B9 THE SANITARY CARE AND TREATMENT OF CHILDREN AND THEIR DISEASES. 2&eing a M>mz# of f itoe *?'» BOSTON: HOUGHTON, MIFFLIN AND COMPANY. SDtje ftitoer£i&e $m$, Cambridge, 1881. &". X «*■ Copyright, 1881. By HOUGHTON, MIFFLIN & CO. The Riverside Press, Cambridge. Printed by H. 0. Houghton and Company PEEFACE. The accompanying letter, addressed to the authors of the essays, will sufficiently explain the motives which led to the publication of this volume. The trustees acknowledge with gratitude their apprecia- tion of the valuable suggestions embodied in these essays, and the interest which the writers manifest in the successful estab- lishment of the sanitarium. They trust that the spirit of philanthropy and science thus shown may stimulate other public-spirited men and women to aid in enlarging the work of the sanitarium, and to become the founders of like charities for the little sufferers in other cities. The public may also be interested in knowing that the trustees have purchased a farm of 150 acres, for the sani- tarium, on the Western Maryland Railroad, nine miles north- west of Baltimore, in a neighborhood long known for its sa- lubrious air, highly cultivated land, and intelligent popula- tion. Adjacent to it on the north is the fine estate of the McDonough School, of 850 acres. Gwynns Falls, a stream with a daily flow of 2,000,000 gallons of water, passes through the entire length of the farm, and a never-failing supply of pure water, from two large springs upon the place, can be forced to all parts of the property by the use of the power of the main stream. At that part of the grounds which lies along the railroad, where the station will be located, and through which the iv PREFACE. stream flows, are thirty acres of meadow and ten acres of wood land, admirably adapted for day excursions. The land then rises rather rapidly to a plateau of about forty acres, on the north, northwest, and northeast of which is a natural forest. This table land has a gentle slope towards the south, the views from it are very extensive, and it affords fine sites for the permanent buildings; the elevation above tide water is 573 feet. All trains will stop at the station, which is distant from Baltimore, in time, twenty to thirty minutes. The four city stations of the railroad will greatly facilitate the transporta- tion of the children to and from their homes. While the trustees believe that they have secured a site for the sanitarium which will, to a great extent, meet the needs of sick infants and their mothers during the heat of summer, they are not unmindful of the fact that they also have the opportunity of contributing largely to the advancement of medical science, and to the instruction of mothers in the care of their children. The building plan proposed by Dr. J. Lewis Smith, in his essay, and that of Mr. J. B. Robinson, architect, New York, prepared by request, are worthy of careful and intelligent study. It is probable, however, that the trustees will begin their work in very simple and inexpensive houses, and decide upon permanent buildings after they have had the experience of several years in the management of their trust. Baltimore, Md., April, 1881. JHILDREN . John Beverley Robinson , Arch t New York . 188! SKETCH OF DESIGN FOR THE THOMAS WILSON SANITARIUM FOR CHILDREN F-RONT ELEVATION . Beverley Robin PLAN OF - FIRST STORY. F>L_AN Of SECOND STORN'. Office of the Thomas Wilson Sanitarium for Children of Baltimore City. Baltimore, December 8, 1879. At the instance and under the supervision of the late Thomas Wilson, of this city, " The Thomas Wilson San- itarium for Children op Baltimore City," was incor- porated, July the second, 1875, — " For the purpose of securing a summer retreat for sick children from the heat and unheal thfulness of the city, and for such other kindred purposes as may he hereafter determined upon by the cor- pora tion." His Will, executed the seventh day of February, 1879, pro- vides as follows : — " I have observed for many years, with much concern, the great and alarming mortality which occurs each summer among young children deprived, by misfortune of their parents, of all opportunity for removal from the heated and fatal atmosphere of the city. " God, in his providence, did not spare to me my children, to be the solace of my declining years, but my pity for the sufferings of little children, and of their parents, is none the less, and I do not think that I can make a better use of some of the means of which God has made me steward, than in the alleviation of the pains, and in the prolongation of the lives, of those of whom our Saviour said, ' Suffer little children to come unto me, for of such is the kingdom of heaven.' I therefore give, devise, and bequeath unto ' The Thomas Wilson Sanitarium for Children of Baltimore City,' a corporation created under the provisions of the Maryland Code of Public Gen- eral Laws, in relation to corporations, under my own supervision* .... in all a bequest of five hundred thousand dollars." The trustees to whom the execution of the above-men- tioned trust has been committed, desire to furnish themselves with the results of the experience and views of those whose VI CIRCULAR. attention and studies have been devoted to the sanitary care and treatment of children and their diseases. The trustees therefore at their first meeting, preliminary to the formation of any definite plan of procedure, determined, — " To correspond with a few persons at home and abroad, who are eminent for their experience and success in the treatment and care of sick children, and to obtain essays from them, to be published for the benefit of this and similar institutions." In asking such a contribution from you, the trustees have in mind the consideration of the best method of establishing a sanitarium (not a hospital, but a summer retreat)- for sick children, under the most favorable hygienic and local condi- tions that the neighborhood of Baltimore may afford. The land lying north and west of the city is high and pic- turesque, and elevations of four hundred feet above tide are reached by steam railways in thirty minutes, and those of six hundred to eight hundred feet in one hour. These districts have always been healthy ; the water is pure, and food of all kinds is plenty and cheap. The ocean is not within available distance, and the shores of the Chesapeake Bay are malarial. The trustees also desire your opinion regarding the regula- tions suitable for receiving and administering medically and otherwise to those who shall be the proper objects of their care, with such suggestions as may occur to you in reference to the character of the buildings that may be requisite — their grouping or isolation — how best to provide for mothers or nurses accompanying their children, and generally such inci- dental recommendations as your experience or reflection may commend as valuable and useful. The trustees wish your suggestions in reference to the most practicable means of lessening the risks and dangers incident to children exposed to the heated and impure atmosphere of a large city during the summer months ; also your views as to the best "methods of extending a general knowledge of simple hygienic rules for the treatment of children at home among the poorer classes. In the fulfillment of their duties they CIRCULAR. vii hope at least " to show a model of experiment," which may- prove of value as a contribution to the best means of lessening the mortality and promoting the welfare of young children here and in other large cities. Whilst thus indicating the nature of the information de- sired by them, the trustees wish you to give your thoughts in the method and manner which you will deem most conducive to their successful presentation. Should you kindly consent to serve us and the cause of humanity in the manner indicated, the trustees desire to receive the paper prepared by you, by the 1st of September, 1880. We are, very respectfully, your friends, FRANCIS T. KING, JOHN CURLETT, WILLIAM A. FISHER, JAMES CAREY THOMAS, M. D., GEORGE W. CORNER, WILLIAM H. GRAHAM, WILSON PROCTOR, Trustees of the Thomas Wilson Sanitarium of Baltimore City. CONTENTS. Page How can Children in a City be kept Healthy. By Eliz- abeth Garrett Anderson, M. D., London, England ... l The Mortality of Young Children : Its Causes and Pre- vention. By Samuel C. Busey, M. D., Washington, D. C. . 28 On the Improvement of the Condition of Poor and Sice Children : General Principles. A Letter to the Hon- orable the Board of Trustees of the Thomas Wilson Sanitarium for Children. By A. Jacobi, M. D., New York 165 Observations upon the Sanitary Care and Treatment of Children and their Diseases. In Answer to Certain Questions propounded by the Trustees of the Thomas Wilson Sanitarium for Children, of Baltimore City. By J. Forsyth Meigs, M. D., Member of the College of Physicians of Philadelphia, one of the Physicians to the Pennsylvania Hospital, etc., etc 206 Causes of the Great Mortality of Young Children in Cities during the Summer Season, and the Hygienic Measures required for Prevention. By J. Lewis Smith, M. D., of New York 239 THE SANITARY CARE AND TREAT MENT OF CHILDREN. HOW CAN CHILDREN IN A CITY BE KEPT HEALTHY,? BY ELIZABETH GARRETT ANDERSON, M. D., London, England. It is plain that this question is a very much more complex one than any which concerns itself only with the study of the conditions which are ideally best for the production of health in children or in adults. Town life is not what suits children, and the problem of how far and by what methods we can get them to submit to unnatural conditions without being seri- ously injured is a much more intricate one than that which seeks only to determine what it is which would be absolutely best suited to them. But Arcadia is a long way off, behind, or possibly in front of us. We have to deal with life as it is, and this includes many thousands of children dwelling in a city, with all its dangers and difficulties. It is of no use to lament this ; we must accept the fact and see how far the evils of such a life can be corrected or avoided. The first step in the inquiry is taken by asking what it is that children most want in order to be in sound health. We know that the essentials are fresh air, suitable and abundant food, to have come of a healthy stock, to be guarded from accidental contact with sources of contagion, to be protected from all the influences which would interfere with the normal development and stability of the nervous sys- tem, — such as undue and too early toil, anxiety, want of ad- equate rest and recreation, unsuitable or excessive excitement, 2 HOW CAN CITY CHILDEEX BE KEPT HEALTHY? — and in early infancy, at any rate, to be the objects of a mi- nute and all-watchful care. "We shall have occasion to study these essentials at length further on ; all that is necessary now is to notice them in a passing way. having the conditions of town-bred children in our minds as we do so. It may be well here to suggest the thought that these essentials, though rightly so-called, are not all and everywhere of equal value. Pure air, for instance, is of such paramount importance that where it can be had children live and thrive upon poor food, in squalor and dirt, and with the minimum of care ; whereas without pure air, or in air distinctly impure, very few chil- dren can thrive, however well they are supplied with all the other essentials of health ; and no doubt the superlative im- portance of fresh air in children's hygiene partly works by the influence its presence has in diminishing the importance of food, cleanliness, and care. "With it children can bear neg- lect and the complete absence of minute care in a way which would be impossible to those breathing an air even but mod- erately impure. They can do without wisdom in their moth- ers with a comparative immunity from harm which no town- bred child can imitate. If the commonly received essentials of health were classified according to their relative impor- tance, fresh and pure air would, for children at any rate, take the first place, and cleanliness the last. Even in towns, where the skin seems to be more neglected than in the coun- try, or where perhaps the dirt is more enamelling in character, and therefore more injurious, it is surprising how little harm seems to result from dirt, and how little mere skin cleanli- ness seems to benefit the health. In London we should be dis- posed to say that as a rule, among the lowest classes, the dirty are more vigorous than the clean, and to explain it by no- ticing that the dirtiest are those whose trades are carried on out-of-doors. The moral influence of dirt is probably much more serious and damaging than its physical effect. When we begin to consider in detail those conditions which we have called hygienic essentials, the difficulties which beset town-bred children become very evident. Let us take pure nOW CAN CITY CHILDREN BE KEPT HEALTHY? 3 air first in the list, as it indeed well deserves to be taken. By the term " pure air " we mean an air containing no appre- ciable admixture or the exhalations of men or animals, free from malaria and sewer gases, from the products of combus- tion, especially when this is imperfect : free from the products of decomposition of either animal or vegetable matter, from the organic £erms which result from a rank vegetation ; an air. finally, which can move, and which is not shut off from the influence of the sun. Such conditions are best fulfilled in sea or mountain air. but by no means invariably even in these. For children, sea air has qualities which apparently none other can rival; but whether these are the result of the small amount of contained iodine, or of a higher degree of purity than that of ordinarily good mountain air. or of its more powerfully stimulating effect upon the functions of nutrition and assimilation, is still undetermined. It is at once apparent that to children in towns pure air. as now described, is an im- possible luxury. Rich and poor alike must do without it. and the only practical points worth prolonged consideration are. how can the air be made as little impure as is possible under the conditions, and how can the :l.i. .: '-i\ get as much as possible of this only moderately impure air ? In dealing with the first of these two points, let us think of the air first as it is in the town, and then as it is in the children's homes. Outside the houses the air will of course be greatly influenced by the po- sition of the town, its elevation, its exposure, the presence or absence of marshes or other sources of malaria, the greater or less closeness of the houses, the width and aspect of the streets ; whether these are for the most part properly laid out and open to a through current of air or not. the system of drainage adopted, the amount of fall provided in the main drains, the abundance of the water supply for flushing the sewers, the total annual rainfall and its distribution through the various seasons, the state of the streets as to cleanliness. that is, the rate of removal of refuse, of dust, etc.; the pres- ence or absence of noxious trades, more especially manufacto- ries which produce poisonous vapors and dense smoke, the 4 HOW CAN CITY CHILDREN BE KEPT HEALTHY? sanitary condition of slaughter-houses, mews, stables, and markets, and the presence or absence of grave-yards. All these and similar influences must greatly affect the degree of impurity of town air. Assuming that a town is efficiently drained and cleansed, and free from malarial or miasmatic in- fluences, the point of chief importance of all those just enu- merated is the density of the population. Where the streets are narrow, the houses high and crowded, and the open spaces few, there must the air be most laden with impurities, there must it be the farthest removed from that aseptic condition which young life especially needs. Passing from the air of the street to that in the children's homes, we see that at the best it cannot be better than the outside air, and is almost certain to be very much worse. It must contain all the impurities of the outer air, and it can scarcely avoid having a good many of its own. In the first place, there are but few houses which are not liable to the in- vasions of sewer gas, either by direct communication with the drains, by the absence of adequate sewer ventilation, by the leakage of pipes, by drains being riddled with rat- holes, or having an insufficient fall, or getting their outlets blocked. Even in good houses, where the occupier would not hesitate a moment to spend any necessary sum to insure the absence of these defects, if suspected, they are frequently present for months before they are discovered, and are as often the source of illness, or of debility and languor. It is easy to understand that they must be still more often present when the house is sub-let to many families of tenants, and when the owner desires to spend as little upon it as is pos- sible. The second great source of the added impurity of house air over and above the impurity outside, is found in the crowding which prevails in the poorer quarters of every large city. Adequate ventilation is simply impossible wher- ever a whole family occupies one small room. Even in the summer time, with open windows, the air does not move with sufficient rapidity ; it becomes gradually saturated with exha- lations ; and at night and in the winter it is still w r orse. The HOW CAN CITY CHILDREN BE KEPT HEALTHY? 5 immense importance of this point, especially to children, is at once seen when we think of the number of hours passed in sleep. Well-cared-for children are glad to sleep eleven or twelve hours out of the twenty-four till they are seven years old, unless they are exceptionally vigorous ; and though poor children do not as a rule get a chance of such long nights as this, they are probably in bed nine or ten hours daily. Nothing can make up to them for the evil of breathing fetid and impure air uninterruptedly for so large a part of each day. In the day-time the injurious influence of crowding appears to be most felt by the more respectable sections of the town poor. Especially is this true of the children. It is very striking in London to notice how much more robust the children of the careless class of mothers are when past early infancy than those of the careful. Roaming the streets all da} r , playing marbles, dancing to the hurdy-gurdies, or watch- ing Punch and Judy, may be bad training for the morals, but it suits the children's health much better than careful guard- ing and keeping at home. Imperfect as the air of the streets is, it is better than that of the houses ; and where, as in London, there is no malaria to fear and guard against, the best remedy for the indifferent quality of town air is to take a great deal of it in quantity. Nothing can exceed the value of open spaces in cities to all classes, but more particularly to young children, and to the poor generally. In London, though we are better off for parks and large open areas than they are in most of the cities in Europe, we yet sadly need the multiplication of small and handy spaces within two or three minutes' run of the children's homes. Probably no single act would confer half so much benefit upon the London poor as buying up the private rights to the squares in the poorer and more crowded quarters, and throwing them open to the public. But even where everything possible is done to improve the purity of city air, and to increase the quantity available for respiration, it cannot either in quality or quan- tity compare with pure country air, and children cannot be induced to ignore its inferiority. Even to the classes inhab- 6 HOW CAX CITY CHILDREN BE KEPT HEALTHY? iting large and airy houses in the best quarters of a town, it is almost a sine qua non, if the children are to grow up strong and healthy, to take them into the country once a year. How much more necessary must such a change be to children living in narrow, closely-packed streets and courts, in houses where every room is as full as it can be packed with, human beings ! It must moreover not be forgotten, that the imperative necessity for occasional escape from city air which exists for all children is indefinitely more urgent wherever the average temperature of the three summer months amounts to 70 c F.. or above it. In this case it is no longer a question of keep- ing children healthy, but of keeping them from dying. In London, the moment the average daily temperature exceeds TO 3 F., children die in numbers every week from diseases which seem to depend intimately upon the combination of a moderately high temperature and city air. How it is, exactly, that summer diarrhoea so frequently ac- companies a temperature not in itself trying to most healthy adults, we do not yet know. Its precise causation is still, no doubt, a matter of dispute ; it is impossible to explain it sim- ply by the presence of a certain degree of summer tempera- ture. Leicester, for instance, is not hotter than many other towns in England, in Julv and August, though its diarrhoea mortality is often greatly in excess of theirs. Everything points to the conclusion that the aetiology of infantile diarrhoea is complex, and that high temperature is but one of its im- portant factors, while impurity of air is another. Probably the two combined induce subtle changes in milk and other staples of children's food. Certainly, no one can observe the swiftness and certainty with which, among hand-fed and ill- tended children, this class of disease follows a rise of tempera- ture, without suspecting it to be due to the direct introduc- tion into their bodies of actively developing germs which the high temperature has supplied with one of their necessary conditions of activity. The fact that children who still de- pend mainly upon cows' milk are the chief sufferers seems to HOW CAN CITY CHILDREN BE KEPT HEALTHY? 1 point to the milk as the probable vehicle by which the infect- ive particles obtain an entry into the child's digestive tract. Whether this hypothesis be true or not, it is certain that in- fantile summer diarrhoea, though not unknown in the country, is indefinitely less of a danger there to well-fed and well- cared-for children than it is in cities, and that the principal weapon with which the ravages of the disease can be com- bated is moving children of the most susceptible age, that is from eight months to two and a half or three years, into the country during the dangerous months of each year. Among the classes where this is as a rule impossible, and where no ex- traordinary caution as to the quality and storage of the milk supply is likely to be shown, summer diarrhoea will probably continue to be an ever-present danger if not altogether the scourge it is at present, so that to the question, " How could it be prevented ? " we are obliged to answer that, so far as we know now, it cannot absolutely be prevented, and that the utmost that sanitary science can do at present is to show communities where the danger lies, and individuals the only known protective agency. A minute and laborious study of the influence of heat on milk and other common articles of nursery food would certainly be worth making. Xow that fresh meat can be carried across the tropics and up the Red Sea from Australia to England, absolutely free from putrefac- tive change, and at a very moderate cost, it ought not to be impossible to supply young children in cities with their neces- sary food quite unaffected by an outside temperature of 72° F. or upwards. The subject is one which might well engage the attention of men of practical science in those towns where the average summer heat is recognized as one of the most serious enemies to infant life. In this country, though we are almost every year reminded for a very short time of the dangers of heat, a temperature of 72° F. or upwards is seldom maintained for more than a few days at a time, and often for not more than two or three weeks in all throughout the year. Diarrhoea is therefore not the grave and ever-present danger in our minds that it is in those of people living in semi-trop- ical towns. 8 HOW CAN CITY CHILDREN BE KEPT HEALTHY? On the other hand, the damp and cold of England and the choking oppressive fogs of London bring a train of evils of their own in the direction of catarrhs, bronchitis, and asthma, evils which, important in themselves, are aggravated by the length of time to which we are exposed to them. Happily, however, they admit of being considerably di- minished by careful management, and, in the comfortable classes at any rate, children in London can be kept well through a winter lasting five or six months very much more easily than they can be through even two months of high summer temperature. The immediate evils resulting from the cold and damp and fog of a London winter, though by no means unfelt by children, press with their greatest heavi- ness on the old and infirm, a fact which was exemplified dur- ing the past winter, when in one week in February, 1880, characterized by severe cold and peculiarly irritating fogs, the death-rate in London amounted at once from twenty- seven to forty-eight per one thousand, mainly from the greatl} 7 increased number of deaths among old people. A general diffusion of sanitary knowledge, increased temperance on the part of the parents, and a heightened standard of com- fort, may be expected to diminish very appreciably that pro- portion of the infant mortality which is directly due to the conditions of the London winters. Asa rule, indeed, children who are well fed, well clothed, and well housed, keep par- ticularly well in London during the winter. What the poor chiefly want to learn with regard to the winter management of their children is the immense value of warm clothing, and if the mothers had more money to spend they would soon learn this. The children often wear too little flannel because the father drinks too much beer. Next in importance to fresh air and the influence of tem- perature comes the question of food. Children urgently need both a suitable and abundant food supply, and we have to ask how their chance of getting this is affected by city life as compared with life in the countiy. If we are careful to con- trast the condition of parallel classes, and to avoid the mis- HOW CAN CITY CHILDREN BE KEPT HEALTHY? 9 take of supposing that every one in the country has a cow and a farm-yard of his own, we shall probably come to the conclusion that only a small part of the extra difficulty of keeping town children in health can fairly be attributed to the inferiority of their food supply. In many cases suitable food for children is even more difficult to get in the country than in large towns. Milk, for instance, is to the poor an im- possible luxury in many country districts in England, and eggs and butter are scarcely less so. In London these are all within every one's reach, and though perhaps of but indiffer- ent quality, they are of great importance in the children's dietary. Variety of animal food, of vegetables and fruit, is also much more within the reach of the poor in towns than in the country. What the country gives in this direction to the children of the poor which the town does not give them is the appetite to eat abundantly, and vigorous powers of di- gestion and assimilation. Nutrition advances more rapidly in the country, not because to the poorest classes the food supply is better, but because the power to use it is larger and less fastidious. So that even from the stand-point of nutrition we come back to the far-reaching influence of fresh air. If we inquire how sanitary science in its application to town life could favorably affect the food supplies of children, it is easy to see that, though they do not as a rule die from any impos- sibility of getting fairly wholesome food, there are many ways in which it could be improved. In London the adulteration of milk, butter, bread, and everything else which can be adulter- ated, is a grievous injury both to children and to adults. Chil- dren, however, suffer more seriously from their parents' want of knowledge and judgment in the choice of food than from its quality, and more especially from the indolence which leads to feeding infants on food only suited to adults. Much has been done in this country to awaken the attention of mothers to the evils of such indolence, especially by very simple popu- lar lectures at mothers' meetings, and to the elder children in schools ; and it may be anticipated that, in time, agencies of this kind will do a good deal towards diminishing the evil. In 10 HOW CAN CITY CHILDREN BE KEPT HEALTHY? ' a large city money could with great advantage be spent in supplying sanitary lecturers specially trained to deal with poor mothers, and to teach them, both by theory and practice, how to adapt the dietary of young children to their special needs, and how to improve the dietary of the adults of their family. The object would probably best be attained by employing people of the class of Bible-women, or district or parish nurses, and giving them a simple and practical training specially ad- dressed to this subject. No machinery is likely to be of much value which cannot be carried into the very homes where the teaching is wanted, and only women can so carry it. The first eighteen or twenty months of life is the time when suitability of food is of greatest importance, and even of this time the earliest months are of far more moment than the later ones. Nothing can make up to an infant for the want of its natural food during the first year of life, and wherever the mothers are to any considerable extent engaged in manufac- tories, or in work which separates them from their infants, the effect is sure, in a large majority of the cases, to appear in the debility or death of the children. It is no doubt true that many children of a higher social class are successfully reared upon artificial food, but every mother or nurse who has succeeded in doing this knows the amount of minute and in- cessant care it requires — care of a kind, indeed, which it is unreasonable to expect from mothers who have the entire work of a household to perform. Even where this vigilant and skilled care is given, and where in addition the infant is helped by every hygienic resource, the attempt to do without its natural food often results in failure. Some advance, how- ever, has been made in recent years in the study of substi- tutes for the mother's milk, and there seems no good reason why a still greater measure of success may not ultimately be reached. One main element in the difficulty of artificial feeding no doubt lies in the great liability to change, characteristic of human, as well as of other milk. Probably organic fluids ex- posed to air at ordinary temperatures are always changing HOW CAN CITY CHILDREN BE KEPT HEALTHY? 11 more or less rapidly, and, apart from its easily recognized chemical difference, much of the peculiar virtue of human milk as food for infants may be in its freshness, in its perfect freedom from infective particles, nay, even in its nascent character. Mothers at any rate agree in thinking that infants neither like nor digest so well milk which has remained an hour or more in the breasts as they do that which is, as it were, manufactured expressly for them the moment it is wanted. It is difficult to anticipate that organic chemistry will ever so completely yield up its secrets as to enable us to understand how this subtle change is effected, or to produce a food at all comparable to that provided by nature. Probably to the end of time the real thing will be much better than any imitation, and some children will always refuse to thrive, or even to live, upon anything but their dietetic birthright. For those, however, who cannot avoid the risk involved in artificial feeding, and also for young infants when partially or wholly weaned, carefully prepared diet rules are, in careful hands, of great practical value. They need to be plain, mi- nute, and dogmatic. Any attempt at physiological or chemical explanation is sure to be misunderstood, and the rule itself is more likely to be remembered if presented in a dogmatic form. The rules should state the degree of dilution cow's milk requires at each age, how to prevent the formation of heavy curds in the process of its digestion, when to add an alkali, its form and quantity, when to begin the addition of farinaceous and animal food, and which of such kinds of food is best for children of each age. These are points so familiar to medical authorities that it would be superfluous to insert such rules in this paper. They can be found at once in the writings of Dr. Eustace Smith, Dr. J. Lewis Smith, Dr. West, and many others. A further important part of the question of the food supply is that which relates to the drinking water. Young children should no doubt not be large water drinkers. Milk is their natural and proper drink till they are almost out of child- hood. But to poor people milk is, as a rule, too costly to be 12 HOW CAN CITY CHILDREN BE KEPT HEALTHY? used in this liberal fashion, and the drinking water becomes to them as important for their children as it is or ought to be for themselves. The first thing: that strikes one in thinking: about the drinking water in connection with the special dif- ficulties of city life is, that here we touch a point upon which town-bred children ought to have an advantage over their country cousins. And even with the many shortcomings (some of them scandalous ones) of our London system, it is probably true that London water is, as a rule, a less danger- ous drink than that at the service of the English agricultural population. Whether this is so or not, it cannot be doubted that a community is in a far better position for getting whole- some water than single scattered families of poor and igno- rant people ever can be, and that it is a grave blot upon their civic organization if they have not succeeded in getting it. A laborer's country cottage must have its water supply close at hand, and it must be the cheapest possible ; therefore it is a surface spring, and close to all the obvious sources of impu- rity round the house. As a rule, in England, the well and the cesspool, or the pig-sty, are within a few yards or feet of each other. In large towns there can be no real difficulty in carry- ing water of almost absolute purity to every house ; it is simply a question of expense. In London, the system breaks down mainly on the point of the storage of the water in the houses. In houses for the richer people there are cisterns, often dirty, and often in direct connection with the drains of the house. Man} 7 of the houses for the poor have no cisterns, but only water-casks or butts, often not covered, and rarely if ever cleansed. Even if the water so stored is not very poi- sonous, it is most unattractive. It is scarcely possible under these circumstances to urge water drinking with much zeal. Bearing in mind all the temptations to intemperance which surround the toiling inhabitants of the poorer parts of our crowded cities, the sense of exhaustion which results from in- door labor, from the absence of pure air and bright light, it is impossible to regret too deeply the way in which, even from childhood, the poor are forced into drinking stimulants by the HOW CAN CITY CHILDREN BE KEPT HEALTHY? 13 want of wholesome and pleasant water. This, however, is a fault not inherent in city life, but one which results only from indolence, ignorance, and supineness, and will, it may be hoped, in time disappear. It is at any rate certain that a town-bred child ought to be better provided with pure water than poor country children are likely to be, and that the ab- sence of wholesome water in a city is a misfortune which need not and ought not to be present, and one to which we should not allow ourselves to become reconciled. The third essential condition of health in children is that they should have come of a healthy stock. This supplies, no doubt, one important factor in the comparative difficulty of rearing healthy children in cities. In many cases the in- fluences of town-life before the children were born have de- teriorated the health of their parents. In every crowded community intemperance, tuberculosis, and s} 7 philis under- mine the health of thousands of parents at a comparatively early age, and the children born of such parents cannot be healthy. Not, of course, that either vice or constitutional disease is rare in the country ; probably morals are much the same in a given grade of education and intelligence every- where, but the influences of town life tend to increase the temptations to vice and to aggravate its physical results. In some cases moreover, country life, with its fresh air and the stimulus this affords to all the nutritive functions, may just supply the child of moderately unhealthy parents with what it needs to enable it to revert to a higher standard of health. For it is necessary to bear in mind that powerful as are the laws of heredity, like to their parents as children are and must always be, there is yet in human beings under favorable circumstances an uncontrollable set towards health and against the perpetuation of disease. If it were not so, if the force of heredity were strong enough to be able to brand the children through many generations with the results of the intemper- ance, the vice, and the recklessness of their forefathers, who among us would be sane, or wholesome, or healthy ? Prob- ably no one could show a clean bill of health, with regard 14 HOW CAN CITY CHILDREN BE KEPT HEALTHY? even to the worst diseases, for even so short a time back as ten or twelve generations, and what are these in the life of the race ? There is, for instance, no disease more truly con- stitutional in character, and therefore more ready to pass from parents to children than gout, and }^et we constantly see people who though coming of a gouty stock, by leading strictly temperate and active lives have almost completely freed themselves from their hereditary enemy, and who do not transmit it to their children so long as they also lead healthy lives. So that but a few generations, two, or three, or four, may suffice to do away with this otherwise most powerful hereditary taint. But no doubt it is true that the regenerating process, by which the race casts off gradually its acquired imperfections and tends to revert to the normal condition of health, requires both time and favoring condi- tions. Children are too close to their parents in point of time not to be very like them, flaws and all, and unless their in- herited flaws can be met and counteracted by wholesome in- fluences, the process of regeneration must be delayed, or even in the worse case, as is so often exemplified in the gradual in- tensification of nervous diseases, a downward course may be taken, and the constitutional type, instead of improving, will progressively degenerate. City life as lived by poor children is certainly not that which would enable them even to begin to throw off inherited imperfection ; and practically we find, and probably always shall find, a vast amount of disease or imperfect health due to hereditary influences which no per- fection of hygiene, so far as it can be applied to the town life of the poor, can tend greatly to diminish. The next important element in the question of how to keep city children healthy is that which relates to the prevention of the spread of infectious or zymotic disease. Diseases of this class are gravely important, not only from the very large number of deaths they directly cause, but also by the chronic debility or disease which too often results from them. This is a part of our subject which would amply repay the careful consideration of all who desire to benefit the children of a HOW CAN CITY CHILDREN BE KEPT HEALTHY? 15 town, for it is one in which much good may be done, though the parents themselves are not in a position to do it. The chief hindrance, indeed, to the most important measures in this direction will be found in the ignorance and unen- lightened affection of the parents. It is of course vain to talk of disinfection or of precautions against the spread of disease while children suffering from measles, scarlet fever, small-pox, or whooping-cough, remain in their crowded homes. The only measure worth discussing is that of removing and isolat- ing them. If the hearty cooperation of the parents could be won, every child taken ill with any of these diseases in a crowded house ought at once to be removed to a special hos- pital, and adequate precautions there taken against communi- cating the infection. The art of disinfection is gradually be- coming so much better understood by professional advisers than it was even a short time ago, that it is not now Utopian to believe that were the sufferer once in skilled hands and isolated, the spread of these diseases from each separate case might be completely checked, and that by repeatedly stamp- ing out infectious disease in isolated cases epidemics might be prevented. Such a scheme as this supposes a separate hos- pital, or at least a completely separate block of wards for each of the important zymotic diseases, each having a separate staff of nurses, and, if possible, separate and resident medical at- tendants and separate administrators. It seems plain, from the history of the epidemics of the Middle Ages, silent traces of which still remain in the vast lazarettos of Milan and other continental towns, that diseases which were then not less serious scourges than scarlet fever is now, have been practi- cal^ stamped out by a general improvement in the sanitary condition of towns once decimated by them, combined with a rigid process of isolation whenever the diseases in question appeared in the community. We have become alive, within the last few years, to the danger of infection being spread wholesale, as it were, in several ways hitherto unsuspected. Epidemics of scarlet fever have now in several well-investi- gated cases been proved with almost mathematical precision 16 HOW CAN CITY CHILDREN BE KEPT HEALTHY? to have been due to the milk supply having been contaminated with the scarlatinal poison. An instance of this, hitherto un- recorded, occurred in Scotland three or four years ago. A large boys' school at Aberdeen had part of its milk supply from a particular farm near by. A girl old enough to be of use in the dairy fell ill, and was shortly pronounced to be suffering from scarlatina. With commendable honesty the farmer sent down to the school, as soon as the girl's illness was recognized, to ask if the milk should still be sent. It was stopped, but the supply of the day before and of the same morning had already been used, and within thirty-six hours eighteen persons in the school-house were ill with scarlet fever, as well as several other persons in neighboring houses who had had milk from the same farm. This case was further remarkable from the fact that, so far as could be ascertained, the girl at the farm was the first per- son who had been ill there, and if so, the contagion from her must have been very active, even in the earlier and acute stage of the disease. Possibly, as suggested in reference to summer diarrhoea, the germs upon which contagion depend may find a very suitable environment in milk, and therefore may develop in it with unusual rapidity. A curious and un- explained fact about the epidemics caused or conveyed by milk is that the type of scarlet fever so conveyed has hitherto appeared always to be mild in character. Further observa- tion of similar cases may serve to show that this has been merely accidental, but it is a point worth noting for future observation to confirm or disprove. No one knows yet why some epidemics of scarlet fever are so immensely more dan- gerous than others, and anything which could help to a clear- ing up of this point might prove to be of enormous practical value. If we knew the conditions, whether individual or general, which lead to the occasional development of malig- nancy in the scarlatinal poison, those conditions could proba- bly be influenced favorably and the malignancy prevented or diminished. Whilst waiting for the time when the general good sense HOW CAN CITY CHILDREN BE KEPT HEALTHY? 17 of the community shall make it po*ssible to isolate rigidly every case of infectious disease, it would be well that the sanitary lecturers employed among the poor in a town should be taught practically a few of the more efficient and available processes for disinfecting clothes and bedding, such as that which depends upon the liberation of a large quantity of chlorine gas. It cannot, however, be too clearly insisted upon that disinfection in any sense which implies safety to the community is an impossibility in crowded houses, and among poor people who cannot afford to destroy their clothes and other property. Only as the handmaid to isolation is disinfection of substantial value. An exception to this asser- tion might, however, perhaps be made where the disinfection can be applied assiduously and skilfully to the centre of con- tagion, that is to the sick person himself. Even in a disease so eminently contagious as scarlatina, cases have occurred in which, without attempting any isolation of the patient, no in- fection has been conveyed, the result having apparently been due to the frequent inunction of the invalid with carbolized oil. Among the poor, however, precautions of this class are sure to be very imperfectly carried out, and the real check to epidemics of zymotic disease must be sought in isolating every case as soon as possible after it has declared itself. Even apart from their crowded homes, the ordinary conditions of life to children of the poor lend themselves with unhappy facility to the spread of infectious disease. From early in- fancy large numbers of children are grouped together, in day and Sunday schools, in church and chapel, in playgrounds and in the streets. Poor children know, as a rule, no soli- tude. They are always in society, and usually in a very crowded society. Objections are occasionally urged against infant and other primary schools on the ground of their being centres of infection, and no doubt it is true that every school must occasionally be open to such an accusation. It appears, however, to be useless to grumble at the school before mak- ing an attempt to isolate the contagion in the home. So long as cases of scarlatina and other infectious disease are allowed 2 18 HOW CAN CITY CHILDREN BE KEPT HEALTHY? to remain in houses of which, perhaps, every room contains a family, it would be beginning at the wrong end to exercise any very zealous supervision over the schools. In addition to the prevention of epidemic disease, an intel- ligent guardianship of the health of town-bred children ought to consider to what extent it can aid in the prevention of various other familiar forms of disease, such as tuberculosis, rickets, syphilis, and nervous disease in its many forms. The inevitable conditions of city life — crowding, intemperance, vice, poverty, and struggle — render it all but certain that these diseases will continue common in cities, and that phil- anthropic efforts will not, except indirectly, greatly diminish the number of children injured or destroyed by them. We know, for instance, that the most potent weapon against the development of tuberculosis is abundance of open-air exer- cise and of good food. But we know also that to hundreds of the dwellers in cities abundance of either of these is out of the question. They have to struggle on upon the minimum rather than the maximum allowance of fresh air and food, and tuberculosis results. Rickets ought no doubt to be capable of being materially diminished wherever the general standard of intelligence and comfort is tolerably high among the working people of a city. It is a rare disease when mothers are themselves well fed, when they know the importance of milk in their infant's diet, and when they can afford to act upon their knowledge. The important social and political question of how to pre- serve children as far as possible from the terrible blight of hereditary syphilis is one which, though coming strictly within the limits of our subject, cannot well be satisfactorily dealt with in this place. It is enough to record its grave im- portance, and the responsibility which attaches itself to any one who does what he can to prevent legislative interference with the diffusion of syphilitic disease among the adult popu- lation. Very little attention has been paid hitherto to the im- portant subject of the prevention of nervous disease in chil- HOW CAN CITY CHILDREN BE KEPT HEALTHY? 19 dren and young adults. Many of the more familiar of the so- called nervous diseases belong mainly to the stage of decline, and as for the most part people wear out at a rate roughly proportioned to their years, they are seen most commonly after the age of "fifty. But these " old age " nervous diseases, as they may be called, often only very accidentally belong to the nervous system. The real fault is, as a rule, in the nutrition of the small arteries, in the condition of the valves of the heart, in the undue development of connective tissue everywhere, or in the kidneys and other leading organs. Faults of these various kinds manifest themselves through the nervous system by the injury they inflict upon it ; for example, the rupture or the embolic closure of a vessel interferes with the nutrition, or destroys the integrity of certain cells or fibres of nervous tissue, and thus indirectly interferes with nervous function. Similarly, syphilitic nervous disease (so-called) rarely starts from true nerve-tissue, though it makes itself manifest by its influence on this tissue. It is not the fault of the nervous cells and fibres that they cease to work when starved by the blocking of their nutritive blood-vessel, or when ripped up by a clot of blood, or when squeezed out of life by a syphilitic deposit. Nor is it these indirect results of disease elsewhere to which preventive medicine should chiefly turn its attention, but to those conditions of faulty working of the nervous system itself to which the name of nervous disease properly and strictly belongs. Many of these conditions are common in childhood and young adult life, and are capable of being influenced for good, or of being deepened and intensified by external influences. What is meant, or implied, exactly by the term " functional nervous disease," can only be fully understood by those who are in possession of a clear and adequate conception of the position and purposes of the nervous system in the human or- ganization. It is necessary to realize that this system controls not only all mental processes and sensation and voluntary motion, but also the functions of organic life, the action of every organ, the formation of every secretion, and the size 20 HOW CAN CITY CHILDREN BE KEPT HEALTHY? of every blood-vessel. All these purposes are accomplished by the aid of a something which we call " nervous force," and which we know is developed or made in the nerve ganglia and distributed by the nerve fibres, very much as the force which we call " electricity " is made in a battery and carried by the conductors. The ideal of nervous health is found in a well sustained and stable equilibrium between the work which the organism, as a whole and in all its several parts, has to perform, and in the equable production and diffusion of the force by which the work is performed. Wherever either the demand for nervous force is in excess of the power of manufacturing it in the nervous ganglia, or where the pro- duction of the force is naturally greatly in excess of the outlet provided for it, or where the several nervous centres work ir- regularly and inharmoniously, or upon too slight a stimulus, there we have departure from the ideal, and we are in the presence of nervous disorder. What we want is, that the work to be done and the force to do it should balance each other, and that the production and distribution of force should go on smoothly and evenly, and in response only to the normal stimuli. A very large part of the total amount of functional nervous disease is due to a fatal want of propor- tion between the demand for force and the power of pro- ducing it. People either want more force than they are able easily to make, and thus are stimulated or urged into efforts beyond their powers, or they have more than they can em- ploy, and they are allowed to fret their hearts out for the want of something upon which to spend it. It is as if a bat- tery of small size and few cells were expected to produce as much electricity as one twice its size, or, on the other hand, as if the current generated were stored under a condition of continually increasing tension. It is too often overlooked that people differ from each other as much in their physiological as in their material wealth. While one has an income so assured and so large that his only duty in relation to it is to spend wisely and liberally, and to invest usefully, another has to struggle daily and HOW CAN CITY CHILDREN BE KEPT HEALTHY? 21 weekly to meet the necessities of the moment ; his power of earning being small, he has to minimize expenditure and even to descend to the most petty economies to make his scanty pittance of an income supply the barest necessaries of life. In the same way there are people who seem to possess almost unlimited stores of nervous force ; let them spend their strength as they will (and some of them spend it with prod- igal lavishness in several ways at once), they cannot come to an end of their resources, and even when, for the moment, they are worn out and weary, they can count upon picking up again with extraordinary rapidity. On the other hand, there are people whose life is a long struggle against absolute physiological bankruptcy. They seem never to have quite enough nervous force, even for a routine life, and any un- usual demand does for them entirely. Effort is not impossible to them ; sometimes, under the stimulus of emulation or anx- iety, they can even sustain an effort for some little time, but presently, when the stimulus ceases, they drop exhausted, and then take months or years to recuperate. Happily, it is exceptional to see this condition in a marked degree persist through mature life, but it is by no means very rare to see it while growth and development are imposing their special taxes on the constitutional powers. Assuredly it is most unsafe to assume that all young people may, without danger, be urged to make the utmost effort in their power, or that stimulants of various kinds, emulation, prizes, even al- cohol, may be used in order to elicit all the force they have without hesitation and without risk. The true remedy for insolvency is retrenchment, and what physiological paupers need is not stimulus, but rest and the least possible demand for such strength as they have. It is especially in towns, where children and young people are surrounded by influences at once debilitatino; and stimulating, that the danger of over- taxing and therefore exhausting the centres which manufact- ure nervous force needs to be remembered. In the country the opposite risk, that of supplying no adequate outlet for the nervous force when developed, is perhaps more frequently 22 HOW CAN CITY CHILDREN BE KEPT HEALTHY? present, but even there this is a danger which belongs prop- erly to a later age. In considering how the special draw- backs of city life can best be dealt with, we have to ask, from the point of view of the people badly off for nervous force, how all the recreative and recuperating influences can be in- creased and the stimulating influences be diminished. The first part of the question is answered by improving the general hygienic condition, providing good air, open spaces, easy access to the country, simple nutritious food, and facilities for plenty of bathing, etc. The second part of the question, however, is a more complex matter. It is not easy to see how the life of a great city can ever be made unstimulating, or how the in- terests of the weak can, in city life, be specially considered. For it must be borne in mind that the stimulus of competition, of rival effort, and of constant variety, which belongs to town life, just suits the strong, and that it is they and not the weak ones who, in a community, will always rule. Therefore, so far as the adult population goes, there would seem to be but little possibility of materially modifying city life to suit the people of feeble nervous power. It must always be too keen and rapid to be really suitable for them. But for children, the difficulty is not quite equally great. Wise parents can do something, even among the poor, in the direction of promot- ing rest and long hours of sleep, of discouraging violent and unusual efforts, of avoiding all forms of stimulation, and espe- ially by not placing the child in a position involving anxious effort and strain. The emulation of school life is often blamed for nervous and other weakness in children, and it seems im- possible to doubt that to some it must inevitably be injurious. Here again, however, we have to accept the fact that in a community arrangements have to be made mainly to suit the fairly strong and vigorous, and not the exceptionally weak. Emulation and the stimulus it provides are great advantages to vigorous people, and in strict moderation they do no harm, even to the young, when they are strong. Primary education in public schools needs the help of some amount of emulation and competition, but even for the strong the danger of over- HOW CAX CITY CHILDREN BE KEPT HEALTHY? 