be used for those constantly exposed. Passive Immunization: No practical method available. Typhoid vaccination is especially indicated for: 1. Family contacts of a typhoid case. 2. Family contacts of a typhoid carrier. 3. Physicians. 4. Nurses. 5. Laboratory workers. 6. Institutional inmates. 7. Campers. 8. Those traveling in areas where they may not be certain as to safety of water, milk, and food supplies. Paratyphoid fevers (salmonella infections) are caused by a variety of loosely related organisms, notably the paratyphoid A and B groups. Paratyphoid A is practically unknow n in Massachusetts. Persons under- taking foreign travel should be vaccinated with triple (typhoid-para- typhoid A and B) vaccine, which is furnished by the Department of Public Health upon request. (See Salmonellosis p. 48.) General: In Massachusetts at the present time cases are usually con- tracted from permanent carriers who have had the disease in the past (recognized or unrecognized). In other areas, the disease is still spread through infected food and water supplies. Good sanitation and personal hygiene are essential in control. CARRIERS Two classes of carriers are generally recognized. 1. Convalescent carriers: Those shedding typhoid organisms in feces or urine during first year after infection. 2. Permanent carriers: Those shedding typhoid organisms in feces or urine one or more years after infection. Certain proved carriers are unaware of previous typhoid, apparently becoming carriers as a result of mild unrecognized infection. 61 RESTRICTIONS ON CARRIERS 1. All typhoid carriers are reportable to the local board of health, usually as cholecystitis of typhoid origin. 2. No typhoid carrier may be employed in a food handling capacity. 3. All typhoid carriers are subject to the regulations of the local board of health. 4. All known typhoid carriers are visited twice annually by rep- resentatives of the Department of Public Health. TYPHUS FEVER DIAGNOSIS Based on clinical findings with aid from the laboratory through Weil- Felix reaction and complement fixation tests. For these tests 5 cc. of blood should be sent in a sterile test tube to the Bacteriological Labora- tory, 281 South Street, Jamaica Plain (see p. 9.) Repeat after one week as a rising titer is of diagnostic significance. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 8.) PREVENTION Commercial vaccines, now available, give considerable protection for a limited period. Used only for persons traveling in areas where typhus fever is prevalent. UNDULANT FEVER (Brucella Infection) DIAGNOSIS Based on clinical observations with the support of laboratory findings. For blood culture and agglutination reaction, 5 cc. of blood should be sent in a sterile test tube to the Bacteriological Laboratory, 281 South Street, Jamaica Plain. (See p. 9.) Special containers for this purpose available through local boards of health; (the lubes in the Wassermann outfit are not sterile). Significance of agglutination reactions 1/15—of no significance l/45 of questionable significance 1/135 and higher—of diagnostic significance. 62 Since an elevated titer may persist long after clinical recovery, a high titer may indicate past brucella infection not necessarily the cause of patient’s present symptoms, Bepeat test after a week as a rising titer is of diagnostic significance. In differential diagnosis, infectious mononucleosis should be con- sidered. A sample of 5 cc. of blood can be sent to the Bacteriological Laboratory, 281 South Street, Jamaica Plain, for heterophile antibody titration. TREATMENT No specific treatment. ISOLATION AND QUARANTINE (See p. 8.) PREVENTION No practical method of active and passive immunization available. Most infections in Massachusetts are contracted from raw milk. The use of pasteurized milk is the best single method of protection. VENEREAL DISEASES REPORTING (All of the following reports may be made on the same form.) 1. All forms and all stages of gonorrhea, syphilis? chancroid KPOIT Of maul OISIASfS TO BASSAtHUffTTS OtPAOHiOI Of public hulto ,aa rr. uti mmstmemm COLORED Ayi, 'sZu.nD.Y.ta . c. d. E . r. „...,_ MAIL TO PATIENTS FORMER PHYSICIAN TO INFORM HIM OF PATIENTS I MALI IFEMALE COLORED I ..HOC | WIDOWED | DIVORCED I PATIENT .TOPPED TREATMENT TOO -OON