23 stimulation should be recognized. All that can be done in the way of specially protecting the exceptionally weak is that parents and heads of schools should recognize that there is an important minority of both boys and girls who are not equal to making any severe and continuous effort, to whom the stimulus of competition is positively injurious, and who re- quire all, or almost all, the nervous force they can supply to meet the requirements of growth and development. It is, perhaps, too much the fashion to think of children, boys and girls, as if they were physically almost exactly like adults, only a few sizes smaller and proportionally less strong. From the point of view of the nervous system, at any rate, this view is certainly unsound. It overlooks the fact that during growth and development the nervous centres are themselves in a developing condition, learning to work together in re- sponse to certain stimuli, and in a certain subordination one to another. The machine is still in process of construction instead of being ready for use. It is not merely not so strong as a larger machine, it is not yet out of the workshop in which it is being made. We meet with this fact again under a slightly different as- pect when we turn to the consideration of the last of the es- sentials of health for children already enumerated, namely, a watchful care during their infancy and early childhood. It be- comes very plain to any one who is able to consider and duly weigh familiar facts that by the very nature of their organ- ization, children, even when healthy, are indefinitely more deli- cate, that is, more easily upset, than ordinarily healthy adults. They are more mobile, their physiological equilibrium is more unstable, and they suffer more quickly for any violation of physiological or hygienic laws. The processes of growth and development are making enormous demands upon their nutri- tive powers ; they want for immediate use all the blood and nervous force that their blood-making organs and their nervous ganglia can supply them with, and the least check in either process threatens them with bankruptcy. To live from hand to mouth, as it were, each day by the help of good food, fresh 24 HOW CAN CITY CHILDREN BE KEPT HEALTHY? air, and good digestion, just contriving to meet the demands made upon their vital powers, is with them the rule, and not, as with adults, the condition of the exceptionally feeble. It is not surprising, therefore, that slight departures from health, and especially those which interfere with the due per- formance of the nutritive processes, tell immediately upon a child's health and vigor. Observant eyes can see at once that the manufacture of good red corpuscles has been checked with every slight disturbance of a child's digestive or as- similative powers. Moreover, besides resenting hindrances to nutrition more than adults, they are far more prone to the occurrence of such hindrances. For instance, every mucous tract in a child is more liable to catarrh than the correspond- ing mucous membrane in adults. Notice how children suffer at once, and certainly, in their nasal and respiratory mucous membranes on coming from fresh pure air to the air of towns. It is a matter of common nursery observation that children on returning from a stay in the country always have pretty bad catarrhs within a week or so of their beginning to breathe the less pure air. Mothers are too well alive to this risk to forget it, and it certainly cannot in most cases be explained by " taking cold on the journey " or by want of care in any other direction. It is most unusual to see children take cold when they go from the city to the country, even at a colder season. The " coming home cold " is almost certainly due to the ir- ritation of delicate mucous membranes by an air laden with smoke and other products of imperfect combustion. A cor- responding susceptibility exists in the intestinal mucous tract. If, then, children are peculiarly prone both to disturbance of function and to the evil resulting from such disturbance, it is not to be wondered at that minute care is wanted to keep them in health till they acquire greater stability and more vigorous powers of resistance. When in addition to the del- icacy common to all children there is superadded the immense drawback involved in trying to rear them from early infancy without their natural food, it becomes impossible to exag- gerate the amount of care required if a successful result is de- HOW CAN CITY CHILDREN BE KEPT HEALTHY? 25 sired. The only thing which can at all make it possible to minimize the care needed is fresh country air, and with it one does occasionally see thriving vigorous children, to whom almost every other advantage has been wanting. But for town-bred infants care is an indispensable condition of health, and care of a kind far more minute and constant than can he given in any creche or public nursery, or to any child put out to nurse for a few shillings a week. Where from any cause this minute and personal mother's care cannot be given, a large proportion of the children are bound to die, in spite of anything which may be done for them by outside agencies. It is evident, from all that has been said in considering the difficulties town-bred children have, to contend with, that the labor involved in any considerable attempt to improve their condition must be great, and also that it is impossible, what- ever may be done in this direction, ever to make town children as healthy as country ones. Much that may be attempted to diminish the dangers of city life has already been hinted at ; as, for example, the multiplication of open spaces in towns, a proper system of drainage, and an abundant supply of good water. For young children, however, the most important remedy is that of encouraging their parents to get out of the town, or at any rate into the suburbs. Ever}^ facility that can be given to the poor to live a little distance from the most densely populated part of a town is of the greatest value to the children. Where land is abundant and cheap, the posses- sion of a small garden even without a house, out of the town, would, by supplying out-door employment, be most valuable to both parents and children, especially to people above the poorest class, as, for instance, artisans and small traders. Passing to the subject of a summer sanitarium for city chil- dren, a great many important practical questions at once arise. Any one familiar with children cannot think with entire sat- isfaction of any plan which involves separating them from their parents, and massing large numbers of them together. It may be feared that such a plan must be fraught with 26 HOW CAN CITY CHILDREN BE KEPT HEALTHY? danger to both health and morals : to health, if the children are intended to be very young, that is under four or five ; and to morals, if they are intended to range between five and four- teen. The ideal summer outing for children is that each fam- ily should move from the city, but should preserve the con- tinuity of its family life. This is impossible of attainment among the poor, but possibly some nearer approach to it might be reached than by massing together several hundred young children in any way which would preclude the possibility of giving them individual care. The boarding-out principle, which, so far at least as the children are concerned, works so well in England for the pauper children, might perhaps be adopted with modifications in the place of having one large building and grouping the children together. If a consider- able number of people living in healthy country localities were registered as being each willing to receive during the summer one or two town children as boarders at a fixed rate, and a system of supervision were organized, such a plan would certainly be more natural and home-like, and therefore more acceptable to both parents and children, than a large central sanitarium could ever be. Children thus placed would also be much more easily provided with employment and amuse- ment than they would be in an institution containing a very large number. They would enter into the duties and pleas- ures of the family with whom they boarded, and would feel themselves to be in surroundings not too unlike those in their own homes. Where such a plan as this might, from the scanty country population or the bad sanitary condition of the country cot- tages, be impractible, it might be possible to arrange the sani- tarium upon the plan of a number of detached houses, each to contain eight or ten children, and each to be under the direct care of one nurse or matron. By either of these methods the children would be secured an amount of personal and individ- ual care and watching which it is impossible to get from the hard-worked staff of an immense institution. The routine, the formality, and even the noise, which are necessary parts of a HOW CAN CITY CHILDREN BE KEPT HEALTHY ? 27 large assemblage of children, are in themselves for a time trying to the health of those used to a free home life ; and among American children, where by climatic and hereditary influences the tendency is towards undue restlessness and irri- tability of nerves, they would be more likely to do harm than in a more phlegmatic or stolid community. Town children everywhere, and perhaps American town children more than any others, are as a rule much more precocious than country children ; mentally and physically they develop more rapidly, and what they need to make a change from city life of the greatest use to them is not the stimulation that goes with numbers, but the quietness and repose which belongs to coun- try life as seen in a small family. Fresh air, the absence of noise, and comparative solitude, form the basis of such a life ; and the combination of the three is probably as wholesome and recuperative to children as it is to adults. By many the stress of town life is felt more in the nervous system than in any other part of the organization; and to them especially one most important part of the value of a change to the country lies in the comparative quietness and solitude which it is pos- sible to have there, but which would be practically destroyed for the inmates of a large sanitarium. If now in conclusion we turn back to the question with which we started, and ask ourselves again how can town children be kept healthy, we are obliged regretfully to admit, that after public and domes- tic hygiene has done its best, city life will always be full of special risks to the children of the poor, and that philanthropic effort cannot do very much directly towards diminishing those risks. It can do something, but it must be mainly through the parents, by improving their knowledge of what the chil- dren need, by raising their standard of comfort, and by deep- ening their sense of responsibility. THE MORTALITY OF YOUNG CHILDREN: ITS CAUSES AND PREVENTION. BY SAMUEL C. BUSEY, M. D., Washington, D. C. Gentlemen of the Boabd of Trustees, — The letter of Mr. Francis T. King, of December 20, 1879, requests my advice in regard to the best method of executing the trust committed to the management and supervision of himself and others by the late Thomas Wilson, of the city of Balti- more. In 1875 Mr. Wilson founded, under the provisions of the Maryland Code of Public General Laws, an institution known as " The Thomas Wilson Sanitarium for Children of Balti- more City, for the purpose of securing a summer retreat for sick children from the heat and unhealthfulness of the city, and for such other kindred purposes as may be hereafter de- termined upon by the corporation." In his will, executed in February, 1879, the testator declares his purpose in making the bequest of five hundred thousand dollars to the institution to be " the alleviation of the pains, and the prolongation of the lives, of children." In the same sentence of this last will and testament occurs the expression of his pity " for the suffering of little children and their par- ents," and of his deep concern and sorrow " at the great and alarming mortality which occurs each summer among young children." How best to execute such a trust is a grave and complex question. A final and satisfactory conclusion can only be reached after a careful and mature consideration of the causes and means of prevention of the diseases and mortality of early life. Those who are to become the beneficiaries of this char- THE MORTALITY OF YOUNG CHILDREN. 29 ity are denominated by its founder "young children, deprived, by misfortune of their parents, of all opportunity for removal from the heated and fatal atmosphere of the city," and by the charter title of the institution "children of Baltimore city." Hence to fully grasp the proposition thus distinctly and suc- cinctly set forth, the various agencies and elements of causes conducive to the mortality of early life, must be considered with special reference to the density, ignorance, poverty, and indigence of the population of Baltimore, together with their hygienic and domiciliary surroundings. Age is the first and essential factor in this complex assem- blage of causes. Childhood properly comprises the period of human life from birth to puberty, but for convenience of sci- entific study, and to secure accuracy of the statistics of the comparative morbility and mortality of the successive stages of growth, it has been subdivided into four periods which are characterized by developmental processes. The first period extends from birth to the appearance of the first tooth (fifth to tenth month) ; the second from the beginning to the comple- tion of the first dentition (twenty-fourth to thirtieth month) ; the third from the termination of the first to the completion of the second dentition (sixth to seventh year) ; and the fourth from the second dentition to puberty (twelfth to fif- teenth year). These successive periods must be studied with reference to the probability of sickness, their comparative mortality, and their liability to special morbid conditions. In view of the clearly defined purpose of the founder to af- ford opportunity for the removal of young children from the "heated and fatal atmosphere of the city," and of the fact that even with such a liberal endowment it will be impossible for the institution to supply accommodations, care, and food for all of the young children of the needy and squalid in a city of three hundred and thirty thousand inhabitants, and in- creasing in population as rapidly as the city of Baltimore, the management will be compelled at the beginning, or very early in the history of the institution, to determine the admissions 30 THE MORTALITY OF YOUNG CHILDREN. by limitation of age, or to regulate them by some well-defined system of individual selection. The first will prove to be the more practicable and efficient method, though it may be wise to reserve the privilege of selection to meet occasional in- stances of exceptional need. The completion and occupancy of the Johns Hopkins Hospital will probably limit the number of applications of sick children beyond five years of age to the very few who may be unfit subjects for hospital treatment, and yet require the invigorating and healthful influences of a salubrious atmosphere. A few years of experience in con- ducting the institution and the determination of the actual daily average cost per capita for maintenance will furnish the requisite data for the final adjustment of the later age of admission, but the earlier age should be fixed before the ac- ceptance of any plan for the construction of the necessary buildings. The determination of the age of exclusion must, however, be considered with special reference to the two classes into which the beneficiaries will be divided. For convenience these may be denominated the visiting and domiciliary classes. The first and larger class will be composed of those children who will be offered a refuge from the city during the day, return- ing again at night-fall. Even if permissible, it would be un- wise to extend this privilege to all the needy and indigent children under the age of puberty. A limitation of age will be imperatively demanded, because of the inadequacy of the endowment fund to meet such an extraordinary outlay, and the impracticability, if not impossibility, of conducting an in- stitution to which would resort daily such a concourse of juve- nile excursionists, including the invalid, sick, hungry, idle, vicious, abandoned, truant, and mendicant, of both sexes, of all colors and nationalities, and all ages under the prescribed limit, together with the mothers or necessary attendants of the younger children. 1 A system of daily excursions during 1 The Floating Hospital of St. John's Guild, of the city of New York, made thirty-five excursions, " between the 9th of July and 6th of Septem- THE MORTALITY OF YOUNG CHILDREN. 31 the summer months, if properly organized and managed, might prove of great advantage, both in its lessons of moral training and opportunities for physical development. The advantages of this department should be offered to the largest number compatible with good order and the welfare of the young. Transportation, accommodations, food, water, shelter, shade, amusement, and protection must be adequate to the ex- igencies of the excursions, the number and personnel of which would vary daily, according to the popularity of the institu- tion and the necessities of the children who might be entitled to the benefits of the sanitarium. But even with all such necessary facilities and with proper appurtenances as a place of daily resort for children, the or- ganization of a system of excursions as a means of promoting health will fail of success unless the confidence of the commu- nity is assured by efficient and expert management. Safety, security, and positive benefit must be made apparent to that class of parents and guardians with whom theoretical asser- tions and predictions of possible advantages will have but little weight in diverting them from their long accustomed routine of life. Their habits, education, poverty, family his- tory, superstition, and proverbial indifference to the welfare of children, lead them into obstinate antagonism towards every so-called encroachment upon their long conceded owner- ship of the body and control of the life of the child. The evidences under their immediate observation that neighboring children have grown to vigorous maturity without such ex- traneous aids as charitable excursions to country play houses and grounds may offer are, in the absence of proof of positive personal gain, arguments far more conclusive than any fact deduced from mortality statistics. They accept the occur- rences of life as they see them, soon forgetting the past and incredulous of evils to come. Life is completed with each ber, 1879, and carried 27,818 children and mothers, being an average of 794A on each excursion, in the proportion of about 2^- children for each adult." (Extract from report of 1880.) 32 THE MORTALITY OF YOUNG CHILDREN.] day's existence. To-morrow may be but the repetition of to- day, and each successive day's life deepens the oblivion of things gone before, and fastens more firmly upon the life of the future the errors of the past. The false interpretation of one's own observation of matters concerning the preservation of health and the cause, prevention, and cure of disease is a fruitful source of error common to all classes of laymen, and is a special characteristic of the ignorant, indigent, idle and laboring classes. They resist, and often resent with threaten- ing ferocity, every innovation upon the established customs, habits, and conditions of their life and domicile. Considerations of domestic economy and convenience will also enter largely into the antagonisms of these communal classes. The ownership of the body will assert its preroga- tive on the pretence of valuable assistance of the child in the trivial concerns of the family household. An idle and de- bauched father will not willingly relinquish, even for a day, the enslavement of a helpless son or daughter, and an incon- siderate mother will cherish the authority which commands the little girl to sit or go, watch or work, while she either fritters away time in idle discontent, or slovenly performs some of the duties of the day. The older must care for the younger child, or run on errands. The pretence of authority, assist- ance of a child, tender affection of a mother, parental care, or fear of harm, will be interposed as an obstacle to the ab- sence of the child from parental observation and control. The pleasures and pastimes of a health resort offer no inducements to parents so stolidly indifferent to the comfort and well-being of children. Another class of parents, whilst professing deep concern for the health and welfare of the little ones, will clandestinely connive at means which will relieve them of their burdens under the guise of disease. They are mostly husbandless mothers who are compelled or wish to engage in employment away from their homes, or who follow vicious habits, and whose inclinations are too frequently interrupted by, or whose THE MORTALITY OF YOUNG CHILDREN. 33 scanty earnings are too heavily encumbered with, the proper support of the child. They will offer many and divers ex- cuses for their cruel neglect, and refusal to surrender the con- trol of the sick and suffering child to competent and intelli- gent management, but will gladly accept the brutal care of the keepers of the iniquitous dens where " farmed out " chil- dren are slowly but certainly starved to death. Many of the " at service " mothers are compelled either to farm out the infant at the breast or abandon all hope of obtaining decent employment, because so many housekeepers will not permit a child to accompany the cook or housemaid. The responsi- bility for such cruelty to helpless children cannot be charged solely to the unfortunate mothers. Either this custom, which inflicts such punishment upon a dependent class, must be re- formed, or some other provision must be made for the bet- terment of their condition. The sanitarium will offer, in its visiting or domiciliary department, the additional option of a refuge during the summer months, and thus save to many good but destitute mothers the " well-spring of pleas- ure." The prejudices of caste will offer formidable obstacles to the early and general acceptance of the benefits of the visiting department. Pauperism and vice draw sharp lines of dis- tinction between their various grades. Misery loves company, and crime seeks coadjutors ; but shop-lifting and burglary are as widely apart in their social relations as industry is from insolent mendicancy. The largest portion of the poorer classes of every municipality are far removed in social and moral standing and interests from the pauper and vicious classes, and very many of the most destitute maintain the dignity of exclusive associations. Poverty and pride are not infrequently united and hereditary, and are as obdurate in ad- herence to the prestige of name and family as they are pro- nounced in their contempt for their neighbors of plebeian ori- gin. The different creeds and trades often organize among the laboring and "hand to mouth " classes fraternities even 3 34 THE MORTALITY OF YOUNG CHILDREN. more austere in their companionships than the aristocracy of descent or the more pretentious caste of wealth. In all grades of society ^ but especially in the lower walks of life, there are Tery many otherwise good and well mean- ing people who are practical fatalists, honestly believing or affecting to believe that the ailments of little children come independent of human or material agencies, and as the just retribution of an inscrutable Providence. The facts are al- ways before them that the number of living children increases year by year ; that many, for years puny and sickly, and many times sick nigh unto death, have grown, without un- usual care or extraneous aids, to vigorous childhood : and that in a neighboring habitation, in no manner superior to their own, there is a corporal's guard or baker's dozen of healthy, robust ragamuffins, whilst other more fortunate families have lost one by one all their children. They point with exultation to the inevitable truth that sickness and death in- vade the palaces of the affluent as well as the humble tene- ments of their less fortunate neighbors. In the grief of the sick chamber and sorrow at the bier they seek consolation in the exculpating wail, " It is God's will." It is not, however, just to charge all of these antagonisms exclusively to the wilful derelictions of parents and guar- dians. Their objections and excuses are not always mere imaginary pretexts, suggested by their morbid sensibilities or class distinctions. Neither are they offered by all to excul- pate themselves from the suspicion or consciousness of wrong- doing. In the lower grades of society there are very many deserving people, as good as the} 7 know how to be, who strive to earn an honest and decent livelihood and supply their little ones with all the comforts their meagre resources will allow. They would accept with alacrity the privileges and benefits of a gratuitous daily health picnic for them but for the unavoidable sacrifice of time and the interruption of their accustomed employment. The rigorous demands of task-masters and the employing classes will not tolerate the tardy performance of allotted work. The widowed mother, THE MORTALITY OF YOUNG CHILDREN. 85 whose hard-earned daily pittances are barely sufficient to supply food, shelter, and clothing for her dependent family, cannot remit a day from the routine of poorly paid labor ;'nor can the wife, whose husband must strike the anvil or drive the jack-plane at the tap of the bell, absent herself from her inexorable duties. Such people cannot defer the work of the hour without loss of time and money. The prospective ad- vantages of the sanitarium will not liquidate their current expenses. Time and ability to labor constitute their only capital. The additional expense, trifling as it may seem, of getting the children ready for the excursions and going to and from the places of departure, will prove a burden too onerous for them to bear. Cleanliness and decent protection of the person of each ex- cursionist must be required. To huddle together in convey- ances half nude and filthy children gathered indiscriminately from the beneficiary classes, and transport them to a pleasure ground for the benefit of health and physical improvement, would be a waste of means and effort, and an idle pretence and show of charity. To commingle the clean and the dirty would be repugnant to the instincts of humanity, and detri- mental to the welfare of the better portion. The common sayings that water is as cheap as dirt, and air is free to all, are not universally true. To the dwellers in the filthy, over-crowded, and ill-ventilated tenements of man}' localities in populous cities, pure and fresh air is unknown, and water is insufficiently supplied even for the most necessary use. Among the indigent families there are some so destitute of the ordinary and necessary implements of housewifery that even an abundant supply brought to their doors would be unavailable. Some are too poor to be clean, and others too ignorant to know the uses of water beyond the demands of a brutal instinct. The enforcement of the requirement of personal cleanli- ness and decency would not only deny to many well-meaning and meritorious parents the privileges of the institution, but would exclude very many children most in need of the moral 36 THE MORTALITY OF YOUNG CHILDREN. restraints and salutary influences of the health resort. Its omission would be culpable negligence. Filth, dirty rags, and foul exhalations from unclean bodies are carriers and propa- gators of disease. With such disgusting accompaniments the daily concourse of visitors would be an excursion of fomites and animal parasites. A large percentage of the mortality of early life is due to the contagious diseases which comparatively few children es- cape. These diseases owe their origin to specific poisons which are the same to-day they were when first recognized as separate and distinct entities, each being capable of reproduc- ing itself in every susceptible person. The recurring epi- demics usually owe their wide-spread prevalence in towns and cities to the assembling together children from infected locali- ties or dwelling with those from other parts which would otherwise have escaped. The virulence of the disease always bears a relation to the amount and intensity of the poison absorbed, and the power of resistance possessed by the sub- ject, but may be greatly increased by accessory agencies, or diminished by efficient sanitation and personal care. Long experience and observation have demonstrated that every new case of any one of these diseases is the same disease re- produced in another person, to whom the specific poison has been conveyed either by contact or by atmospheric communi- cation. By dilution of the poisons, isolation of the sick and convalescent, and disinfection of clothing, bedding, and dwell- ings these diseases are greatly lessened in prevalence and in- tensity. In fact if the same interest and concern which are exhibited in the monetary and business affairs of every-day life were wisely and intelligently employed, these diseases might be eradicated, and the lives of thousands and tens of thousands of children be annually saved. The children of no class, condition of life, or locality are ex- empt from these contagions ; nevertheless the prevalence of the diseases, the dangers of complications and consequences, and the mortality therefrom may be greatly lessened by good hygiene, sparseness of population, isolation, disinfection, proper TEE MORTALITY OF YOUNG CHILDREN. 37 and well ventilated apartments, personal and domiciliary cleanliness, suitable diet, and intelligent nursing. In view of these facts it will become the duty of the sanitarium, which seeks to prevent disease, promote health, and prolong life, to ascertain that the children which it may assemble together in its daily excursions are free from infection. Fortunately the young children not exceeding two years of age, who will com- pose the large number of the beneficiaries, are less susceptible to these diseases than those between two and five years old, and the season of the year during which the institution will be in operation includes those months during which these infec- tious maladies are less prevalent and usually less virulent. This latter fact is an instructive and practical corroboration of the previous statement, that the intensity of these poisons is di- minished by their dilution, and by the improved ventilation of the dwellings and apartments incident to the warmer tem- perature, lesser crowding, and less constant occupancy. The relatively undeveloped susceptibility of infants must not, how- ever, be accepted as an absolute protection from possible dis- semination of the poisons when infants from infected dwellings are brought into close association with others from uninfected localities, for the clothing, especially when made of woollen fabrics, is perhaps as often the carrier of the germs of disease as the person of the wearer. The foregoing are some of the more common and serious hindrances which will embarrass the establishment and suc- cessful working of a visiting department. Will its utility as a health-preserving and life-saving charity compensate for the disappointments, vexations, and expense ? The theoretical humanitarian would insist that such considerations should not interpose insurmountable obstacles, but that a good intention, when persistently pursued, will always open a way to success. In a practical age like the present, philanthropy, like the busi- ness affairs of life, will be measured by the balance between the credit and debit sides of the account. Even if the man- agement should not recognize a failure and should blindly and persistently follow the hope of success, those who would claim 38 THE MORTALITY OF YOUNG CHILDREN. an interest in its practical benefits would soon clamor for these benefits. To offer its privileges to every claimant, with daily changes of personnel, would result in an evanescent popu- larity, soon followed by discontent. For a time the excursions would be popular festivals, but pleasure without vice, profit, or some good or bad motive, does not seek frequent repetition. Soon the elements of antagonism would begin to develop, and discreditable confusion and turmoil ensue. The argument in its favor which will appeal with most force to the parents and custodians of the little children will be the proof of actual gain. As a method of preventing or a means of curing disease, has a monthly, a weekly, or a daily excursion to a health re- sort any money value ? If so, will it compensate for the loss of time, and the inconveniences and sacrifices imposed ? These considerations will present themselves as soon as the novelty and excitement of the gala days have ceased to interest and attract a class of people rudely practical in matters of stern necessity, but soon tiring of the aesthetic and more formal di- gressions from the habitual course of life. As a rule, the in- appreciable benefit of a single excursion, or one a month for each of the three, or at most four months, to a sick or inva- lid child, will not be observably increased by two or three a month or one a week, during the same period. Yet it must be admitted that in occasional cases of the summer diseases of young children the turning point of the disease dates from a day or night of cooler temperature, a drive in the open air during the cool and shadowy evening or early morning, a day's sojourn in a salubrious locality, or a voyage by steam or sail. In fact, other circumstances far less important, but in- volving some trivial change in a day's sick report, such as more efficient nursing or more careful feeding have seemed, at times, to have enabled an ebbing life to elude the chase of death. No observant physician will deny the health-preserv- ing and health-restoring influence of tri-weekly, much less of daily excursions of little children exposed to the causes of, or sick from the intestinal diseases so prevalent in cities during the summer months. Few children die of these diseases be- THE MORTALITY OF YOUNG CHILDREN. 39 fore they are consumed. Life feeds as long as there remains food to supply its demands. Inanition and exhaustion are the ominous harbingers of death. Waste must be supplied ; assimilable aliment must be furnished, nutrition must be restored. Instead of bringing the milk skimmed, jostled, churned, watered, or otherwise injured, to the child, carry the patient to the cow, to the country ; not to the scantily supplied and crowd-poisoned village or roadside boarding-house, but to the farm where milk, pure and fresh, and air rich in oxy- gen and free from putrid exhalations, can be obtained. Even the air of the streets and of the open and shady parks is pref- erable to the atmosphere of the foul and stinking lodging-room. The writer has thought, not without some show of reason, that carrying the child through the streets, washed and dressed for exhibition, to a dispensary building, is not wholly without curative power, and that the cleanly and properly clothed were more amenable to remedial agencies. To express in a few words both the method of prevention and surest plan of cure is to say, Remove the child away from the city, away from the immediate and accessory causes ; restore and main- tain nutrition ; and supply suitable food. Whilst conceding in occasional cases the possible good of several, and even a single excursion, with the necessary ad- juncts of personal cleanliness, suitable diet, proper care, and skilled supervision, there cannot remain a doubt of the sana- tive and curative value of successive daily excursions for chil- dren who have not completed the first dentition, which com- prises the periods 1 of childhood to which the summer intesti- nal and alimentary disturbances are mostly confined and from which the largest percentage of mortality annually results. In a large and populous cit} 7 there will occur many cases of bowel and wasting diseases among older children, which will 1 Of 297 cases of the " summer complaints " of children treated in the out-door department of the Children's Hospital of the District of Columbia, 127 were under one year of age ; 83 between one and two years ; 53 be- tween two and three; 22 between three and four; and 12 between four and five years of age. 40 THE MORTALITY OF YOUNG CHILDREN. appeal for succor, and to whom a day's or week's gbod sanita- tion and wholesome diet ought not to be denied. To this de- partment, 1 which will be the first attempt to organize an intel- ligent and proper system of health excursions as a method of prevention and treatment of certain infantile maladies, the good or bad results of which will so much depend upon its wise or unwise management, it will not, at least in the begin- ning, be conducive to its success to limit the admission by any rule of age which will exclude any child to whom it might prove to be the essential and otherwise inaccessible remedy. The character of the charity, the nature of the diseases in- cident to the season during which it will be in operation, and the circumstances of life of its beneficiaries, suggest the rule of arbitrary selection by skilled and experienced discretion, preference being given to those whose condition demands im- mediate amelioration, and the privilege to continue as long as the same supervision may deem it needful and beneficial. Then, to secure a success commensurate with the most com- mendable effort, the visitors should be divided into daily, tri-weekly and occasional classes. Experience and practical observation will soon determine the relative remedial and san- ative value of these subdivisions. Seven or more days in the life of any number of the same sick children passed in the salubrious atmosphere of a properly conducted health resort, with experienced and efficient nursing, proper feeding, clean- liness, and suitable clothing, must yield more speedy, decisive, and satisfactory results than would an equal number of days extended over a longer period of time by the omission of every second, third, fifth, or seventh day. And if the daily expense per capita of each class should be the same (and 1 For several years past the St. John's Guild of the city of Xew York has had in operation a system of occasional excursions on a Floating Hos- pital, which is a most commendable charity. In the report of 1880, it is stated that all medical and sanitary experts who have given any attention to the subject concur in indorsing the value of the summer excursions in preserving the lives of infants. In several other cities a system somewhat similar has been inaugurated. But these charities are not identical with this institution. THE MORTALITY OF YOUNG CHILDREN. 41 there is no reason why it should not), it must follow that the continuous system will be the most economical use of both money and time, and by reason of its more positive results it will save the greater number of lives, whilst at the same time increasing the number of admissions because of the less number of days each patient will remain on the invalid roll. But the saving of money must not be the main consideration in the management of this department. The aim should be to accomplish the greatest good to the greatest number. "Whatever may be the daily capacity of this department, the tri-weekly system would double the number of beneficiaries, but there are as good reasons why it should not be the only one, as there are why it should be a part of the general plan. To it may be transferred the convalescents from the daily class, and may be admitted those only slightly sick, the cases of relapse, and children of parents who cannot incur the in- conveniences and increased current expenditure of a daily excursion. To popularize the institution and establish it in the affec- tions of the people, the most intelligent and thoughtful dis- cretion will be required successfully to combat the various elements of antagonism. These antagonisms grow out of ig- norance, vice, poverty, or destitution, or some combination of these factors. The ignorance is not so much an incapacity to learn as it is the absence of instructive example and proof of certain benefit. These will be presented in every case of sickness cured, and every ill child restored to vigorous health will become a teacher of a school of loving parents, who will picture with graphic enthusiasm the good results, and exhibit the proof in the sturdy health of the infant. Unfortunately, however, deaths will occur ; and though such an event is oft- entimes soon forgotten by such people, because another sup- plies the place, or the after- coming baby soon solaces all sor- row ; nevertheless, every death will be an instance and proof of failure held in remembrance by the croakers and malcon- tents to be found in all grades of society and in every circle of acquaintance. It cannot be expected that the institution 42 THE MORTALITY OF YOUNG CHILDREN. will ever be free from such unjust criticism, but as the life roll will' so far exceed the death roll, and each recovery will continuously multiply itself in an increasing ratio of recruits, whilst the grave will hide from view and time will efface the memory of each successive death, the mass of people will eventually, and very soon under proper management, accept the visible evidence of the value of the summer sanitarium. As a practical instructor in personal and domiciliary hy- giene, and the selection and preparation of aliment for and feeding of young children, this department should occupy a field hitherto neglected. Its method of teaching by the exhi- bition of good results and the constantly increasing number of children restored to health will accomplish more, and in less time, in the direction of preventive medicine than could otherwise be attained. This educational influence will not be limited to the beneficiary classes or confined to the city of Baltimore, but will be widely disseminated. As a pioneer institution in an enterprise so important and so closely con- cerning the health interests of large and densely populated communities, it cannot take the hazard of failure by intrust- ing the performance of its simplest duties to incompetent agents. It will probably never be possible altogether to pre- vent the summer intestinal ailments of young children, and it will be equally impossible to restore every case to health ; but the education of the masses in the causes, methods of pre- vention, and proper management and treatment in the early stages will diminish their frequency and vastly lessen their mortality. It may indeed be surmised, even before the selec- tion of the location or the determination of the plan of the necessary structures, that its most valuable contribution to the welfare of society and to the wealth and power of the city and nation will be in the instruction of the general public in the art of preserving the health and prolonging the lives of little children. The obstacles which poverty and destitution may interpose will, in a measure, be beyond the reach of any educational influence. Undoubtedly the general diffusion of a knowledge THE MORTALITY OF YOUNG CHILDREN. 43 of the laws of health and disease will tend to diminish suffer- ing, want, and poverty, and in time to come the agency of this institution will be recognized as an important instrumen- tality in effecting the betterment of the condition of the pau- per classes. But at present it is not so much the incapacit} 7 and unwillingness of the poor and destitute to be taught, as it is their inability to accept even a gratuitous benefit at the expense of a trivial loss of time, or a penny's addition to cur- rent expenses. It so happens, however, that in ever} 7 civil- ized community there are individuals, organizations, and soci- eties whose sympathies are keenly alive to the wants and sufferings of little children, to whom it will be necessary only to make known their indigence to obtain for them abundant supplies. The goodness of a woman's heart and the innate love of the sex for children will always find the ways and means to meet all such demands. 1 It may be accomplished by some organized system of discovery which will send its agents into the homes, alleys, and hovels where want, hunger, and disease are to be found, and the establishment in connec- tion therewith of depositaries in different parts of the city where can be collected cast-off garments and donated fabrics suitable for the manufacture of clothing, and other articles of daily use ; and where also need} r mothers, without work, may find employment, at even better wages than could be obtained from dealers, in making and repairing such necessary wearing apparel as might be dispensed to those in need. In this man- ner the scraps and remnants of unused fabrics and aban- doned clothing, not unfrequently sold by pilfering servants to the rag-gatherer, at the alley-gate, might be utilized in 1 The St. John's Guild, of New York, has established, in connection ■with its other charitable operations, a sewing department, in which women and girls are taught to do " shop work," and which gives them such employment as it can during the winter. " Lady volunteers are brought into immediate association with the poor and hungry sisters who are unable to earn a livelihood, and those who are blessed with cult- ure, intelligence, and influence give the helping hand which puts the less fortunate in the way of comfort and independence." (Report of 1880.) 44 THE MORTALITY OF YOUNG CHILDREN. securing the privilege of the health excursions to many little children to whom it would otherwise be inaccessible. It may not be any part of the duty of this institution to clothe naked and feed hungry children, but clothing, cleanli- ness, and food 1 are the essential adjuncts of a health excur- sion, and very many will be excluded unless some plan is de- vised by which assistance in these particulars can be rendered. If not incumbent upon the management, it will be none the less the part of wisdom to secure through auxiliary organiza- tions the cooperation of the benevolent in promoting the health interest of the destitute class. In almsgiving, as in matters pertaining to health, the general public needs instruc- tion. System and organization in such activities are far more effective and economical than individual effort. Thoughtless and indiscriminate almsgiving is a prevailing and reprehensi- ble practice. It encourages vice and idleness, degrades hon- est poverty, and invites the infliction of cruelties upon defence- less children. In every populous city children are driven, hungry and half naked, by wicked and debauched parents, to walk the streets in sunshine and in storm, and beg with out- stretched hands and lying lips of every passer-by a penny's worth of bounty ; and woe betide the thriftless beggar-child who, having through many weary hours, in tutored cadences, sung and re-sung the Miserere of the sick and starving little ones at home, returns to the wretched lodging with an empty pocket. The aggregate amount of money thus contributed annually, and worse than wasted, can never be ascertained, but in all probability it far exceeds the sum which could be diverted, even if the custom was abandoned, to proper and charitable objects, for there are very many persons, who will dismiss a beggar from their presence, with a liberal dole be- fore the story of his suffering is half completed, who would higgle half an hour rather than give a half dime to any benev- 1 On each excursion of St. John's Guild " every woman and child re- ceived an abundance of substantial and well-cooked food, consisting of fresh meat, vegetables, bread, butter, milk and (when recommended by the doctor) tea." THE MORTALITY OF YOUNG CHILDREN. 45 olent purpose. No argument will convince such people of the indubitable fact that mendicancy will continue and in- crease so long as it commands a premium and can subsist on the bounties of the thoughtless. If half the money and ma- terial wasted by injudicious individual giving could be dis- bursed through a well-directed, systematic, and organized agency, destitution, suffering, and disease would be greatly lessened, and the condition of many paupers be so much im- proved that they would become not only self-supporting, but contributors to the wealth and power of the state. It has been truly said that " a large and healthy population is the life and strength of a nation, and the source of its success in science, art, agriculture, and commerce." The laboring classes are the instruments for the creation of wealth, and all the comforts and luxuries which it brings. Surely, then, it is the duty as well as the interest of every one to save the little children of this class from the preventable diseases which cost so many lives and such an immense loss of treasure. The densely in- habited courts and alleys of every populous city are so many gold mines, which properly and intelligently worked would yield more wealth than the fabled Eldorado. There is no lack of good intention or willing hands, but for want of sys- tematic, concerted, and harmonious effort the sum total of good accomplished is far less than it should be. There is also a class of over-zealous humanitarians whose good intentions are without a balance wheel and who are as profligate in disbursement as they are assiduous in the solicita- tion of alms. Upon a few petted and pampered favorites means and effort are lavishly bestowed, and luxuries are sup- plied, of the value and use of which the recipients know no more than a brute does of a holy-day or sacerdotal ceremony ; and, fortunately, it is so in many cases, for the waste of such largess is less detrimental than the uses to which they might be applied. It is the repetition of the old story of casting " pearls before swine." Health, nutritious food, decent protec- tion of the person, and proper shelter are what poor children most need. 46 TEE MORTALITY OF YOUNG CHILDREN. Among the affluent and society people there are very many whose good resolves, benevolent impulses, generous intentions, and liberal proposals are frittered away in harmless dissen- sions, weary formalities, individual rivalries, sectarian and de- nominational prejudices, or some other more frivolous and equally unfortunate exhibition of the weakness of human nature, or are permitted to languish and die out because of lack of force, indirectness of purpose, and absence of united effort. If the laity could be educated to a full realization of the facts that nearly one half of all children born die under five years of age, and that the larger part of this mortality results from preventable diseases, the better elements of nat- ure, and the instinctive love of mankind for children, would dominate personal bickering and factious discord, and unite the mass of the better-to-do class in a common struggle to alleviate the sufferings and prolong the lives of little children. Who with these facts before him is exempt from responsibil- ity, or would refuse to contribute his mite to such an activ- ity ? The medical profession has, especially during the pres- ent century, labored to combat the ravages of the maladies of early life, and has succeeded, through diligent research, skilled observation, discovery of new remedies, and more scientific treatment, in reducing the ratio of mortality under five years of age. Much more remains to be done by curative, but far more may be accomplished by preventive measures. In this, as in the study of the nature and treatment of disease, the science of medicine must assume the leadership. The art of preserving health is not, however, the exclusive prerogative of physicians ; unsupported by public opinion and unaided by the civil authorities the profession can do little more than point out the evils of bad hygiene and suggest the methods of correction ; and, perhaps, here and there impress a discreet mother with the folly or wrong of a blind adherence to the customs of a grandmother, or to the dicta of a venerable fossil who boasts that she has reared a dozen or more sons by stuff- ing them with the masticated pulp from her own morsel. The average man will listen to the doctor only when he fears THE MORTALITY OF YOUNG CHILDREN. 47 the devil awaits at his door to conduct his craven spirit to eternal perdition, and so soon as assured that the evil demon awaits in vain or has departed, his gratitude, generosity, and sometimes his sense of justice, ekes out in mere words of slaver. But then, it would be manifest injustice to charge all this extraordinary mortality to the derelictions of the laity. There are dunderheads in the medical as well as shysters in the legal profession ; and no other avocation in which man can engage affords such opportunities to conceal error, practice fraud, or misrepresent the truth. In the seclusion of the sick chamber and privacy of the consultation room, audacious and culpable ignorance oftentimes hides its venality and malprac- tice in the verbiage of a language unknown to ordinary peo- ple and unintelligible to the learned ; and sickness and sorrow are laden with the requisitions of misapplied and pernicious agencies, administered under the garb of a special skill in the treatment of the particular complaint, it matters not what that may be. Little children, whose remonstrances can be expressed only in the language of suffering and disease, are thus frequently victimized to the credulity of unsuspecting parents. The summer sanitarium, with its liberal endowment and independent authority, possesses facilities and advantages never before equaled in this country for the education of the masses in the art of preserving health. It is charged with the special duty of alleviating the sufferings and prolonging the lives of little children. In this special department of sanitary science it must assume the leadership, and the good and bad results of its operations should be made known throughout the civilized world, that the good may be culled from the bad, and that other less fortunate communities m&y be educated by its example in the methods of saving life by preventing disease. To fully discharge this duty, as impe- rious as it is important, it must invoke the assistance and good will of all classes, high and low, rich and poor, learned and unlearned. To confine its operations within the limited sphere of simply furnishing, and providing conveyance to, a 48 THE MORTALITY OF YOUNG CHILDREN. country resort and play-ground, to which children may go at pleasure during the heated months of the summer, and to lose sight of the higher aim as an educator with unrivalled re- sources for the practical instruction of parent and the general public in personal and domestic hygiene and alimentation of young children, would be a sad commentary on the philan- thropy of its founder. It must necessarily seek through good report to inculcate its lessons of wisdom, rather than enforce them through the majesty of law. It is not probable that in a country where the sovereignty of the individual citizen is the unit of power that the salutary influence of law will ever be available to force acceptance upon those for whose benefit charitable insti- tutions are established, but very much may be accomplished in matters pertaining to health by the enactment and impar- tial execution of health ordinances. The State of Maryland will never sanction, nor will the municipality of Baltimore ever enact a law to compel any class of its citizens to accept the gratuitous privileges of the Thomas Wilson Sanitarium, but the time is not far distant when public opinion will de- mand legislation in the interest of health far in advance of any that has heretofore been tolerated. The cupidity and self-interest of every citizen, if there were no higher incen- tives, will insist upon additional and more exacting legislation in sanitary matters. When the representatives of the whole people of the United States in Congress assembled can enact a law authorizing and directing policemen to enter any dwell- ing in the District of Columbia on suspicion that water is being wasted, and of his own volition cut off the supply, and arrest and drag to trial the head of the family, the time ought not to be far distant when the same authority will declare domiciliary and personal filth, bad air, over-crowding, spoiled food, malaria and infection nuisances detrimental to health and decency ; and neglect, bad nursing of and cruelties to little children, and bad cooking misdemeanors punishable by fine or imprisonment. Such authority may be irresponsible, but nevertheless a system of house-to-house inspection under THE MORTALITY OF YOUNG CHILDREN. 49 the direction and management of a properly organized health department must sooner or later become a part of the munici- pal code of every populous city. It will be dictated by a sense of self-security, and protection from the preventable causes of disease, and by considerations of gain and economy. As an aid to the success of the sanitarium a municipal health department will be an important if not a necessary adjunct. THE DOMICILIARY OR HOSPITAL DEPARTMENT. To this department will be admitted those children who will need constant and continuous care, nursing, and feeding, for a shorter or longer time, under the immediate supervision and direction of skilled management. The determination of the earlier age of admission must therefore be made before the construction of the necessary buildings, and involves many important considerations. The reception of nurslings from the date of birth will con- cede the right of the mothers to accompany their infants, and incur the additional expense of providing proper accommoda- tions, and the maintenance of a number of mothers. The capacity of the institution as a place of temporary domicile must be limited by some definite relation of the size and plan of the buildings to the number of patients and area of terri- tory, otherwise it might cease to be a sanitarium supplying fresh and invigorating air to its occupants. The admission and support of such mothers would diminish the number of children at any particular period at least equally with the number of the women, nevertheless the educational ad- vantages which such women might derive by even a single summer's sojourn in such an institution may more than com- pensate in its remoter results for the diminution in the num- ber of its beneficiaries. It is a lamentable fact that much disease and suffering among infants and a very large percentage of the mortality is directly traceable to the ignorance and mismanagement of mothers. Most young mothers are entirely ignorant of their duties, and of the dangers which beset infantile life. They 50 THE MORTALITY OF YOUNG CHILDREN. eagerly accept any information volunteered by a nurse, or the officious suggestions of a maiden aunt or of the neighbor, " so good in sickness," and learn when it is too late that the skill and experience of a well-educated physician is far more valu- able than the advice of any casual observer, however intelli- gent. The time has come when many otherwise well-meaning persons, who assume to direct the medical management of sick children, should recognize the responsibility incurred by attempting to do that which only those skilled in the science of medicine can hope to do successfully. No one will submit the delicate machinery of a watch to the rough usage of a blacksmith, yet the disorders of infancy, oftentimes trivial in the beginning, are frequently made worse by dosing with un- suitable medicaments, because a neighbor's child happened to get well in spite of similar bad treatment. It is only the ed- ucated eye, touch, and judgment which can properly detect and value s} T mptoms and their slight differences. Amateur doctoring may occasionally (Annie M. Hale, M. D.) do well, but it is an unsafe dependence. The teaching of mothers how best to nurse and to feed those needing artificial alimentation, either because of insuffi- cient supply or inferior quality of breast milk, or who may have reached the age when additional food is necessary, is an important and indispensable requirement of any systematic effort to prevent sickness and to lessen the mortality of early life. The only efficient method of accomplishing this, espe- cially among the poor and ignorant classes, is practically to in- struct them by making them, under the immediate observa- tion of competent superintendents, perform every necessary act in selecting, properly preparing, and preserving suitable articles of diet, and in the time, quantity, and manner of feed- ing. Verbal directions are too often forgotten, and when written the language is frequently misunderstood. Many in- fants are sacrificed through inattention to or omission of some apparently trivial matter, not because of neglect or unwilling- ness to do, but because of incapacity, ignorance, or want of THE MORTALITY OF YOUNG CHILDREN. 51 method. Milk, which is so universally employed as an article of diet, is frequently supplied in sufficient quantity and of good quality, but is spoiled either by some improper mode of preservation or preparation, and thus is not only rendered un- fit as an aliment, but the cause of serious and often fatal ill- ness. Even when not otherwise injured it may be fed from an unclean vessel, or sucked through a dirty mouth-piece. The education of such mothers is not free from difficulty, and many will, after their discharge from the institution, re- lapse into their former habits ; but some, thus thoroughly trained, will become instructors, each in her respective circle of acquaintance. The proverbial fondness of women for im- parting to others what they think they know of the manage- ment of children may be thus utilized as a channel through which useful information may be disseminated, many errors corrected, much sickness prevented, and many lives saved. To a limited extent at least, dependent upon the capacity and intelligence of the women, each will acquire by observa- tion and association some knowledge of the causes of disease and how to avoid them, of its course, and of favorable and unfavorable symptoms ; but, perhaps more important than all things else, she will be taught to know that the summer infantile ailments are preventable and curable. The educa- tion of mothers to this single conviction, coupled as it must necessarily be with the realization of personal responsibility for the welfare of her nursling, will effect vast improvement in infant hygiene, and strike at the root of parental indiffer- ence and neglect. If, however, the advantages of the sanitarium are accorded to infants whose mothers (poor and needy though they be) are animated by the tender sensibilities and affectionate care known only to a mother, and who supply the natural and nec- essary aliment to the child, can it be denied to foundlings and other nurslings who may have been deprived, through the ac- cidents of .labor and by disease, of maternal care and suste- nance? The admission of the abandoned and motherless classes of nurslings would impose additional cares, incur grave 52 THE MORTALITY OF YOUNG CHILDREN. responsibilities, and probably augment the current expendi- tures ; but mere considerations of policy, which do not pre- sent insurmountable obstacles, should not determine their ex- clusion. It is true that most large cities are provided with hospitals and asylums for the reception and care of foundlings, but there always will remain a number of these, and very many motherless infants who find refuge among kindred, and in poor and needy families, who will not relinquish to any in- stitution permanent possession of their wards, to whom the privileges of a summer's retreat from the heated air of the city and the baneful influences of squalid habitations will prove a boon of inestimable value. During the first or nursing period the probability of sick- ness and mortality are disproportionately larger than during the subsequent periods of childhood. The greatest mortality occurs during the first month, 1 and though it gradually lessens during each succeeding month, it aggregates at the termina- tion of the first year one fourth of all the births. The causes which conduce to this mortality include the un- avoidable diseases inherited from one or both parents, the congenital diseases and defects of formation, and the numer- ous preventable disorders specially incident to infantile life. Many of the congenital diseases and malformations are incur- able and, perhaps fortunately, terminate life during the earlier months; but some of the transmitted vices of constitution are remediable. The syphilitic infection submits, as a rule, to early medication and suitable regimen; and the scrofulous and phthisical predispositions, if not entirely eradicated, are 1 Quetelet says: "There die during the first month after birth, four times as many children as during the second month after birth, and almost as many as during the entirety of the two years that follow the first year, although even then the mortality is high. The tables of mortality prove, in fact, that one tenth of children born die before the first month has been completed." In the city of Baltimore there died during the years 1875-78, 8,549 children under one year of age; 3,563 between one and two years of age; and 1,868 between two and five years of age. THE MORTALITY OF YOUNG CHILDREN. 53 frequently so modified and improved by timely and appropri- ate hygienic and dietary regulations as to insure comparative good health throughout a long and useful life. But it is the preventable causes of disease which demand special attention in an institution of this character. And, notwithstanding the marvelous advances in the treatment and prevention of the diseases of earl} 7 life during the past decade, the opportunities for further improvement are limited only by the constantly increasing population of the habitable world. The perfection of life and happiness cannot be attained while such a large proportion of children die under five years of age from avoid- able diseases. The post-natal causes of the morbility and mortality of the nursing age find their origin in the condition of the body as well as in the circumstances of life. With the completion of birth, important changes take place in the organism. The function of respiration begins, and the lungs, previously only passive and non-essential adjuncts of intrauterine life, are sud- denty and violently transformed into organs, without which an independent existence cannot be sustained. The circu- latory system becomes self-sustaining, receiving oxygen and eliminating carbonic acid through the lungs ; the alimentary tract, which previous to birth was only the receptacle of de- bris, now assumes the important functions of digestion and depuration ; the skin, which had been bathed in the high temperature of an innocuous fluid and protected by the more or less thick coating of a fatt} 7 secretion, is suddenly exposed to the detrimental influences of a medium of greatly lowered temperature, and subjected to the cruel formalities of super- stition, ignorance, and destitution ; and the brain, which at birth is a semi-diffluent mass of material, begins a rapid growth, with increased blood supply and organization of nerve and intellectual organs. To these must be added the delicacy and softness of the anatomical structures, and the helplessness common to all and the feeble vitality of many. These developmental changes are the physiological attri- butes of infantile individuality ; nevertheless, the new duties thus imposed upon the organs involved entail a tendency to 54 THE MORTALITY OF YOUNG CHILDREN. special diseases, which is vastly increased by the improprieties of infant hygiene and the circumstances of life. The death- rate is higher among the first bora than among subsequent births; higher in cities, more especially in the densely popu- lated parts, than in the country ; higher among the needy poor than among the affluent and well-to-do ; higher in local- ities where those employed in manufacturing industries reside, than in agricultural regions ; higher during the prevalence of epidemics than during seasons exempt from such deleterious influences ; and higher among the illegitimate than among those born in wedlock. All these contingencies of life are more or less favorably impressed by the life, dwelling, habits, and education of the family. This mortality is not, however, confined to the children of the poor, or of those living in nar- row and foul alleys, or of the dwellers in the ill-ventilated and stinking tenements of populous cities, nor to the improperly fed, to the early weaned, the harshly treated, or the impru- dently exposed, for all these causes are, presumably, of as fre- quent and constant occurrence during the winter as during the summer months ; yet it is during June, July, August, and September that the greatest mortality annually occurs. It is during these months that the highest mean monthly tempera- ture prevails. This general relation of mortality to a high average temperature is exhibited by the appended tabulated statements, 1 and is no less true of the city of Baltimore than 1 TABLE I. [Prevailing direction of winds in summer months, S., S. E., S. W. In report of deaths under one year of age, still-born not included.] Temper ATCEE. Highest and Lowest. Mean Monthly. 1875 1876 1877 1878 1875 1876 1877 1878 52-1 59- 3 63-19 74-23 88-42 97-54 93-61 88-58 92-43 77-34 65-16 67-12 71-17 65-12 69-12 75-SO 88-34 95-51 99-59 90-55 8S-45 77-30 76-25 56- 1 54- 1 63-18 65- 9 80-32 92-41 95-55 93-64 94-63 83-48 80-41 6S-25 67-22 57- 6 63-20 72-21 79-42 85-43 92-51 93-65 92-59 87-47 80-35 61-33 j 61-15 ; 30.1 29.3 39.5 49.4 64.1 73.7 78.0 73.4 65.9 55.5 42.9 33.3 41.5 37. S 39.8 52.1 61.2 75.9 80.4 75.9 65.6 52.4 47.1 28.7 32.1 40.5 41.4 53.6 62.7 73.7 78.7 77.6 67.9 59.7 48.4 43.5 35.7 February Mar h 47.6 49.3 53. 7 Mav 63.5 70.1 Julv 80.8 76.0 69.3 58.7 47.3 December 35.4 THE MORTALITY OF YOUNG CHILDREN. 55 of other large manufacturing cities. It is less in sparsely populated localities, less still in elevated regions, and least when to these conditions is added aridity. Then to the bane- ful influences of bad air, improprieties of diet, injudicious feeding, malnutrition, elevated temperature, personal neglect, and destitution must be added the conditions of moist atmos- phere, lowness of situation, and the congregation of a number of individuals within a limited area to complete the catalogue of causes and fill the measure of endemic requirements. METEOROLOGICAL INFLUENCES. The fact that very many young children die annually of the summer complaints 1 who are free from the detrimental Table I. Continued. Deaths. 1875. 1876. 1877. 1878. to OQ to m M 03 g O C !S c£: »> ss n £ SH ss SH 2fc< U £ SH Sfe 1-2 m 05 -a 3 4) 5 £* January. . . 133 39 78 116 74 35 121 85 41 104 5S 29 February. .. 153 66 70 131 62 45 122 112 35 120 44 32 March 141 54 54 152 99 45 144 155 65 151 63 41 April 113 42 38 101 56 41 135 109 42 103 44 32 May 119 29 63 105 63 28 121 88 44 161 43 38 June 236 43 36 549 88 20 382 176 43 270 58 37 July 489 66 49 418 105 20 423 140 34 257 53 34 August 259 91 25 261 119 31 248 If 3 35 203 65 35 September.. 174 90 28 1,4 70 34 167 109 44 125 67 34 October. . .. 165 71 22 104 49 22 98 69 57 117 42 33 November.. 101 46 25 89 45 25 96 63 35 116 34 46 December. . 133 68 30 137 95 52 125 80 43 107 33 53 Total 2,216 705 508 2,317 925 398 2,182 1,329 518 1,834 604 444 1 " To determine the precise extent of their prevalence in any commu- nity is impossible, so inaccurately are the diseases of infancy and child- hood everywhere registered. Cases of fatal diarrhoeal diseases are re- corded under a great variety of designations, among which the following may be enumerated, as being the least equivocal: diarrhoea, cholera in- fantum, cholera morbus, enteritis, gastritis, gastro-enteritis, entero-colitis, inflammation of the bowels, dysentery, etc." (Curtis, Hygiene and Public Health, vol. ii., p. 281.) 56 THE MORTALITY OF YOUNG CHILDREN. influences of foul air, privation, uncleanliness, over-crowding, and improper alimentation, points to some general agency, probably atmospheric, which affects alike all classes and con- ditions of life. When to this is added the further fact that these diarrhoeal diseases are almost exclusively confined to the heated months of the year, and are more prevalent in low and damp localities and during seasons of excessive rainfall, the conclusion seems manifest that continuous high tempera- ture and a humid atmosphere are essential elements of causa- tion ; yet that these two climatic elements are not the only necessary considerations is equally evident from the fact that these disorders are much less frequent in the Gulf cities and those on the Pacific coast, where the temperature is more uniform during the entire year, than in the cities of the Mid- dle and Northern States, which are subjected to very wide excursions of temperature between the extremes of heat and cold. Professor N. S. Davis, 1 of Chicago, who has studied the relation of bowel complaints, both in children and adults, to temperature and geographical region submits the following conclusions : — (1.) They are far more destructive to infants than to adults. (2.) They prevail almost exclusively during the warmest months of the year. (3.) They are most prevalent in the region of this country north of the north line of the Gulf States, and east of the Rocky Mountains. He asserts two additional facts, not previously recognized, which are of great importance : First, that these diseases occur in groups when the cases rapidly multiply during suc- cessive days for a week or fortnight, followed by an interval during which few or no cases occur ; and, secondty, that these groups correspond with the waves of continuous high temper- ature during day and night, which spread, at shorter or longer intervals during the summer months, over the northern cli- matic belt of this country, lasting from three to fourteen 1 Trans. Amer. Med. Ass., vol. xxx., 1879, p. 145. THE MORTALITY OF YOUNG CHILDREN. 57 days, and varying in intensity at different times and in differ- ent years. The first of these tropical waves usually occurs during the latter half of June, two or more occur in July, and one or two in August. To ascertain, with probable accuracy, the time of occur- rence and duration of these periods of continuous high tem- perature at different localities in the climatic belt of the country in which they annually recur, together with the ad- ditional information set forth, the following inquiries were addressed to General Albert J. Myer, Chief Signal Officer of the Army : — (1.) The date of beginning and duration of the periods of continuous high temperature for the cities of Washington, Baltimore, New York, and Chicago, for the years 1876, 1877, 1878, and 1879 ; and the mean daily temperature of each period. No period of less than three days to be considered. (2.) Amount of rainfall at same places during each period or at their termination. (3.) Relative humidity of the air at each place during each period. The accompanying tabulated statement (Table II.), cour- teously supplied by that distinguished officer, fully answers these inquiries. 1 The cities named were selected without any previous exam- ination of the data to be supplied, or knowledge of the information to be derived therefrom. If a lower standard than that of the normal for July at each locality with the addition of ten degrees had been adopted in the preparation of the statement, the periods of continuous high temperature would have been more numerous and of longer duration than 1 The writer takes pleasure in acknowledging the polite and valuable assistance, which Lieutenant Craig and Professor Abbe have, with the permission of General Myer, rendered him in his effort to study the rela- tion of the meteorological phenomena to the causation of infantile diar- rhoeas. He has been supplied, upon request, with data from the official records of the bureau which have enabled him to consummate the results set forth in these pages. 58 THE MORTALITY OF YOUNG CHILDREN. TABLE II. — Statement showing the Periods, in the Months of May, during which the Temperature of the Air rose Ten Degrees or more City, N. Y., and Washington, D. C. ; also, showing the Mean Tem- duriny the specified Periods. Compiled from the Records on fie at 1. The normal for July, with ten degrees added, is as follows : 2. The dash ( — ) in the columns for the rainfall indicates that the Baltimore, Md. Chicago, III. Temperature. £*; Temperature. •fi d| Rain. ft 2 Rain. Dates. c 2 Inches. Dates. c S Inches. Max. Mean Daily. £ 3 ~ — Max. Mean aily. ei 3 1876. 1876. June 24 90° 80.7° 59.7 June 24 85° 78° 70.7 25 90 81.7 57 25 85 79.2 72.3 26 94 84.2 58.7 26 87 80.5 72.7 .04 27 95 85.2 57.3 — July 6 90 80.2 77.3 28 93 80.7 66 .59 7 93 84.7 66.3 July 2 94 85.2 68.7 8 93 85.7 61.3 • * 3 93 84.7 54.3 9 93 83.7 64.7 .02 4 95 80.7 61.7 .22 Aurr. 22 85 77 623 5 92 82.7 67.7 .15 23 92 83.2 64.7 6 90 81.2 61 .01 24 85 79.2 75.7 .88 8 97 88 59.7 1877. 9 99 90.2 533 o July 7 86 77.7 67 10 97 88.2 60.7 8 91 80.2 72.3 .01 11 96 84 70.3 .21 9 89 78.5 82.3 12 96 82.7 68.3 .05 26 88 SO 72.7 .02 13 95 83.2 68.7 .25 27 86 78.7 72 .01 14 91 83.2 65.3 .90 28 84 76 87.7 .54 15 91 81.7 63 .01 Aug. 26 84 74 63 16 90 81.2 51.3 27 89 77 78.7 .04 17 90 82 61.3 28 84 74.2 83.3 .46 18 93 83.7 60 .15 1878. 19 92 85.5 67 July 7 85 78.7 72.7 20 97 87.7 64.3 .19 8 86 78.5 76.7 — 1877. 9 87 79 73.7 .11 July 25 92 81.5 59.3 .01 14 87 81 77.3 26 92 84.2 62.3 15 88 82.5 71 27 93 84 72 .50 16 97 88.2 61.7 28 92 79.5 76 .02 17 95 89.2 61.3 1878. 18 88 75.7 74 July 4 92 81.5 67 ; l 89 80.2 55.7 .01 5 92 83.7 61.3 Aug. 1 87 78.5 56 .09 6 92 83.7 48.7 2 84 77.2 66.3 7 90 81 54.7 3 84 77.7 67 8 92.5 81.2 71.3 .02 4 85 78.5 65.7 .12 9 91 82.2 73 .32 5 87 77.7 71 10 94.5 84.7 62 .26 1879. 11 91 84.2 60 June 23 86 78.7 58.7 17 91 82.2 73.7 24 87 79.7 61.7 18 98 88 62.3 25 85 79.7 59.7 THE MORTALITY OF YOUNG CHILDREN. 59 June, July, and August, of the Years 1876, 1877, 1878, and 1879, above the July Normal at Baltimore, Md., Chicago, III, New York perature, Mean Relative Humidity, and Total Rainfall for each Day the Office of the Chief Signal Officer, U. S. A., Washington, D. C. Baltimore, 89.6°; Chicago, 84.4° ; New York, 84.9° ; Washington, 89.3°. amount of precipitation collected in the run gauge was too small to measure. New York City, N. Y. "Washington, D. C Temperature. r^iA Temperature. fi I:-g Rain. fi2 Rain. Dates. d 3 Inches. Dates. c 5 Inches. Max. Mean Daily. e 3 a) i— t Max. Mean Daily. eS 3 > P2 Rain. n: 2 Rain. Dates. c 2 Inches. Dates. Inches. Max. Mean Daily. | 3 Max. Mean Daily. a; — i 1878. 1879. Julv 19 95.5 84.7° 62.7 .17 Julv 13 86° 82.2° T4-7 20 92 84.7 63.7 14 91 86 2 58.7 21 95 85 62.3 .05 15 93 8S7 64 3 1879. 16 90 75 5 56.3 July 15 94 84 55 — Aug. 1 88 82 2 48.3 16 99 90 49.3 2 91 84.7 53.7 17 91 82.5 39.7 3 85 77.7 72.3 .01 Aug. 2 92 83.2 58.7 20 85 77.7 59.3 3 92 82.7 63.7 — 21 88 79.5 62 4 90 80.2 72.3 .26 22 87 81.2 55.7 5 90 82.7 68 6 90 84.5 57.3 THE MORTALITY OF YOUNG CHILDREN. 61 Temper at u re, Con tinued. New York City N. Y., Continued. Washington, D. C, Continued Temperature. Temperature. £>. A3 Rain. RJ2 Rain. Dates. a S Inches. Dates. s S Incces. Max. Mean Daily Max. Mean Daily. 7 = 1877. 187S. Aug. 29 89° 77.2 = 67 .13 July 5 91.5° 82° 70 1878. 6 93 83.5 58 June 27 87 78.2 62 7 91 80.5 52 28 88 80 57.3 8 96.5 83.7 66.3 29 86 77.5 62 9 93.5 82.2 71.7 .21 Julv 1 86 76 69.3 10 96 80.7 73.3 .10 2 87 76.7 72 11 93 84 65 — 3 88 77.5 76 12 93.5 80.7 79.3 .83 4 88 76.5 75.3 — 17 94.5 83.2 73 5 92 82. 58 18 98 89 63.3 6 85 77 38.3 19 96.5 83 74.3 1.10 8 88 77 73.7 .13 20 91 82.6 743 9 88 76.2 83.3 1.26 21 95.5 84.2 69.7 10 86 77 72.7 .02 31 91 80 68.3 — 18 93 83 74 .41 Aug. 1 93 81.5 75.3 .64 19 94 84.7 68.3 .01 2 89.5 80.6 61.7 — 20 87 78 59.3 3 92 80.5 63 Aug. 2 85 74.2 74.7 1.46 4 92 805 69.7 3 88 77.2 62.3 5 90 77.2 77.7 2.15 4 85 75.5 68.3 .12 1879. 1879. May 31 94 82.2 65.3 May 31 86 76.2 71 June 1 95 82.5 57.3 June 1 89 79.7 64.7 2 90 77 67 .45 2 86 75 70.7 .24 26 91.5 80 63.7 July 14 85 76.7 57.3 27 94.5 83.2 59.7 15 92 82.2 58 28 95 82.2 63 .09 16 94 78.7 70.7 .42 July 2 90 79.5 50.3 27 86 77.2 70 .06 3 95.5 83 50.3 28 85 76.5 75 4 99 84.7 50.3 .02 29 85 77.7 6S.3 .01 14 91 79.2 55.7 31 89 77.5 54 15 98.5 86.7 52.3 Aug. 1 86 76.5 80.7 16 102 88 7 51.7 2 90 80.5 74.3 17 90 80.7 45 3 89 79.5 70.7 — 22 93 81.2 59 23 93 83.7 53.7 .02 24 91.5 81.2 64 .02 Aug. 1 90 79.2 74.3 5 94 81.7 63 3 94 84 61.7 4 92 80.5 73.3 .32 5 93 83.2 71.3 — 62 THE MORTALITY OF YOUNG CHILDREN. are shown in the tabulated arrangement, but they would have been less distinctive as exacerbations of temperature, and consequently less valuable in exhibiting the relation of such periods to the prevalence of the infantile intestinal diseases. If the July normal at each of the four localities had been adopted as the basis, a more uniform temperature would have been shown for the months named at each of the places selected, and very many days would have exhibited a daily mean and minimum too low to be regarded as a heat factor in causing bowel complaints. In fact it would have transferred the question from the study of the exacerbations of temperature as a causal element to the consideration of the duration of summer heat as the essential and important agency. The periods are of shorter duration in Chicago and New York, and occur quite as early as in Washington and Balti- more. The earliest stated began May 31, at New York, in 1879, and the latest terminated at Washington, August 31, 1877. The first usually begins during the latter half of June and either extends into July, or is succeeded, after a brief in- terval, by the second period, which most frequently begins dur- ing the first seven days of July. In 1876, a period began al- most simultaneously in the four cities in June. Two or more periods usually occur in July, and the average maximum and mean daily temperature of the periods are uniformly higher in July than in either of the other months. The normal for July is highest at Baltimore, but the high-' est average maximum temperature of the corresponding peri- ods is at Washington. (See Table XII.) A comparison of the four cities according to the average, for four years, of the maximum and mean daily temperature, and average relative humidity for the same period, will ar- range the cities as follows : — THE MORTALITY OF YOUNG CHILDREN. 63 TABLE III. Chicago. 87.4 79.2 67.3 Average maximum temperature . . Average mean daily temperature . . Average percentage relative humidity Washing- ton. Balti- more. New York. 93.9 92.9 88.5 82.4 83.2 78.5 63.8 61.4 63 The atmosphere is never absolutely free from moisture. It is called dry when it contains less moisture than it might at the existing temperature ; saturated, when it can contain no more ; and damp, when its saturation is high relative to heat. The capacity of the air for moisture increases with the eleva- tion of its temperature, but the relative saturation of a given volume of air diminishes with the rise of its temperature. As a rule, the body loses more water through the skin and lungs when the air is dry than when it is damp. A warm and damp air diminishes the radiation of body heat, exhausts the muscular and nervous system, lessens the appetite, impedes digestion, and obstructs the respiration. So that an average mean daily temperature of 79.2°, with an average mean daily humidity of 67.3 per cent., as is shown to be the condition of the atmosphere of Chicago, is more oppressive than the higher average mean daily temperature of Baltimore, with a lesser average relative humidity of 61.4 per cent. Applying this rule to the four cities, they may be arranged according to the data for the heated periods of the four years named ; Balti- more possessing the most endurable temperature during those periods, and, successively, Washington, New York, and Chi- cago. Other things being equal, these meteorological obser- vations would indicate that the city of Baltimore, 1 or its vi- 1 The temperature differences between Baltimore and Washington are hardly appreciable, but the relative excess of moisture in the air of Wash- ington favors the former city as the preferable locality of the two ; assum- ing that the hygrometric observations are sufficiently accurate to distin- guish between such slight differences of relative humidity. 64 THE MORTALITY OF YOUNG CHILDREN. cinity, would be the most favorable of the four localities for the establishment of a summer sanitarium for the prevention and cure of the bowel complaints of young children. The meteorological data are, however, as yet insufficient to deter- mine the comparative healthfulness of different cities. En- demic influences, condition of soil, drainage, sewerage, local sanitary supervision, the character, pursuit, density, and pri- vation of the population, altitude, food suppl} 7 , and dwelling accommodations must enter largely into the consideration of the question. The temperature of the air diminishes, approximately, in the ratio of one degree to every three hundred feet of eleva- tion above the level of the sea ; the probability of more fre- quent and stronger currents of air increases with the altitude, and the relative humidity of the atmosphere at any given point ought to increase with ascent above the sea level. The movements of the air bear important relations to its tempera- ture and humidity. A calm, especially when the air is very warm, is detrimental to health, because the products of ani- mal and vegetable decomposition, and the exhalations from living bodies, are not diffused and dispersed. Ventilation is inadequate for the demands of health. Upon the direction of the currents depends, in a great measure, the heat and moist- ure of the atmosphere. By the movements of the air the ven- tilation of dwellings is promoted, and the air is dried. The influence of winds upon the production of disease is not very well understood. Cold, damp northerly and easterly winds provoke catarrhal and pulmonary diseases. Hot, dry south winds are enervating, and are supposed to exercise a peculiar evil influence upon very young children. The relation of the winds to the prevalence of special diseases varies with the season of the year. A current that would mitigate suffering during July and August might greatly augment it during the months of December and January, or even in the balmy months of spring. The relation of elevation to the tempera- ture, humidity, and movements of the air is an important consideration in directing the selection of a suitable location THE MORTALITY OF YOUNG CHILDREN. 65 for a summer sanitarium for sick children. Diminished heat, agreeable relative humidity, freer ventilation, a purer and more salubrious air, are curative and preventive agencies es- sential to the clinical success of such an institution. These can be secured by the choice of some of the elevated plateaux in accessible proximity to the city of Baltimore. The data furnished by the Chief Signal Officer of the Army, previously summarized, lead also to very important and definite suggestions in regard to the time when an insti- tution of this character should annually begin active opera- tions. Preventive measures should commence before the time when the earliest period of continuous high temperature an- nually recurs, and continue sufficiently long to escape the probable time of the occurrence of the latest period. To cover the earliest date at which such high temperatures have occurred at Baltimore and Washington, the institution should be in readiness on or before the middle of June, and not close until the latter part of September or first of October. The latest period noted in the memoranda terminated on August 31, 1877, at Washington, with a mean daily temperature of 80.5°, and mean daily humidity of 64.3 per cent. Even though there might be few or no cases of disease after this date, the convalescent could not be safely returned to the city and to their lodgings before the temperature had fallen suffi- ciently to insure them against relapses. This is not likely to occur before the autumnal equinox. The first period, usually occurring during the latter half of June, is quickly followed by another of longer duration, with higher mean daily temperature and mean daily humidity, which envelops the entire middle and northern parts of the country east of the Rocky Mountains, beginning in some lo- calities as early as the first of July, in others usually not later than the fourth. 1 This exacerbation is followed by the greatest 1 The average of the aggregate maximum temperatures of the fourth day of July for the cities of Baltimore, New York, and Washington, for the years 1876, 1878, and 1879, was 95.25°. 5 66 THE MORTALITY OF YOUNG CHILDREN. outbreak of bowel diseases among children. 1 Previous cases are made worse or suffer relapses, and a large number of new cases occur. Usually, two other but shorter periods follow this in the month of July. As a rule the largest monthly mortality of children under five years of age occurs annually in July. The following tabulated statements (Tables IV. and V.) show that the total mortality of children under five years, and the death-rate from cholera infantum, dysentery, and diarrhoea for a period of seven years in Philadelphia, 1862-68, (excepting 1863) and in New York, 1871-77, were, for each year in either city, higher in July than in June, August, or September. The same is true of Boston. If the mortality excess during July is due to the circum- stance that very many children, taken sick during the tropical period of June, die during the succeeding month, then it ought to follow that the number of deaths should be greater in August than in July, because there are two or more ex- acerbations of temperature, and very many more children are taken sick in July than in June. Undoubtedly, a large per- centage of the August mortality results from cases of sickness beginning in the preceding month. This fact, (as do the clinical and mortality statistics of July) indicates that the atmospheric condition peculiar to the summer months which seems to exert a specially detrimental influence upon children under five years of age is much more constant and intense in July than in either of the other months. What is this agency ? It is not the heat of a single day, as has been shown to be usual with the Fourth of July, nor the heat of several consecutive days, each followed by cool nights, for 1 In this connection it is proper to invite attention to the greater prev- alence of disturbances of the alimentary tract in young children during the week following Christmas Day, the Fourth of July, and other gala clays, due manifestly to the improper indulgences of the appetite. Parents and kindhearted friends are very often responsible for cases of serious and, un- fortunately, sometimes fatal illness, which would not have occurred if they had adhered on such occasions to the simple and proper dietary to which the children had been accustomed. THE MORTALITY OF YOUNG CHILDREN. 67 CO CS -1 —I Cholera Infantum, Dysentery, Diarrhoea. Total. Mean Temperature. Cholera Infantum, Dysentery, Diarrhoea. Mean Temperature. Cholera Infantum, Dysentery, Diarrhoea. Total. Mean Temperature. Cholera Infantum, Dysentery, Diarrhoea. Mean Temperature. -Jt I*' CO 30 CO o Cholera Infantum, Dysentery, Diarrhoea. o "5? CO OS OS "co cs Id — to — CS GC Total. OS CO l 3 o s CO o So o •o Mean Temperature. — ' CO o cs — ~-1 £ Cholera Infantum, Dysentery, Diarrhoea. o ST ■5T "O "tO to ^ Qi co CO o Total. CO as OS ~1 CO C» 'to J-» t <3 CS 3 -1 to CO o Mean Temperature. s S 03 co CO CS Cholera Infantum, Dysentery, Diarrhoea. O p CO OS CO St -1 CO O *CO s c "to o Total. 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O CO L— O th_CO i— "co"o"tJ>~N — t-^tcfoo""o"cc"^'N"o CC xVx'xVfcH x N NlO l~ 00* t* OO HI «o«M tO N O O N to J- o — si-r-nc — H H — i N H H o i— ii-H CO Tji i— 1 OH^hcO NNHCOHN i— 1 .2 6 • s © ' "JriSS *-o " •■§ ' a fi • • *" ^hTS .« .. -d . c-g tiftS £-^ K o 2 „ -ord I :l|l*il-£ll 1 s llsliliSl a 11 M !| 1 EiS:css-jQot;2HHHSo;iBr;i"zS ii i i \ " Children who have had breast"] milk up to sixth, eighth, and ninth J Well developed . month; after which they were )■ Medium developed partially weaned, and received j Badly developed . other food." J " Those having had breast milk^ T -, 7 T1 , , , ,° Well developed . moderately abundant and bread »« -.. , , , J . . V Medium developed food along with it from birth or £„ devel d . early age. ■> " Children from birth or the age of two or three months, besides an abundance of breast milk, had received boiled bread and milk ; or merely water, sugar, and ar- row root." "Children having had from ear-^i liest infancy a moderate or small j supply of breast milk ; some for a Well developed . \- Medium developed Badly developed . Well developed 6. x .i i .i £ i ^Medium developed lew months only, others for much ! L longer times, with other food j Bad1 ^ develo P ed ■ from birth." J , Well developed . » Children fed entirely by hand, J Medium deve i ped and with no breast milk at all." J Ba(]ly developed . 62.6 per cent. 23.3 per cent. 14 per cent. 58 per cent. 26 per cent. 16 per cent. 51 per cent. 25 per cent. 24 per cent. 52 per cent. 28 per cent. 20 per cent. 26.5 per cent. 26.3 per cent. 47.9 per cent. 1 per cent. 26 per cent. 64 per cent. The pernicious influences and extraordinary mortality pro- duced by the want of breast milk is more fully exhibited in the reports of foundling hospitals. In the hospitals of Lyons and Parthenay, France, where the children (Kouth) are suckled at the breast, the mortality is respectively 53.7 and 85 ; whereas in Paris, Rheims and , where arti- ficial feeding is very generally employed, the mortality is respectively 50.3, 63.9, and 80 per cent. The observations of Drs. Merei and Whitehead show that the percentages of the medium and badly developed increase with the diminution of the breast milk and shortening of the period of lactation, until it reaches respectively 26 and 64 among those dry- nursed from birth. They show the equally important fact that additional food, when the mother is healthy and has an 128 . THE MORTALITY OF YOUNG CHILDREN. abundance of milk (compare classes 1 and 4), reduces the percentage of the " well developed " from 62.6 to 52. These are the results among living children. The number of deaths from similar causes may be estimated upon the basis of the mortality in foundling hospitals. The foregoing data demonstrate the importance of preserv- ing to the nursling the breast of the mother. It is best when sufficient for its sustenance, but better even when insufficient than none at all. " The worst," says Routh, " that can be done under ordinary circumstances for a child, is to bring it up exclusively by hand ; at least, in the way in which it is usually done." He asserts, furthermore, that " the mere sub- stitution of a hired wet-nurse increases the mortality " and cites in proof, in addition to others, the circumstances that in Switzerland and Holland, where the smallest number die, the mothers nurse their own children ; and " of one hundred chil- dren suckled by their mothers, in Paris, eighteen die in the first year ; of the same number at nurse, twenty-nine die." In the department of the Gironde are two communes, under similar hygienic conditions. In one the mothers suckle their own children ; in the other a number of mercenary wet- nurses take in children from Bordeaux in large numbers to nurse. In the first the mortality is 13 per cent, in the last it is 89 per cent. In view of these considerations the preservation of the func- tion of the mammary gland, and its restoration when impaired, becomes a duty of paramount importance. The more general diffusion among women of information concerning the causes of defective lactation, and the importance of early recognition of and attention to the evil effects, will accomplish much towards modifying or obviating the dangers. The general management of cases of defective lactation consists in local or mechanical, hygienic, dietetic, and medical treatment. A discussion of the details of these several methods would involve an elaborate and unprofitable review of the literature of a subject concerning which a vast amount of nonsense has been written, and for the treatment of which THE MORTALITY OF YOUNG CHILDREN. 129 many remedies have been recommended, both by physicians and laymen, with which the writer has had no experience, and of the value of which there is no confirmatory evidence. Nevertheless, the subject is too important to be passed with- out comment. The local treatment involves the management of the gland and nipples before and after labor. Any disease of the gland, or irregularity in shape or position of the nipple, should re- ceive the necessary attention before or during pregnancy. Sore nipples and sore breasts are quite common, and some- times unavoidable, occurrences after confinement ; but with proper care and timely treatment they are usually manage- able affections, and do not necessarily permanently disturb the function of the gland. Various local and mechanical means have been emplo} f ed to provoke and increase the flow of milk. Suction, titillation of the nipple in imitation of the process of milking animals, pressure, kneading, gentle friction, electricity, fomentations, and the application of various stimulating substances have been employed, with more or less success. Of these, suction and electricity have yielded the most favorable results. Suc- tion is the most certain and powerful means of promoting, increasing, and preserving the lacteal secretion. This is illus- trated by the numerous instances of maidens and barren women, and of the few cases of males, who have by this means established a copious secretion of milk ; by the cases reported by Livingstone, Dunglison, Thorwarth, Waddy, and others, of old women, who had long before ceased to men- struate and bear children, who had reproduced the secretion, and nursed their grandchildren ; and by the very common occurrence, — the gradual, sometimes rapid, loss of the milk after the death of the child, notwithstanding the efforts made to preserve the breast for mercenary considerations. The preferable mode of suction is by the child. There are sundry contrivances for this purpose, but unless handled by experts they are more often productive of harm than good. Regular and methodical nursing of the baby will often, especially in 130 THE MORTALITY OF YOUNG CHILDREN. the cases of natural scantiness of flow and torpor of function, promote the secretion, and in those cases of defective lactation due to insufficient, irregular, or over-nursing it will frequently completely restore the gland to its normal condition. Electricity has not been so extensively employed ; but in the hands of those who have given it a fair trial the results have been encouraging. It is a valuable adjuvant to suction. It stimulates the nerve distribution and circulation, and pro- motes the nutrition of the gland. The local treatment of the gland by the application of plas- ters, ointments, oils, embrocations, and poultices, for the cure of any form of defective lactation, is, so far as is known to the writer, useless. The hygienic treatment refers to personal and domiciliary cleanliness ; healthy exercise in the open air ; proper sleeping apartments ; sufficient and refreshing sleep ; fresh and pure air ; protection from the debilitating influence of a continuous high temperature, and from the equally injurious effects of severe cold ; and sufficient and proper clothing. The change of residence from town to country, or to sea-shore, sometimes promotes an abundant flow of good milk. In short, the hygienic rules and regulations which are so conducive to the health of nurslings are equally important for the mother. The dietetic treatment is the most important of the several methods, and yields most satisfactory results. This is so gen- erally recognized, both by laymen and physicians, that it is almost exclusively employed. There is, however, no universal diet suitable to every mother, no continuous regimen of speci- fied foods which can be relied upon in every case with a uni- formity and constancy of results. The general law governing the dietetic management is to supply such foods as are simple, nutritious, easily digested, and easily assimilable, and to avoid such as may be injurious to the nursling. It is worse than useless to attempt to sustain life, and at the same time nurse a baby, upon crude articles, knickknacks, candies, preserves, pickles, and bonbons, together with teas, ptisans, and pota- tions. The watery constituent may be increased, but the nu- THE MORTALITY OF YOUNG CHILDREN. 131 tritive quality of the milk will be deteriorated. A judicious combination of animal and vegetable foods is always desirable. Strong salt foods and indigestible and acescent fruits and vegetables should be avoided. Potatoes and other vegetables, in which oxygen and hydrogen exist in the proportion to form water, such as the starchy, saccharine, gummy, and ligneous varieties, should be used in moderation. Neither should the diet be exclusive^ albuminous. Fats in moderation are bene- ficial. Oatmeal and barley are generally admissible. Fish, tender birds, crabs, and oysters are considered specially effi- cacious. Routh commends whiting soup and conger-eel soup as milk-producing foods. Among the vegetable aliments many varieties have from time to time been extolled as valu- able agents to improve the flow and richness of the milk, but most of them have been relegated to the usual disuse of over- estimated specifics. Among this class, Routh regards the len- til, pea and bean soup, and among the edible fungi, the deer balls, as the most efficacious promoters of the secretion of milk. The influence of turnips is familiar to every one accus- tomed to use milk ; but no one prefers the milk of cows fed on turnips, nor do puny babies thrive on the milk of mothers fed on any of the brassica species of vegetables. The proper dietary management of puerperal women, espe- cially during the earlier days of the month, will influence favorably the lacteal secretion. The practice in times past, and one too common now, of limiting the diet of a recently confined woman, during the first week, to tea and toast, or some other equally innutritious aliment, has given way to a more generous system of feeding women who have to live themselves and feed others. The process of making milk in the laboratory of one's own person must consume a large amount of force, which can only be replenished by food. There is great diversity of opinion in regard to the value of drinks. Perhaps the rule which governs most persons is the special fondness for a particular beverage. Good, pure, wholesome drinking water, in requisite quantities, is certainly unexceptionable and harmless ; and perhaps equally as effi- 132 THE MORTALITY OF YOUNG CHILDREN. cacious as the more valued and palatable compounds and mix- tures of alcohol. Stimulating and appetizing drinks are some- times very efficient promoters of digestion ; but no healthy nursling needs alcohol, and, when sick and needing it, it had better be fed from the spoon than nursed from an intoxicated mother. To even enumerate the medicines, disgusting compounds, and nauseous mixtures which have been suggested, employed, and extolled as galactopoetics 1 by their inventors and dis- coverers would be a waste of time and space. No one but themselves has ever witnessed the benefits which their enthu- siasm has so lavishly bestowed. The simple rule of guidance in the medical management of cases of defective lactation is to address the remedies to the improvement of the health of the mother. If her digestion is impaired, blood impoverished, or bowels sluggish, meet the indications with the appropriate remedies. Heal old sores ; cure chronic discharges ; arrest hemorrhage. Restore her, if possible, to the condition of a vigorous and healthful woman in the prime of life. So far as this is accomplished, so far will all be done that can be to re- store the sufficiency and richness of the milk. The removal of the cause of insufficient and unfit mother's milk and the restoration of the function of the organ con- stitute the most conservative and certain method of supple- menting the natural aliment of the infant. In this aspect of the question the sanitarium can accomplish a vast amount of good. The improved hygiene and regimen, together with the salutary influences of change of residence, and freedom from the cares and sorrows of want and destitution, with such medical advice and medicines as a careful and skilled expert may deem needful, will prove successful in very many cases. Supplemental alimentation must necessarily be considered in two other and very different aspects ; one relates to the supply of additional food which most children need after the appearance of the eight front teeth ; the other to those cases 1 Substances to which has been attributed the property of favoring the secretion of milk and augmenting its quantity. THE MORTALITY OF YOUNG CHILDREN. 133 in which the mother, from some one or more of the unremova- ble causes previously enumerated, has failed to furnish ade- quate sustenance, either from birth or during the earlier months of lactation. It is demonstrated that not only does the composition of the milk change materially as the period of lactation advances (see Table XV.), but the infantile or- ganism usually demands, after that age, more nutriment than most women can supply. How best supply the deficiency is an important question. Common sense would reply, with the milk of another woman ; but common experience teaches that this method is not only inexpedient and impracticable, but is pregnant with untold evils to the defenseless nursling. The mercenary wretch who sells her breast and thus robs her own child of its birth-right, leaving it to suffer, or perhaps starve, and often abandoning or destroying it, is not fit either morally or physically to properly nourish any other child. The model wet-nurse should be a woman of suitable age who has lost her own child at about the same age as the foster child. She should have a breast of good and abundant milk ; be free from actual or hereditary predisposition to disease, possess a kindly disposition and even temperament ; have no vicious, gluttonous, lazy, or uncleanly habits ; and finally, be animated by a love of children rather than the money value of her services. When such an one can be had, she will measurably fill the mother's place. In the sanitarium, to which will be admitted a number of mothers with nursing babies, it may happen that some will possess a superabundant flow of good milk, which can, with great propriety (barring always the objections just stated), be used in aid of those in- sufficiently nourished, but the institution cannot engage in the immoral and criminal business of making wet-nurses, or hold out inducements for them to make themselves. Wet- nursing will then, practically, be limited to the mothers pos- sessing a superabundance of milk, who may temporarily re- side in the institution, and who will furnish a wholly inade- quate supply. The deficiency must be mainly supplied by artificial lactation. 134 THE MORTALITY OF YOUNG CHILDREN. <«s > £ X JS» w »c> ^ ss PQ si H «o S e £ £ ^ Nineteenth to i— i CO lO tq IQ a CO co CO twenty-fourth d ed co i— i CO month. OO o co CI I-H CO o >* CO CM _H oo Ol Thirteenth to eight- eenth month. ■q CO CO OS ^ OS CO oi o CO CO o 1.0 CN CO 09 1-1 00 -* co ,_ ^ CO CO co © OS OS co p co Twelfth month. © i— r OS CO CO d s ss 5l rt co . CM t_ CO g^ CD cr co CO o Eleventh month. _5 o CB |*2 d ,_5 PH CO c OS i— i CO p_ OS rH -# CO N -* CO L~ CO CM L~ CO © U0 CM Tenth month. r-i os O ta IQ CO ,_) CO CO •*t< CM CO O^ CO l-H «-*" CO s lO _ CO — OS CO CO CO p Ninth month. a os CO CO 1-4 «o CO CM 00 co " t~ OS _j CM OS CM 00 CO o iq p Eighth month. rH OS d _' ci i.-O rH CO DO CO |H •<* CM i* fc- «o IQ ,_, id to CO OS M S3 CO CO CO N Seventh month. o r-T T— en CO' CO c iH 5 CM fo' rH ia H CT3 § t_ CO OS co iq *# i-O to CM Sixth month. »o _ 9S CM 83 CO rH CO cc oa -* CO o OS r* o ta SO CO a s Fifth month. oi CO P-i •>* t-^ CO !-H co 00 >* CM CO o CO rH r* o ,^ CO !_ OS eo r-J OS Ci CO *# L~ cr: IH Fourth month. cm OS d — r~ CO oo 'CO rH 4< CM CO o CO rH r-T o sp ,a t _ CM CM CO CO co CM os CO Third month. CM to oo CO r-J 1-1 r-i CO co X* CO CO o CO •H ,_, OS |H CO o to t. OJ © l-H p CM_ «q Second month. CO oo L— CO CM rH CO CO CO OS ■>* CO Q »o CO CO p CO IQ CO CO First month. DO cm CO CM d S id r-i X j5» "fl 'p- if] .2 u «3 u ft a - g □Q 1 ;2 o CO CO pq '3 s 03 I THE MORTALITY OF YOUNG CHILDREN. 135 ARTIFICIAL LACTATION. Artificial lactation means the substitution of animal milk for that of the mother, and is applicable to three very dif- ferent classes of young children : — (1.) The motherless, the abandoned, and those whose moth- ers are wholly incapacitated for nursing. (2.) Those who are insufficiently nourished by their mothers from birth or during the earlier months of life. (3.) Those who are insufficiently fed because of their ad- vanced age and rapid growth. As milk is the only natural, it should be the exclusive, diet of infants until after the appearance of the eight incisor teeth. The milk of an animal is the only suitable substitute for, or addition to, breast-milk which is generally applicable to the artificial lactation of classes one and two. There may occa- sionally occur an exception to this general law, due to some digestive idios}mcrasy of the infant ; but most frequently the exception is only apparent and properly attributable to some impropriety in the management of the baby, or some mistake in the preparation or preservation of the milk. After the cutting of the front teeth the three classes become practically one, designated as the third in the above classification, for which milk should be the chief, but need not be the exclusive, aliment. Cow's and goat's milk have been almost exclusively em- ployed as substitutes for that of the woman. Cow's milk is preferable, because it is more abundant, more easily obtained, and is free from any disagreeable odor. The proportion of water and solid ingredients in the milk of the goat (see Table XVI.) differs less from that of woman than does that of any other animal. The milk of all, excepting the ass, contains a larger quantity of solid constituents, the cow's containing more casein, butter, and salts, but less sugar, than that of woman. To adapt the milk of the cow to the purposes of artificial lactation, the proportions of the solids and water must be approximated to the percentages found in human milk. 136 THE MORTALITY OF YOUNG CHILDREN. TABLE XVI. — Moleschofs Analyses of Milk. Woman's. Cow's. Goat's. Sheep's. Ass's. Mare*s. Water 889.08 857.05 863.58 839.89 910.24 828.37 Solid ingredients . . 110.92 142.95 136.42 160.11 89.76 171.63 Casein 39.24 48.28 33.60 53.42 20.18 16.41 Albumen - 5.76 12.99 53.42 20.18 16.41 Butter 26.66 43.05 43.57 58.90 12.56 68.72 Sugar 43.64 40.37 40.04 40.98 57.02 86.50 Salts 1.38 5.48 6.22 6.81 57.02 0.29 This is done by adding water and sugar, and should be, as a rule, according to the age of the nursling, and the corre- sponding changes which take place in woman's milk from month to month, as shown by the analysis (see Table XV.) of Vernois and Becquerel. This law cannot, however, be followed in every case, for infants differ very much in diges- tive and assimilating capacities. Most frequently too little water and too much sugar are added. It often happens that the quantities of sugar and water added must be varied from day to day until the proper proportions are ascertained by the evidences of relief and subsidence of digestive disturbance. Human milk is alkaline ; cow's milk is acid, but least so when the animal is pasture fed. Zahan, Stohmann, and Kerl believe the acidity is due to some change occurring in the udder of the cow. Be that as it may^ the practical fact is that it is generally, if not always, acid, and that the acidity increases continuously from the time of milking. Conse- quently the addition of antacids is a necessary part of its proper preparation as a suitable aliment for children; and this is the more necessary because of the constant tendency of milk sugar to transformation into lactic acid, and the danger of ex- cessive formation of acids in the stomach. The casein of cow's milk coagulates in firm and dense masses, that of woman's in loose and flocculent ones ; hence THE MORTALITY OF YOUNG CHILDREN. 137 the latter is more easily digested. The more stale and acid the milk, the quicker and firmer the coagulation. Skimmed milk when taken into the stomach coagulates sooner than the same before the separation of the cream, because of loss of fat and other consequent changes. Various suggestions have been made for obviating these objections, but none have fulfilled the object. Perhaps, as remarks Jacobi, there is no way of making the casein of cow's milk any more digestible than it is as found in the natural condition. Cow's milk contains more butter than woman's, hence the greater tendency to the formation of the fat-acids, which are so frequently the cause of digestive disturbances in bottle-fed infants. Many unsuccessful experiments have been made to equalize the percentages of casein and butter found in the milk of the cow with those existing 'in human milk. The ad- dition of cream has proven detrimental. Fats are not di- gested in the stomach, but in the intestines, where they meet the bile, intestinal and pancreatic secretions. The formation of fat acids in the stomach and their admixture with the pan- creatic fluid neutralizes its property of emulsifying and prepar- ing the fats for absorption, producing intestinal indigestion. Intestinal digestion, at best, is feeble in infants, especially so in very young nurslings. Wegscheider has shown that the fat of the mother's milk is never completely absorbed, a part passing through the intestinal tract as fat, a part being sapon- ified, and a third part escaping in the form of fat acids. The writer believes that he has quite frequently successfully treated intestinal indigestion, both in infants and adults, by the addition of Dobell's pancreatic emulsion x to the milk. When the excessive formation of fat acids cannot be success- fully arrested by alterations of the proportions of water and sugar, and the addition of alkalies, it may become necessary to withhold the milk, and substitute rice or barley water, for several days. It will frequently be judicious to add to the milk a fluid prepared from barley or oatmeal ; the former 1 A saline essence of pancreatine has been recently introduced by Savory and Moore of London, which promises favorable results. 138 THE MORTALITY OF YOUNG CHILDREN. when diarrhoea is present, the latter when constipation exists ; bnt when the addition of either is made the quantity of milk should be diminished. Butter, which is present in so much larger proportion in cow's than in human milk, seems, both from experimental in- vestigation and clinical observation, to be the constituent most productive of digestive disturbances. Notwithstanding the diligent efforts that have been made, this difficulty has not been overcome. The addition of a sufficient amount of water, better too much than not enough, is so far the only practica- ble method suggested. As a rule milk is the only fluid a young baby ever gets, and generally, especially in hot weather, this furnishes an insufficient supply of water for the purposes of the animal economy. Water is as necessary as food ; in fact digestion cannot be carried on, nor can health be main- tained, or life sustained, without it. But it is not necessary to convert a child's alimentary tract into a common funnel, through which all the liquids and slops at a housekeeper's command are to be poured. How much milk should be given a child, and how best to feed it, are very important questions. The statistics of Merei and Whitehead show conclusively that over-feeding is detri- mental, and clinical experience proves as conclusively that over-feeding diminishes the expectancy of life. The quantity must of course bear some relation to the vigoivof development, and, therefore, a general rule can only be approximately ac- curate. The prevailing error, especially among the better-to- do classes, is to over-feed. Authors do not agree in regard to the quantity required by a healthy baby. Dr. W. H. dimming 1 has estimated the amount ordinarily furnished by a healthy woman to be from one and a half to two quarts daily. He thinks that an infant three months old will consume from forty-eight to sixty-four ounces daily, in six or eight half pint doses. Routh 2 thinks this estimate too high. He asserts that a child three months 1 Routh, Infant Feeding, page 101. 2 Amer. Journ. Med. Sci., vol. xxxvi., page 25. 1858. THE MORTALITY OF YOUNG CHILDREN. 139 old will generally thrive on five meals a day, the quantity taken at each meal not exceeding eight ounces. A younger child would nurse oftener, but the quantity would not exceed three ounces at each meal, so that from birth to the comple- tion of the third month the amount would vary from thirty- two to forty ounces daily. After that age the child may take forty-eight ounces daily. MM. Guilliot and Lamperiere (Routh) have shown that infants can absorb in twenty-four hours from forty-eight to sixty-four ounces ; and Hervieux insists that the} 7 thrive best when they take all they can ap- propriate, which he believes is a larger quantity than gener- ally supposed. Boussingalt's experiments on animals lead to the conclusion that infants require proportionately more food than older children or adults. The proportion of strong and healthy mothers who will yield an abundant supply of milk may be approximately conject- ured from the calculations of Merei and Whitehead. See Table XVII. TABLE XVII. — Supply of Breast-milk in 952 Women. *L% _>. £>£ u CD a 3 a abundant mi months and u rds, some t\ irs. a Fh a> ft a .2 a a P o< a 4) .T2 a a n <2 a . eS e3 p pM CD III 3 n * d £ o "S* "Sol < PL, M a Strong and healthy . 629 420 66.7 114 95 Delicate and sick . . 323 88 27.2 69 166 ' Total .... 952 508 " 183 261 Thus it appears that 66 per cent, of mothers are strong and healthy ; of these 66.7 per cent, furnish milk in abun- dance, and 46.G per cent, of all mothers supply inadequate sustenance. 140 THE MORTALITY OF YOUNG CHILDREN. Artificial lactation may be performed with the spoon, mug, or nursing bottle ; the last is the preferable method. The bottle should be one with a smooth and even internal surface, without shoulder, angles, corners, or inverted bottom, to which should be adjusted, by means of the stopper, a flexible tube, with a soft mouth-piece, and attached at the distal end to a glass tube within the bottle. 1 When the child has been fed, any remaining portion of the prepared milk should be thrown away, the different parts of the nursing apparatus separated, thoroughly cleansed, and laid aside in an alkaline solution. Many artificially nursed babies are annually sacrificed through omission of these apparently trivial matters. Coagula of milk attached to any part rapidly undergo such changes as will spoil the milk at subsequent feedings. When the child ceases to suck at the mouth-piece the bottle should be re- moved, and the child should not be urged to continue taking food when it has enough ; nor should it be allowed to hold the bottle any longer than is necessary, or dally and play with it, sucking and quitting, or sleeping and waking, with the mouth-piece held between its lips. The warmth of the body and hand, and the lapse of time, favor and hasten the deterio- rating changes which are so liable to occur in the milk. Dewees 2 insists that "the child should not receive its nourishment while lying ; it should be raised, which will not only become a pleasanter position, but it also diminishes the risk of strangulation." Routh 3 asserts that the semi-erect position, which is that occupied when nursing at the breast, is not only the most convenient, but, for anatomical reasons, the best. After having been fed the child should be allowed to rest, sleep, if it will, and not be jostled up and down as if one desired to convert its stomach into a churn. The practice is injurious and productive of much mischief. No less repre- hensible is the familiar habit of rudely and quickly tossing, or 1 The bottle sold by Rey riders & Co., and described by Jacobi, in his essay on Infant Hygiene, is perhaps the best. 2 Dewees on Children, paragraph 575. 3 Infant Feeding, page 97. THE MORTALITY OF YOUNG CHILDREN. 141 swinging by its shoulders, a child high in the air. It is grati- fying, however, to know that the stomach sometimes retaliates by pouring out its contents upon the chief performer in such acrobatic sports. Dewees says milk should never be boiled, and Jacobi is op- posed to its being given raw. The former asserts that the for- mation of the pellicle by boiling deprives it of a part " of one of its most valuable constituents." Parmentier and Deyeux concluded from their experiments that the loss of the volatile principle by boiling was disadvantageous ; others hold the opposite opinion. No one doubts that boiling will diminish the tendency to decomposition and. acidity, and will some- times restore alkalinity. Gas is also disengaged, and. the tend- ency to the formation of lactic acid is thereby diminished. Boiling also diminishes the absorbing power of milk, and de- stroys mold and germs. The absorption power of milk is very remarkable. If raw milk is placed in closed apartments with highly flavored fruits and vegetables, as for instance the orange or cantaloupe, it will rapidly absorb the flavor. How far this property of absorption may prove detrimental has not been determined. These considerations lead manifestly to the conclusion that heating the milk, especially in warm weather, is essential to its preservation. The writer has not adopted either of the extreme opinions, but has preferred a medium course. As soon as the milk is received (and there should always be at least a morning and evening supply of fresh milk), it should be prepared by the addition of hot water, in quantity sufficient together with the alkali for the proper di- lution. It should then be placed, in a covered vessel, in a refrigerator, and as needed the required quantit}^ is warmed and sweetened with white (not brown) sugar. This process of scalding the milk has appeared to secure all the benefits of heat, and when the other necessary attentions — perfect cleanliness and purification of every utensil employed, and of the place of keeping — were carefully carried out, has usu- ally proved satisfactory as a method of preservation. Many healthy children from eight to twelve months old, and older, 142 THE MORTALITY OF YOUNG CHILDREN. will take milk without any dilution, and thrive. In such cases it is best to add a very small quantity of boiling water, or to simply boil it. CONDENSED MILK. Condensed milk has been very extensively employed as a substitute for breast-milk, and there exists a great contrariety of opinion in regard to its value. Daly and Jacobi, perhaps, represent the two extremes of opinion : the former believes that all children fed upon it are weakly, and possess a feeble power of resistance to disease ; the latter holds, that when mixed in proper proportions with barley water or oatmeal gruel, according as diarrhoea or constipation may be present, it is quite as good " as ordinary city milk " prepared in a similar manner. The writer's experience differs somewhat from that of either of these gentlemen, and this difference re- lates to the peculiarities of infants. When prepared as rec- ommended by Jacobi and largely dilated, it has, in very many cases, proved sufficient, but in a larger number of cases it has proved unsuitable. It has seemed, at times, to cause thrush and diarrhoea ; and it is undoubtedly true that some infants fed exclusively upon it manifest a feeble resistance to mor- bific agencies, but this is very far from being the general rule. OTHER SUBSTITUTES. As a matter of fact there is no such substance as a substi- tute for milk. It is true that many children have been reared without ever having tasted breast-milk. The statistics of Merei and Whitehead, before cited, show that of those fed exclusively on breast-milk to the ninth month or longer, 14 per cent, were badly developed ; and in 23.3 per cent, the development was only medium ; while of those " fed entirely by hand and with no breast-milk at all," only 10 per cent, were well developed. The conclusion is thus quite apparent that feeding exclusively on breast-milk does not always pro- duce the best results, but it is even more apparent that the exclusion of breast-milk from birth yields the worst results. THE MORTALITY OF YOUNG CHILDREN. 143 The substitution of animal for human milk is the alternative best adapted to the artificial feeding of classes one and two (see page 135), but it is alleged there are occasional instances when infants cannot be nourished with milk. Such cases are so rare that the writer cannot recall a single instance occurring in his own practice. The cases in which milk should be with- held for a time, especially during the hot summer months, are numerous among those infants who have not passed the pe- riod of the appearance of the incisor teeth. How best to nour- ish such infants is a problem that has not yet been solved. Arrow-root, tapioca, sago, and many other farinaceous sub- stances have been very generally abandoned. The " sugar- teat," corn-starch, and " cracker- victuals " ought to be univer- sally condemned. The various manufactured and patented " Infant Foods " are mere articles of traffic, as unsuitable as they are unreliable. Occasionally an infant in vigorous health is exhibited as an illustration of the remarkable nutritive virtues of some one of these unknown compounds; but it is more probably the exhibition of a development attained in spite of them. When the cause is an evanescent one, it should not be forgotten that total abstinence from food, and some- times from drink, — stomachal rest for a period, — will prove sufficient to restore the function of digestion ; and when to this can be added rectal alimentation, the period of stomachal rest may be prolonged. In such cases the decoction of barley and oatmeal gruel, of the farinaceous substances, have been gen- erally preferred, because of their large percentage in protein compounds, and (Jacobi) richness in salts. But, notwith- standing the protest of Jacobi against the use of rice water, the experience of the writer coincides with that of Trousseau in regard to its value. He has too often witnessed its bene- ficial effects in cases of diarrhoea with uncontrollable vomiting in young infants, to abandon its employment on mere theoret- ical grounds. The eau albmnineuse 1 of Trousseau ; the gel- 1 Prepared by diluting the whites of four eggs with a quart of water ; sweetened to taste by adding sugar, and aromatized with orange-flower water. 144 THE MORTALITY OF YOUNG CHILDREN. atine food of Meigs ; 1 and Liebig's Infant Food will serve a good purpose as temporary expedients in many cases. But, as previously stated, a diligent and persistent effort to adapt good fresh milk in some form, either by varying the dilution or the preparation of some compound of which it is the basis, will in a vast majority of such cases be crowned with success. Animal food is rarely, if ever, admissible to the dietary of infants under six or eight months. Healthy children are very frequently supplied with animal food before the cutting of the teeth begins, in fact during the earlier months, without detri- ment, but it is always a hazardous experiment. In cases of sickness, especially in that class of diseases usually compre- hended under the designation of " summer complaint," ani- mal food is more often a cause than a preventive of death. When necessary or admissible, broths, teas, essences or ex- tracts prepared from beef are to be preferred. The supplemental and artificial alimentation of young in- fants constitute one of the most important problems which must engage the attention of the sanitarium. No such oppor- tunity has ever before been presented for the study of this sub- ject. To execute the trust confided to the management, the whole subject of infant diet must be reopened and reexamined in the interest of preventive medicine. Speculations and sug- gestions are simply the result of individual observation and experience, which are only valuable in so far as they may present a reasonable hypothesis upon which more extended and scientific experiment and investigation can be conducted. The field is not less inviting than it is rich in results which will contribute to the diminution of the mortality and allevia- tion of the suffering of young children. DENTITION. The preceding sections on supplemental alimentation and artificial lactation have been devoted mainly to the discussion of alimentation of infants classed in the first and second sub- divisions (see page 135), and for the period of life termi- 1 Diseases of Children, Meigs and Pepper, page 304, ed. 1870. THE MORTALITY OF YOUNG CHILDREN. 145 nating with the beginning of dentition. The second period is characterized by the eruption of the twenty deciduous teeth, and extends to the twenty-fourth or thirtieth month of age. During this period all children, sooner or later, should be weaned, and will require additional and different food. Previous, therefore, to the consideration of the influ- ence upon mortality of weaning and feeding, it is proper to consider the relation of dental evolution to the progress of growth and development in infantile life. These teeth ap- pear in successive groups. The period of appearance of these groups has been variously stated. The writer's observations coincide with the results obtained by Drs. Merei 1 and White- head, which Routh also accepts. There are, however, very many exceptions to this general law both in the time and order of the appearance of the members of the separate groups. The beginning and progress of the eruption of the teeth is very generally accepted as the index of progressive, and delayed dentition as the evidence of retarded, develop- ment. Merei and Whitehead state that in 79 per cent, of the well developed, the first teeth appeared before the eighth month had passed ; while in 60 per cent, of those with unfa- vorable development " the first were cut at eight months and upwards." As it is the almost universally accepted belief that the appearance of the first tooth is the proof that veg- etable foods can be allowed, it appears from these data that in a large majority of infants the eighth month is the earliest period at which such food would be a suitable addition to the diet. At that time the progressive development of the organs of digestion has sufficiently advanced. The salivary and pan- creatic secretions, and the gastric and intestinal fluids, are capable of digesting some vegetable aliments. The inference is equally apparent also that even trivial indiscretions in diet may at this period induce grave disturbances of the alimentary tract ; for it does not follow that because nature by such posi- 1 Anterior incisors, seventh month ; lateral incisors, ninth month ; ante- rior molars, twelfth month; canine, eighteenth month; posterior molars, two years. 10 146 THE MORTALITY OF YOUNG CHILDREN. tive evidence has indicated that the child is maturing, that therefore it can be fed indiscriminately with vegetable foods. As the several groups of teeth appear at distinct and succes- sive periods, and at intervals varying from two to six (stated approximately) months, what relation, if any, do these alter- nating periods of time in the child's life bear to the digestive disturbances which are so common during the age of dental eruption ? The process of dental evolution is a physiological one beginning during intra-uterine life, and should be pro- gressive until completed. Yet it is the common belief that with the appearance of the first tooth begins the era of disas- ter, and that the acme of danger is coincident with the erup- tion of the several groups. This does not seem to be a rational conclusion. The sacs of both the milk and perma- nent teeth are formed during intra-uterine life, the ossification of the former dating back as early as the fifth month of that period. By continuously increasing growth upwards, the crowns of the front incisors appear above the alveolar borders of the jaw at or about the seventh month, and are followed at somewhat regular periods by the others in successive order. The evolution is a continuous process from the beginning of the formation of the dental sac and papilla, and progresses pari passu with the development of the entire digestive appa- ratus. Why should the periods which mark the completion of each part of a continually progressive physiological process be periods of greater danger than the intervals of equal activ- ity in the development of these incompleted parts ? The fact is that all children are teething from the moment of birth un- til they have cut their last posterior molar ; and it is not true that the periods of eruption are any more conducive to bowel disturbances than the intervals. The statistics of mortality show conclusively that alimentary disorders are far more fre- quent and more fatal during the months preceding the eruption of the teeth than during any period of an equal number of sub- sequent months. Dental evolution and eruption are not any more frequently the cause of disease than the simultaneous and consecutive evolution of the other and more important parts THE MORTALITY OF YOUNG CHILDREN. 147 of the digestive apparatus. It so happens that the appear- ance of a tooth is an object of distinct observation fixing a period of time, whereas the changes that are taking place in the glands and alimentary tract progress in an uneventful succession. Again, if this- natural process is so destructive of infantile life, it should be equally so in winter as in summer ; in the farming regions as in populous cities ; among the well- to-do as among the destitute ; in an equable as in a vari- able climate, during the periods of dental eruption which occur during the other months as during those which occur in July ; and in Philadelphia as in the neighboring cities of New York and Brooklyn. Why should it be so destructive at a given locality during one season and so much less so the suc- ceeding summer? Why more disastrous to children, at a given age, weaned, than to those nursed, at the same age ; to the wet-nursed than to those nursed by their mothers ; to those partially or wholly fed artificially than to those fed ex- clusively on breast-milk ; to the abandoned and motherless, who are carefully and tenderly nursed in well arranged and appropriately constructed asylums, than to those rudely man- aged at home, but supplied with abundant and good breast- milk ? All these circumstances, which are but the restate- ment of facts previously narrated, go to show the fallacy of the prevalent opinion that the eruptive periods are times of unusual danger. Nevertheless, authors of very high repute continue to reassert the doctrine. Meigs and Pepper assert that they " have rarely observed cholera infantum before the beginning of the process of dentition, and very rarely after its completion." J. Lewis Smith says, " it usually occurs under the age of two years." In 282 cases in which the observations were made, 47 had no teeth, and 28 had all the teeth. The statistics of Dr. Emerson show that it is more fatal in the first year than in the second, thus contrasting the causal influence of the very rapid growth of the first year with the more active eruption of the teeth during the second. In 138 children at the Necker Hospital, during the first dentition, Bouchut says, 26 were free from all indisposition, 38 had transient diar- 148 THE MORTALITY OF YOUNG CHILDREN. rhcea, and 46 had abundant diarrhoea ; in 19 it appeared at the time of swelling of the gums and ceased with it, to re- appear with the subsequent eruption of teeth. Yogel, who confounds entero-colitis with cholera infantum, under the designation of intestinal catarrh, says, " in children over one year of age the process of dentition is the most frequent cause," and " that the ordinary looseness of the bowels, which usually accompanies dental evolution, may become cholera- like, and prove fatal in twenty-four hours." West deduces the general conclusion " that the greatest prevalence of diar- rhoea and dysentery coincides exactly with that time during which the process of dentition is going on most actively," and asserts that half of his cases occurred between the ages of six months and two years. Bouchut says, " the influence of den- tal evolution upon the diseases of the alimentary canal is com- pletely established." So constant and active an influence does Trousseau consider dentition that he insists that weaning should not be completed prior to the eruption of the fourth group, and that it should never be terminated suddenly. Eus- tace Smith says the bowels are, during dentition, " ripe for diar- rhoea," because of the augmented irritability growing out of the increased development of the follicular apparatus ; *' but, without the presence of the ordinary exciting causes, diarrhoea is by no means a necessary result of such a condition of the ali- mentary canal." No one will deny the occurrence of fever, and, occasionally, of convulsions, in cases of difficult dentition, and that the congested condition of the gums and inflamma- tory state of the buccal mucous membrane may extend to the intestinal mucous membrane and set up increased peri- staltic action for all parts of the alimentary canal, and of its dependencies, which are undergoing active evolution to fit them for the proper assimilation of the varied food on which the voun^ beinor will soon have to subsist. All these consider- ations point to the conclusion that it is the relation subsisting between alimentation and the physiological evolution of the digestive organs and their dependencies which is so easily dis- turbed during the period of life when nature is preparing the organism for an independent and self-sustaining existence. THE MORTALITY OF YOUNG CHILDREN. 149 WEANING AND FEEDING. It matters not whether the conclusion reached in the pre- ceding section, or its converse, that dentition is the constantly- prevailing factor, be the correct one, the accommodation of the diet to the changing condition of the organism must be equally important. The cutting of the teeth marks the stage of development at which the supply of additional aliment is usually required, and during which the gradual preparation of the digestive apparatus for the duties of self-support should be completed. The deprivation of breast-milk and the addi- tional feeding should both be gradually accomplished. Wean- ing, unless rendered imperatively necessary by some condition either of the mother or child, should not be completed before the eruption of the fourth group of teeth, from the twelfth to the sixteenth month of age. It is best, as a rule, that it should not be done during the heated months of the year. Many intercurring circumstances and conditions, some of which have been previously referred to, may determine an early or a late weaning. When practicable, and it is practica- ble with the greater number of infants, the digestive function should be accustomed to some form of farinaceous food be- fore the beginning of weaning. Milk made into a pap with wheaten bread, or thickened with wheaten flour, barley, or oatmeal gruel, will usually prove sufficient in the beginning, to be followed, when the anterior molars have appeared, by oatmeal porridge, or cornmeal mush, and milk, with the occa- sional allowance of good wheaten bread, the juice of fresh beef, meat gravies mixed with bread, or well cooked, ripe and mealy potatoes, and finally by a larger allowance of solid food, a moderate supply of tender meat, not over-done, scraped or finely minced ; but milk, or some composition of which it is the basis, must constitute the main reliance until the first dentition has been completed. The feeding of weaned children is second only in impor- tance to the alimentation of nurslings. The mere enumeration of suitable substances which may be allowed in successive 150 THE MORTALITY OF YOUNG CHILDREN. order is often objectionable and will accomplish but very little good. Parents should, so far as may be possible, be made to understand the principles of alimentation. It is not probable that very many, especially among the ignorant classes, can be taught the minute anatomy of the various parts of the diges- tive apparatus and the correlation of the functions of the sev- eral parts; but most people are sufficiently intelligent to learn more than they now know. Example, observation, and prac- tice are wise and efficient instructors. Very many persons who know nothing of the principles of mechanics can be taught to work and handle certain machines with consummate skill. The chief obstacle to the proper instruction of parents in the principles governing the alimentation of children consists in the fact that these principles have not as yet been definitely ascertained and formulated. The whole subject is obscured by hypotheses, individual speculation, and unsatisfactory labo- ratory experiments. Very many interesting and important facts seem to be definitely established, but they are of little value to the general public because they have not been reduced to the practical methods of every-day uses. The first and most important lesson in the art of feeding children is to teach parents that they can learn all that it is absolutely necessary to know ; and the second is to disabuse their minds of the errors which ignorance, superstition, and bad example have inculcated. Every mother knows that milk is the natural aliment of babies, and that hand-feeding is always attended with more or less danger. They know equally well that the milk of an animal is the best substitute for breast-milk ; but they are generally ignorant of the most simple methods for the preservation and preparation of it. Over-feeding and feeding with unsuitable substances are the most frequent and gravest errors committed by parents. Merei and Whitehead have shown that over-feeding from birth reduces the percentage of well developed from 62 to 51 per cent., and increases the percentage of the badly devel- oped from 14 to 24 per cent. It is equally disastrous if com- menced at a later period, and is far more frequent after the THE MORTALITY OF YOUNG CHILDREN. 151 eruption of the incisor teeth. The over-fed are those most frequently fed on improper food. The commission of the first error leads to the second and more serious mistake. There is no such thing as an indifferent or negative aliment for young children. That which they do not need is detrimental. They need suitable and sufficient food, but do not seek savory dishes and unfit substances until their natural tastes and instincts have been perverted by the constantly repeated temptations of indiscreet parents. It is a prevailing error to allow young children to come to, or rather to force them to, the family table, and tempt them with bits of first one thing and then another, until they fret and cry for everything within reach or sight ; and when sickness follows, the parents are as re- luctant to acknowledge the cause of the bowel trouble as most adults are to confess that anything they eat ever makes them sick. The circumstances which should govern weaning relate first to the mother, second to the child, and third to the season of the year. In addition to the various conditions of defective lactation previously discussed, the mother is sometimes rendered ineli- gible from acute diseases either of a general or local charac- ter. Febrile and exhausting diseases, and acute inflammatory and chronic local affections of the mammaB and generative organs, unfit women for the duties of nursing, either tempo- rarity or permanently. Instances are also reported of women whose milk contained blood, pus, and other extraneous and poisonous matters. Whenever anything injurious to the mother is increased by suckling, or her milk becomes unfit, weaning is justifiable. On the part of the child, the state of the teeth and the state of its health must determine the period of weaning. The first has been considered in a previous section. It is never judicious to take the breast from a child while it is sick, or during convalescence, unless it is manifest that the milk of the mother is injurious. Even an inadequate supply will often be all-important for the nourishment of a child exhausted by sickness. 152 THE MORTALITY OF YOUNG CHILDREN. The season of the year should be that in which the tem- perature is most equable, and which is most free from the bowel disturbances so prevalent in the summer months. The spring and autumn are the preferable seasons. In view of the relation subsisting between the evolution of the teeth and the digestive apparatus, the following conclu- sions may be stated : — (1.) There is no fixed age at which all infants ought to be weaned ; and only in exceptional cases should it be permit- ted previous to the appearance of the eye and stomach teeth. (2.) There is no routine diet suitable to all weaned infants, but the food must be adapted to the progress of development and the condition of the infant. (3.) The most effective preventive of the ill effects of im- proper and unsuitable alimentation of weaned infants will be the education of parents in the art and science of nursing and feeding. ' (4.) The age of exclusion from the domiciliary department of the sanitarium cannot be under the thirtieth month. THE MILK SUPPLY. The supply of milk must be obtained either by purchase, production, or a combination of both methods. The last will be the most desirable and expedient. That portion obtained by purchase must come from dairies at convenient distances from the institution, to avoid the in- juries of transportation, lapse of time before delivery, and ex- posure to the air. The dairy or dairies, (and it is best that the herds of animals should not be too large), should be con- ducted according to the most approved methods of feeding, pasturage, stabling, care, and milking of the animals. The dairymen and other necessary attendants should be scrupu- lously neat and clean. The vessels employed in milking, straining, and transportation should be inspected daily. Care should be taken to avoid every source of contamination from imperfectly cleansed vessels, careless attendants, filthy stables, unsuitable food, unfit or contaminated drinking water, disease THE MORTALITY OF YOUNG CHILDREN. 153 among the cattle, and other extraneous sources of impregna- tion with the germs of disease peculiar to the human being, which have so frequently, of late years, been conveyed to large numbers of consumers of milk. The milk of every animal should be examined microscopically and chemically by a competent person, at times, if possible, unknown to the pro- prietor, and at the dairy before it is mixed with any other, that the good may not be contaminated by the bad. Each morning and evening supply should be carefully examined after delivery. The adulteration of milk is the common practice of dealers and dairymen. Becquerel and Vernois have discovered the following substances in the milk supplied to Paris : water, glucose, flour, starch, dextrine, infusion of rice, barley, and bran, yolk of egg and white of egg^ sugar, gelatine, liquorice, boiled carrots, broken down calves' brains, serum of blood, bicarbonate of soda, chalk, turmeric, emulsion of hemp or al- mond seeds, and other substances. In England Hassall found eleven out of twenty-six samples adulterated with water in the proportion of from 10 to 50 per cent. Sanderson found in all but one sample examined, excess of water. Hillier found the quantity of water added varied from 25 to 50 per cent. Thompson, Salter, and Hunt ascertained that the quan- tity of water usually added was one gallon to two of milk. The addition of water has proven even more detrimental than the mere dilution. The poison of infectious diseases has, in a number of instances, been added by its pollution with con- taminated water. Recent observation seems to show that epidemics of disease originating through the milk are very virulent. Parmentier and Deyeux maintain that " nothing 2 con- tributes more to maintain the good quality and quantity of cow's milk than scrupulous cleanliness in the sheds. If the refuse matters are left about and removed only at long in- tervals, the cows lying amid all this mess are always weak ; the udders are hot, and the milk, so susceptible of acquiring a 1 Routh. 154 THE MORTALITY OF YOUNG CHILDREN. bad odor, soon contracts a bad taste, of which it is with diffi- culty again deprived." Dr. Normandy found a herd of " thirty or forty cows in a most disgusting condition, full of ulcers, their teats diseased, and their legs full of tumors and abscesses ; in fact, quite horrible to look at ; and a fellow was milking them despite of all these abominations." Hillier ex- amined a number of cow-sheds, none of which did he find suitably located, properly ventilated, properly drained, or of sufficient capacity. Some were under inhabited dwellings, some with insufficient water supply, and some the common receptacle for every form of filth. In many the animals were too long confined, poorly fed, and otherwise ill used. Country milk differs from town milk ; summer from winter milk ; and morning from evening milk. In the country the animals are less crowded, have more exercise, and are not fed so exclusively on dry food. Winter milk contains less water, and evening milk is richer in cream. Milk is deteriorated by transportation, more so when the distance is long and the conveyance rough. Agitation causes separation into butter and butter-milk. This change is promoted by dilution. Exposure to the air sets up lactic acid fermentation. The sooner the delivery after milking the better the condition of the milk. The difficulties which may embarrass the purchase of milk are not insurmountable, but they will require all the care and vigilance of the officers in charge to detect and avoid. It will be wisest to suspect the cupidity of the dealer rather than rely upon his honesty. There are many other and equally important reasons why the institution should produce at least a portion of the neces- sary supply. Many of the questions which refer to the in- fluence of different food, amount of drinking water, weather, season, care, and attention of the animals, upon the quality and quantity of milk, need further investigation. The rela- tion of the condition, care, and food of the animal to the health and nutrition of the beneficiaries must also be care- fully studied. The alterations of the milk occasioned by the THE MORTALITY OF YOUNG CHILDREN. 155 time and frequency of milking, by stall-feeding and pasturage, and by rest and exercise require examination. Experiments should be made to ascertain the kinds of food that will most closely approximate the milk of the animal to that of the woman. The advantages or disadvantages of a single cow's milk as the exclusive aliment of a child ; of feeding it directly from the animal, either by putting the child to the udder or as soon as convenient after it has been drawn from the animal, are questions as yet unsettled. Should the milk be protected from exposure to the air and carried, with least possible agita- tion, to the place of keeping, and there preserved by such means as may be best ; or should the children, at regular in- tervals, be carried to the place of milking and there be fed with the fresh and raw milk, before it has lost its natural aroma and warmth ? If the milk of an animal is the only proper and suitable substitute for breast-milk, may it not be as important to imitate as near as possible the manner and process of nursing as it is to approximate the constitution of the milk of the animal to that of the woman? Routh says, " the newer the milk is the better it is for the child," and ex- presses the belief that " immense advantage would accrue by allowing all infants to take the milk directly from the nipple of the animal." When practicable, he recommends that the animal " be brought to the door and then and there milked, and the milk in its fresh state at once given to the child." " Children will thrive under this mode of procedure when other means have failed." These investigations and experiments should not be con- fined to the milk of the cow. The milk of the goat more closely resembles that of woman than that of any other animal, and is believed by many to be preferable for the pur- poses of artificial lactation. Routh 1 relates the circumstance that " the foundlings of Dublin were very many years ago sent to the mountains of Wicklow, to feed upon the goats' milk. As the children grew older the goats came to know them, and became very tame ; so that the infant could go to 1 Infant Feeding, page 311. 156 THE MORTALITY OF YOUNG CHILDREN. the goat to be suckled by it, as it would to a human wet- nurse." The children throve remarkably well. A similar result is said to have been observed in Malta. To put in operation the suggestions in regard to the home production an immediate outlay will be required and the cur- rent expenses will be increased. Necessary stabling and other convenience must be provided, and competent and trust- worthy employees must be secured. Proper food must be purchased, or produced on the farm. A portion ought to be produced, and the pasturage should be supplied, at home. The herd need not be large, five or ten cows, and perhaps half that number of goats, will be sufficient for experimental purposes. The additional outlay in the beginning, and the increased current expenditure, is a small consideration in view of the immense advantages which may result. The manage- ment cannot neglect such an opportunity of contributing " to the best means of lessening the mortality and promoting the welfare of young children." LOCATION. The vastly greater prevalence of disease among infants, and the larger percentage of mortality in towns than in the country, are sufficient to show that the institution must be located in the country. The remoteness of the city of Balti- more from the sea-coast, and the insalubrity of the shores of the Chesapeake Bay, are decisive in favor of an inland locality. The high and picturesque region lying north and west of the city indicate the direction in which a location of sufficient elevation must be sought. The schedule of railway elevations running north and west show elevations varying from 400 to 800 feet at accessible distances from the centre of the city. The requirements of the site, as suggested in the circular of the trustees, may be stated as follows : — 1. It must be on a steam railway, within one hour of the city, and the building site not over five minutes' walk from a station. 2. The quantity of land should not be less than 100 acres, THE MORTALITY OF YOUNG CHILDREN. 157 facing south and southwest, with no stagnant water, marshes, or mill ponds in the vicinity ; and a portion of it must be in a natural forest. 3. The elevation must not be less than 600 feet above tide- water. 4. A stream of water of sufficient capacity, in the driest season of the year, must be within available distance. 5. The building site should possess the advantages of nat- ural drainage ; the soil should be porous. 6. A portion should be good agricultural land, at least suf- ficient for pasturage and a kitchen garden. 7. It should be in a healthy region, where the water is pure, and food of all kinds is abundant and cheap. TRANSPORTATION. Transportation must be by steam railway cars. The run- ning and general management of the trains must be left to the officers and employees of the road, but must be conducted in the interests of the institution, and in the manner most conducive to the comfort and welfare of its beneficiaries. Sick and invalid children ought not to be huddled pell-mell into an unfit coach, and dumped out at the place of destina- tion in the hurry of ordinary railway travelling. The accom- modations should be comfortable and ample ; the cars should be clean and well ventilated ; order should be maintained ; and all risk of danger should be avoided. Suitable and ample accommodations for their reception must be provided at the stations of departure and destination. The institution must provide for each train a prudent and competent agent, whose duties must be definitely prescribed. Discipline should be impartially but gently enforced from the reception to the discharge of the patient. Drinking water must be supplied at the place of reception and on the trains. Food must be supplied to the very young infants needing it. The inspection of the children should be thorough at the place of reception. Their bodies and cloth- ing should be clean, and every care should be taken to avoid 158 THE MORTALITY OF YOUNG CHILDREN. the dissemination of contagious diseases. No child or attend- ant should be permitted to carry with them anything of the nature of food, beverage, or medicine. The control and man- agement of the beneficiaries must be absolute from their re- ception until their discharge. ORGANIZATION AND GENERAL PLAN OF MANAGEMENT. The supreme authority and direction should reside in the Board of Trustees, which should prescribe all rules and regu- lations relative to the discipline and internal management of the institution. It should issue all its orders through, its chief executive officer, who should be an experienced and competent medical man, and known as the physician-in-charge. The physician-in-charge should have the general superin- tendence of the active operations of the sanitarium. He should be the head and only one, and should receive his di- rections from the trustees, and be responsible directly to them. All assistants, clerks, nurses, servants, and employees should be subordinate to him. He should be provided with a suitable dwelling, paid an ample salary, and hold his office during good behavior, but be removable by the Board of Trustees for in- competency or neglect of duty. There should be one permanent medical assistant, who should be a competent microscopist and chemist. He should, under the direction of the physician-in-charge, conduct all chemical analyses and microscopic examinations, and perform such other duties as may from time to time be assigned to him. He should reside in and devote his entire time to the institution. His salary should be commensurate with his du- ties. There should be such temporary assistants as may be nec- essary, employed only for the time during which the sanita- rium is in active operation. They may, as experience will dictate, be either graduates in medicine or under-graduates. They should receive only such compensation as may be re- quired to meet their necessary current expenses. There should be one clerk to the physician-in-charge, em- THE MORTALITY OF YOUNG CHILDREN. 159 ployed temporarily or permanently as may be found neces- sary. There should be employed permanently one head cook, and one head female nurse. The number of additional cooks and nurses must be determined by the number of beneficiaries. It will probably be found most expedient to permanently retain more than one efficient and thoroughly trained nurse, as it may be difficult to secure trained nurses for temporary service during the summer season, and the duties will be too impor- tant to be intrusted to incompetent and untrustworthy women. The number and selection of servants and employees should be left to the discretion of the physician-in-charge. Economy should be observed and efficiency should be required in every branch of the service. There should be appointed a board of consulting physicians, to serve without remuneration. This board should visit the institution at stated periods, and record, in writing, the results of their observation and inspection, with such suggestions as may be deemed proper and judicious for the better manage- ment of the institution. There should also be appointed annually a committee of vis- iting physicians, to be selected from the most distinguished physicians in different parts of the country, whose duty it should be to visit the institution at some stated time during the summer months, and thoroughly examine and inspect every branch of the sanitarium. This committee should report in writing to the Board of Trustees. This duty should be performed at a trifling cost, certainly not more than the actual travelling expenses of the members of the committee. One or more of this committee should be female physicians. The records of the institution should be full and complete. The age, sex, color, nativity, residence, and clinical and family history of every beneficiary should be accurately recorded. PEOVISIONAL SUGGESTIONS. In view of the fact that the sanitarium will be in active operation for only a portion of each year, some provision must 160 THE MORTALITY OF YOUNG CHILDREN. be made for the employment of the permanent officers and employees during the greater part of the year. The permanent medical officers will find ample occupation in study, investigation, and original research, for the advance- ment and improvement of the institution, and in the prepara- tion of the annual reports. The institution owes something to the advancement of science, and it will be mainly, if not exclusively, through the efforts of these two officers that such contributions can be made valuable. The character and na- ture of these investigations have been very definitely indicated in the foregoing pages. How best to utilize the services of the permanent cook and nurses is not so easily answered. It occurs to the writer that the management will find it proper and necessary to establish in the city of Baltimore a depot or salesroom, where suitable articles of diet for young children may be sold at actual cost to the poorer class. In such case the services of these em- ployees in instructing those poor persons in the proper manner of preparing the food, and in feeding their infants, may con- tribute much towards lessening sickness and mortality. THE ADMISSION OE BENEFICI ABIES. It may not be wise to exclude any invalid child under five years of age from the benefits of the visiting department. None older should be admitted. Asylums, hospitals, and con- valescent establishments are the proper places for such chil- dren. To the domiciliary department, preference should be given in the order following : — 1. To sick infants under thirty months of age. 2. To those between thirty months and three years of age suffering from bowel diseases. 3. To well children under thirty months. No child suffering from any contagious or infectious disease should be admitted. No mother suffering from any contagious or infectious dis- ease should be allowed to accompany her child. THE MORTALITY OF YOUNG CHILDREN. 101 No mother who will refuse compliance with the regulations should be permitted to remain in the institution. No mother admitted to the institution should be permitted to pass her time in idleness. When able, and not engaged in the proper and necessary attention to herself, infant, and sleep- ing apartment, she should be required to perform such other work as may be conducive to her health. Sewing, knitting, washing, and ironing, will always be necessary. The management should carefully avoid the encouragement of pauperism, — an error which many benevolent institutions constantly commit. Those parents who are able to defray the expense of their maintenance, or a part thereof, should be re- quired to do so. A schedule of very moderate charges should be established for the information of the public and guidance of the officers. CLOTHING. Clothing must be provided for the sick children admitted to the domiciliary department. Before admission to their proper apartment their clothing should be removed, and, as soon as practicable, washed, disinfected, and put away, to be restored when discharged. The children should be washed and dressed, according to the regulations, before being con- veyed to the ward or sleeping-room. Great care is necessary with children confined to their beds, to protect them from the deleterious influences of their discharges. MEDICAL MANAGEMENT AND TREATMENT. The medical care and treatment of the sick must be left to the judgment and discretion of the physician-in-charge and his assistants. It must be assumed that these officers will be competent in every respect to discharge all such duties. None others should be selected or retained. If the duties of the physician-in-charge and the professor- ship of the diseases of children in the medical department of the Johns Hopkins University could be united in the same person, both institutions would thus be enabled to command 11 162 THE MORTALITY OF YOUNG CHILDREN. the services of a man of the highest order of ability and pro- fessional acquirements. Such an arrangement would contrib- ute to the success of both institutions, and to the advancement of knowledge concerning the causes and treatment of those diseases from which such an alarming mortality annually occurs. The medicines needed will be few and simple. It may, however, be important that one of the temporary assistants should have sufficient knowledge of pharmacy to fit him for the compounding and preparation of prescriptions. BUILDINGS. As the sanitarium proper will be open only during the warmer months of the year, the buildings intended exclusively for occupancy by the beneficiaries, and by the officers and employees, should be constructed solely with reference to use during the summer season. They should be plain, simple, cpmfortable, and inexpensive wooden structures, as fol- lows : — Two private dwellings, one each for the physician-in- charge and the permanent assistant physician. An administration : building, with two wards arranged as wings for the accommodation of those infants who may not be accompanied by their mothers. " The plan of the first floor, the designation and dimensions of rooms, and the positions of doors, chimneys* windows, and beds, are shown on Plate A ; the plan and dimensions of the second floor on Plate B ; the front and side elevations of the building on Plate C ; the sections are shown on Plate D." The first floor should be raised several feet above the sur- face of the ground, on piers or open arches. The spaces be- tween these piers or arches should be filled with lattice-work. " A good cistern of suitable capacity should be constructed and connected with the gutters and eave spouts. 1 For the details of description and specifications of this plan, see Cir- cular No. X., Surgeon General's Office, War Department. It is the plan of the present Army Post Hospital. THE MORTALITY OF YOUNG CHILDREN. 163 " The windows should be furnished with outside shutters. " The privy and dead-house should be removed one hun- dred feet from the building. " All the doors should have transoms." There should be a number of cottages for occupancy by the mothers accompanied by their infants. These may be constructed with two, four, six, or eight rooms on the same floor. They should be one story, and elevated above the ground. The rooms may be arranged in a single row, the doors opening upon a wide veranda, or in double rows, with doors opening into a wide covered hallway open at both ends. All the doors should have a transom ; all the windows outside slat shutters ; and all the rooms a fireplace. They need not be plastered, but should be constructed in a substantial and workman-like manner. They should be sufficiently removed from each other to afford ample space, and abundant fresh air and sunlight. Too much shade should be avoided. The water-closet and sink arrangements should be entirely discon- nected. At a convenient distance from these cottages the general kitchen should be erected, where all the food for the mothers and their children, and for the excursion parties, should be prepared. A dining-room should be directly connected with the kitchen, bat no child should be allowed to enter it at the meal-times of the mothers, nor should the mothers be permit- ted to carry to their rooms any article of food prepared for themselves, or give it to their children. The children need- ing it should be fed at regular intervals, under the super- vision of a nurse, either in the dining-room or at their lodg- ings. The buildings for the visiting class should be convenient to the general kitchen, but should be entirely distinct and sep- arated from the cottages by an inclosure sufficient to prevent the two classes from commingling. These buildings should be constructed on the pavilion style, with benches and other necessary appurtenances pertaining to a picnic resort, such as are usually provided by the German associations on the grounds where their annual festivals are held. 164 TEE MORTALITY OF YOUNG CHILDREN. At a convenient distance from the cottages and festival buildings, the bath-house should be erected and provided with all necessary conveniences for hot and cold bathing, both for adults and children. The laundry should be remote from all inhabitable build- ings. The ice-house should be of ample capacity. On another part of the grounds should be erected a number of single cottages, each with sufficient accommodations for a small private family, for occupancy by such persons as are able and willing to defray their own expenses, and who may wish to avail themselves of the salutary influences of a coun- try health-resort. It is not improbable that many parents, with young children, may prefer, if suitable accommodations are provided, a health-resort which will supply all that is essential to the proper care and treatment of young children during the season when a residence in the city is so hazardous to infants. ON THE IMPROVEMENT OF THE CONDITION OF THE POOR AND SICK CHILDREN: GEN- ERAL PRINCIPLES. A Letter to the Honorable the Board of Trustees of the Thomas Wilson Sanitarium for Children. / BY A. JACOBI, M. D., New York. Gentlemen, — You favored me with a note dated Balti- more, December 8, 1879, in which you honored me with the request to write an essay on the best method of establishing a sanitarium (not a hospital, but a summer retreat) for sick children. At the same time you also desired my opinion regarding the regulations suitable for receiving and adminis- tering medically and otherwise to those who would be the proper objects of your care, with such suggestions as might occur to me in reference to the character of the buildings that might be requisite, their grouping, or isolation ; how best to provide for mothers or nurses accompanying their children ; and generally such incidental recommendations as experience and reflection might commend as valuable and useful. You also wish my suggestions in reference to the most prac- ticable means of lessening the risks and changes incident to children exposed to the heated and impure atmosphere of a large city during the summer months ; also my views as to the best methods of extending a general knowledge of simple hygienic rules for the treatment of children at home among the poorer classes. And while you express your hope, " at least, to show a model of experiment," which may prove of value as a contribution to the best means of lessening the mor- tality and promoting the welfare of young children in Balti- more, and in other large cities, you direct me to give my 166 IMPROVEMENT OF THE CONDITION OF CHILDREN. thoughts in the method and manner which I shall deem most conducive to their successful presentation. All these questions and demands I look upon as in perfect harmony with the objects of your corporation, when first es- tablished. For though a summer retreat was mainly contem- plated by the originator of your vast plan of benevolence, the general object was to " alleviate pains and to prolong life." And while a summer retreat for sick children was mentioned as the one prominent end to be reached, other kindred pur- poses, as might be hereafter determined upon by the corpora- tion, were included in the points to be gained. Thus, the original intention of Thomas Wilson, and your specifications, questions, and demands, comprehend a vast amount of important matter. Not only do you ask for the best means of extending the knowledge of simple hygienic rules for the nursing and treatment of children, — which are the same for those of the rich and the poor, white and black, Christian, Gentile, and Infidel, — but you desire to provide for those who are well, so as to protect them from sickness ; for the sick, to cure them ; for those, in particular, who suffer from impure air and heat, so as to save them ; and also ask for plans and specifications. While I express my fear that I may not be able to say anything new, and my doubt whether I can do justice to the subject as understood by you, I am gratified, at least, by the fact that you do not expect to cor- rect a great universal evil by a single remedy or by a single method. Benevolent efforts avail but little, as a general thing, because they are directed against special evils, which are either the outgrowth of a false system or but a link in a chain. The breadth of your views includes the desire to benefit the poor children, be they well or sick, — as they are almost certain to be, because they are young ; and more so because they are poor. The latitude, however, extended by you to the expression of my views, renders my task very diffi- cult ; because, to do it justice, extensive discussions upon the hygiene and diet of infants and children, the physiology of their digestive and other systems, the influence of heat on IMPROVEMENT OF THE CONDITION OF CHILDREN. 167 their nerves and blood, and upon the condition of their food, the essential points in their diseases, and the rates and reasons of their mortality, might be expected. Fortunately, the main principles of many of these points are settled ; and therefore my remarks can, in part, be fragmentary. There are a num- ber of truths which, by this time, are considered self-evident; and strictly scientific questions, which are still undecided, do not belong here. The class of people to be benefited by your corporation are the poor and sick children. The main attention is to be paid, however, to the children threatened by, or suffering from, the heat of the summer and impure air, both of which not only affect the nervous system directly, but destroy life by acute or chronic affections of the alimentary canal. To what class and age do they belong ? And is it mainly the heat, or mainly the impure air, or mainly the food, which destroys them ? Which of these factors is most objectionable and preventable ? And are there no other factors of excessive infant mortality which can be obviated ? Of 100 newly-born babies, 16 or 18 will die before they are a year old in most countries. In England, of 100 born to the gentry, there lived after a year, 90 ; tradesmen, 79 ; working class, 68. Of 1,000 dead in the first families in Germany, 57 were under five years of age ; amongst the poor of the capital there were 345. In the starvation years of 1841 to 1851, the population of Ireland decreased by 19.8 per cent., the number of children under five years by 37 per cent. The average mortality of the new-born in France up to the completion of their first twelve months is 16 per cent. ; in four of the districts to which infants of Paris are sent for nursing purposes, it was 25.63, 30.28, 27.62, 51.33 per cent., while the mortality of babies born in these very same dis- tricts, and less neglected by the women, was less frightful. Of Paris babies sent to the country for nursing and rear- ing purposes, and strictly superintended by the proper au- 168 IMPROVEMENT OF THE CONDITION OF CHILDREN- thorities, 17 per cent, died before the end of the first year, — that is, but one per cent. beyond the average mortality of that age in France. Of the babies sent out by private societies, with the same pay and regulations, not officially watched, however, 42 per cent. died. The foundlings of the Departe- ment Eure et Loire, who were bottle fed, and in many in- stances a number of them in charge of a single woman, from 60 to 75 per cent, were destroyed before they reached the end of their first year ; many of them never had their faces lit by a smile. Of 1,000 children in France, an average of 554 reached their tenth year ; of 1,000 French " assisted chil- dren," but 271. That babies at the breast suffer less, and fewer die, than those raised on artificial food, is a common- place experience and statistical fact which need not be insisted upon any further. That the nature of the artificial food, — a single meal of sour milk, or indigestible farinacea, — swells the lists of deaths, is well known. It was mainly the injurious feeding which, with the over- crowding, resulted in the heart-sickening rates of mortality amongst the population of the Prague foundling asylum. It was 82.97 per cent, in 1857 ; 90.46 in 1858 ; 87.07 in 1859 86.95 in 1860; 89.71 in 1861; 88.79 in 1862; 93.19 in 1863 72.52 in 1864 ; 62.46 in 1865 ; 60.14 in 1866 ; 54.07 in 1867 46.68 in 1868 ; 46.08 in 1869. 1 Lessened mortality of the infant under a year depends to a great extent on favorable external circumstances, sufficient food and its appropriate selection. When Menier insists upon the rate of mortality depending upon the intellectual cult- ure of the people, he forgets, in behalf of his bright saying, that intellectual culture and abject poverty do not go hand in hand, but that the former requires the foundation of physical comfort and ease. Of 100 deaths taking place in the total population of Eu- rope, 26.5 per cent, were under a year ; 5.6 from 1 to 2 ; 2.6 from 2 to 3 ; 1.8 from 3 to 4 ; and 1.35 from 4 to 5 years old. Such is the average of all classes in all seasons. 1 A. Jacobi, " On Foundlings and Foundling Institutions," Med. Rec- ord, N. Y., Nov. 15, 1872. IMPROVEMENT OF THE CONDITION OF CHILDREN. 169 Of 2,216 infants who died under a year in Baltimore dur- ing 1875, the number of those who died in June, July, and August was 984, equal to 44.5 per cent., instead of 25. Of 705 who died between their first and the end of the second year, there were in the same months 200, equal to 29 per cent., instead of 25. Of 508 between the second and fifth years, 110. Thus the months of June, July, and August proved very murderous to the population of infants under a year, to a certain extent so for those between the first and second years. Those between the second and fifth years were rather safe from the influences which destroyed the very young infants. Their main mortality was in the first quarter of the year 202 out of 508, a fact the repetition of which in almost every year directs the attention of every student to those causes of sickness and death which are apt to develop in the colder season, — that is the period of closed doors and windows, and epidemic influences. Of 2,317 infants, of less than a year, who died in Balti- more in 1876, the same quarter, namely, June, July, and Au- gust, took off 53 per cent, of the whole number, instead of 25. Of 2,182 in 1877, 48.3 per cent. ; of 1,834 in 1878, 40 per cent. Of 925 children of more than a year and less than two years, who died in 1876, the same quarter took off 33 per cent, of that number ; in 1877, 35.3 per cent, of 1,329 ; in 1878, 29 per cent, of 604, instead of 25 per cent. Of 398 children of more than two and less than five years, who died in Baltimore in the whole year 1876, the same quar- ter of the year destroyed 18 per cent. ; in 1877, 23.6 per cent, out of 578 ; in 1878, 24 per cent, of 444. The months of June, July, and August, with their high temperatures and diarrhceal diseases, with all their conse- quences, destroy large percentages of the babies under two years of age, mainly those of less than one year, while the greatest mortality of the children of from two to five years depends on other causes, and takes place in other seasons. Of a total mortality of 4,070 in the city of New York, in 170 IMPROVEMENT OF THE CONDITION OF CHILDREN. the four weeks ending on July 17, 1880, there were 1,962 in- fants under one year ; under two years, 2,451 (1st to 2d years, 489) ; under five years, 2,641 (2d to 5th years, 190). In these four summer weeks the mortality of infants under a year amounted to 48.2 per cent. ; under two years 60 per cent. ; under five, 64 per cent, of the total mortality. The mortality of babies under a year was about equal to the total average mortality for the whole year of all diseases under ten years. The statistical proofs, which might be accumulated indefi- nitely, show only what we know too well, that the heat of the summer destroys life in uncommon numbers, and mostly where the air is not only hot, but also impure. And they prove also that it is mainly the infants under two years who suffer from the effects of the season, through its influence on the alimentary canal. It is mainly those in their first year who are liable to be affected by digestive disorders, while those in the second are more decimated by respiratory dis- eases ; this is contrary to the prevailing impression, which at- tributes the majority of digestive disorders to the second year, and mainly the second summer. This belief is an incorrect one, and not founded on facts. The second summer is in it- self not more dangerous than the first, on the contrary ; for morbility and mortality decrease from day to day after birth. The youngest is the most liable to fall sick and die, and mor- tality decreases with every day, week, and month. It is not the second summer which kills the baby, it is after the child has been weaned, the sour cow's milk, the ice-water, the candy, the green apple, the short socks, the partaking of all, as mothers will proudly state, " that is on the table." The mistakes in the diet of young children and its injurious effects are the results of both the ignorance on the part of the mothers as to what constitutes a proper nourishment, and the difficulty of obtaining it either fresh or unadulterated. Igno- rance cannot be cured at once ; in regard, however, to the fea- sibility of supplying the poor infants of a large community with wholesome, fresh, and unadulterated food, I desire to make a practical proposition. IMPROVEMENT OF THE CONDITION OF CHILDREN. 171 Again I insist upon the fact that the part of the population which is subject more than any other to acute disease and chronic ailment, consequent upon improper feeding, is below two years of age ; that at that age mortality is greatest, and depends mainly upon diseases of the alimentary canal. It is therefore the food required for the first two or three yeais for which my suggestions are meant. Now, infants' and chil- dren's food has a peculiarity which renders a sufficient and wholesome supply very easy to obtain. They require no va- riation, no stimulants, under ordinary circumstances, and with the exceptions to which I shall have to allude, no spice, no mixture. Day after day, month after month, the baby takes the breast, sucks the bottle ; the child takes his plain food, the same every morning, noon, and night, without longing for a change, refusing it, even, and, thriving, gains weight and spir- its. Thus the bill of fare for babies and children is a very simple and short one, easily obtainable, and, as a rule, easily procured but for the heart! essness of trade. And this very heartlessness of trade, the recklessness with which the conse- quences of deception, as far as the health of the community in general, and of the little children in particular, is concerned, are disregarded, is the reason why I desire that some means should be found through which an adequate supply of whole- some food could be placed within reach of every infant and young child of the poor classes. The safest food for an infant is the breast milk of either its mother or wet-nurse. The latter is out of the question amongst the babies of the poor. Where no breast milk can be had, or the supply is insufficient, substitutes must take its place. As soon as weaning becomes a necessity, that is, under ordinary "circumstances, after a few teeth have made their appearance, artificial feeding has to take the place of the natural supply. The articles of food remain the same for a long time, no change being required except as far as a gradual increase in the consistency of the meal is concerned. What this nourishment should be I have mentioned in my work on " Infant Diet," 1 and in my essay on " Infant Hy- 1 First ed., 1872; Second ed., 1875. 172 IMPROVEMENT OF THE CONDITION OF CHILDREN. giene," in the first volume of the "Handbook of Hygiene," edited bj Dr. A. H. Buck. 1 The rules I laid down in these publications are the result of no mere theoretical combinations, but the outgrowth of my experience through a quarter of a century, and are borne out by chemical facts and the teach- ings of infant physiology. In the hands of the Board of Health of the city of New York, by whom they have been ex- tensively published and distributed in the beginning of every summer, for the last seven years, they are known to have done much good ; they have certainly done so in my prac- tice. They read as follows, with the judicious official additions mainly under III. : — RULES FOR CARE OF INFANTS. Health Department, ) No 301 Mott Street, New York. ) At a meeting of the Board of Health, held June 3, 1873, the fol- lowing series of rules (approved by many physicians) for the man- agement of children during the hot season, with a view to prevent the large annual mortality of this class, was submitted by the Sani- tary Committee, and ordered to be printed : — I. Nursing of Infants. Over-feeding does more harm than anything else ; nurse an infant a month or two old, every two or three hours. Nurse an infant of six months and over, five times in twenty-four hours, and no more. If an infant is thirsty, give it pure water, or barley water, no sugar. On the hottest days a few drops of whiskey may be added to either water or food ; the whiskey not to exceed a teaspoonful in twenty -four hours. II. Feeding of Infants. Boil a teaspoonful of powdered barley (ground in coffee-grinder) and a gill of water, with a little salt, for fifteen minutes ; strain, then 1 New York, 1879. IMPROVEMENT OF THE CONDITION OF CHILDREN. 173 mix it with half as much boiled milk, add a lump of sugar, size of a walnut, and give it lukewarm, from a nursing bottle. Keep the bottle and mouth-piece in a bowl of water when not in use, to which a little soda may be added. For infants five or six months old, give half barley-water and half boiled milk, with salt and a lump of sugar. For older infants, give more milk than barley-water. For infants very costive, give oatmeal instead of barley. Cook and strain as before. When your breast-milk is only half enough, change off between the breast-milk and this prepared food. In hot weather if blue litmus-paper, applied to the food, turns red, the food is too acid, and you must make a fresh mess, or add a small pinch of baking-soda. Infants of six months may have beef- tea or beef-soup once a day, by itself, or mixed with other food ; and when ten or twelve months old, a crust of bread and a piece of rare beef to suck. No child under two years of age ought to eat at your table. Give no candies, in fact nothing that is not contained in these rules, without a doctor's orders. III. Summer Complaint. It comes from over-feeding and hot and foul air. Keep doors and windows open. Wash your well children with cool water twice a day,- or of tener in the hot season. Never neglect looseness of the bowels in an infant ; consult the family or dispensary physician at once, and he will give you rules about what it should take and how it should be nursed. Keep your rooms as cool as possible, have them well ventilated, and do not allow any bad smell to come from sinks, privies, garbage boxes, or gutters about the house where you live. See that your own apartments are right, and complain to the Board of Health, 301 Mott Street, if the neighborhood is offensive. Where an infant is cross and irritable in the hot weather, a trip on the water will do it a great deal of good (ferry-boat or steamboat), and may prevent cholera infantum. By order of the Board, Chas. F. Chandler, President. Emmons Clark, Secretary. 174 IMPROVEMENT OF THE CONDITION OF CHILDREN. The object then, is to place a full supply of infant food within the reach of every infant or young child. The arti- cles are : — Powdered barley, or powdered oatmeal, sugar, milk, eggs (for children of about a year and over), in about the follow- ing quantities : — Powdered barley, a package of a half pound for a child under a year, every week. Two such packages for a child from one to two years of age. When oatmeal is required, the latter in place of barley. Eggs, seven a week for a baby a year old, or less ; fourteen a week for a child over a year old. Sugar, a half-pound a week. Milk, twelve ounces to a baby under a year, twice a day ; twenty ounces to those over a year, twice a day. In regard to milk only, there is a difficulty ; adulterations can be avoided by watching and examining, but the influence of heat on cow's milk is such that it is hard to avoid ; during the hot days there is danger of acidity and fermentation. Cow's milk, when leaving the udder, is but rarely alkaline at the best; the transformation of its milk sugar into lactic acid takes place very rapidly, and a single failure in procuring sweet and proper milk may be the cause of disease and death. As this is so, while the frightful mortality from improper food is explained easily enough, the efforts to avoid it must be permanent and persistent. I propose that your body should have and superintend a place or places in the city of Baltimore, where the infants and young children of the poor class can purchase the simple, though sufficient and ample, articles of food. If there be an expense to be risked for your fund at all, it would be for rent and saleswomen. But this expense may as well be borne by the purchaser, for I do not propose that the whole population should be a receiver of alms. From a humane and an econom- ical point of view only, I insist that the poor should be ena- bled to buy, in absolutely good quality and at a fair price, the necessaries of life and health. It is they who are more IMPROVEMENT OF THE CONDITION OF CHILDREN. 175 liable to be deceived as to quality and price in all they buy, therefore they ought to be protected. Thus, whatever the infant requires in the way of food ought to be bought by those who are responsible for it, at a fair price, — be the responsible party the working man who supplies his family, or society who sustains its members not provided with family support. Your stock of cow's milk during the summer must be large enough for your summer sanitarium. One good cow will sup- ply the milk for five babies and five children over a year old. It can, however, be kept at any figure high enough to yield a full supply of good milk transported to the city twice daily, for all those infants and children coming under the provisions of this arrangement. If all the milk you sell to the infants and children in Baltimore comes from your own farm, you are sure of the article you sell, provided you know that your cans are always cleaned and washed out with soda solution, and your help always trustworthy. In case you have to purchase milk, you require additional watching. While admixture of water alone does not harm milk except by diminishing its rel- ative value both as merchandise and nutriment, it is still a de- ception to be guarded against, and admixtures and adultera- tions will always require the application of proper tests. Though I expect that fresh milk would be supplied twice daily, souring may take place so rapidly that I think proper to guard against it, at all events in the hot summer months. I recommend that the milk be not sold in its raw condition, but boiled at once. Without going into the chemical and physical reasons for that step, I simply refer to the unmistak- able fact that boiled milk keeps better than raw milk. Yet another step may be taken in the same direction. I propose that an addition of bicarbonate of sodium be made to the milk sold by you for infant food in the proportion of one in a thousand. This small quantity will retard the souring of milk somewhat, and the addition of the sodium salt to cow's milk, and its farinaceous admixture (with its superior amount of potassium) renders the milk sold by you a little more sim- ilar to mother's milk in regard to the chemical constituents of its salts. IMPROVEMENT OF THE CONDITION OF CHILDREN. Barley, oatmeal, and sugar are to be sold in ready made packages. This sale of food ought to be a permanent affair, and not limited to the summer months only ; for though the influence of summer heat is certainly most detrimental, in connection with improper feeding, this alone, at any time, is the main in- jury to infants and young children, endangering their whole future life. Mortality is great from diseases of the alimentary canal in winter as well ; and though they are not fatal to the same extent or number, the amount of permanent harm done to the digestive organs, lymphatic glands, and powers of assim- ilation after apparent or partial recoveries can be judged only from the large class of dyspeptics and prematurely decrepit persons, both pl^sieally and mentally, who owe their ailments to chronic or acute abdominal disorders of their early years. The persons to whom the sale could be trusted would be best selected from such help in your summer sanitarium as you would care to give permanent employment to, because of their intelligence and usefulness. The localities would be either a small store or stores, rented for the purpose, or a part of a store in a convenient part or parts of the city, be they groceries, or apothecary shops, or a part of, or a place adjacent to, a dispensary building. Persons applying and being regularly supplied from your stores ought to be known as deserving the privilege. Those who have been inmates of the sanitarium during a season would be recognized at once as entitled to being served. The poor, who are attended in dispensaries, can easily prove it. Such, however, as have not required medical treatment for some time can soon prove their claim by a note from some neighbor, or a physician. At all events, care should be taken lest that part of the population who, under the present ar- rangements of society, must be expected to pay a certain legit- imate percentage of profit to the class of traders, should not avail themselves of undue advantages by crowding your legiti- mate customers out of their rights and privileges. The well- to-do and rich have more facilities in guarding against being IMPROVEMENT OF THE CONDITION OF CHILDREN. 177 deceived and overreached, than those in whose favor you are called upon to interfere. At all events, the well-to-do and the rich will gather an advantage from your efforts which every one will have a reason to rejoice over. It depends upon the certainty that a public sale of the simplest food for infants and young children, which at the same time is the very best, will always constitute a powerful admonition and instruction to the whole community. The facts that infants and children do not only bear, but that they require, absolutely plain, simple, wholesome, digestible, nutrient food only, only, only ! cannot be repeated too often. Let your practical teaching be a warning and a blessing by the information extended to the public at large ; that the few articles you sell to the poor are those which are also best adapted to the rich, and the only ones } t ou recommend for the food of the infant and the young child of both poor and rich. Nature is too republican in spirit, too democratic in character, to bow to differences of social standing. In this connection I again insist upon a fact which appears to be so self-evident as not to deserve mention. And still with the utmost pertinacity the public insist upon giving their chil- dren, as soon as weaning time arrives, or before that period, such articles of food as they know nothing about. When an adult sits down to a table, he or she will inquire about a strange article of food with which he was not acquainted, before. The baby, however, is credulously fed upon things which neither baby, nor father or mother, nor doctor is in the least informed about. I speak of the baby foods in the market, and in general use. Most of these foods, which are sold in large quantities, have compositions which are not known. When the manufacturer deigns to say anything about his merchandise, he assures you that it is the best in the market ; that it is the proper thing, the only proper thing, for children and invalids of all ages ; that the relation of albu- minous substances to carbon hydrates is exactly correct, and that a package costs a certain amount of money. In regard to this subject the public appear to be smitten with absolute 12 178 IMPROVEMENT OF THE CONDITION OF CHILDREN. blindness. They insist upon forgetting that the man who offers for sale, and advertises at a heavy expense, any article of merchandise, does so — as society is constituted — for his pecuniary advantage solely. To say that when his article is not good it will find no market is deceiving yourself, experi- menting on your baby, relying on the character of a single man, or a corporation, on the honesty or intelligence of his chemist, or his superintendent, or his workmen, on the nature and condition of the elements offered for sale, and on a great many influences, which can be at work before the manu- factured articles get into the hands of the consumer. Why the sellers and advertisers of unknown compounds should be trusted more than those who raise and sell a simple article of food, such as milk, which is constantly adulterated, can hardly be perceived. Is it necessary to say that the factory furnace works more in the interest of the proprietor than for the benefit of the public, and that the examination of many of the foods for sale in different packages and in different years yielded different chemical and physical results ? Meanwhile, it is a fact that no better food can be procured than what nature offers with a willing hand, for little work, at a trifling expense. There is no food on which infants and children of all classes thrive better, thrive so well, as the few articles the sale of which, in the manner described, is recom- mended to you. In this respect at least, and at this early age, there is equality amongst members of society. Therefore, no patented article of food should ever be sold by you. If, in the Summer Home of the Brooklyn (L. I.) Children's Aid Society, they allow every child to continue, and every outside practitioner to indicate, its artificial food, it is simply a grave mistake, which will certainly be remedied as soon as understood to exist. Nor do I see that anything could be added to your stock, with the exception of brandy. The influence of the summer heat is not only destructive by the influence it has on food, but also, and mainly, by its debilitating effect on the nervous system. It is a physiological fact, always observed and firmly IMPROVEMENT OF THE CONDITION OF CHILDREN. 179 founded on experimental science, that the nervous system of little babies is easily overthrown by two entirely different con- ditions, both of which are equally" dangerous. The nervous system of the newly-born is rather torpid and dull in its action, there is very little nervous function ; particularly the sensitive portion is but poorly developed. This condition depends on the crude and undeveloped state of the brain and nervous system, from an anatomical point of view. The nerv- ous system of the baby is not yet fully differentiated into its later constituents ; it is not mature. Thus a slight influence from outside may blow out the light which is burning but dimly. On the contrary, after a number of months, the sen- sitiveness of the rapidly developing baby's brain and nervous system is so great, while the equilibrium between the several constituents is not yet established, that a slight disturbance will result in irregular reflexes, convulsive movements, and death. The influence of heat exhausts not only the action of the great nerve centres, but also the peripheral nerves, mainly of the digestive organs, as well. There are days in which a stimulant may safely, and ought to be, given to an apparently healthy child. When the baby can be taken from a stifling room to a gentle breeze, from the rear of his tenement with the exhalations of the sewer and privy to sea-air, or the mount- ain, it is not required. But when the hot season is at its height, and the baby suffering from it, without an opportu- nity to escape it, a few drops of brandy are required. Then it is simply a preventive remedy. The clamor of a few temperance papers and fanatics over the teaspoonful of brandy or whiskey, recommended in the rules distributed by the New York Board of Health, has not prevailed upon that authority to withdraw the advice, and has not prevented that advice from rendering good service. I propose therefore that an ounce of either brandy or whis- key, per week, be added to the list of your foods for sale, dur- ing the four months from the 15th of May to the 15th of Sep- tember, provided the weather is as dangerous as it must al- 180 IMPROVEMENT OF THE CONDITION OF CHILDREN. ways be expected at that time. Whether you will conclude that the sale of the above article in the afore-mentioned quan- tity ought to be controlled by the advice or direction of a phys- ician, may perhaps depend on local or personal considerations, and must be left to your wisdom. The furnishing of proper articles of food, in the manner proposed above, will prove health protecting and life saving. Still, proper food is but one of the sources of health and life. The heat and the atmosphere of a large city destroy many infants and children, in spite of appropriate food and tender care. Therefore the removal from both is urgently indicated. To prevent those who are still well from falling sick, and to restore to health those who have been stricken down by the heat of the summer, is of equal importance. An attempt to fulfill both indications has been made in New York city by the steamboat excursions made under the auspices of the St John's Guild, for a number of children. Hundreds of chil- dren with their mothers are received in the morning on board a vessel, on which they are carried into fresh air, and fed on wholesome articles of food for some hours. For it is only a few hours that the excursion can last. The children have to be carried to the landing in the morning through the stifling streets, and back through the same in the evening to their stifling homes, and must wait on crowded docks before they can be admitted on board. It is far from me to detract from the good intentions of the guild which surpervises, and the so- cieties and individuals who pay for, these attempts at enter- taining and saving, but it has always appeared to me that the possible good results are disproportionate to the labor and expense connected with the excursions. There are in the neighborhood of New York two institu- tions which may be considered as the types of the attempts made up to the present time at either preventing or curing the diseases generated by the heat of the large cities. A ref- erence to both may be found instructive when the plan of establishing a summer sanitarium on a large scale is being contemplated. IMPROVEMENT OF THE CONDITION OF CHILDREN. 181 The Summer Home of the New York Children's Aid So- ciety at Bath, Long Island, is established for the purpose of affording a temporary recreation of one week, or one day, to the children mainly of some mission schools. Nothing, in- deed, is amiss that is done for the children of any age. But the question is permissible whether, — as so little can be done at the best by private exertions, and much must be left un- done, — the large expense incurred for the recreation and pleasure of school children of, at an average, ten or 'twelve years, is justifiable, when the same amount of money, and the same good will spent on the instantaneous saving from imminent death of the many babies who die for want of just such a day or week, would be needed more and could be more profitably employed. When little can be done, that which is absolutely required should be done first. This is not meant to include a reproach, however, for a society which, with large means, is known to do a great deal of good. Still it is worth while to learn what is, and can be, done with the means at one's disposal. The Annual Report of the Summer Home for 1879 yields the following facts : l — In the Summer Home — 915 girls spent each 1 week = 6,405 days. 268 girls spent each 1 day = 268 days. 734 boys spent each 1 day = 734 days. 1,917 Total, 7,407 days, or 1,060 weeks. The expenses amounted to $6,387.18 Of which there were for construction and repairs $1,000.00 For rent, 1878 350.00 1,350.00 $5,037.18 No other expenses besides railroad fare are accounted for, thus the sustenance of every child for one day costs seventy 1 Twenty-seventh Annual Report of the Children's Aid Society, New York, November, 1879. 182 IMPROVEMENT OF TEE CONDITION OF CHILDREN. cents in food exclusively, plus railroad fare. The expense for railroad fares amounts to $739.20, that is ten cents for every child every day (leaving nearly sixty cents for food, etc., alone) during the whole period, or, calculated for every week, eighty cents. This appears enormous, and again the question arises, whether the result, a single day's recreation for a girl or boy of ten or twelve years, where so very much has to be left undone, is not paid — I dare not say too dearly, but — dearly for, when the average amount of railroad fare is added to the cost of sustenance. 1 And it cannot be proven that a single life has been directly saved by either the exertion or the expense. In this respect the aims and results of the Seaside Home of the Brooklyn Children's Aid Society, at Coney Island, 2 are quite different. It is no pleasure ground for school children, but a home for sick babies, struck down by the heat of the summer, and suffering from diseases of the alimentary canal. According to the rules, the babies are received on Monday morning and remain until Saturday night. Admission is granted to sick children of early age, very few being admitted over a few years of age, and then only when a sick baby re- quires the presence of its mother, who has no other home for the rest of her children, upon the certificate of any re- spectable ph}'sician of the town, or directly by the superin- tendent. Very few remain over Sunday, but admission is not restricted to Monday ; any sick baby may be admitted any day. Thus it is that the average time a patient remains in the institution may be set down at four days, a period amply sufficient in most cases to restore the exhausted and dying tenement house unfortunates to a possibility of living. Then, too, one cannot assert that four days are sufficient in every case, but surely they are in the majority. 1 In a circular directed to the public for the purpose of obtaining con- tributions, the number of children " brought down to this resort" from the 9th of June to the 15th of September is pronounced to have been 2,912, and the weekly expense " some two dollars." I have preferred to be guided by the figures of the official report, which, however, appears over the name of the same gentleman who signs the circular. 2 Fourteenth Annual Report, November, 1879. IMPROVEMENT OF THE CONDITION OF CHILDREN. 183 And at Avlmt expense ? In 1879, the number of admissions amounted, during thirteen weeks, to 2,423 children, and 805 mothers. 3,228 X 4 days = 12,912 days. The expenses amounted to $8,331 22 Of which there were for alterations to buildings and furniture . . . $3,748 20 Building fund 571 04 4,339 24 $3,991 98 These S3, 991. 98 were the expenses for provisions, milk, ice, coal, drugs and medicines, horse, wagon, harness, and care, express, rent ($125), railroad fares (but $12.34), printing, in- surance, salaries and labor ($1,018.15), and sundries, — that is thirty-one cents, daily, per head, — well spent on dying babies, most of whom would have succumbed but for these thirty-one cents, daily spent both humanely and intelligent^. Is it possible that a human being should have to perish be- cause of the want of thirty-one cents ? The influence of heat on disease and mortality is felt mainly by children under two years. It is these to whom a summer sanitarium which has but limited accommodations must mainly be opened. When there is room, older children ought to be admitted, up to the age of ten, but the direct life- saving influence is principally felt by the children under two. The younger they are the more will they be benefited. As soon as a mother can leave the bed in which she was confined, she may transfer the baby to the sanitarium. When she has older children, who cannot be left behind, they must be ad- mitted. No delay must be allowed in the cases of those sick with diarrhoea. Another night, a few hours in the stifled at- mosphere of a hot cit}^, will destroy a life, which may, and of- ten is, saved by removal from its danger. In these cases the 184 IMPROVE ME XT OF THE CONDITION OF CHILDREN. removal alone is the remedy. Where it is expected to act as a preventive, a few hours, a day, even, may be allowed to pass b} T . Those suffering from chronic ailments of nutrition, such as scrofula and rachitis, and those affected with chronic respiratory diseases, also convalescents from diseases gone through at home, ought to be counted amongst those worthy of prime consideration. In all of these cases whose sickness is the cause of admission, whether it be diarrhoea, chronic bron- chitis, or scrofula, age is no longer a consideration, unless the patient is beyond or near the limits of childhood. In certain classes it is dangerous to allow older children, of twelve or more, to mix too fieely with their equals of either sex. Sex- ual consciousness is developed so 'early in very many that the responsibility in accumulating many, without very strict su- pervision, is too great. Those who are poor have a good claim to be admitted? those who are poor and sick have the best, no matter whether the little human being happens to be the offspring of white or colored ; Gentile, Jew, or Christian ; wedlock, crime, or love ; church-goers or agnostics. A human child not relieved or saved where there was a possibility ought to weigh heavily on the conscience of society. It is advisable, though, that the sanitarium should be large enough to admit such, although they may not be absolutely poor, as are entitled to considera- tion simply because they are young, and to be preserved and saved. The babies of the workingmen who are willing and capable of paying must find a better place than a boarding house, the prices of which are usually higher than the laboring man or small storekeeper can afford to pay. The babies of these ought to be admitted on paying the expense of their keeping, under the rules and regulations of the general insti- tutions. They may be admitted for just the length of time which is allowed to the poor, whether the term be three, four, or five weeks. To benefit a large number, I propose that an admission in every case be valid for four weeks. If advisable, a prolonga- tion may be granted, or a new admission given. If the child IMPROVEMENT OF THE CONDITION OF CHILDREN. 185 be sick at the end of its term, no discharge must take place. Removals against the advice of the institution are out of the question. Parents must bind themselves not to remove their young without the permission of the officers in charge. This rule must be enforced as much as the law of the land allows. It permits too much ignorance and cruelty at the best. I have seen low-bred, brutal, drunken people, tearing their chil- dren from their beds in a hospital ward, take them to what they call " home," and deliver them, who had every chance to live and get well, to a certain death. These are actual cases ; the law permits the innocents to be slaughtered as fam- ily property, and the sanitarium must try to counteract the lawlessness of inhuman laws by enforcing a certain restriction in the indiscriminate and careless removal of their charges be- fore the stipulated time. The adult accompanying the admitted baby has, besides, some office to fill. The mother who comes with the baby or babies is naturally bound to perform a certain amount of w T ork for them. At home she takes care of the household, cooking, washing, sweeping, and attending to the children. In the in- stitution she is expected to do the same. While her main services belong to her children, these services must be super- intended and directed by the large household of which she happens to be a temporary member. She has to share in the general housework, washing, cooking, and sowing. It is ex- pected that cheerful obedience to simple rules and not onerous duties will be considered as but a slight recompense for the boon conferred upon her and her child. The case may occur, though rarely, that a person prove so disobedient and unruly as to necessitate her removal. Such a case is certainly rare, for those so inclined behave quite well when they are in the hands of an orderly community, deprived of the injurious influences of coarse example, loose talk, and bad drink ; in such a case, when the mother is to be refused or expelled, the present laws will permit of the retaining of the baby. I can hardly conceive of any other reason for removing a 186 IMPROVEMENT OF THE CONDITION OF CHILDREN. child from the sanitarium before the time has elapsed. For sickness must be cared for, as it must be expected to happen. There will be occasional attacks of diarrhoea, of bronchitis, and pneumonia. There will be whooping cough, there may be diphtheria, scarlatina, measles, ophthalmia, varicella, even variola or varioloid. For the time being, that is, until the in- stitution in some future time will be prepared to take charge of those already sick, such as are known to be affected with any of the above infectious or contagious diseases must not be admitted before their complete recovery. But those who are taken sick while inmates must find proper care and treat- ment in the institution. There must be a separate portion, of the same construction and material as the other buildings, at safe distances, for whooping-cough, for diphtheria, for measles, for scarlatina, for varicella, for varioloid, for ophthalmia. There must be rooms for the temporary accommodation of those who come in with fever or any other sudden symptoms of a sickness not yet fully developed, but of a suspicious character. To return them to the city may be required in institutions crippled by narrow means and space, but the welfare of the patients demands that they should remain where they have an infinitely better chance for complete recovery. What sort of buildings should be erected for the use of the admitted children and their attendants, — brick or wood, large or small dormitories, large buildings with small rooms, or large dormitories ? One or more stories ? It is a mistake to believe that brick buildings are more proof against destruction by fire. I have taken some trouble to ascertain, as far as the reports were accessible, whether more public brick, or wooden, buildings were destroyed by fires. It so happens that the larger majority of those so de- stroyed were built of brick. For it is not claimed, nor ex- pected, that they should be fireproof. Nor can it be claimed that plain wooden buildings are apt to be easily destroyed by age and wear to such an extent as to render their erection and use objectionable. As the sanitarium is not expected to be opened for any but the IMPROVEMENT OF THE CONDITION OF CHILDREN. 187 summer season, wooden buildings, to live in, are certainly preferable. With but little expense they can be made rain- proof and wind-proof, and their proper and complete ven- tilation for the purposes for which they are erected offers no difficulties, and requires no architectural ingenuity or pecuni- ary outlay. Large and solid brick walls, covered with plas- tering and wall paper, or oil, or cement, necessitate both ; a wooden structure need only be left alone to secure good air and sufficient ventilation. Simple clap-boarding, plainly painted, does not destroy the necessary spontaneous ventila- tion ; large windows and doors admit sufficient light and air. Moderately high ceilings, from ten to thirteen feet, accord- ing to the size of the rooms, permit the rising of warm and foul air, if ever there be any, to a sufficient extent. Plain roof ventilation, or a ventilating apparatus near the ceiling, is all that I should advise or permit. Open windows, open doors, and the spontaneous and constant exchange of air through the wooden inclosures are fully satisfactory. As I have lived many a year, from four to eight weeks in succes- sion, during July and August, in a small frame house, clap- boarded outside, and with a plain vertical boarding inside, without any inconveniences, and with great advantage to my- self and mine, I know that plain and cheap buildings will be eminently adapted for your purposes. The question as to the general size of dormitories is an im- portant one. Large dormitories have the advantage of easy superintendence, and some reduction in expense. Thus in orphan asylums, and similar institutions for children of ad- vanced age, the use of dormitories large enough for a number of children has been found appropriate. But the wants of very young infants differ from those of the above mentioned class. Very few babies, though ever so well, will sleep a whole night. Babies will wake up once or twice, and cry. They will require the lighting up of the room to have their wants attended to. Their attendants will have to get up, walk about, and disturb their neighbors, or the whole ward. When there are but twenty, or even less, babies in one dormitory 188 IMPROVEMENT OF THE CONDITION OF CHILDREN. there is some disturbance all the time, in the way of noise or light. If that be so where all the babies are perfectly well, how much more will it be the case when one or more are not in perfect health. Amongst a dozen or two babies there are always some who are sufficiently disturbed by intestinal catarrh, flatulency, or even lesser ailments, although there may be no actual disease. Thus the night's rest for all the babies and their attendants is more or less interrupted, not to speak of the exhalations of excrements, which annoy the neighbors as well as the individual baby and attendant. This is more than a theoretical speculation ; it is the result of actual observation in hospital wards and other institutions. Thus I cannot advise the erection of large dormitories for the class of infants and children you propose to benefit. The houses, large or small, ought to be divided up into small rooms. These ought to be large enough to accommodate a mother, with all her children, when you will now and then find yourself under the necessity of admitting a whole family at once. It is perhaps not necessary to allow a separate room for a baby and its attendant ; but two, or at the utmost, three such parties ought to be the limit. Whether small houses be built with a few apartments, or large houses with corresponding broad and well lighted corridors to allow of freer ventilation and access of light, may appear to be of no moment. But as it is not proposed to employ deafening, it appears to be more appropriate to build a number of smaller houses in preference to a limited number of larger ones. The great number of rooms and walls in the latter requires so much more material than would large dormitories that the diiference in the expense will not be very great. If it were, the advantage of separating the inmates, and by separation affording them better chances for rest, is so eminent that the moderate increase in expense is not worth noticing. The ad- visability, however, of separating the babies during the night, and in their sleeping hours during the day, does not exclude the usefulness and necessity of procuring large halls as a com- mon meeting and play-ground for the better part of the day. IMPROVEMENT OF THE CONDITION OF CHILDREN. 189 There, noise and crying or any other mode of their enjoying themselves or expressing their wants is rather desirable than otherwise. Besides, the presence of all in common rooms se- cures the only possibility of close superintendence, as far as the cleanliness of the babies, and regularity of feeding hours is concerned. This close supervision is necessary both in the interest of the little ones, and as a means of discipline for the adults, part of whom will always endeavor to benefit their individual children, by breaking the rules laid down for the whole community, as long as a wholesome habit has not been inculcated into them. For the reasons given above, I think houses with but one story preferable, when the space is sufficient for erecting a number of them, with the allowance of enough space between each, to secure the free access of air. As, however, the houses are but low, the distance between them need not be great. In fact, if I allow a surface of one hundred and fifty square feet for a baby with its attendant as the size of a bedroom, a dozen such collected under one roof would form a house of thirty- six by fifty feet, or about two thousand square feet. A dis- tance of ten or fifteen feet between two such houses, low as they will be, ought to be ample. A row of them ought to be connected on one side, with a continuous veranda for increas- ing the facility of communication, mainly for the use of the superintending nurses and officers. The medical service of the sanitarium is of vast importance. There will be sickness, and good medical advice ought to be procured. It is possible, but not probable, that a superior man, and well informed in the physiology and pathology of childhood, will or can give four months of every year gratui- tously. Such a contingency may be hoped for now and then, but cannot be expected. Thus, the physician-in-charge ought to be paid for his services. His duty will be to convince him- self that the diet of infants and children and adults is just what it is meant to be ; to see every room, dormitory, or house, and privy once daily, enforce sanitary regulations, and attend to every case of sickness. That is serious work, but it can be 190 IMPROVEMENT OF THE CONDITION OF CHILDREN. accomplished with the aid of assistants. These latter must be selected from the young physicians, or advanced students, who declare their readiness to serve continuously, for board and lodging, at least two months — better four. The facility for learning in your sanitarium will be so extensive that the places will be eagerly sought for. Eight or twelve such assist- ants may be required, double the number ought to be bidden welcome ; for the institution, while it is meant to benefit the infants, can be made serviceable to the improvement of young medical men, and through tbem, again, to those whom they will have in charge in future. It will be easy to regulate the duties of the assistants; the number of infants, children, adults, houses, bedrooms, closets and grounds under their charge must be determined by their superior officer ; meanwhile, though the studies of each man are left to his own selection, a well posted physician will do well to treat his assistants as a pro- fessor would his students, collect them in a class, discuss gen- eral topics connected with the service, and the class of the well and sick under their charge, direct their studies in infant pathology and therapeutics, see the cases with them at certain hours in either a Socratic or didactic manner, and thus pre- pare in every season, better than any of our colleges or clinics ever yet succeeded in doing, a number of young men for the knowledge of, and practice upon, a class of diseases which are very frequent, but like sealed books to the young, and many an old, practitioner. The infants and children remain a number of weeks in the institution. The benefits to be derived therefrom are expected to be very great for every individual, through the immediate effect of the sojourn there. I expect, however, a lasting effect also from the sojourn of their attendants and mothers. When they leave they ought to be wiser and better. Their weeks of staying in the sanitarium must be like a school to them, and a source of information. They will gather some informa- tion simply from being told what they are to do for the little one in the way of dressing, cleaning, and airing, and from learning the manner of feeding and the articles of food appro- IMPROVEMENT OF THE CONDITION OF CHILDREN. 191 priate. But more can be done, and easily ; they can be taught theoretically besides. I propose that ten or fifteen minutes every day should be given to a sort of simple lecture on just such topics as are connected with the diet and bringing up of children. A woman who stays in the institution a month or two ought to take with her, when she leaves it, a stock of veiy plain knowledge on a number of points connected with the health and sickness of babies : How many passages from the bowels are normal, how they ought to look, and what their consistency is to be ; how to bathe a child, how to dress it, how to keep its feet warm and head cool ; the danger of short socks, feather pillows, and woolen head-gear ; how to prepare an enema, and apply it ; how to observe the voice of the cry- ing child, and judge of the frequency or difficulty of breathing ; what to look for in the growing child, — accumulations of filth and dead skin on the head, growing mother's marks, increas- ing baldness on the occiput, softening of the cranial bones, thickening of the long bones ; what to think of the presence of, or danger from, worms ; how not to believe in the old superstition of dentition being an almost unavoidable danger ; and that she is culpably neglectful when not trying to relieve, by medical aid, a diarrhoea, or fever, when her child is sick, only because her neighbor tells her the child is teething. All of these things are very simple, and can be told in simple words. Any woman of average intelligence, and with no pre- vious schooling, will comprehend and remember them. I know that I succeeded in private and dispensary practice in a great many instances, and the task will be found very much easier when the teaching comes to them in an official manner and clad with authority. I admit, however, that not every advanced student, or even every young practitioner, is conversant with all of the above topics to such an extent as to be able to teach them ; but their superior medical officer is so, or must be. He can sup- ply the knowledge, and when no viva voce teaching is possi- ble or advisable, short directions, or lectures, can be provided. The purpose in view must be obtained, at all events. If 192 IMPROVEMENT OF THE CONDITION OF CHILDREN. there were none in the whole medical staff who would feel capable of teaching the above subjects to the by no means un- sophisticated, but mostly slow and plain intellects before them, — and there is nothing more difficult than a popular lecture, or popular teaching, — a good book ought to be procured and read aloud ; if there be none adapted to the purpose, it ought to be made. A great deal of common sense and judicious knowledge can be condensed in forty or fifty pages, and a single page read every day, and discussed ten or fifteen min- utes, may be able to change the condition of the poor little ones of a large city in a few years by removing ignorance and superstition, and breaking the force of bad habits in their mothers. When these leave the institution, the babies must have laid in a stock of health, and they themselves one of good will and some improved knowledge on children and nursing. The information gathered by the mothers during their stay in the sanitarium I look upon as highly important. They will not only be told what to do, but made to do it. The class of people from whom your beneficiaries are recruited never learn by theory alone, it must be accompanied by practice ; still that theory is a necessity for them also, and a blessing, pro- vided it be in the right shape : therefore the teaching ought to be plain, — what they listen to, intelligible ; what they read, clear and brief. It cannot be expected that extensive treat- ises on hygiene, or hygienic measures, should be read and di- gested by the men and women of the working classes, but brief rules will be read and heeded. The effect of the very brief rules for feeding babies usually distributed by the New York Board of Health goes to prove it. A short tract of a page or two, or better one large page, several times a year, ought to be carefully worded and widely distributed ; every mother ought to be supplied with two or three when she leaves the sanitarium. At regular intervals the infant food depots, or some other public place, might be made the distrib- uting centre of another such tract. One or two topics might be treated of at the same time, such, for instance, as have been mentioned above. A lithograph, or cheap print of a sub- IMPROVEMENT OF THE CONDITION OF CHILDREN. 193 jeet connected with baby life, could be distributed every Christmas, with the main rules concerning feeding, washing, airing, and dressing, underneath, on a strong pasteboard, so as to secure its indestructibility, and its forming a part of the wall ornaments in the residence. Such rules, tracts, and pictures could be copied indefinitely. They may be kept for sale in the interest of benevolent indi- viduals and societies of other cities. It may be that Balti- more can thus be made the centre from which every large or small city can be induced to obtain its supply of useful, plain knowledge on diet, health, and sickness of the young. No other city, it appears to me, will have the opportunity of Bal- timore, with the magnificent occasion offered by your under- taking. The publicity of your work, and its details, and of the facilities offered by you, will not be wanting ; for the newspapers and journals will have no more interesting or more important topic to discuss for a long time. They will also con- tribute to diffusing the knowledge you intend to spread, by copying your publications, and though but a limited number of readers will cut out — as I have seen them doing — just such items of domestic and hygienic importance, the notoriety given to your plans, and their execution, will create a constant demand for the supply of your communications, papers, or tracts. Again, they must be brief, not one in a hundred work- ing men or women will read an essay, but every one will read a page of clear print with home truths. Lectures are out of the question ; poor people cannot go, and will not. Clergyman, as a class, have no special familiar- ity with the topics alluded to, nor would many of them be disposed to take an active interest in matters involving merely the health of the body. There are, however, some who would aid in the development and progress of such a trust as this, and appreciate the necessity of now and then giving a thought and word to the well being of the future citizen of this world. Lectures, however, to another part of the community, which may be printed or not, will be found of great service. The 13 194 IMPROVEMENT OF THE CONDITION OF CHILDREN. educated and better situated classes of society will listen, and read. Your efforts are mostly directed to benefit the children of the poor ; but, even if you meant to, you cannot prevent the seed you sow from spreading beyond your own acre. The knowledge you spread, the habits you inculcate, the success you obtain, will tell their own story. The talk of the people, and the discourse of the newspapers, will spread healthy opin- ion all over. There is no better teaching than by example, which is not only good, but has proved profitable and success- ful. But the indirect influence of your efforts need not be all; a few lectures every season on subjects connected with the questions so dear to you must be delivered in Baltimore, by persons whose position and reputation is such that their assertions carry weight. These lectures, or some of them, ought to be printed and kept for sale. The book trade and the news agencies would distribute them by the thousand, by the ten thousand ; and while most advantage would be derived from them by the publisher, your funds may be benefited by the profits obtained. Even though it would be necessary to pay the lecturer a fee, it is more than probable in my mind that a considerable pecuniary result might be accomplished. Thus far I have proposed that what is known to the best of the medical profession should, in its results, be communi- cated to the public by teaching, tracts, and lectures ; your cor- poration may go further, and contribute to the improvement of the science of the subject. I advise that a subject be se- lected by you, or by a committee of yours, annually or bien- nially, belonging to the domain of diet, physiology, and pa- thology of infancy or childhood, and that a prize should be established for the best competing paper on the subject. No money ought to be paid for the best effort. A medal gained for scientific honors from your body will fully pay the crowned winner. It is not at all necessary, or advisable, that the question proposed should be taken from the domain of diet alone ; on the contrary, it is rather advisable to select a prob- lem out of the many which are still waiting for their solution. America has not contributed very much to psediatric science. IMPROVEMENT OF THE CONDITION OF CHILDREN. 195 I hope it is you who will succeed in creating the taste for it, and usher in a most needed progress. To provide the poor infants and children of a large city with wholesome food, and to establish a summer sanitarium for the prevention and cure of the diseases depending on heated arnd contaminated air is an undertaking of vast importance, and in itself a great blessing, such as no other corporation in any community ever had an opportunity of conveying to the same extent. The thoughtful benevolence of Thomas Wilson, however, and the careful preparations being made by your board for the execution of his will and the administration of his bequest, encourage me in putting in a further plea in be- half of the poor and sick infants and children. It is true that even large means do not suffice for all purposes, but these purposes must be first stated to be generally understood, and aims must be pointed out first before the efforts can be made to reach them. It has often appeared to me that misery is so great and universal only to enlist greater and more universal sympathy, pity, and humane efforts to relieve and remove it. The historical development of mankind which led to poverty, sickness, and sin has also evolved wealth, knowledge, and humanitarian enthusiasm. The race of the Hopkinses and Wilsons cannot be, and is not, extinct. If the means at your disposal be not sufficient to accomplish all that is required, I trust that they will be increased by well-directed benevolence of citizens equally blessed with great riches and great souls. My plea is for the establishment of children's hospitals. It is true that there is hardly a general hospital in which sick chil- dren are not met with. They are mostly chronic cases, bone diseases, malformations, and disorders of nutrition. For reasons connected with the general discipline of a hospital, and the difficulty of procuring fresh air to a sufficient extent, the lat- ter class are seldom benefited. The first class, also, are but rarely benefited, unless they be of recent origin. If there be any class of diseases dangerous to other patients, and not improved themselves, and which requires special accommoda- tions of their own, it is that of chronic bone diseases. All of 196 IMPROVEMENT OF THE CONDITION OF CHILDREN. these children are, as a rule, kept in the wards of adults, there to be cared for partly by the nurses, and partly by the con- valescent patients. This usage is of little advantage to the sick, while it may prove an annoyance, and detrimental to the class of legitimate inmates. Besides, the association of older children with most of the inmates of a hospital is not an ad- visable one. The moral tone of the wards is mostly not very elevated, and it is a wrong to expose the children — subject already to so much doubtful home and street influences — to moral contamination in order to obtain a rather uncertain physical benefit. Infants, who are so much more liable to be taken with acute and life-endangering maladies than the class we generally meet with in hospitals, are not admitted. Thus, those who require most aid receive none. To obviate the incongruities and disadvantages of placing infants and children in the same wards with adults, in some hospitals a special ward has been reserved for children ; but by so doing, the administration of an institution being of ne- cessity, uniform, no justice is done to the wards of the young, as I shall say later. The classes of diseases are so various, the number of contagious affections so great, the propagation and multiplication of disease in a single ward or two, with no possibility of removal or isolation, so palpable, that this ar- rangement has been found to be dangerous in many cases, though in a number of instances it proves serviceable. Con- tagious eye and eruptive diseases are often multiplied in a child's ward. One of the reasons why the number of children's hospitals is still so limited in most countries, and mainly in ours, may be found in the fact that the needs and wants of an institu- tion designed for the care of sick infants and children are very much more complicated than of those for the reception of adults. The difficulties alluded to are so serious that there are so-called children's hospitals which will receive no patients at less than five years. On the other hand, those who under- stand their duty, and mean to do it, take the responsibility IMPROVEMENT OF THE CONDITION OF CHILDREN. 197 when it offers itself. Thus the child's hospitals of St. Peters- burg, Vienna, Stettin, Basle, Berne, and Frankfort have a percentage of from eight to twenty-seven per cent, of inmates under a year, and of from thirty to fifty per cent, under three years. The children's ward of the Mount Sinai Hospital, New York, never asks for the age of the patient before deciding on the propriety of admission. Amongst the difficulties to overcome in a child's hospital is the necessity of procuring an increased number of nurses. The mortality of children is greater than that of adults, their dis- eases mostly more changeable, their personal wants must all be attended to by others. Thus the number of nurses is to be larger than for the same number of beds in a general hos- pital for adults ; and the training of the nurses, if anything, more careful. The wards must be smaller, for the patients are more apt to disturb each other; therefore not too large a number must be congregated in one ward. The largest ward of a large child's hospital ought not to have more than from fourteen to twenty beds, part of which ought to con- tain convalescents. The number of smaller rooms must be greater ; they must be so arranged as to be capable of com- plete isolation, when this is required, along a light and airy hall. The cubic space reserved for each child must be at least as great as that for adults, for their respiration is very active ; their evacuations are in part passed into the beds or linen, or at all events inside the sick-room, and a larger staff of attend- ants and nurses is present in addition to the patients them- selves. Not only a sufficient cubic space, perhaps of 1,500 cubic feet, is required ; it is perhaps of still greater import- ance that the distance of the beds from each other, and from the walls and windows, be made ample, in the interest of com- fort, and of nursing and attending. More of these minutiae, however, come into consideration when the building of a hos- pital is actually contemplated. My object was only to show that the difficulties in the way of a child's hospital are rather greater than those met in general hospitals, and thereby, cer- tainly not to discourage the undertaking, but to secure com- 193 IMPROVEMENT OE THE CONDITION OF CHILDREN. plete and perfect preparations. We have done but little in our country for the benefit of sick children, as far as hospitals are concerned. In fact, there scarcely are any, if those insti- tutions are excepted, which, under the name of nurseries, suc- ceed in so keeping and nursing their little inmates, that those admitted in health are soon taken sick, and those taken sick die ; this is by no means an exaggeration. If there were a close superintendence on the part of the authorities over the many so-called private institutions for which cities and states pay largely with the understanding that they never look into the manner in which their money is spent, they would be sur- prised at the death-rate of the inmates. When ten years ago I proved that a large institution in Xew York city spared al- most none, literally, of its many babies, I was requested to resign my position, and, when I insisted upon publicity, ex- pelled, and the very next annual report exhibited the fact, that the admissions of children not born in the institution were almost exclusively of those near or over two years, when both danger and mortality are naturally lessened. Many countries have clone more than ourselves; none, how- ever, enough ; still there are a few European cities which have accomplished a certain result in procuring accommoda- tions for their sick babies and children. The following table has been taken from Rauchfuss, in Gerhardt's Handbuch der Kinder Krankheiten, i. p. 419. ■r. . — ■ a Tor every 10,000 Inhab- b£? .£ *** itants at the rate of a. Beds. Is r: =. « * ~' £ a. 6. c. London 310 2,500 60,000 1.4 7 170 Liverpool SO 4S4 8,000 1.5 9 150 Vienna 300 2,000 25,000 3.5 23 300 Manchester 210 - 14,250 4 - 300 Prague 92 1,180 7,220 5 60 360 Moscow 280 - - 7 - - Paris 1,100 7.100 35,000 6.5 3S 200 St. Petersburg .... 470 3,000 30.000 7 42 420 Lisbon 160 - - / - - Stettin 56 2S0 1,000 7.3 37 130 Basle 60 230 232 12 50 50 IMPROVEMENT OF THE CONDITION OF CHILDREN. 199 It contains the number of beds in children's hospitals, the annual number of patients, and patients of dispensaries. In Dr. Rauchfuss' opinion the highest above figures are still to be considered as minima ; ten beds with seventy annual patients, and five hundred dispensary patients to ten thousand inhabitants, will not be found to surpass the needs of the com- munity. Dispensaries for the children of the poor are a necessity as well as hospitals. Many cases of sickness require no hospital treatment, and no superior knowledge of nursing, such as a well-kept hospital can alone suppty. Slight ailments which, when either not understood or neglected, become great evils ; malformations which can be remedied by an occasional dress- ing, or manipulation, or operation, at longer or shorter inter- vals ; chronic ailments which require the same or similar medicinal treatment, besides advice in regard to diet and nurs- ing; many an acute case even which will run a favorable and smoother course, when once guided and directed, — all these numerous cases are sufficiently benefited by dispensary treat- ment. The opportunities of a dispensary are two fold: it acts as a healing institution, and prevents, by its easy accessibility, many a trifling complaint from becoming a serious malady. It affords medical advice and medicine. In some Paris dis- pensaries baths are given besides. The out-door department of the Prince Oldenburg Child's Hospital in St. Petersburg has moreover a room to rest in for those who come from great distances. Its second great opportunity consists in its ability to prevent disease by sound advice given. It is a fit place to teach simple lessons, to distribute brief tracts on hygienic sub- jects. There is a serious drawback, however: the child needing advice and going to obtain it, in a dispensary, is necessarily exposed to the air ; many a sickness may be, and has been, rendered severe by such exposure to all kinds of weather. The time spent in waiting before the individual patient's turn comes is a serious infliction upon its comfort, temper, and some- 200 IMPROVEMENT OF THE CONDITION OF CHILDREN. times health. It is, while waiting, exposed to the possibly contagious diseases, wittingty or unwittingly brought to the same place, for this is a possibility which cannot be altogether avoided, though some large dispensaries in Europe have a place in which a cursory preliminary examination concern- ing contagious diseases is made before the patient is admitted to the general waiting room. It is, however, not only the sick child who may be injured bj being taken to a dispensary ; as it is liable to be endan- gered by others, so are others by it. The danger of spreading contagious diseases is enhanced by the indiscriminate trans- port in public vehicles, which cannot be prevented. Thus, whatever is done, is not always for the best — as in all human things. Nor can such danger always be avoided. Possibly the establishment of several small dispensaries in place of a single large one, and greater facilities for the treatment of sick children at home, and the procuring of more extensive hospital arrangements, are amongst the improvements and blessings to be wished for. At all events, as the danger of communicating diseases is so very great, it is advisable not to have the dispensary depart- ment, although it may be connected in its administration with a hospital, under the same roof. If barely possible it ought to be in a separate building, and care taken tha^t no communication takes place between the two. No nurse of one ought to attend in the other. There can be but one connection, which is this : the out- door department is necessarily the feeder of a hospital ; cases too severe to be treated at home under unfavorable circum- stances or such as would be injured by letting them return home, must be admitted to the hospital immediately. Both hospitals and dispensaries wield a wider influence, however, than through their immediate effect only upon those whom they directly influence. Their mediate blessings are at least as great, perhaps greater, for the greatest boon to infants and children is the increased number of physicians who are intimately acquainted with their nature and ailments. The IMPROVEMENT OF THE CONDITION OF CHILDREN. 201 field of observation in large institutions is so great, and the opportunities for learning so extensive, that the medical men connected with special establishments of the kind cannot but progress rapidly in the knowledge of the topics connected with that special branch of practice. It is only the half educated, or poorly gifted of them, who would be induced to look upon the practice in children as a specialty. In fact, the tendency of running off into unjustifiable specialties to such a degree as is done in our country and in a few centres of Europe, for instance in Vienna, is but the outgrowth of insufficient gen- eral education or mercenary motives. The really educated and intellectual physicians would avail themselves of their opportunities for the benefit of their charges and their peers ; for it is to them that the profession would, and has to look for for further instruction and progress. Their assistants and clinical pupils — for I take it for granted that the advantages of observation would not be lost, no matter whether the hos- pital and dispensary were closely connected with Hopkins University or not — would learn directly, participate in their observations, study their method, and go out well prepared for the strife with disease. Their clinical lectures, their pa- pers in medical journals, their publications in the annual re- ports would not only contribute directly to the stock of knowledge of medical men, but — and that is of vastly greater importance yet — create a widespread interest in the physiol- ogy and pathology of childhood. That it is necessary to still create such an interest is a remarkably sad fact, but such it is. Not one of the colleges of the United States twenty years ago but had a " chair for obstetrics and the diseases of women and children," — not one, not a single one of them, which ever taught diseases of children either theoretically or practically. The first clinic for diseases of children — a poor single hour every week — was established in the New York Medical Col- lege. When this closed its doors, the clinic was transferred to the University Medical College, it still being the only one in existence. During the last ten years, a few of the larger colleges of the country have imitated that example, but with- 202 IMPROVEMENT OF TEE CONDITION OF CHILDREN. out admitting the teacher of diseases of children to the ac- knowledged position of a member of the faculty : and without making the study of the diseases of children compulsory on the part of the students, without subjecting them to an exam- ination on that subject before the}^are given a diploma, which gives them a right to go out into the world to destroy or spare — as fate wills it — their neighbors' young offspring. And all the time the teacher of obstetrics calls himself also the profes- sor of the diseases of women, and the professor of obstetrics and diseases of women calls himself, also, professor of the dis- eases of children. Thus it is not only that the study of the diseases of children has been neglected, but that a young stu- dent is led to think of it as a rather superfluous task. Be- sides, babies and children in practice are easy to deal with, for they cannot resent ill treatment, claim damages, or impair the good doctor's reputation by complaining. All that may be changed by you, in Baltimore, and beyond the city's limits. For while a bad example is contagious, a good one is fortunately, at least, just as much so. I feel that a single earnest attempt is all that is required. When it is made at Baltimore, with its just expectation of becoming the centre of learning, and particularly medical learning, in the United States, it will be doubly effective. The hospitals for sick children, and hospitals in general, are necessarily limited in their means, the space they occupy, and the accommodations for beds which they offer. A large city ought to have, therefore, in proportion to its population, sev- eral institutions for rather different purposes. An institution for the relief of acute inflammatory diseases, while located as healthily as possible, must necessarily be at no unreasonable distance from the homes of the sick ; for transport to a dis- tance is, of necessity, attended with dangerous consequences ; many a patient dies of it. On the other hand, places destined for the relief and cure of chronic ailments, such as rhachitis, scrofula, bone diseases, ought to be established at a greater distance from the cities, on mountains, or the sea-shore ; chronic pulmonary diseases IMPROVEMENT OF THE CONDITION OF CHILDREN 203 require plateaus protected from changing winds and temper- atures. Professor G. Barellaj, of Florence, Italy, founded the first sea-shore hospital for chronic ailments in Viareggio ; and in 1873 as many as eighteen existed in Italy, that were founded on the same plan. Count Ricardi de Nestro established, in Turin, a hospital for rhachitic children in 1872. Within a year, two additional ones were called into existence. Moral contagion is not always detrimental in character. In Milan, Dr. Pini founded a similar institution. The hospital for scrofulous, rhachitic, and anaemic children, in Berck-sur-Mer, admitted, between the years 1861 and 1865, 380 children, of whom 234 recovered, 93 were improved, 35 were not im- proved, and 18 died. The stations at Venice, Rimini, Seotri, and Fano, had 1,359 recoveries, and 758 partial recoveries, out of 2,283 admissions. The establishment of Oranienbaum, near St. Petersburg, Russia, admitted 217 children at an av- erage age of nine years, of whom 96 are reported as recov- ered, 95 as improved, 20 as not improved, 5 as worse, and 1 dead. These percentages of entire recoveries in a class of cases which, under ordinary circumstances, give rise to pro- tracted illness and lingering are so satisfactory, that the very mentioning of them ought to be enough to enlist the warmest sympathy in behalf of a class of children who, while suffering from the curse of inherited poverty and acquired ill health, might be readily aided by the benevolent efforts of wealthy individuals, — or the collective means of society. They are the very class who, when they grow up with their ailments and incapability to produce, will, through the course of their lives, consume the marrow of the land in hospitals, refuges, almshouses, and penitentiaries. A large number of children, and very often healthy and vig- orous ones, are destroyed yearly by infectious and contagious diseases. Municipal consciences have been awakened some- times to the knowledge of that fact, and endeavored to guard against it by closing school rooms in the faces of children com- ing from infected houses. This is a necessity from the point 204 IMPROVEMENT OF THE CONDITION OF CHILDREN. of view of protection to the well. From that point of view it is even explainable and justifiable that the whole population of a tenement house, in which a single case of communicable disease happens to exist, is driven back to its dens ; all of this is just and proper on the part of those who do not yet suffer, but is it just and humane when considered in the interest of those locked up in their pestiferous atmosphere ? Or does this very process of locking up yield any favorable results ? By no means ; for the fact is undoubted that from one or more such infected localities the epidemic will spread ; it is apt to spread in the same degree that the population is densely concentrated around the infected locality. That is natural enough, for the disease will spread where it took hold, the number of cases will increase, the character of the epidemic become graver. If the first case could have been removed, isolated, and taken care of, the malady might have been stopped, lives and means been saved, and the community effectually protected. Now, general hospitals do not admit contagious diseases, though some of them, for instance, the Victoria Hospital, London, England, have fever wards for the admission of that class of cases; there is always one or the other communicable affection which is not allowed to enter ; thus, for instance, small-pox. The majority of hospitals remove from their wards even such as are taken with contagious diseases while inmates of the same. There are but few, and particularly but few children's hospitals in existence which have the opportunity of isolating those who are taken sick so as to require separa- tion. Such are the St. Wladimir of Moscow ; Nicolai, Elisa- beth, and Peter Von Oldenburg, of St. Petersburg, or the Child's Hospital of Basle (Switzerland), or Lisbon, the Eve- lina Hospital of London, and also some others, to a certain extent Vienna, Prague, and Stettin. If there were hospitals enough with sufficient accommoda- tions for the isolation of those who are taken with a contagious disease after having been admitted for other reasons, and other hospitals established for the acknowledged purpose of IMPROVEMENT OF TEE CONDITION OF CHILDREN. 205 receiving at once those taken with communicable affections in their residences, these homes crowded with children and adults would be protected and saved, and many a fatal epi- demic stamped out at the beginning. The unnecessary and preventable waste of life is fearful, and if the waste of prop- erty annihilated by preventable disease and death was counted, or could be estimated, — with the loss in material, money, labor, time, health, and comfort, — the political economist would be surprised. It is not too earty, then, to emphasize the necessity of es- tablishing hospitals for the reception and treatment of con- tagious diseases. They are required in the interest of those taken, and those who are still well and almost certain to be taken. In regard to small-pox, some communities enforce the rule of isolation even against those who are unwilling, in the interest of the whole community. Small-pox, however, as we meet it, in both sporadic cases and epidemics, and modified by vaccination, is by no means the most dangerous scourge ; many an epidemic of diphtheria and scarlet fever has proved more fatal than varioloid. Special hospitals are a necessity, and public opinion will not always be satisfied with halfway measures. The progress of human development will insist upon the necessity of greater protection for the community, and better accommodations for those who suffer from the most dangerous forms of sickness. Besides, humane thought and sympathy will readily be enlisted in behalf of those who, while suffering most seriously and most frequently, are most helpless ; for childhood is the harvest-field for the murderous epidemics. The man who, in any town of the globe, will sac- rifice part of his wealth for the erection of a hospital destined for the exclusive reception of children suffering from conta- gious diseases, is sure to make his name a blessed household word, and crown his head with immortal glory. OBSERVATIONS UPON THE SANITARY CARE AND TREATMENT OF CHILDREN AND THEIR DISEASES. In Answer to certain Questions propounded by the Trustees of The Thomas Wilson Sanitarium for Children of Baltimore City. y BY J. FORSYTH MEIGS, M. D., Member of ike College of Physicians of Philadelphia, one of the Physicians to the Pennsylvania Hospital, etc., etc. The trustees of " The Thomas Wilson Sanitarium for Chil- dren of Baltimore City " having requested me to prepare an essay on certain matters connected with the establishment of this institution, I proceed to fulfil this request to the best of my ability. The trustees desire information, first, as to " the best method of establishing a Sanitarium (not a hospital but a summer retreat) for sick children, under the most favorable hygienic and local conditions that the neigh- borhood of Baltimore may afford." They state that " the land lying north and west of the city is high and picturesque, and elevations of four hundred feet above tide are reached by steam railway in thirty minutes, and those of six hundred to eight hundred feet in an hour. These districts have always been healthy - — the water is pure, and food of all kinds is plenty and cheap. The ocean is not within available dis- tance, and the shores of the Chesapeake Bay are malarial." In regard to the choice of the site for the institution, I may say that my experience in the diseases of children in Philadel- phia has led me to think on the whole, that an interior region of some altitude above the sea is preferable to the sea-side. The healthiest localities near Philadelphia are those situated from four hundred to five hundred feet above tide and away from the lower river- valleys. Sites which drain rapidly into swiftly SANITARY CARE AND TREATMENT OF CHILDREN 207 running streams, so that the surface shall be dry, are the best. A rolling country is for the same reason better than a flat one. The soil ought to be gravelly or porous, and at the same time reasonably fertile, in order that it may yield good grazing fields for the animals which must supply one of the main foods, milk, for the inmates of the establishment. There ought to be some large and open woods on the grounds, to afford shade in hot weather, both for the children and for the animals, and, if possible, the soil should be of such character as to afford a rich soft grass beneath the trees. For the site of the buildings, I recommend the highest point on the ground selected for the farm, in order that these may be exposed to all the summer breezes. As the institution is intended for use in the hot months of the year, an expos- ure of this kind will be altogether advantageous. Were they to be used in the winter season, also, such a situation might be objectionable, but, as the summer diseases of young children are largely the result of high temperatures, it should seem that the cooler the buildings can be kept in the heated term of the year, the better for the inmates. The trustees state that elevations of four hundred feet above tide can be reached by railway from Baltimore in thirty min- utes, and those of six hundred to eight hundred feet in one hour. It appears to me that the elevations of six hundred to eight hundred feet would be greatly preferable to those of four hundred feet. If, therefore, the distance does not raise the cost of transportation too high for the funds of the san- itarium, the higher altitudes are those I should recommend. The temperature falls decidedly as the elevation rises, and this single consideration ought v to decide the trustees to select the higher points if they are at all attainable. In order to assist the trustees in their choice of the site for the institution, I will quote a few of the rules laid down by Dr. Edmund A. Parkes, in his "Manual of Practical Hygiene in- tended especially for Medical Officers of the Army [of Eng- land] and for Civil Medical Officers of Health," fourth edition, London, 1873, upon the relative value of localities and soils 208 SANITARY CARE AND TREATMENT OF CHILDREN. for military encampments. He states that " as a rule, it is considered that loose porous soils are healthy, because they are dry, and with the qualification that the soil shall not furnish noxious effluvia from animal or vegetable impregnation, the rule appears to be correct." He also states that " gravels of any depth are always healthy, except when they are much be- low the general surface, and water rises through them; gravel hillocks are the healthiest of all sites, and the water, which often flows out in springs near the base, being held up by underlying clay, is very pure." He remarks that " among hills, the unhealthy spots are inclosed valleys, punchbowls, any spot where the air must stagnate, ravines, or places at the head or entrance of ra- vines." . ..." A saddle-back is usually healthy, if not too much exposed ; so are positions near the top of a slope." — On plains the most dangerous points are generally at the foot of hills, especially in the tropics, where the water, stored up in the hills, and flowing to the plain, causes an exuberant vegetation at the border of the hills." " Herbage is always healthy. In the tropics it cools the ground, both by obstruct- ing the sun's rays, and by aiding evaporation ; and nothing is more desirable than to cover, if it be possible, the sandy plains of the tropics with close-cut grass." Speaking of trees, he says, " Trees should be removed with judgment. In cold countries they shelter from cold winds ; in hot, they cool the ground ; in both, they may protect from malarial currents. A decided and pernicious interference with the movement of the air should be almost the only reason for removing them. In some of the hottest countries of the world, as in Southern Burmah, the inhabitants place their houses under trees with the best effects ; and it was a rule with the Romans to encamp their men under trees in all hot countries." In his directions for the preparation of a site for military purposes, he gives the following summary of rules for improv- ing the healthiness of a site. " (1.) Drain subsoil, and lower the level of the ground water. " (2.) Pave under houses, so as to prevent the air from ris- ing from the ground. SANITARY CARE AND TREATMENT OF CHILDREN. 209 " (3.) Pave or cover with short grass all the ground near buildings in malarial districts. o " (4.) Keep the soil from the penetration of impurities of all kinds by proper arrangements for carrying away rain, sur- face and house-water, and house impurities." The supply of water at the Baltimore sanitarium will con- stitute one of the points most important to be considered in the choice of a site. To secure, if possible, one or more springs of pure water within the grounds would be a great desidera- tum. A stream of pure, good water running swiftly through the farm would be invaluable, whether for the supply of drink- ing-water, water for cooking, washing, and bathing, or for the coolness it imparts to the air. The amount of water ought to be large, in order that it may be supplied by water-wheels, windmills, or rams, to all parts of the buildings. Whether such a stream could be used, after all the water needed for the buildings had been taken from it, for the purposes of drainage, would depend upon its volume and force, and upon the dis- tance from the buildings at which the drain or sewer might be led into it. The trustees request suggestions as to the " character of the buildings that may be requisite ; their grouping or isolation ; how best to provide for mothers or tmrses accompanying their children." I know little myself in regard to the details of buildings intended for these purposes. I applied therefore to Dr. F. W. Lewis, of this city, for information on these points. Dr. Lewis has been one of the managers of the Children's Hospi- tal of Philadelphia since its foundation, and has always taken an active interest in it. He was also one of the original man- agers of the " Sea-Shore House for Invalid Children" at At- lantic City. His experience has been large and recent, and he allows me to lay before the trustees some of the opinions he has formed upon these points. He says, " in the first place I would, for various reasons (but especially for the difficulty in the way of proper super- vision, etc.) object to the system of small detached buildings 14 210 SANITARY CARE AND TREATMENT OF CHILDREN. (cottage hospitals so called), except in the case of nursing in- fants, whose mothers also require change, and of children af- fected with loathsome or offensive discharges ; and even for these it would seem preferable to have small (creche) wards immediately adjoining the nurses' quarters in a large hospital building." He proposes a centre building with a long ward on either side. In the centre building he would place the rooms for the administrative offices, and at the point where the wings spring from the centre, the nurses' quarters. In the same building, and next to the nurses' quarters, he proposes two small wards, that on one side for nursing women and their children, and that on the other for cases of loathsome or offensive discharges. The two small wards, for these pur- poses, should communicate with the nurses' quarters, but should be separated by the nurses' rooms from the long wards. In the rear of the centre building he proposes to place the kitchen, laundry, etc., communicating by a covered passage- way. There should be additional small rooms, he thinks, ad- joining the wards, with arrangements for cooking broths, etc. At the outer ends of the two long wards should be placed the water-closets and bath-rooms, separately ventilated, i This arrangement can be made for either one or two stories, and, in either case, the roof is simply an ornamented air- chamber aiding in the ventilation. Piazzas should, of course, surround the wards, on the lower story at least. " The de- tails," he adds, " could be infinitely varied to suit the nature of cases received." At the House for Invalid Children at Atlantic City, they have adopted a system for nursing children whose mothers are obliged to accompany their infants, or who themselves need change of air, of small, detached, one-story cottages (without cellars of course), built of wood, with one window and door. Each cottage cost about $150. About twelve have been erected between the main building and the sea- beach. Mothers and infants are received for a fortnight or more. Dr. Bennett, the physician in charge, informs Dr. Lewis that the plan has worked admirably, although, at first SANITARY CARE AND TREATMENT OF CHILDREN 211 sight, these structures might seem difficult to keep dry in wet or stormy weather. Dr. Lewis further suggests, that for an " institution to re- main open for the summer months only, and designed as a convalescent hospital, the following seem to me to be the offi- cers and help required, say for ninety children : — " (1.) A resident physician. " (2.) A steward. " (3.) A matron. " (4.) Fifteen nurses, or one to every six children. This is about the proportion at the Children's Hospital, and, where infants and very young children are received, it is none too large. A night nurse is included in the number. " (5.) Two cooks (head and assistant). Three laundry maids, and such male help as the hospital grounds may re- quire (say three). " This, I must admit, appears a very large force of officers and help for only ninety children (twenty-six officers, that is, in all), but I do not see how the number could be lessened without prejudice to the efficiency and completeness of the hospital." " I roughly figure," he goes on to say, " the entire cost of such an establishment, with such a corps of officers, nurses, etc., at about $16,000 per annum. This estimate is based on the following figures, derived from the annual reports of the Children's Hospital for the year 1877 and for 1879 : " — 1877. Cost of a child per day, including food, wages, fuel, and medicines ........ 38^j- cents. Cost of a child per day, for food only . . . 25||- cents. Cost of a child per day, including all expenditures . 54 cents. 1879. Cost of a child per day, including food, wages, fuel, and medicines ........ 38 T V cents. Cost of a child per day, for food only . . . 18 T 2 T cents. Cost of a child per day, including total expenditure . 54|f cents. 212 SANITARY CARE AND TREATMENT OF CHILDREN. He adds that the Children's Hospital total expenditure in- cludes a large dispensary, providing free advice and medicines (some surgical instruments, appliances, also) for nearly eight thousand cases (not visits) annually, so that the estimate should be relatively less in a hospital not having this adjunct. Making a reasonable deduction for this, the cost would per- haps be about fifty cents, or even less, per child in the total expenditure. The trustees, again, desire information as to " regulations for receiving and administering medically and otherwise to the proper object of their care." Upon this point I will remark that I have been informed, by a gentleman connected with the dispensary attached to the Children's Hospital of Philadelphia, that the women who bring their young children to the dispensary for treatment are very unwilling, as a rule, to place their children in the hospital. When advised to do so by the prescriber they not only refuse, but often do not return for further advice. How this difficulty is to be met by the Baltimore sanitarium I do not see, unless arrangements can be made for taking, in some cases at least, the mothers with the children. The institution will be obliged, in the instance of nursing children, to provide accommodations for both mother and child, since to wean a child at such a period would greatly increase the danger to life. Another difficulty in such cases, connected with the removal of the mother from the city with her ill child, will be the question, what is to become of her other children, if she have any ; who is to take care of them, should she have no relation nor friend to take her place in the family during her absence ? I will suggest that the sanita- rium have in its employment several elderly, respectable women, or nurses, stationed in the city, who might, for mod- erate compensation in urgent cases requiring immediate re- moval from the city, take the place of the mother in the care of the household during her absence. Of course such a sys- tem would need great care in the selection of the agents, but I do not think of any other plan to meet this difficulty. It SANITARY CARE AND TREATMENT OF CHILDREN 2l3 would be expensive, but it would solve what otherwise ap- pears to me a great obstacle to the full success of the sani- tarium. The sanitarium ought to have attached to its central office in Baltimore one or more competent physicians, whose duty- it would be to see at the office, or visit at the houses of the applicants, the children for whom relief is sought. The phy- sician or physicians selected for this duty ought to be men of some considerable experience, in order that they may be skilled to detect contagious diseases in the proposed patient. In doubtful cases, the authorities at the sanitarium should be informed of the possible existence of contagious diseases, in order that the patient may be secluded from the general fam- ily, in some part of the main building intended for such cases, or in a detached building, until the true nature of the doubt- ful case shall be determined. A child with a contagious dis- ease of the skin, with whooping-cough, or some eruptive fever, or even with syphilis, may be the victim of exhaustion from heat, diarrhoea, cholera infantum, or dysentery, and may need the advantages of country air as much, or more, than one who has no such complication. In connection with the request of the trustees for informa- tion in regard to " regulations for receiving and administering medicines, and otherwise, to the proper object of their care," I propose to consider briefly the frequency and causes of sum- mer disease in young children in large cities. By showing the frequency of such diseases in large cities the wisdom of the charity established by Mr. Thomas Wilson will be dem- onstrated. By a study of the causes of this frequency, we shall learn much as to the proper treatment of the several diseases, both preventive and therapeutic, and we shall find that one of the most important objects for the trustees to ex- amine and arrange for is the character of the food to be sup- plied to the inmates. In the circular sent me by the trustees of the sanitarium is a table of mortality in Baltimore during the first five years of life in the four years 1875, 1876, 1877, and 1878. I find, 214 SANITARY CARE AND TREATMENT OF CHILDREN. from this table, that 8,549 children died in the first year of life in these four years. Of this total, 3,930 of the deaths, or 46 per cent, occurred during the three hot months of sum- mer, June, July, and August. In the second year of life 3,563 died, of which number 1,157, or nearly 32 per cent, died during the three months of June, July, and August. Of the whole mortality under one year, therefore, nearly one half, and in the second year almost one third, occurred in the three hot months. Nothing could show more clearly the great danger to life in the first two years of age than these simple facts. In Philadelphia, of the total annual mortality at all ages, about one fourth (25.16 per cent.) occurs in the first year of life. Over two fifths (40.49 per cent.) of the total mortality occurs in the first five years of life. (Report of the Board of Health of the City and Port of Philadelphia, to the Mayor, for the Year 1874, page 134.) In the same report it is stated that, in the fourteen years, 1861 to 1874, of the whole num- ber of deaths 23.97 per cent, were in infants under one year of age, and 41.51 per cent, in children under five years of age. It is also stated, that over one third of the deaths at these specified ages occurred in the hot months of the year. " These proportions," it is added, " great as they appear, are consid- erably less than those in most of the large cities of the coun- try, and compare very favorably with statistics for the whole United States." Dr. Thomas B. Curtis, of Boston, in the article on Infant Mortality in Buck's Treatise on Hygiene and Public Health, New York, 1879, vol. ii. p. 286, says: " In the cities of North America, the effect of the invasion of high tempera- tures in each year is the same, the mortality varying, how- ever, in proportion to the intensity of the heat. In moder- ately hot summers (1867, 1871, 1873,) the mortality under one year in Boston is doubled or tripled during the hottest month, while the mortality from one to five years is increased by half, or at most doubled. In a very hot summer month, on the other hand (July, 1872), deaths under one are sud- SANITARY CARE AND TREATMENT OF CHILDREN. 215 denly almost quadrupled, the deaths from one to five being barely doubled. Thus, we see that the distinctive influence of excessive heat is felt much more acutely during the first year of life than subsequently, while the reverse is noticeable with regard to the influence of winter cold, which tells se- verely upon children who have passed one year of age." One of the primary objects of the trustees of the Thomas Wilson Sanitarium must be, therefore, the selection of the site for the institution in as cool a region of country as can be found near Baltimore. Another powerful influence in determining the mortality at all ages, and especially in early life, is the density of the pop- ulation. In the Fortieth Annual Report of the Registrar General of England for 1877, at page 236, may be found the following curious and instructive statements as to the relative mortality according to the density of the population. The density is calculated upon the proximity of the population in yards. The proximity is given for five hundred and ninety- three districts of England and Wales, arranged in seven groups in the order of mortality. The districts of London are excluded. In Liverpool, the proximity being seven yards, the number of living out of which one will die annually is twenty-six, and the mean duration of life is twenty-six years. In Manchester, the proximity being seventeen yards, the number of living out of which one will die annually is thirty- one, and the mean duration of life twenty-nine years. At the other end of the scale, of three hundred and forty-five dis- tricts, in which the proximity is one hundred and thirty-nine yards, the number of living out of which one will die annually is fifty-three, and the mean duration of life is forty-five years. The smallest rate of mortality given is in fifty-three districts, in which, the proximity in yards being one hundred and forty- seven, the number of living out of which one will die annually is sixty, and the mean duration of life fifty-one years. Another cause which influences largely the mortality in early life is food. Children who are supplied with their nat- ural aliment, nursed by their own mothers, or suckled by a 216 SANITARY CARE AND TREATMENT OF CHILDREN. good wet-nurse, are much less seriously influenced by the summer heats, and by the other unfavorable hygienic condi- tions of large cities, as density of population, than those who are deprived of this aliment. My experience in Philadelphia convinced me long since that hand-fed children were vastly more apt to die of the summer diseases than those brought up at the breast. In the early part of my professional life it was one of the traditions of the nursery that, if a child could but be nursed through its second summer, its chances of es- caping the dangers of the hot season were greatly increased, and women of all classes were disposed to prolong the period of lactation through this age ; of late years this habit or rule seems to be going out of fashion. Few children of the upper classes of society, it seems to me, are now nursed beyond the end of the first year. Man} 7 are weaned at the eighth and tenth months. I am of opinion that the system referred to is a wise one, and that it is well for women to follow it, when they can do so. The objection made is that it exhausts the mother. When this is the case, there is no alternative but to wean the child, since not only the mother, but the child as well, would suffer from such exhaustion. For a number of years past, as I shall state at greater length further on, I have advised nurs- ing women to begin to feed their children at the age of from three to five months, and to persevere until they are taught the habit. By doing this in the mode I shall recommend, the mother's strength is greatly husbanded, the child is brought gradually and with more safety to the period of weaning, and the flow of breast-milk is maintained to a moderate extent as a precious resource, should the child be attacked by any of t the summer diseases. To show the mortality of hand-fed as compared with that of children nursed at the breast, I will cite a statement to be found in Professor Kehrer's excellent lecture on the Food of Infants (German Clinical Lectures, Second Series, Syd. Soc. Ed. p. 347). Professor Kehrer quotes C. Meyer as having found that of 8,329 children, six months and under, who died SANITARY CARE AND TREATMENT OF CHILDREN 217 in Munich from 1868 to 1870, 1,231 (that is, 14 per cent.) had been suckled, and 7,098 (that is, 84 per cent.) brought up by hand. It is nevertheless true that a great many children must be, and are, brought up on artificial food. It is important, there- fore, to discover, if possible, the causes of the great mortality in hand-fed children. The main cause is, of course, the loss of the natural aliment, and the impossibility thus far in the history of medicine of discovering any perfect substitute for it. The best substitute yet discovered is the milk of some one of the mammal class of animals. That of the ass, the goat, or cow is generally employed. The best is probably that of the ass, and it may be not difficult for the managers of the Balti- more Sanitarium to keep on the farm of the institution some of these animals to serve this purpose. But as cow's milk is the form of milk almost altogether employed in this country, I shall confine the remarks I have to make upon this subject to it alone. I shall not attempt to discuss the chemical qualities of cow's milk, or to trace minutely the causes of its occasional indiges- tibility, but shall confine myself to a consideration of facts so far as we know them. There are two points connected with the use of cow's milk for children which especially deserve consideration, and which I have learned to deem of the highest importance in practice. On these two points, I propose to dwell in some detail. One is the growing belief among practical men that the degree of freshness of the milk, and its preservation from all contami- nation with foreign matters, and specially with filth matters, have a great deal to do with its fitness or unfitness to serve as a food for the human infant. The second is the question as to whether it is best to use it pure for young children, or di- luted, and if diluted, in what proportions at different ages. It has long been known that cow's milk which has been kept too long, or which, having been preserved in unclean vessels, has undergone some change of a putrescent nature, is extremely apt to disagree with the infant and to be the cause 218 SANITARY CARE AND TREATMENT OF CHILDREN. of indigestion or diarrhoea at any season, and to incite attacks of summer disease in hot weather. Of late years several ob- servers have suggested, as one chief and potential cause of summer disease in children fed on cow's milk, the remarkable tendency of this fluid to undergo, when kept for some time after being drawn from the cow, putrescent changes. As this fact, if true, must be one of great importance to the officers of the sanitarium, and as it is one capable in large measure of prevention, I need not hesitate to quote in this essay the opin- ions entertained upon the subject. Dr. Thomas B. Curtis (Buck's Hygiene and Public Health, vol. ii. p. 290) says : " Milk, when exposed to atmospheric air, is known to be excessively putrescible. So liable is it to become contaminated by the development of various ferments, that Professor Lister used it as a substitute for Pasteur's solu- tion in his experimental investigations into the subjects of fermentation and putrefaction. i Milk,' he says, ' is a pabu- lum for all kinds of organisms ; nearly all kinds of bacteria (and there are indeed very many varieties) will live in milk ; whereas only a small proportion of such organisms will live in Pasteur's solution.' Not only is milk very prone to decom- position, but it is exceedingly difficult to disinfect it when once it has begun to undergo fermentation or putrefactive changes, in consequence of the access of organisms." Dr. Curtis (loc. cit. page 291) quotes some instructive facts observed by Dr. Baginsky during an investigation undertaken to ascertain the causes of the prevalence of infantile diarrhoea in Berlin. He came to the conclusion that the disease was chiefly due to the use of improper food. " He made a series of comparative experiments for the purpose of ascertaining the degrees of putrescibility of various articles of infant food, comprising woman's milk, cow's milk, Swiss milk, and two kinds of farinaceous food. These, having been previously boiled, were exposed to a continuous temperature of 37° C. (98.6° F.)." "After twenty-eight hours' exposure to this temperature the woman's milk and cow's milk remained al- most unchanged ; but the Swiss milk, although appearing SAXITARY CARE AND TREATMENT OF CHILDREN. 219 fresh, and the two farinaceous foods, exhibited bacteria in ac- tive motion. The woman's milk was alkaline, the cow's milk slightly acid, and the farinaceous foods strongly acid. After a further exposure of eighteen hours, the cow's milk and the Swiss milk were coagulated, and the farinaceous foods in a high state of putrefaction ; the woman's milk remaining still alkaline and almost unchanged. The experiments were re- peated many times, and always with the same results. They were also varied, and it was found that by careful manipula- tions and the use of distilled water, these changes might be delayed; but for all practical conclusions the first experiments hold good. The preeminence of woman's milk is acknowl- edged ; then comes cow's milk and the Swiss milk ; and only at a far-off distance the farinaceous foods experimented upon can be admitted, not as substitutes, but as merely supplement- ary substances, which are rendered less mischievous by the ad- dition of milk." Meissner is quoted by Dr. Curtis as asserting that cholera infantum never attacks children raised wholly upon breast- milk, and as being a determined advocate of the bacterial the- ory of diarrhoeal infection. " He expresses his conviction that the agency which, in midsummer, in densely populated districts occasions fatal diarrhoea does not reside in animal milk per se. The pernicious agent, he says, must be sought solely in the drawn milk resulting from the access of atmos- pheric air, and from the imperfect cleansing of the vessels in which the milk is kept and transported, and of the bottles, tubes, and mouth-pieces through which it is administered to infants." I will state at this point, that my own experience does not agree with Meissner's that nursing children never have cholera infantum. They certainly do have it in Philadelphia, but much more rarely in comparison with hand-fed children, nor do they have it so severely, nor in so dangerous or fatal a form. These experiments of Baginsky tend to confirm the opinion expressed by Mr. Simon, in 1858, to the General Board of 220 SANITARY CARE AND TREATMENT OF CHILDREN. Health of London, to the effect that " diarrhoeal infection owes its prevalence to infection by filth" See article by Dr. Curtis, in Buck's Hygiene and Public Health, vol. ii. p. 290. These views, which seem to be consonant with both theory and practice, may be of great service in guiding the officers of the sanitarium to a more successful use of cow's milk for the children who are to become the inmates of the institution. They show how important it may be in the economy of the institution to have the supply of milk drawn from the cow twice, or even three times a day. The proper care of the dairy, and a rigid inspection of all the vessels, utensils, cups, or bottles, intended for the younger children in particular, whose almost sole food must be milk, becomes a matter of singular importance. It would be well, too, it seems to me, to discard, as far as possible, in this institution the use of sucking bottles, with their tubes and mouth-pieces. It is very difficult to keep these instruments perfectly sweet and clean, even in private families, where each young child has a mother or nurse, whose whole time and care are given for it alone. How much more difficult in an institution where each nurse must have the care of five or six or more children. They can, I think, be safely dispensed with at the age of three or four months. Prior to that time, a common four or six ounce bottle, with a rubber mouth-piece or nipple slipped over the mouth of the phial answers every necessary pur- pose. This simple contrivance has the inestimable advan- tage of being easily kept clean, or, at least, much more easily than any of the more elaborate apparatus. Even this mouth- piece will soon become foul unless kept soaking in water be- tween the periods of use. The bottle itself ought to be care- fully cleansed after being used. In my own family I always used for the purpose of feeding, at the ages mentioned, a small glass or silver cup with a handle. I advise the use, at the sanitarium, of glass cups or small tumblers. There is no other material so readily kept clean, and none which can be more easily inspected by the proper officer. SANITARY CARE AND TREATMENT OF CHILDREN. 221 In a foot-note at page 427 of M. Parrot's work on Athrep- sia it is stated that in the foundling hospital of Moscow the children are half fed and half nursed, and that the only feed- ing vessels employed are made of glass, and have no nipple. I will mention that I have, for many years past, been in the habit of advising my patients to begin to feed their chil- dren on artificial food at the age of three or four months. I' did this in my own family and had no cause to regret it. I have followed this system for several reasons. In the first place, the child is taught to feed from an open vessel, instead of sucking from a bottle with its mouth-piece or tubes, which are so prone to become offensive that only the vigilant eye of a sensible mother or trained nurse can prevent it. The mere habit of taking food from a cup prepares the child to undergo weaning with much less trouble than when it is weaned ab- ruptly from the breast, and, lastly, the digestive organs be- come habituated by degrees to the reception and digestion of the new food. In advising this course I am careful to order only one feeding a day for the first two or three months. Afterwards, as the child strengthens, it is fed two or three times, and, in the second year, if the mother is able to nurse the second summer, I prescribe enough food to make it nec- essary for the mother to nurse only three or four times a day. I pass on now, under the request of the trustees for infor- mation as to " regulations for receiving and administering medically and otherwise to the proper object of their care," to the subject of the food to be supplied to the young chil- dren who are to be the inmates of the institution. There are few practical subjects within the domain of the medical art more difficult to deal with, about which more confusion and uncertainty prevails, than the simple one of the food for young children. My remarks will be confined almost exclusively to cow's milk. Should the officers of the sanitarium see fit, and find it possible, to have a few wet-nurses at the institution, for very young hand-fed infants who may arrive at the establish- ment dangerously ill, whether from heat, the malaria of the 222 SANITARY CARE AND TREATMENT OF CHILDREN. city, or improper food, and whose lives might, perchance, be saved by nursing for a few days or weeks, it would be well. They might also, perhaps, as was suggested before, have a few asses on the farm attached to the sanitarium, for the rea- son that the milk of this animal resembles human milk more nearly than does that of any other animal. But cow's milk will undoubtedly constitute almost the sole supply of food for children under one year of age, the chief supply for those in the second year of life, and a large proportion of what will be required for those over the last mentioned age. In seeking to determine how we are to feed children who have been deprived of the breast, I can conceive of no method so likely to lead to correct results as the very simple one of taking nature for our guide. By ascertaining the quantity of milk a healthy nursing woman furnishes at different periods of lactation, we determine the amount of liquid food we must administer to the hand-fed child, always bearing in mind that the food we choose shall resemble the natural aliment as nearly as possible. By careful comparison of the proportions of the constituents of cow's milk with those of woman's milk, we are enabled to bring the former, by the addition of water, sugar, and sometimes of cream, to a physical constitution much more like the latter than it is in its natural state. At least this is my opinion. We have, besides the comparison of the physical qualities of the two kinds of milk, long experience to assist us in determining the relative value of cow's milk vari- ously prepared. I have found very few statements by medical writers as to the quantity of milk furnished by nursing women, and the few that I have found differ so much from each other that I deem them of very moderate value. In the recent very able work by M. Parrot, of Paris, on Athrepsia, the author quotes Dr. N. Guillot as assuming from his observations that a child two days old takes from the breast twenty-one ounces of milk ; one of five days, seventy-eight ounces ; and one of eighteen days, ninety-one ounces. These amounts are, ac- cording to M. Parrot, entirely too large. He quotes, with SANITARY CARE AND TREATMENT OF CHILDREN. 223 strong approval, some observations made by Dr. Bouchard, at the Maternity Hospital at Paris. Dr. Bouchard concluded that a child one day old takes one ounce of milk per day ; one of two days five ounces ; at four days seventeen ounces ; after the first month, twenty ounces ; after the third month, twenty-three ounces ; after the fourth, twenty-seven ounces ; and from six to nine months, thirty ounces. M. Parrot says of these results of Dr. Bouchard : " I accept them entirely, after having determined their correctness by observations of my own." I may add that Guillot's results were obtained by weighing the child before and after the act of nursing. But this was done only for one nursing. He then assumed that the child nursed no less than twenty-five times in the twenty- four hours, and multiplied this number by the weight gained at the one nursing. Dr. Bouchard, on the contrary, weighed the children observed by him before and after the act of nurs- ing, and each time in the day that the act was performed. He found the average number of nursings in one day to be from eight to ten. My own observations amount to only three in number, but the mode of determination of the amount of milk yielded in each case was so necessarily exact, that I have entire faith in their accuracy so far as they go. The milk was drawn from the breasts by a breast-pump in each case, and then accurately measured. The first observation was made some thirty years since. A healthy woman, whose mother was a monthly nurse, was con- fined of a still-born child. The flow of milk was kept up by means of a young puppy. At the end of six weeks, she ob- tained a place as wet-nurse, and the day before she went to her place, I had all the milk her breasts furnished for twenty- four hours, drawn by a good breast-pump. It measured ex- actly a quart. I measured it myself. Is it not reasonable to suppose that, had the breast-glands been stimulated in this woman in the natural method, to wit, by the maternal in- stinct and by the suction of a healthy child, the amount would have been larger — say three pints. Since that period, I have 224 SANITARY CARE AND TREATMENT OF CHILDREN. had two admirable opportunities for determining exactly the amount of milk supplied by a healthy woman. In one case, a child four months old, suddenly, owing to a long illness from a chronic suppuration, weaned itself from its mother. It was fed for a time on cow's milk, with Mellin's food, but becom- ing very ill, I sent for a wet-nurse. The child could not be induced to take the breast, and the milk was therefore drawn by a breast-pump, and fed to the child from an ordinary nursing-bottle. The wet-nurse's child was at this time two months old. At first only small quantities, one and two ounces, were retained ; but after several days the child took daily of this milk as much as 36 ounces. Besides this quan- tity, which was drawn regularly by the breast-pump, the nurse suckled her own child in part. Assuming that she gave her own child a pint, we find that the amount supplied by her was fully three pints, or 48 ounces daily. In the second case, a child born of a very healthy young woman was unable to nurse because of a congenital defect of the mouth. The milk was drawn by a breast-pump, and ad- ministered from a sucking-bottle. When the child was five and six weeks old, it was taking 18 and 23 ounces per day. But, at the same time, the quantity drawn each day from the breasts, accurately measured, was 39-f, 41, 33|, 39, 39i, 39J, 31J, 41|-, 44i, 35, 40, and 39£ ounces. The largest amount any one day, in this case, was therefore 44J, and the smallest 31| ounces. Is it not probable that, had the breasts been stim- ulated in the natural way in this woman, the quantity would have been greater rather than less ? The difference in the estimates given by M. Parrot and myself are certainly curious. He supposes that a child re- ceives from its mother in the second month, 20 ounces of milk per day ; after the third month, 23 ounces ; and from the sixth to the ninth month, 30 ounces. My observations show that one woman supplied at the end of the sixth week 32 ounces; another, in the second month, 36 measured ounces drawn from the breast, and some given to her own child by nursing ; the whole amounting probably to 48 ounces ; and SANITARY CARE AND TREATMENT OF CHILDREN 225 a third who gave in the fifth and sixth week of lactation, from 31^ to 44J ounces each day. I feel so sure of the correctness of these observations that I shall take them as the guide for determining the amount of liquid food that children in good health ought to take at the ages mentioned. I proceed next to set down in detail what I conceive to be the best method of feeding children deprived of the breast. I shall, with a special view to the needs of the Baltimore Sanitarium, refer first to the diet for healthy children and those convalescent from disease, and second, to that which may be proper for those who arrive at the institution suffer- ing from indigestions, diarrhoeas, cholera infantum, dysen- tery, and general debility, induced by the summer heat of the city. In a large institution, such as the sanitarium is probably destined to be, the more simply the food can be prepared, the better for all concerned. I advise therefore that, as a general rule, the milk should be used diluted with simple water in the proper proportions. Milk containing fifteen per cent, of cream is the kind I prefer, when it can be had ; but as eight and ten per cent, of cream are considered a fair average, I assume in the rules I mention that the cream is ten per cent. If the child be young, one to three months old or younger, I advise the addition at first, until the degree of digestive force of the particular child may have been determined by ob- servation, of two parts of w r ater. To each pint of this mixture should be added half an ounce of sugar of milk, or half the quantity (two drachms) of cane sugar. After it has been as- certained that food of this strength is well borne, the patient may be put upon the proportion generally to be employed at the age of the child, whatever that may be. From birth to the end of the first month, and often in the second month, the proportion of two parts water to one of milk is the one I deem the safest and best. In the second month, and up to five or six months, the proportion ought to be half and half in healthy children. After this period it may be 15 226 SANITARY CARE AND TREATMENT OF CHILDREN. made two parts milk and one water until the end of the first year. In children in the second year of life the milk may often be given pure, though even at this age I have met with many cases in which the permanent addition of a fourth or a third of water renders the food more digestible, and productive of better results. So long as the child thrives well on diluted milk, there can be no valid objection, especially during the hot season, to a continuance of its use. It is certainly true that nature does not increase materially the richness of the breast-milk in the second year of nursing. The exact quantity of food required by different children varies according to their constitutional peculiarities. The proper amount in each instance can be determined only by the careful observation of an intelligent and experienced phy- sician or nurse. Still, there ought to be, and there must be, some general standard for the guidance of the officers of the sanitarium, and especially for the nurses on whom will de- volve the task of supplying to the various patients what they may need. I have already stated, as the result of my own observations, that nature supplies to the child, in the second month, as much as a quart per day, and in the third and fourth months three pints. These amounts accord closely with the quantities of diluted cow's milk that healthy children of good appetite and digestion generally take at those ages. I believe that the amount is not much increased between the sixth month and the end of the first year. Some large and healthy children are very hearty feeders. Some few such take as much as two quarts after the eighth or ninth month. I do not venture to lay down these standards as invariably right, but I do venture to say that when a child of three or four months old is taking only a pint of food a day, it is tak- ing quite . too little, and it is proper and necessary for those having it in charge to use every cautious endeavor to increase the sum. It is important, also, to establish some general rules as to SANITARY CARE AND TREATMENT OF CHILDREN. 227 the number of feedings per day. In very early life, the first and second months, food should be given every two hours, so much at each feeding as to make the pint, pint and a half, or quart per daj 7 required at the different ages. From the third to the sixth month, the feedings may be repeated every three hours. If this be done from six or seven A. M. to eight or nine P. M. there would be six in the day. From six to eight ounces should be given at a time, according to the vigor and natural appetite of the subject, making in all from thirty-six to fort}^- eight ounces, or from a little over a quart to three pints. After eight months most hearty children will take the eight ounces and some even more, or they may require now and then a extra meal, making up the total to nearly two quarts. I believe it is unnecessary, as a rule, to feed children in good health in the night after the age of eight months. If the last meal be given at nine or ten P. M., the child may usu- ally go to six A. M. of the following day. Should it be uneasy in the night, a drink of plain or sweetened water ought to suffice. If the child does not thrive well on simple milk and water, it will be proper to add some farinaceous substance to the diet, and to give once or twice a day beef or chicken tea. The best farinaceous materials are barley, oatmeal, or arrow- root, the choice in each case being determined by the taste or fancy of the child, and by its tendency towards constipation or diarrhoea. In the former case oatmeal, in the latter barley or arrowroot, are the best. When barley or oatmeal is used, two teaspoonfuls of either substance should be boiled for fif- teen minutes in a pint of water, and the fluid strained and added to the milk in place of simple water. Of arrowroot a teaspoonful and a half to the pint of water is sufficient. When the barley is used, it is best to procure whole barley, grind it in a spice-mill, and employ the ground substance. When beef-tea is to be used, I think the best mode of pre- paring it is that recommended by Dr. Letheby of London. Equal weights of lean beef and cold water (a pound to the pint) are to be infused together for an hour. The beef and 228 SANITARY CARE AND TREATMENT OF CHILDREN. water are then put into a pipkin, placed near the fire, and allowed to beat gradually, so that they shall reach the boiling point in fifteen minutes. They are allowed to boil only a few minutes ; I direct two minutes, in order to avoid a hard and tough coagulation of the albuminoid juices by more prolonged boiling. The water is decanted off the meat, the beef squeezed to obtain all the fluid, and the tea used w T ith the small and soft sediment which it contains. Salt, of course, is to be added. To make chicken tea for young children, I direct the half of a small chicken, or the leg and thigh of a large one, to be deprived of the skin, the bones to be broken, and the chicken put into a quart of w 7 ater, which is to be simmered down to a pint. To this sufficient salt is added. Children often take this thin tea with great avidity. I pass on, now, to the second portion of this subject, — the kind of food to be employed for children who arrive at the sanitarium suffering under the forms of disease induced by the heat of the city. In acute cholera infantum, one of the dangerous and dis- tressing features of the disease is the vomiting which often attends it. I have often seen children with this disease go to the breast, nurse eagerly, and vomit as though under the in- fluence of a powerful emetic. If this happen several times, the child ought to be allowed to nurse for one or two minutes only, when it should be removed from the breast. If this plan succeed, the nursing may be repeated every hour or two, and cool water, with half a teaspoonful of brandy to the half- pint, in the quantity of one or two tablespoonfuls at first, ought to be offered the child between the acts of nursing. Should even these small quantities of milk be rejected, the child must be withdrawn from the breast for twenty-four hours, and the brandy and water given frequently, in such amounts as the child can retain. Small doses, one or two tablespoon- fuls, or even teaspoonfuls, of beef tea, and especially of the chicken tea, may be tried every two hours, and they will often be retained. At the end of twenty-four hours, if the vomit- SANITARY CARE AND TREATMENT OF CHILDREN. 229 ing have ceased, the child may again go to the breast, being allowed to nurse at first for only one or two minutes at a time. As to the amount of water to be used on these occasions, my own practice is to give one or two tablespoonfuls every ten or fifteen minutes, until I find that it is well borne. When this proves to be the case, I give all the child will take of with pleasure and avidity. When the patient with cholera infantum is weaned, and on artificial food, it is necessary to dilute the milk largely (half or even three fourths) for a day or two, and give only two or three. tablespoonfuls every two hours, and to allow cold water, or brandy and water between, as directed above. In obstinate vomiting, the milk ought to be withheld entirely for twenty- four or forty-eight hours, and the small doses, two to four tablespoonfuls, of beef or chicken tea given instead, once in two or three hours. If this quantity is not retained, a single tablespoonful may be given every hour, or teaspoonfuls may be tried every fifteen minutes. It is a curious fact that a young child, one of three or four months to one and two years old, will often take eagerly brandy and water, and retain it, when all food, so-called, is rejected. I saw a child this past winter, four months oldi reject, by vomiting, breast-milk drawn from the breast by a pump, when more than two and three tablespoonfuls were given at a time, who could and did take with great avidity, and retain, considerable draughts of cold water containing a teaspoonful of brandy in each half-pint. This patient drank in this way two and three half-pints of water in the twenty- four hours. After three days the appetite for the brandy and water passed away, and the child turned from it with loath- ing. Some days later the desire returned, and the fluid was again taken for some time, with the same eager appetite. The patient recovered completely in a month, and was able to return to the diet of cow's milk and water. A month after this, again, the child was taking each day two quarts of the gelatine, milk, and cream food, to be referred to presently. 230 SANITARY CARE AND TREATMENT OF CHILDREN. When the vomiting has ceased and diarrhoea alone remains, and when the disease has been simply diarrhoeal from the first, the regulation of the food is the most essential part of the treatment. If the ordinary simple milk and water is not well borne, and if the stools contain masses of undigested casein, the food recommended in the work on Diseases of Children by Meigs and Pepper, consisting of milk and thin arrowroot water, with the addition of a little gelatine and cream, often succeeds extremely well, particularly in very young children. There is another preparation I have used in teething chil- dren, with severe summer diarrhoea and occasional vomiting, with excellent results. It consists of equal parts of thin ar- rowroot water, lime-water, cream, and ordinary milk. The arrowroot water is made of a small teaspoonful of that sub- stance to the half-pint of water. One tablespoonf ul of each of the ingredients, making two ounces, is given every two hours at first. In a day or two, three ounces, and afterwards four ounces, are allowed every two hours. If the diarrhoea im- prove, and the appetite increase, the proportions of the ingre- dients may be changed. The milk may be increased and the cream diminished, and the patient restored gradually to its or- dinary food. I am well aware of the fact that some writers of authority oppose the addition of cream to ordinary cow's milk, on the ground that any excess of cream is injurious rather than bene- ficial. The objection, however, seems to me to be based upon theoretical rather than upon practical reasons. I have employed the food referred to above, made of arrowroot water, gelatine, milk, and a small additional amount of cream, with sugar, for many years with much success, and I know that it has been used a good deal by others. Moreover, the second preparation mentioned above, consisting of milk, cream, lime-water, and arrowroot water, in equal proportions, in cases of acute sum- mer diarrhoea, has answered admirably well in my hands in a good many cases. It is twenty-three years since, in a case of severe typhoid fever in a boy ten months of age, who had SANITARY CARE AND TREATMENT OF CHILDREN. 231 been recently weaned, and whose digestive powers were at a very low ebb, I asked my father, Prof. Charles D. Meigs, what diet I should give the child. He advised me to have a thin arrowroot water made, and to add two tablespoonfuls of pure cream to six ounces of water, with a little sugar. The child took this food freely, lived on it for a number of days, recovered, and is now a vigorous and healthy man. In an- other boy, in the second year of life, I found it impossible for him to digest ordinary cow's milk, either pure or diluted. It invariably brought on diarrhoea, and I was compelled, after a number of trials, to use cream alone, diluted with water. He took a pint of the cream daily, with small quantities of beef or chicken tea and some bread. He was pale and weak-looking during all this time, but got safely through his dentition and is now a healthy, active boy of twelve years of age. I am acquainted with the history of a family in this city, in which the mother (not under my advice) has brought up three children, chiefly on cream. Two were fed from birth on it ; at first, they had a gill a day, then half a pint, and afterwards a pint a day. Two parts of water, and sugar, were added to the cream. In the second year, milk w T as added to the cream until a quart of each was taken daily. The last child, now eleven months old, a healthy-looking and well- grown child, is partly nursed, but takes a pint of cream mixed with water daily. None of those three children, the mother assures me, have ever had cholera infantum. I do not men- tion these facts as an advocate of the use of cream, saving in exceptional cases, but as showing how true it is that children have their idiosyncrasies. Children, like adults, are a law to themselves, and he is the successful physician who discovers the law of each patient, and so is enabled to carry him through some special crisis of his life. When diarrhoea in teething children -becomes chronic, in addition to the catarrhal state of the bowel a serious dyspeptic condition is set up, and the child often loses all appetite, iv L 'uses ordinary food, emaciates, and is in great danger of sinking 232 SANITARY CARE AND TREATMENT OF CHILDREN. from a slow inanition. In this state I have known life saved by a resort to articles of food which would not, and ought not, to be thought of in ordinary cases. This form or stage of digestive disorder seldom occurs except in teething children. I have seen it at the ages usually of eight or ten months to the close of the second year. The child, like some dyspeptic adults, comes to loathe its accustomed food. Under these cir- cumstances, I have learned to study what Dr. Joseph Parrish of this city often called the language of the stomach, — to offer new and unusual articles of food, until I find something which is taken eagerly or at least willingly. Pieces of stale bread cut thin, and spread with a little currant-jelly, are often very ac- ceptable, and they very seldom disagree with the child. Slices of bread, lightly toasted, with beef-tea, or pure beef-juice squeezed from rare or raw beef with a lemon-squeezer, poured over them, and salted, are frequently relished. I have used the yelk of an egg^ hard-boiled, broken into a powder, with salt, or finely minced rare beef, or mutton-chop ; or, what used to be famous in the nursery, a bit of fried ham, of which the fatty portion is often sucked with great pleasure, may be tried. Stale and crisp sponge-cake, in the form called finger-cakes, or ginger-bread made light and moderately hard, and not too highly spiced, are useful. In one case, I saw a child take the roe of herring sprinkled over bread, from time to time, and then begin to recover appetite. Lumps of white sugar, or small portions of good mint-candy, may be allowed. The prep- aration of chocolate called Rackahout, or very thin chocolate, made partly of milk, is sometimes liked, when all ordinary food is refused. In such cases great danger arises from the slow inanition going on ; and if we can prolong life for a few days, and at the same time rouse the dead appetite, and stimulate the salivary and gastric glands to renewed action, life may be saved. If this plan be followed carefully, and the various articles named tried in succession, we shall often be able to find something that will be taken willingly. The trustees ask for " your suggestions in regard to the most practicable means of lessening the risks and dangers in_ SANITARY CARE AND TREATMENT OF CHILDREN. 233 cident to children exposed to the heated and impure atmos- phere of a large city, during the summer months." These " risks and dangers " can be lessened only by the removal, when removable, or by the lessening, when irre- movable, of the causes which give rise to them. The chief causes of danger are heat, uncleanliness, density of population, and improper or unwholesome food. The heat is greater in the cities than in the rural districts, and it is more fatal. One cause of the greater heat is the diminished movement, and the stagnant condition of the air in the streets, and these condi- tions are most marked, of course, in the narrower streets, and especially in the blind courts and alleys, where the poor and unfortunate are often compelled to live. Our large cities can- not unbuild themselves, but they might, by municipal author- ity, determine that, in the future, the main streets should be made wide avenues, and that no streets shall be opened of less than a certain width, and no blind alleys nor courts whatever. Let each city insist on a plan, hereafter, which shall secure a free and unimpeded movement of the air, and she will soon lessen the mortality of the population, and especially of her young children. The refusal of permission to open any more streets below a certain width, or of any blind courts or alleys whatever, would have another most useful result. It would diminish the density of the population, which, as has been shown, is a large factor in the determination of the death-rate, and of the expectation of life, in the population. The establishment in a city of as many open squares or parks as possible tends to diminish heat by increasing the ven- tilation, and by the effect of trees and grass, and to improve the purity of the atmosphere. The gift of such open spaces by munificent citizens, their retention in the original plans of the town, or their purchase by the municipality, would' diminish the intensity of two causes which act so fatally on children, — heat, and density of population. To diminish the injurious effects of heat in summer, the houses ought to be built with considerable window-space. It might be enacted as a law that no house shall be erected in 234 SAXITARY CARE AXD TREATMENT OF CHILDREN. future with less than a certain amount of window-space. Nor should any house be erected without windows opening on two sides, front and back, if possible, so as to secure a free venti- lation through the main body of the house. The windows of the upper rooms of the house, at least, ought to be hung with shatters of the Venetian pattern, so that currents of air may pass freely, while the brilliant light of midday may be excluded. The houses should be built with an open fireplace in each room, to promote thorough ventilation in summer. And when this cannot be done, and the house is warmed by a furnace alone, ventilating flues should be run through the walls. Besides heat and density of population, one of the chief causes of infant mortality is unwholesome food, and especially, as would seem from modern investigations, stale and impure milk. To lessen this cause, each city ought to have a legalized inspector of milk, who, after a certain standard quality of milk shall have been agreed upon, ought to make frequent in- spection and occasional analysis of the milk, to see that the provisions of the law are carried out. One part of his duty ought to be to see that the vessels in which the milk is carried to and transported about the cities are kept pure and clean. Any milkman whose vessels are unclean and foul ought to be suppressed as a public nuisance. Uncleanliness in the household being another cause of dis- ease, and one especially rife among the poor, the supply of water ought to be large and its cost as moderate as possible. In the ninth Report of the Registrar General of England, for 1846, it is stated, page 27, speaking of Manchester : " The house and the children of a laboring man can only be kept clean and healthy by the assiduous labor of a well-trained, industrious wife, as any one who has paid the least attention to the subject is well aware." Dr. Curtis 1 goes so far as to say: "It appears probable, then, that the poisonous miasmata, which are evolved from urban filth under the influence of high temperatures, do not 1 Buck's Hygiene and Public Health, vol. ii. page 293. SANITARY CARE AND TREATMENT OF CHILDREN. 235 exert their universally recognized noxious action upon the in- fant directly by inhalation, but indirectly through the inter- mediate instrumentality of putrescible articles of diet. The injurious agent by which this particular form of filth infection takes place is rotten food taken into the stomach rather than foul air taken into the lungs." If the city could allow one faucet to each house, free of cost, or at a very low rate, it would be a great boon to the poor. Possibly, if the poor house- wife could afford, like the rich, to have a faucet on each story of her house, instead of running to the hydrant in the yard for all her water, she might learn to be more liberal in its use, and thereby keep her house, herself, and her children cleaner and fresher. The husband, too, when he returns from his day's labor, reeking with sweat and begrimed with the dust of his necessary toil, might then purify himself from all these sources of unwholesome odors, which assist to poison the air of his small rooms. The trustees desire, moreover, " your views as to the best methods of extending a general knowledge of simple hygienic rules for the treatment of children at home among the poorer classes." I can think of but two modes in which the poorer and more illiterate classes of society can be taught better hygienic rules for the treatment of children at home. One is by gratuitous distribution of a proper tract or tracts on the subject, and the other (this would apply only to Baltimore) would be for the Baltimore Sanitarium to make it one of the duties of its offi- cers (not medical alone) to endeavor, in their intercourse with the poor, to teach them such simple rules as may be nec- essary. I suggested, in the early part of this essay, that the institution should have in its employment, in Baltimore, a few elderly, respectable women or nurses, who might, when the mother of an ill child is compelled to leave other children helpless at home, take her place in the household during her enforced absence. If this plan were adopted, these women, with a very little previous training, might do more to promote correct views of hygiene amongst the poor than many tracts. i 236 SANITARY CARE AND TREATMENT OF CHILDREN. If it is determined to publish a tract on this subject, I sug- gest something like the following. SHORT HINTS TO THE POOR FOE, THE CARE OF YOUNG CHIL- DREN DETAINED IN LARGE CITIES DURING HOT WEATH- ER. There is no one thing so essential to the safety and health of a young infant as breast-milk. Let the mother therefore use every care to keep the supply of this food which nature gives her. To attain this end, the father of the house should be willing and anxious to toil for the income necessary to enable the mother to remain at home, taking care of the household, and nursing her child, for the first year or year and a half. Let her suckle her child, if possible, through its second summer, feeding it in part, large part, if she will, but keeping the flow of the milk in the breasts to fall back upon, should the baby be taken ill. The father, to enable his wife to do this, must avoid intem- perance. The money spent in drink by the intemperate man would supply food for the mother, and, when necessary, milk for the child. Let the mother see to it that the house is kept clean and sweet. To effect this, she must not be afraid of using water freely to keep the floors and culinary vessels, and, above all, the vessels for holding milk or broths, clean. Carpets, especially old ones, must be taken up, beaten, and hung in the open air, to rid them of the dust and filth-par- ticles, which will cling to them when not thus treated. An old, soiled carpet gives out, when kept long on the floor, a most foul and musty odor, w T hich is a sure sign that it needs a good ventilating. When the hot days of summer arrive, when the tempera- ture rises to 80° and 90 ° in the shade, let the mother beware. One or two such days will often double the mortality amongst young children. The house must be well ventilated. There is much more danger from a close, musty, and stagnant atmos- phere in the house than from any currents or draughts neces- SANITARY CARE AXD TREATMENT OF CHILDREN. 237 sary to change the air constantly. Chimney-places should be kept permanently open. Windows must be opened, and in hot weather kept open day and night. If the temperature rise in the rooms at night (and every mother ought to have a thermometer and learn to read and use it) above 90°, not only should windows be opened but doors as well. It is im- possible to have too much air in the house in such weather, unless it is blowing a gale from a thunder-gust, and then the thermometer will soon fall below 90°. During these spells of extreme heat everything should be done to keep children cool. They should be bathed in water from which the chill has been taken, or washed in cool water morning and evening. All heavy clothing must be removed. The thinnest possible flannel or merino shirt on the body, with a muslin frock, are all that the child needs. He should sleep on a firm mattress or a paillasse, dressed in a thin flannel or merino undershirt, and a muslin night-dress. He needs no flannel petticoat, and should be covered only with a sheet. No blankets, and above all no old family shawls, ought to be wrapped about a young child on a hot night. The dan- ger from over-heating at such times is far greater than any that will arise from light covering and abundance of fresh air through open windows. Children who are hand-fed entirely, or in part, must have the simplest food. In the first year no other food than one of which milk is the base, with sometimes a little beef or chicken tea, ought to be allowed. The milk of the cow, goat, or ass may be used. In this country cow's milk is nearly al- ways employed. To be sure that this is fresh and pure when it reaches the house must be one of the mother's chief anxie- ties. She ought to know her milkman personally, in order to judge whether he be honest and painstaking or not. If she can discover one who brings his milk from a farm of his own, it is best to do so. The milk must be taken, of course, once a day, and in very hot weather, if a fresh supply could be obtained in the afternoon, it would be a great safeguard against illness. When the milk is taken but once a day, it 238 SANITARY CARE AND TREATMENT OF CHILDREN. should be boiled directly upon being received, in hot weather. Boiled milk keeps sweet longer than unboiled. In very hot weather the addition of ten to twelve grains of carbonate or bicarbonate of soda to each pint of milk assists greatly in keeping it from becoming acid. But however good and per- fect the milk may be when received, it will not continue so long unless the mother take good care of it after it has come into her hands. If put into unclean or partially foul vessels, if set down near half-spoiled meats, or old decaying vegetables, or in an unclean, stinking cellar, with a filthy atmosphere round about it, it will soon itself become more or less putres- cent, and when given to a child in this state it becomes one of the most potent excitants of summer disease that can be found. When the child is over four or five months, let it be taught to drink from a small glass tumbler or china cup instead of from sucking-bottles. Such vessels are much more easily, and therefore certainly, kept clean and sweet than any sucking- bottle. When the child is younger than this, and when it must be fed from a bottle, the simpler the one used the better. An ordinary medicine-bottle of four, six, or eight ounces, ac- cording to the age of the child, with a common India-rubber nipple or mouthpiece, makes the best apparatus. Between the feedings the bottle must be carefully cleansed with boil- ing water, and both it and the rubber nipple kept in water. Give the child no anodynes, no medicines, no stimulus, un- less it be ill. Then send for a physician. Take care at all seasons, but take care especially in hot weather, to offer chil- dren who cannot yet indicate their wants, cool water fre- quently through the day. In very hot weather, a child of a few months old needs more water than it gets in its mother's milk or in cow's milk. Let it drink all the water it wants. It ought to want a wineglassful, or more, several times a day. CAUSES OF THE GREAT MORTALITY OF YOUNG CHILDREN IN CITIES DURING THE SUMMER SEASON, AND THE HYGIENIC MEASURES RE- QUIRED FOR PREVENTION. BY J. LEWIS SMITH, M. D., Of Neio York. PREFATORY NOTE. " The Thomas Wilson Sanitarium for Children of Baltimore City," was incorporated " for the purpose of securing a sum- mer retreat for sick children from the heat and unhealthful- ness of the city, and for such other kindred purposes as may be hereafter determined upon by the corporation." Mr. Wil- son gives the following reason for making the bequest : " I have observed for many years, with much concern, the great and alarming mortality which occurs each summer among young children deprived by misfortune of their parents of all opportunity for removal from the heated and fatal atmosphere of the city." In executing the trust committed to their care, the trustees secured a tract of land, consisting of one hundred and fifty acres, about six hundred feet elevation above sea- level, and distant from the city one half-hour by railroad. The information which the trustees seek from essayists may be presented in the following propositions embodied in their cir- cular of December 3, 1879 : — I. The best methods of extending a general knowledge of simple hygienic rules for the treatment of children at home among the poorer classes. II. The most practicable means of lessening the risks and dangers incident to children exposed to the heated and im- pure atmosphere of a large city during the summer months. III. The regulations suitable for receiving and administer- 240 MORTALITY OF YOUNG CHILDREN IN CITIES. ing, medically or otherwise, to those who shall be the proper objects of their care, special reference being made to the char- acter, isolation, and grouping of the requisite buildings and provision for mothers or nurses accompanying their children. The trustees add : " In the fulfillment of their duties they hope," at least, " to show a model of experiment, which may prove of value as a contribution to the best means of lessen- ing the mortality and promoting the welfare of young children here and in other large cities." It is apparent, from these quotations, that while Mr. Wilson especially contemplated making provision for the care of sick children in a summer retreat during the summer months, he still empowered his executors to devote his bequest to " such other kindred pur- poses " as they might determine upon. The trustees evidently regard a sanitarium as the main feature of the scheme to be carried out, and have accordingly given due prominence to that part of the plan by purchasing the site and specifying some of the details of arrangement. They have, however, somewhat extended their inquiries beyond the sanitarium, and in general language invite the discussion of the proper care of sick children of the poor, as to the hygiene of their homes, and the prevention of sickness during the heated months, in the following language : " The trustees wish your suggestions in reference to the most practicable means of lessening the risks and dangers incident to children exposed to the heated and impure atmosphere of a large city during the siimmer months, also your views as to the best methods of extending a general knowledge of simple hygienic rules for the treatment of children at home among the poorer classes." It is in this larger sense that this paper is written. The following essay will consist of three parts. In the first we will explain in what way the summer season is so fatal to children ; in the second what remedies should be employed, and how the sanitarium should be constructed and conducted ; while the third part will be devoted to the consideration of the hygienic care of the children in the sanitarium or else- where. The first and third parts will furnish information MORTALITY OF YOUNG CHILDREN IN CITIES. 241 upon such subjects as family visitors in Baltimore, who may be employed by the Association, should fully understand, and such information also as it would be proper to impart to poor families of the city, by tracts or other cheap publications. PART I. TEMPERATURE AND MORTALITY ; DISEASES. Baltimore city, in latitude 39° 17', has a summer tempera- ture which varies between 50° and 99° Fahrenheit. Its mean temperature in the three summer months in four consecutive years was as follows : In 1875, 74.6° ; in 1876, 76.6° ; in 1877, 76°; and in 1878, 75.3°. The following thermometric statis- tics of these four years — those of last year I do not possess — correspond, as will be seen, with the statement made in the "Encyclopaedia Britannica " in reference to Baltimore, to wit : " Its mean annual temperature is 56° Fahrenheit ; the mean summer and winter temperatures 76° and 36° respect- ively." Temperature of Baltimore. Highest and Lowest. Mean Monthly. Months. 1875 1876 1877 1878 1875 1876 1877 1878 January 52- 1 71-17 54- 1 57- 6 30.1 41.5 32.1 35.7 February 59- 3 65-12 63-18 63-20 29.3 37.8 40.5 47.6 March . 63-19 69-12 65- 9 72-21 39.5 39.8 41.4 49.3 April . . 74-23 75-30 80-32 79-42 49.4 52.1 53.6 58.7 Mav . . 88-42 88-34 92-41 85-43 64.1 64.2 62.7 63.5 June . . 97-54 95-51 95-55 92-51 73.7 75.9 73.7 70.1 July . . 96-61 99-59 93-64 98-65 78.0 80.4 78.7 80.8 August . 88-58 90-55 94-63 92-59 73.4 75.9 77.6 76.0 September 92-43 88-45 88-48 87-47 65.9 65.6 67.9 69.3 October . 77-34 77-30 80-41 80-35 55.5 52.4 59.7 58.7 November 65-16 76-25 68-25 61-33 42.9 47.1 48.4 47.3 December 67-12 56- 1 67-22 61-15 38.3 28.7 43.5 35.4 Baltimore " is pleasantly situated on slightly undulating ground," and is much less densely populated than many of the large cities of the United States. According to the cen- sus of 1870 there were, in the average, only twenty-seven in- 16 242 MORTALITY OF YOUNG CHILDREN IN CITIES. dividuals to each acre within the city limits. Nevertheless, with apparent sanitary advantages, there is a large mortality of the infantile population during June, July, and August, as will be seen by the following table : — Deaths of Children under Five Tears of Age. 1875. 18' 6. 1877. 1878. Months. o jj g! o it o 8 eg 5* EH* °ti £ > O £ 5 * p.- O £ C £ 0.5 .• t * c > >- V or -1 oE u 3 in o fe u o» SH gfe ■- a SE -3* s p 39 78 1^ p £-a p £■3 41 c* P January 133 116 74 35 121 85 104 58 29 February . 153 66 70 131 62 45 122 112 35 120 44 3^2 March . . 141 54 54 152 99 45 144 150 65 151 68 41 April. . . 113 42 38 101 56 41 135 109 42 103 4+ 32 May . . . 119 29 53 105 63 28 121 88 44 161 43 38 ( June . . . *. ( 23S 43 36 x> (549 88 20 eo (382 176 43 (270 58 37 [July . . . 1 <489 66 49 Si J 418 105 20 S } 423 140 34 8 {257 53 34 ( August . . °> (259 91 25 -" ( 261 119 31 M ( 248 159 35 l ~ (203 65 35 September . 174 90 28 154 70 34 167 109 44 125 67 34 October . . 165 VI 22 104 49 22 98 59 57 117 42 33 November . 101 46 25 89 45 25 96 63 35 116 34 46 December . 133 68 30 137 95 52 125 80 43 518 107 33 53 Total . . 2,216 705 508 2,317 925 398 2,182 1,329 1,834 604 444 The above table is instructive. It shows that the children in Baltimore who suffer most from the heat and insanitary conditions of summer are chiefly under the age of one year. Therefore special regard must be had for such infants in the measures to be employed for the purpose of reducing the mor- tality of children. The table shows that the average monthly mortality in the first year of life during the four summers was 382.9, while that of the remaining months of the same years was only 12&5. In other words, the mortality of the summer months was nearly threefold the average mortality of the spring, autumn, and winter months, as regards infants under the age of one year. If the mortality of infants of this age had averaged the same during the three hot months that it did during the remaining nine months, there would have sur- vived 573 infants in 1875, 865 in 1876, 928 in 1877, and 608 in 1878', making an annual average saving of 743 lives. MORTALITY OF YOUNG CHILDREN IN CITIES. 243 IN WHAT WAY THE SUMMER SEASON IS SO FATAL TO CHILDREN. We purpose, in this part of the essay, to consider briefly the nature of the diseases, to which the increase of mortality among children, during the summer months, in Baltimore, as well as other large cities of the Union, is chiefly due. If we obtain a clear and accurate idea of these diseases we will bet- ter understand what measures to employ for the purpose of preventing them, or rendering them milder, and more tract- able. We hope to be able to show why the summer weather is so fatal to children. 1. General Depressing Effect of the Summer Weather. It is the common belief among people, derived from expe- rience and observation, that the prolonged elevation of temper- ature of the summer months impairs the appetite and diges- tion, produces languor, and diminishes the vitality and recuper- ative powers, so that one under its influence is less able to endure disease of whatever kind than in cool and bracing weather. There is, no doubt, truth in this, especially as re- gards infants, for they badly tolerate a high elevation of at- mospheric heat. Perspiring less than adults, they suffer more from the heat. It has not been unusual in my practice to see infants, after a very hot day, thirsty and fretful, sleeping little, with a temperature, one, two, or three degrees above the nor- mal, which state I could attribute to nothing except the hot weather. It is not unusual also that infants remaining in the city gain nothing in weight and strength, or lose in both dur- ing the three summer months. Now exhaustion is the imme- diate cause of a large majority of the deaths in infancy and childhood, and anything therefore which lowers the tone of the system, increases just in that proportion the gravity and danger of most diseases. The injurious effects of the summer season upon the system are only partially due to the heat, as we shall see hereafter, but are largely attributable to the noxious gases which are engendered by the heat where there is a large popu- 244 MORTALITY OF YOUNG CHILDREN IN CITIES. lation, and therefore children of the city suffer more than those in the country from this cause. It is known to physicians that many constitutional and local maladies to which children in the summer season are liable, are more apt to occur when the tone of the system is lowered than in the state of robust health, for one who is vigorous, with full and active circulation, more quickly and completely reacts under noxious agencies, and so to speak throws off the disease. This is notably true of the inflammations, and the numerous forms of scrofulous ailments, which are so com- mon in the families of the poor, and which are apt to end in tuberculosis. Therefore the condition of the general health which hot weather is apt to produce in young children of the city may properly be regarded as a predisposing cause of the sickness and mortality of the summer. It is customary with nosologists to classify diseases in two divisions, the constitutional, and local; and to group the local, according to the part or system which they affect, namely, into diseases of the cutaneous, nervous, respiratory, digestive sys- tems, etc. There are no serious diseases of the cutaneous and respiratory systems, which are due to the summer weather. The nervous system is more frequently involved, but the most frequent and fatal of the summer diseases, and therefore the one which demands most attention, pertains primarily and chiefly to the digestive system. 2. Nervous System. We shall see hereafter that the brain occasionally becomes seriously involved in the course of the diarrhceal maladies of young children, and that this complication is common during the hot months. This constitutes, indeed, one of the chief dangers of the summer diarrhoeas in infancy, and will be fully described in the appropriate place. Children as well as adults are occasionally overcome by heat, having a genuine coup de soleil. It is attended by great heat of head, drowsiness, jacti- tation, and perhaps convulsions. The ordinary form of con- vulsions in children, occurring suddenly in a very hot day, has MORTALITY OF YOUNG CHILDREN IN CITIES. 245 so many causes, that it is often assigned to something else than the heat ; but although there may be other causes, the high atmospheric temperature must, in my opinion, be re- garded as a cooperating cause in not a few cases, and some- times as the chief cause. Young and nervous or susceptible children, who have been taken out in the sun, or have exer- cised or been excited in a hot room, are especially liable to these convulsive seizures. I have sometimes attributed, I think correctly, that very formidable disease meningitis, or inflammation of the mem- branes which cover the brain, to either direct exposure to the sun's rays, or to excessive and protracted atmospheric heat. Infants, whose heads are scantily covered with hair, and in consequence cooler, and are ordinarily in the shade, seem to me less frequently affected in this way than children of two to three years and older, whose heads are more covered, and who, beginning to go about, are more apt to be exposed to the sun, or to suffer from the heat. I may cite the following cases, which I have published elsewhere, as an example : July, 1876, in New York city, was characterized by excessive and long-continued atmospheric heat, the temperature in the Cen- tral Park Observatory, in the shade, never falling below 61°, though never above 98°, and having a mean of 82.9°. There was also unusual dryness of the atmosphere, since during the entire month prior to July 30 there were only fourteen hours of rain, with a rain fall of .77 of an inch, and the average at- mospheric humidity was represented by 65, saturation being denoted by 100. During this month I treated in private practice four fatal cases, all between the ages of two and seven years, which I diagnosticated meningitis, none of them presenting any symptoms of otitis or tuberculosis. It would seem that the atmospheric heat had much to do with the de- velopment of the disease in these cases. One died in two days, but in the others there was the usual duration. Men- ingitis, however, occurring independently of inflammation of the ear or of tubercles at the base of the brain, is not common, and it cannot be said to increase materially the death-rate of the summer season. 246 MORTALITY OF YOUNG CHILDREN IN CITIES. 3. Digestive System. The Summer Diahrhcea (the summer complaint). It is to this disease that the increased mortality of the summer months is chiefly due. It is the most common and fatal of the summer maladies in all our large cities. The first cases begin to occur as the weather becomes warm in the middle of May, and new cases constantly occur, until the weather becomes cooler in October or November. Its maximum prevalence is in midsummer. The history of this disease is in the majority of instances as follows : The infant is observed to droop, and be less cheer- ful, and its alvine discharges are more frequent, and of less consistence than formerly. At first little attention is given to this change in the health by parents or nurse, who often at- tribute it to teething, and consider the diarrhoea a relief to this physiological process, so that in many instances medical advice is not sought till several days or weeks have passed, and what might in the beginning have been readily checked by hygienic or medicinal treatment becomes by slow increase a formidable malady. Occasionally the commencement is more abrupt. In conse- quence of some indigestible food, as unripe vegetables or fruits, pasti*}', etc., vomiting and purging are excited, which con- tinue till the offending substance is removed. The gastro- intestinal surface is irritated, and under the deleterious in- fluence of the hot weather the diarrhoea which has been established continues, having the same symptoms and ana- tomical characters as when it begins in the ordinary way. Cholera Infantum. Now and then the initial symptoms are very severe, indicating a form of diarrhoea which is ex- tremely dangerous unless speedily checked or modified. The infant may have endured the hot weather with little impair- ment of its general health or the digestive function, when suddenly, from the effects of a very warm day or of some error in the feeding, symptoms occur which resemble closely those of Asiatic cholera. Frequent vomiting and the purging MORTALITY OF YOUNG CHILDREN IN CITIES. 247 of thin watery stools, which contain little or no solid matter and wet the diaper like urine, produce such rapid prostration, and such pinched and shrunken features, in the course of a single day or night, that the friends do not require to be told of the danger, for they perceive it in the changed physiog- nomy, and summon the physician early. This form of the disease has been long known by the name cholera infantum, or choleriform diarrhoea. Resembling in its symptoms Asiatic cholera, except that it is unattended by cramps, it neverthe- less has no kinship with that disease, for it occurs every sum- mer, quite independently of choleraic epidemics. It does not always occur in those whose previous health has been good, but it occasionally supervenes on a milder type of diarrhoea. However commencing, it does not continue long without abatement in its intensity or a fatal ending. Whether the summer diarrhoea begins mildly or with chol- eriform symptoms, whether its course be uniform, or now and then exacerbations occur, it causes progressive weakness, and emaciation as long as it lasts. In a large majority of cases, even when not treated, or improperly treated, it is not speed- ily fatal. If not controlled by remedies or a favorable turn of circumstances it continues for weeks. Therefore towards the close of warm weather, in addition to the new cases that may arise, there are many protracted cases that had an earlier be- ginning, presenting an appearance from wasting and weakness like that in advanced consumption. As death may occur with- in a few days or not till after many weeks, according to the severity of the attack and the strength and endurance of the patient, so the summer diarrhoea may be arrested within a few hours from its commencement, or not till after several weeks. But if it have continued several weeks with the usual emacia- tion and weakness, convalescence is necessarily very gradual. In no other disease in which, recovery may occur do we ob- serve so great loss of flesh and strength as in protracted cases of this malady, and in no fatal disease is it excelled, unless in tuberculosis. The bones become prominent, the cheeks hol- low and thin, the eyes sunken, with eyelids open during sleep, 248 MORTALITY OF YOUNG CHILDREN IN CITIES. the walls of the chest showing deep grooves between the ribs, the abdomen hollow, the limbs shrunken, and the skin cover- ing them lying in wrinkles ; and yet many of these cases have received the best nursing and all the attention which the de- votion of a mother is able to supply. Although this disease affects primarily and chiefly the di- gestive apparatus, other organs, as might be expected when the general nutrition is so much impaired, suffer also. The brain wastes from lack of nourishment, so that the anterior fonta- nelle, or open space on the top of the head, is depressed, and the cranial bones, if not firmly united, begin to sink and over- ride each other. In a certain proportion of cases, in conse- quence of this waste of cerebral substance, and the feeble ac- tion of the heart, which propels the blood, passive congestion occurs in the veins and capillaries in depending portions of the brain, and in the cranial sinuses, which contain venous blood, and as a result some of the serum, or watery part of' the blood, escapes from the vessels (hydrocephalus ex vacuo) into the cranial cavity. When these changes occur in and upon the brain, cerebral symptoms appear, as drowsiness, roll- ing the head, apathy, tardy action of the pupils, and some- times irregular respiration, and diminished amount and fre- quency of the alvine and urinary evacuations, the result of impaired innervation. The London physicians of the first half of the present century particularly called attention to this state of the brain, which they designated spurious hy- drocephalus, or hydrocephaloid disease. The lungs also are not infrequently involved in protracted and feeble cases. A cough occurs, painless, not frequent, and perhaps overlooked in the presence of graver symptoms. This is due to a state of the pulmonary circulation, similar to that within the cranium, namely, a retarded flow and conse- quent congestion in depending portions of the lungs, due to the feeble propelling power of the heart, and partly, perhaps, to the altered state of the blood and the blood vessels. The pulmonary congestion thus arising (hypostasis) involves only a small portion of the lungs. It does not produce pain, or MORTALITY OF YOUNG CHILDREN IN CITIES. 249 accelerate the respiration. It continues till a more vigorous state of the system, and a stronger and more active flow of blood are restored. This retarded encephalic and pulmonary circulation, and the anatomical changes to which they give rise, are therefore to be regarded as complications, and not es- sential elements. They increase the gravity of the primary malady, and that involving the brain is not infrequently the immediate cause of death. Obviously, in order to understand the nature of this sum- mer diarrhoea, and the structural and functional changes to which it gives rise, the pathologist must examine carefully and fully the state of the digestive apparatus, since in it, as stated above, the primary and essential lesions occur, and as the prominent symptoms are vomiting and diarrhoea it is evi- dent that the stomach and intestines are chiefly in fault. This malady is anatomically a catarrh or inflammation of the gastro-intestinal surface. The intestine consists of two portions, namely, an upper or small portion, which extends from the stomach downward, and a lower or large portion which, continuous with the small intestine above, extends to the end of the digestive canal. The designation " small " and " large " refers to the relative diameters of these two divisions of the intestinal tract. Although there have been frequent vomiting, we usually find at post-mortem examinations nearly the normal color and appearance of the gastric mucous membrane. It may be softer and more easily detached than in those who have died of diseases not implicating the digestive tract, but com- monly the redness due to increased vascularity, ordinarily present when a mucous surface is inflamed, is lacking, or it is much less marked in the stomach than in the lower portion of the intestinal tract. The same is true of the upper part of the small intestine, known as the duodenum and jejunum, the surface of which either has the normal color or presents vascular streaks, and arborizations. It is only in exceptional instances, according to my observations, that the stomach and upper part of the small intestines present decided inflam- 250 MORTALITY OF YOUNG CHILDREN IN CITIES. matory lesions. Cases of this sort, which I recall to mind, have been chiefly young infants. But when in tracing down- ward the intestinal tube, we reach the middle portion of the small intestine, more marked evidences of inflammation ap- pear : the redness and thickening are more decided, and in- flammatory lesions occur from this point onward, with per- haps occasional interruptions, to near the end of the intestinal tube. From the lesions which it produces, namely, the red- ness or vascularity and thickening of the mucous membrane, and the occasional small, circular ulcers, like canker sores in the mouth, which are in many cases present in the large in- testine, it appears that the inflammation increases from its point of commencement above to its termination below. Pro- jecting from the inflamed surface here and there are little bead-like prominences, which are swollen solitary glands, and the destruction of which has probably caused the ulcers al- luded to. In exceptional instances, I have made post-mortem ex- aminations in protracted cases, as well as in those of short duration, without finding those marked inflammatory lesions which are commonly present, and which I had expected to observe, and it is now admitted by pathologists that a deep injection or vascularity may be present during life and disap- pear in the cadaver. In some rapidly fatal cases of cholera infantum the redness does not appear, or is less pronounced, on account of the quick extinction of life, when there is reason to think that if life had been prolonged for a few days there would have been marked inflammatory appearances. Such are the nature and anatomical characters of the malady, which causes so much sickness and mortality among the in- fants of our cities from May to November. Its ill effects are sometimes far-reaching in those who recover. So great im- pairment of the nutritive process for three or four months, at a very important time in the development, does not infre- quently produce diathetic diseases, as rachitis and scrofula. In looking for the causes of this disease, we must evidently consider those conditions which are peculiar to the summer, or MORTALITY OF YOUNG CHILDREN IN CITIES. 251 are more operative in it than in other seasons. The condi- tion peculiar to the summer which is most apparent is the in- crease of atmospheric heat, but that this in itself does not cause the summer complaint is evident from the fact that in sparsely settled country towns there is often equal elevation of temperature, for many weeks, but with continued health- iness. The atmospheric conditions which render the summer months so detrimental to young children in the cities must be the noxious products which the heat generates, and which, diffused through the air, contaminate it. In the poor quarters of the cities, more than anywhere else, those conditions occur which render the atmosphere impure and unsuitable for res- piration. Hence those diseases which foul air produces occur most and present their severest type in those quarters of the city where the destitute, ignorant, and degraded congregate. One accustomed to the pure air of the country would hardly believe how stifling and poisonous it becomes during the hot summer days and close summer nights, in and around the apartments of the city poor. Among the causes of this foul- ness of the air, and the consequent sickness which it entails, may be mentioned too dense a population and the occupancy of small rooms by large families, rigid economy, and ceaseless endeavor to make ends meet, so that in the absorbing interest sanitary requirements are sadly neglected. Adults of such families, and children of both sexes, as soon as they are old enough, engage in laborious, and often dirty occupations. They seldom bathe, and often wear for days the same un- der-garments, foul with perspiration and dirt. The intemper- ate, vicious, and indolent, who always abound in the quarters of the city poor, are notoriously filthy in their habits. Chil- dren old enough to be in the streets, and adults away at their occupations, escape to a great extent the evil effects of impure air produced by such mode of life, but the infantile popula- tion a ways suffer severely. Families thus living, being habituated to foul air and odors, often do not appear to notice them, and neglect to obtain a purer air by open windows and doors. To add to the insalu- 252 MORTALITY OF YOUNG CHILDREN IN CITIES. brity, dirty and worn-out garments, and utensils of various sorts, collect under their beds and in their closets. Waste products of the table and excrementitious substances are al- lowed to stand for hours in the room occupied by the family, or in the attached bed-room, undergoing fermentative changes* With such disregard of sanitary requirements in the apart- ments, as might be expected, the halls, stairways, areas and alleys, within and around the domicils, ordinarily show a simi- lar culpable neglect. They are seldom kept clean, when families in their rooms are so slovenly and dirty, being the receptacle to a greater or less extent of rejected and waste animal and vegetable matter. The fate of the infant com- pelled to breathe day after day an atmosphere which such uncleanliness produces is evident. It pines away, becomes pallid, perhaps exhibits strumous ailments, and in the hot weather is apt to have diarrhoea. At least, this is a very common result. If it do not suffer in the way mentioned, it is because there are countervailing circumstances, as an unusu- ally robust constitution, or it is kept much of the time in the open air. It is true that in our large cities, Health Boards have done much to mitigate the evil alluded to, producing in families more regard for cleanliness. Still even with vigilant health and police boards, it is impossible to obtain sufficient purity of air so essential to infantile health, when families are totally indifferent to hygienic requirements through ignorance, vice, intemperance, or poverty. No city in the United States has probably experienced so great sacrifice of infantile life in times gone by, from personal and domiciliary uncleanliness, as New York, of which I have been an eye-witness, but the evil which we have experienced in this city, in an aggravated form, exists in all our large cities. The exact changes which the atmosphere undergoes and the noxious principles diffused in it, which render it unwhole- some to man, have been only partially ascertained. We know that the air is the medium of communication of most of the infectious maladies, though the agents by which these maladies are propagated are so subtle that they have for the MORTALITY OF YOUNG CHILDREN IN CITIES. 253 most part escaped detection. We know that when our senses can detect nothing wrong, the air frequently contains princi- ples which produce the most violent and fatal diseases ; and that impurities in the air arising from animal exhalations and excretions, and from decaying organic matter, are a common and potent cause of diarrhceal maladies is well established. The most violent and fatal disease to which the human race in modern times is liable, namely, Asiatic cholera, belongs to the class of diarrhoeas, and it always assumes its worst form and numbers its chief victims where the air is most tainted by effluvia from filthy streets and domiciles. The ravages of this disease chiefly occur where population is most dense and measures to insure personal and domiciliary cleanliness and purity of air are neglected. I might mention striking and pertinent examples which I witnessed in New York during the cholera of 1854, which ravaged chiefly the families living along the dirty streets and in tenement houses, and those whose occupations necessitated the respiration of a foul at- mosphere. Moreover, an interesting fact often observed in the dirty sections of the city, and in the crowded tenements where the air was sensibly impure, during the epidemic of that year, and in similar epidemics of cholera, deserves mention, namely, that persons exposed to the anti-hygienic conditions which predispose to cholera were apt to have diarrhoea very similar to the ordinary infantile summer complaint, whether or not they afterwards had a true choleraic attack. But each summer furnishes abundant direct observations, showing that foul air sustains a causative relation to infantile diarrhoea. Several years ago, while serving as sanitary in- spector for the Citizen's Association, my attention was par- ticularly arrested by the state of one of the streets which was not sewered, though supplied by Croton water, and was densely populated on either side by families mainly of foreign birth. The ashes and garbage were placed in barrels and boxes along the sidewalks, or thrown at random in the street. The Croton water and the house slops flowed into the gutters and mixed with the refuse and excrementitious matters from 254 MORTALITY OF YOUNG CHILDREN IN CITIES. the tables and bed-chambers of the houses, while the interior of some of the houses and the spaces around them were in a similar filthy state. There was no Health Board at that time to enforce sanitary regulations, and any attempt to abate the nuisance of a filthy street in the absence of a sewer, and with the presence of a large and ignorant population, could be only partially successful. Consequently this street, with gutters constantly wet and containing decaying organic matter, was, during the hot months, one of the sickliest in the district which was assigned to me. The noxious gases emanating from such a source told fearfully on the general health, and a house-to-house visitation revealed the fact that diarrhoea was extensively prevailing among the infants thus exposed, and was a common cause of death during July and August. In another locality, occupied bj tripe dealers and a low class of butchers, who carried on fat and bone boiling at night, the air was so foul after dark that the peculiar impurity which tainted it I could distinctly notice in the taste for a consider- able time after a nightly visit. In the street where these nuisances existed, and in adjacent streets, a choleriform diar- rhoea was most destructive to infantile life. It is impossible to isolate and determine all the deleteri- ous gases of which the atmosphere of a city is composed, but this we know, that in streets which are not properly cleaned of refuse matter and in and around dwellings occupied by the destitute and degraded who disregard sanitary laws, the air becomes so foul during the hot months, when chemical changes are most active, as to be quite perceptible and offensive to the visitor. The common practice of watering streets which are dirty only adds to their unwholesomeness, for organic matter, whether in masses or triturated to powder by passing vehicles, is comparatively harmless when dry, but yields poisonous gases in abundance when moist and undergoing decomposi- tion. The amount of carbonic acid present in the air is regarded as a pretty correct test of the degree of its impurity. This gas is always present in the atmosphere, but when it exists MORTALITY OF YOUNG CHILDREN IN CITIES. 255 in abnormal quantity it is associated with other poisonous gases, generally in quantities proportionate to its own, but which cannot be so readily isolated. Its quantity is always greater in the city than in the country, and in badly ventilated dwellings and public halls it frequently accumulates so as to be decidedly hurtful to those who respire it. Pure air, it is estimated, contains three to four parts by measure of carbonic acid in 10,000 of air, but Pettenkofer found 72 parts in a school-room two hours after the school was convened, and W. R. Nichols found 32 parts of the gas in 10,000 in a room which had been occupied by a Sunday-school for one and a half hours, while Baring discovered 120 parts in the rooms of a Volks-schulen. Now, it is admitted that carbonic acid may be largely increased in an atmosphere otherwise pure without causing serious consequences, but if this increase is from res- piration, cutaneous exhalation, and from decomposition of or- ganic matter, the carbonic acid is associated with other gases which are exceedingly poisonous. Pettenkofer remarks, and those who have investigated the subject agree in the general statement, " Air is bad and improper for continuous use when it contains in consequence of respiration and perspiration more than one part of CO 2 in 1,000, and a good air for cham- bers in which a person may remain for a long time in a state of health and comfort contains no more than .... seven parts in 10,000." The gases which are found with carbonic acid in occupied rooms have been enumerated by Parkes as follows : carburetted hydrogen, sulphurous acid, sulphuric acid, sulphuretted hydrogen, phosphuretted hydrogen, and ammoniacal vapors. In addition to these gases, which it will be perceived are very detrimental to animal life, the air contains motes of or- ganic matter, often in considerable quantity, as every one has noticed by viewing a sunbeam in a darkened room. Among these motes in an occupied room, the microscope discovers vegetable debris and various animal substances, as fragments of epidermic cells. Eulenberg discovered many animal and vegetable fragments and forms in the air, which he examined, 256 MORTALITY OF YOUNG CHILDREN IN CITIES. some of them evidently having been wafted from long dis- tances. The air of the city contains a vastly greater quantity of these organic particles than the air of the country, as is evident from the dust, which is incessantly settling on furni- ture, and the dirt which is seen in neglected and unfrequented streets and lanes in the course of a few weeks. These many impurities, solid and gaseous, in the air of the city, together with the countless monads, vibriones, and bac- teria, just visible under high powers of the microscope, which spring into existence wherever decomposition is going on, afford sufficient explanation of the greater insalubrity of the city than of the country. Precisely in what way impurities in the air cause infantile diarrhoea is not known, though there are so many striking examples of the fact. Murchison states that twenty out of twenty-five boys in a school-room were affected with vomiting and purging from inhaling the effluvia from the contents of an old drain near the play-room. Per- haps the gases form certain combinations in the system which are purgative. Sulphuretted hydrogen, one of the most poi- sonous of these gases, is believed by those who have investi- gated the subject, to be changed into sulphuric acid in the air, and we know that this acid, if it unite with a potassium or sodium base, forms a purgative salt. Another important cause of the summer diarrhoea is the diet. A large proportion of those who every year fall victims to this malady would doubtless escape if the feeding were exactly proper. The following facts relating to this subject are substantiated by the experiences of each summer : In- fants weaned before the proper time are very liable to the summer diarrhoea, and the younger the infant thus artificially fed, the greater the liability. In New York a large propor- tion of the infants, under the age of six months, when the warm weather begins, if deprived of the breast milk, take the diarrhoea, and unless removed to the pure air of the country, where also fresher and better cow's milk can be obtained, perish. Aware of these facts, the managers of the infant and foundling asylums employ, so far as possible, wet-nursing for MORTALITY OF YOUNG CHILDREN IN CITIES. 257 the young infants in these institutions, although it greatly increases the expense. Before the establishment of the Health Board in New York, when the air in and around the city was much more foul than at present, from the common disre- gard of sanitary laws, it was seldom that an artificially fed infant under the age of six or even ten months, residing within the city limits, escaped the summer diarrhoea. So fatal was this malady among bottle-fed infants in those days, when both atmospheric and dietetic causes were operative, in a high degree, that when I was appointed physician to the foundlings, about fifteen years since, I found it the common belief among the nurses and others, that all of them would sooner or later die. One was pointed out as a curiosity, since it had been several months in the institution, and was still alive. Such mortality was remarkable, for the foundlings of the city at that time exceeded one thousand annually. They were consigned to the care of the pauper women in the almshouse, who were mostly old, infirm, and filthy in their habits and apparel. Their beds, in which the foundlings were also placed, were seldom clean and properly aired, or washed, and under the beds were various garments and uten- sils which they had brought with them, as their possessions, from their miserable abodes in the city. With such sur- roundings the air which these infants breathed night and day was obviously totally unfit, while the diet was not less unsuit- able, for it was prepared by these degraded women from such milk and farinaceous food as the Commissioners of Charities furnished the almshouse. The common disease of these found- lings was diarrhoea, and the cause of the frightful loss of life was obviously both dietetic and atmospheric. Such waste of life was the legitimate result of the condi- tions ; for it occurred under a law of general applicability, that whenever the diet is improper and the air foul, infants pine away and die. What occurred with these foundlings is repeated every summer in the domicils of the city poor, when- ever infants are improperly fed, and the air which they breathe is loaded with poisonous gases, produced by over-crowding or 17 258 MORTALITY OF YOUNG CHILDREN IN CITIES. the prolonged action of the atmospheric heat on the decaying organic substances. Dietetic errors by which diarrhoea is produced, and if they are repeated intestinal catarrh results, are numerous. The reader is referred to the chapter relating to diet, for a state- ment of the kind and quantity of food which is suitable for different ages in infancy and childhood, departure from which is apt to cause indigestion and diarrhoea, and therefore to act as a potent cause of the malady which we are now consider- ing. But there is one dietetic cause of infantile diarrhoea oper- ative not only in the hot months, but at other times also, to which I wish to call attention. The late Dr. James Jackson, of Boston, pointed out the fact that too frequent and too pro- longed nursing, even when there is no fault in the milk, is a common cause of diarrhoea. Infants sometimes overnurse, and they may or may not vomit the surplus food. If they do not, the portion of the food which is not digested undergoes fermentative changes, becomes an irritant, and causes green and too frequent stools, which contain particles of undigested casein, and other ingredients of milk. If such infants fret, as they often do from indigestion, they are applied still more frequently to the breast. Gases and acids form in the stomach and intestines, and in consequence of the irritation thus produced, intestinal catarrh may result. Too frequent feeding with artificial food often produces the same result. In these various ways dietetic errors operate as the second factor in the causation of the summer diarrhoea, and they are not infrequently the immediate exciting cause. Having now considered the nature and aetiology of this malady, we are better prepared to consider by what measures its frequency can be diminished and its severity mitigated. It is evident from the above facts, that measures designed to diminish the severity and frequency of the summer diar- rhoea must be two fold : namely, such as provide' pure air, and secondly, the use of the best possible diet. The modes in which pure air can be obtained are various. MORTALITY OF YOUNG CHILDREN IN CITIES. 259 Since, in recent times more attention has been given to sani- tary requirements, and the large cities have their Health Boards, most of the glaring nuisances which formerly poi- soned the air have been removed, and a corresponding decrease in the death-rate has been effected. Still in populous cities, even with vigilant police and Health Boards and strict sani- tary regulations, it is difficult to obtain that purity of the air which is required to produce the maximum degree of health and vigor in children during the summer months, and dimin- ish to the minimum the atmospheric cause of the diarrhoeal maladies. Children, even young infants unable to walk, realize the benefit obtained from fresh air, and are always more cheerful and contented when out-door during the hot sea- son than within-door, so that nurses have learnt that a quick and sure way to quiet a child made fretful by the heat and the close air of the house is to take it outside. This has the double advantage of giving it purer air, and of allowing the apartments to be thoroughly ventilated during its absence. The common practice in the cities of carrying children to the parks, of taking them on excursions by railway or boat, always has a salutary effect on those who are sick with the summer diarrhcea if they are not too weak, as well as upon those who without actual disease are languid, fretful, and with poor appetite, from the depressing influence of the warm weather. Observing this beneficial effect of pure air upon sick children in the hot months, benevolent people of New York have established a floating hospital, which three times each week, from June to September, carries sick children of the poor, who have no contagious diseases, on long excur- sions down the bay or up the rivers. The result has been so good that it is probable that this mode of aiding the poor will be continued during future summers. Now the method which we see practiced each day by mothers who carry their sick children into the shaded streets, or parks, or on excursions, lasting from morning till evening, with excellent results, indicates the way in which pure air should be provided on a more extensive scale, and therefore 260 MORTALITY OF YOUNG CHILDREN IN CITIES. with greater result in saving life. If a large number of children, all, indeed, who urgently require purity of air to protect them from the sickness which we have described in the foregoing pages, could remain in the country during the period of greatest atmospheric heat, much good would accrue. Removed entirely from the operation of one of the chief causes of the disease which we have been considering, the effect would be to render the symptoms milder of those already sick, and to lessen the danger of contracting the malady on the part of those who might not yet be affected. The re- moval of children, even the youngest infants, with their at- tendants, in the morning and their return in the evening, seems quite feasible, but those sick with diarrhoeal maladies will often need longer and more quiet sojourn in the country than could be had by a morning removal to it and an even- ing return to the city. For such the Sanitarium will be in- valuable, where the benefits of country residence can be obtained both night and day as long as may be deemed nec- essary. The night air of a city is more impure than that of the day-time, for vegetation absorbs and appropriates by day, but not by night, to a great extent those deleterious gases of animal origin, the effects of which have been de- scribed in foregoing pages. Hence critical cases of the diar- rhoea should be kept entirely away from the city as long as their state involves danger. Those who enter the Sanitarium with infants seriously sick with the summer disease should expect to remain there till cooler weather or abatement of the symptoms occurs. The facilities for obtaining pure and fresh milk at the sanitarium, from its rural location, will also greatly increase its advantages as a place of resort for chil- dren whose ailments pertain to the digestive apparatus. Par- ticulars in regard to the proper dietetic treatment of cases will be found in the pages relating to diet. ACUTE INFECTIOUS DISEASES. A considerable number of preventable diseases occur, which increase the mortality of infancy and childhood in all seasons MORTALITY OF YOUNG CHILDREN IN CITIES. 261 of the year alike, and they must not be overlooked in the adoption of measures designed to diminish the death-rate in the summer. I refer to the acute infectious diseases which children contract from each other, and which are therefore more prevalent and fatal in the cities than in the country, where the population is more scattered. Small-pox, there is good reason to think, will, at a day not far distant, be eradicated from civilized communities by gen- eral vaccination. It is now virtually eradicated from our largest city (New York) through the efficient action of the local authorities, in compelling the vaccination of all children in the schools and tenement houses, but there is no such prevention of scarlet fever, measles, diphtheria, and whooping- cough, and they therefore largely increase the aggregate of deaths in all our cities. The treatment of cases of these mal- adies must obviously be left for the most part to the family physicians, but much can be done to check their spread by as- sociated action, having the confidence of the community, with the requisite facilities. The one palpable way of effecting this is by strict isolation of the well from the sick as soon as the first symptoms of disease appear. It is difficult to ac- complish this, as families are ordinarily situated in the city, without extraneous help, and the physician is compelled to witness the spread of a fatal malady from child to child, which might have been prevented. Families even under the tie of relationship are reluctant to receive in their midst children who have been exposed to an infectious disease and may at any moment sicken with it and communicate it to others. There is need, daily felt in our cities, of a place of resort to which children who are well, and who reside in a house where a contagious disease breaks out, can be removed and kept till the case terminates, and the house by disinfec- tion is rendered safe for their return. But a difficulty arises with any institution or association that has the care of chil- dren, in providing for this want, since a child exposed to one of the ordinary infectious maladies, and liable at any mo- ment to have it himself, should not mingle with other chil- 262 MORTALITY OF YOUNG CHILDREN IN CITIES. dren, inasmuch as the specific poison may be in his clothing or upon his person, and thus may infect those with whom he comes in contact, or he may himself at any moment exhibit symptoms, and become the source of contagion. Now in solving this problem, how to prevent the spread of the infectious diseases, it is evident that any child who is to mingle with other children in receiving the benefits of the Thomas Wilson Association should carry with him the cer- tificate of the family physician, stating that he has no con- tagious malady, as is done in case of the Floating Hospital in New ~iork. To meet the emergencies which will arise in the city, it seems to me that a cottage sufficiently isolated should be provided in or near the city, to which the well chil- dren could be immediately taken as soon as an outbreak of an infectious malady occurred ; and if any one thus removed showed indubitable signs of having contracted it, he could be immediately returned home. If after two weeks' isolation they exhibit no symptoms they could be removed farther, if thought best, and mingle with other children. The specific principles of the infectious diseases are so subtle, and spread so insidiously, that it is difficult for any institution where children are received from a city to remain entirely and permanently free from them. With all the precautions which have been employed, the Xew York insti- tutions are now and then visited by measles, scarlet fever, diphtheria, and whooping-cough. Therefore the Sanitarium would require a cottage conveniently situated, but sufficiently isolated, to which cases that presented suspicious appearances could be at once transferred, and three or four additional cot- tages, isolated from each other, for those that presented clear and indubitable symptoms of the common infectious maladies. This subject will be more fully considered in Part II. In this connection it may be well to allude to important facts in reference to the infectious diseases of children, which should not be lost sight of in determining the plan for a quar- antine building. They are very contagious to a short distance, and the specific principles of scarlet fever and diphtheria ex- hibit great tenacity in adhering to a room or furniture. MORTALITY OF YOUNG CHILDREN IN CITIES. 263 PART II. CARE OF THE CHILDREN OF THE POOR IN THEIR HOMES, IN HOSPITAL, AND IN A SANITARIUM. The conditions under which sick children of the poor of cities may best receive medical care are various. In the first place, by far the larger number should be treated at their homes. Nearly all acute non-infectious diseases should re- main at home under the care of the mother and family phy- sician. Such diseases do not bear transportation well at an early stage ; nor is it necessary for their proper management that they should have other care and nursing than that which may be obtained at home. Secondly, acute infectious diseases should be treated at home, if they can be properly isolated ; but if this is impossible, it may be best sometimes to remove them to a hospital ward. But it should be re- membered that it is hazardous to remove the eruptive dis- eases from one building to another without precautions against taking cold ; and their distant removal during the eruptive stage is never proper except under very unusual circum- stances. Thirdly, certain cases, as surgical accidents, diseases requiring operations, etc., are ordinarily better treated in the hospital than at home. Fourthly, among the poor, cases of maladies of different kinds will always be found, which, on account of impoverishment of the blood and reduced state of the general health, cannot be so successfully treated at home, on account of the anti-hygienic surroundings, as in the coun- try, either at the sea-shore or in the mountains. For such persons sanitaria are very useful. It follows, that a scheme for the care of the sick children of the poor of a city, which adequately meets all the require- ments of this class, must comprehend suitable provision for them : first, in their homes ; second, in hospital ; third, in a sanitarium. This Part will, therefore, be devoted to the de- velopment of a plan which, in its details, comprises the three- fold conditions under which the children of the poor of a city may best receive hygienic and medical care. 264 MORTALITY OF YOUNG CHILDREN IN CITIES. Before entering upon the formal discussion of special top- ics it is important to consider what form of central organiza- tion will be best adapted to give stability, unity, and force to the proposed institution, which is to be the pioneer in a new field of charity. 1st. It should have all the conditions of permanency fully established at the very outset. No great charity can be suc- cessful in the highest degree if it have no other palpable existence than that given to it by a will, or by articles of agreement and a board of managers or trustees. It must have a local habitation and a name as a public institution where all its work centres, and from which its influences pro- ceed. But there are other reasons for the establishment of a central office. 2d. There must be a school for training nurses to perform the duties which will be required of them as visitors among the sick poor, or while serving in the hospital, or at the san- itarium. This service will require of the visitor and nurse especial knowledge, which can be satisfactorily obtained only by systematic training. Nowhere can this school be so well and thoroughly managed as at the central building or office. 3d. There must also be a common residence for nurses, where they will be under constant discipline, and this can best be provided for at the main building. 4th. A plan for gratuitous medical relief in a city requires a central office where all of the work is systematized and supervised. This central office will thus give unity to the entire work of the institution, however extended or diversi- fied it may be. The Home. — The central office should be known as " The Home," or by some other kindred title of equal significance. In its establishment the following points should be consid- ered : — (1.) The location should be such as to render the Home conveniently accessible to all parts of the poor districts of the city. The site should combine all possible conditions of health, as elevation, good drainage and sewerage, and open spaces around it, as parks. MORTALITY OF YOUNG CHILDREN LN CITIES. 265 (2.) The building should be constructed on a plan which will give the largest southwesterly exposure, both on account of the sun, and of the prevailing winds. Its service should be arranged as follows : — (1.) The matron should be a skilled nurse, educated to such duties, and trained to their performance, by long experience. She should have the general supervision not only of the Home, but of every branch of the work. (2.) The training school should be organized for the pur- pose of giving instruction in the care of the sick, in hygiene, and especially in the relations of domestic life among the poor of cities to the diseases of childhood. (3.) The nurses, when under training, should be assistants to the other nurses who have completed their education and have received their proper testimonials. Provision must be made for the trained nurses, and for a lecture room. Every nurse should have her own private room with all necessary conveniences. The lecture room would be small, and for this purpose adjoining rooms might be thrown into one on an oc- casion. I. Sanitary Care and Treatment of Children and their Dis- eases in their Homes. Although the care and treatment of sick children in hos- pital and sanitarium are important, it cannot be denied that, considered as a scheme of benevolence, the largest benefits will result from the efforts put forth to secure the proper pro- vision for their care and treatment at home. For by far the larger number of cases of sickness among the children of the poor must, of necessity, be treated at home. If indeed we exclude surgical accidents, acute infectious diseases, and chronic affections, which require other hygienic conditions than can be secured in the family, the remaining infantile diseases would be better attended at home, provided that suitable pro- vision were made for their care. Again, it may commonly happen that the mother cannot leave home, though her per- sonal attention, as in the case of an infant, is absolutely es- sential to its proper treatment. 266 MORTALITY OF YOUNG CHILDREN IN CITIES. In the second place, the indirect benefits which the parents derive from the care of their own sick children, when aided and advised by a skilled physician and competent nurse, are of the greatest importance. It is therefore in this branch of the subject that we shall consider " the most practicable means of lessening the risks and dangers incident to children exposed to the heated and impure atmosphere of a large city, during the summer months, and also as to the best methods of extending a general knowledge of simple hygienic rules for the treatment of sick children at home among the poorer classes." In any well matured plan for the care of the sick poor in their homes, two things are requisite, namely : (1.) medical at- tendance, and (2.) skilled nursing. Neither of these important duties should be left to the discretion of the family to pro- vide. In this plan something more should be contemplated in the functions of both physician and nurse than is ordi- narily intended and performed. They should be practical teachers of household hygiene, and should illustrate and en- force their lessons by daily examples. They should not only teach the art of caring for the sick, but should take advantage of their special duties in the family to aid, by advice and per- sonal attention, in improving the condition of the home, and the methods of administering its affairs. (1.) The Medical Service. The method of providing medi- cal attendance for the poor of a city, is through the agency of the dispensary. This institution is organized so as to have a dispensary and district service. The in-door dispen- sary service is entirely devoted to the sick poor who can leave their homes and visit the dispensary, and who do not require special attention. All of the minor ailments of chil- dren may thus be successfully treated. The district service is designed to supply medical attendance to the sick who cannot leave their homes. It is performed by a separate class of physicians, who attend to the sick regularly, as in pri- vate practice. The medicines are all obtained at the dispen- sary. MORTALITY OF YOUNG CHILDREN IN CITIES. 267 The dispensary system is now recognized as the best or- ganized method of dispensing medical relief to the poor. But to meet the full requirements of the scheme proposed in this paper, the dispensary system should be organized on the im- proved plan, which requires that the dispensaries should be self -supporting. To effect this object a small sum is charged for medical attendance and medicines. This small tax, in- stead of being a burden to the poor, is generously paid, and always proves very useful. It tends to create a feeling of in- dependence in the recipient of medical care and medicines, and thus prevents the pauperizing influence of gratuitous serv- ices rendered in the interests of charity. The general dispensary consists of a building centrally lo- cated, as regards the district to be served, with apartments for the classes of diseases to be treated, and for the resident officer and apothecary. The medical attendants are divided into two classes, namely, the attending and visiting physicians. The attending physicians attend daily at the dispensary, at the hours fixed for their individual classes, and prescribe for those who are able to visit the institution. The visiting or district physicians have certain areas of the general district assigned to them, and they visit those patients who have been registered at the dispensary as unable to leave their homes. In this manner all the sick poor of a city may receive medical care and attendance with but little expendi- ture of money, and if a small charge is made for medicines and attendance, the dispensary readily becomes self-support- ing. It is quite impossible to organize a system of gratuitous medical care and attendance upon the sick poor of a city more complete in all its details than that furnished by the dispen- sary. Every person who asks or seeks medical care receives prompt attention from skilled physicians, who, in turn, have ample means of determining their social condition and real necessities. If a dispensary system exist, as generally happens in large cities, it may be made available for the purposes which we 268 MORTALITY OF YOUNG CHILDREN IN CITIES. now contemplate, and thus the expense and care of organizing a new system may be prevented. If, however, the general dispensary do not exist, or be not available, a system of information and medical care should be organized which will meet as nearly as possible the same conditions. The " Home " may now become the centre of this service. The area to be supplied with relief should be divided into districts, each one being of such size and form as will economize the time and efforts of the district visitor. To each district a physician, living if possible in the district, should be selected, whose duty it shall be to act in the capaci- ty of a district physician. Young men very cheerfully volun- teer their services for this work, and, with care, a thoroughly competent class may be secured. The duty of the district physician should be to visit the sick on call, as in the ordi- nary dispensary. He may also be one of the attending physi- cians at the other branches of the institution, a position which young physicians seek, and which they regard as a decided step of advancement in their profession. The record of the cases which he is to visit should be daily sent to him at his office, and his returns of visits should be daily made, in writ- ing, in the register. 2. Skilled Nursing. To each medical district should be assigned as many women visitors as may be necessary to sup- ply one visitor to every fifty families. The women district visitors should be trained nurses from the "Home." Their duties should be (a.) The prevention of sickness in the fam- ilies of the poor, (5.) The care of sick children, under the direction of the district physician. (a.) The prevention of sickness in a family will require more or less frequent personal visits of the district visitor. The frequency of these visits must depend on the intelligence, moral tone, and temper of each individual household. Many families will receive the visitor in the most cordial manner, and quickly respond to every suggestion. Such families will require but little personal attention, for whatever reform in household management is desired and enforced by the visitor MORTALITY OF YOUNG CHILDREN IN CITIES. 269 will be commenced and continued without her constant super- vision. These families will also make stated reports, if re- quested, of their condition, and especially of the occurrence of cases of sickness. A smaller number of families will respond less promptly to the wishes of the visitor, but by more frequent visits at first, and a closer acquaintance of the visitor with the parents, and especially with the mother, confidence is gradually established, and in time these families closely approximate the former. There still remain in every city community certain families closely allied to the vagrant classes. They are, indeed, so nearly on the border line, that any slight disturbing cause breaks the feeble domestic ties which hold them together, and precipitates them into hopeless vagrancy. Sickness, acute and wasting, is never absent from these families, and death is a familiar visitor. Few children, comparatively, attain the fifth year, and if by chance they grow to manhood or womanhood, they find decrepitude at twenty, and death with all the condi- tions of old age at thirty to forty-five. Hapless and hopeless as these families seem to be, it is in the efforts to elevate and improve them that modern philanthropy has won its greatest victories. As long as the domestic ties are sufficiently strong to maintain the semblance of family individuality, this class of the poor of cities may be reclaimed. More often it will be found that the parents have fallen from a better estate through misfortunes or vices, and it only requires a sympathizing friend with hopeful and encouraging words to awaken old emotions and aspirations for a better condition in life. It is true that the progress which such families make in improvement is often painfully and discouragingly slow ; but that fact should not dampen the ardor or weaken the determination of true philanthropy. One such family raised to a better life by such aid as may be given by the Thomas Wilson Association will prevent more sickness among children, and be more far-reach- ing in its results, than the care of a score of children of the better class. The object of the ordinary visit should be to secure such 270 MORTALITY OF YOUNG CHILDREN IN CITIES. relations between the visitor and her families that a mutual and permanent interest would be established between the two parties. The district visitor should soon become familiar with the peculiarities of her families. She should silently note at each visit the condition of the apartments as to cleanliness, the orderly arrangement of the furniture, and the condition of the clothes. She should observe the kind of food, and unob- trusively inquire as to the methods of cooking. Gradually, as she becomes more and more ingratiated into the affections of the family, she would learn its secret history, its moral, relig- ious, and social tendencies, and everything that directly or indirectly affected its healthful development. As she acquires this knowledge and wins the confidence of the famity, she in turn imparts such instruction on subjects relating to the hy- gienic management of the children as she sees is needful and timely. Little by little, under this training, the habits of the family change. Improvement occurs in the various branches of its limited yet multifarious duties. Order gradually suc- ceeds to disorder in the arrangement and management of the house ; cleanliness appears on the floor and walls, in the cloth- ing and bedding, and in the persons of the parents and chil- dren. As a legitimate consequence of the improved hygiene, a better state of health succeeds. Apathy and long disre- gard of sanitary laws, the result of ignorance and poverty, is replaced, under the sympathy and encouragement of the vis- itor, by a strong desire for improvement in the mode of life. The children, formerly repulsive from filth and external evi- dences of disease, are now clean and tidy, and the ruddiness of health appears in the features. This is not an over- wrought picture, nor a fancy sketch having little foundation in reality. The mass of people, however low in society, desire improvement, and the strong love of the mother for her off- spring will prompt her to make many exertions and sacrifices in the humblest sphere, and with the most limited resources, that her children may have health and comfort, of which she perhaps has been deprived. That visitors among the poor, actuated by the right mo- MORTALITY OF YOUNG CHILDREN IN CITIES. 271 tives, and having the authority of an appointment from a legally constituted board, do have a decided influence in im- proving the physical condition of families, is abundantly shown by our experiences in New York. For, since the first sanitary inspectors, a body of young physicians, were sent out by the old Citizens' Association some fifteen years ago, to visit all the tenement houses and report their condition, the great mass of poor families are certainly much more cleanly in their habits than formerly. They welcomed this effort made in their behalf, which has been continued under the Health Board, and through the visits of city missionaries. Another fact in the same direction has also often been noticed, namely, that wives and mothers who have been servants in families, and upon whom their old mistresses occasionally call, and in whom they thus manifest an interest, have clean and tidy apart- ments and apparel, though living on the scantiest income. Not only would diminution in the amount of sickness, and in the death-rate, result from the visits of conscientious, intel- ligent, and sympathetic women, in consequence of improve- ment in the hygienic condition of families, but their labors would be beneficial in another important way. Maladies are more easily controlled, and are rendered milder in a large pro- portion of instances, if detected in their incipiency, and if the proper remedies are then applied. Now it would be entirely practicable for a trained visitor to anticipate some diseases, and to detect the approach of others, in time to prevent the attack, or make it milder. The ravages of Asiatic cholera have been greatly mitigated by visitors, who went from house to house, and impressed upon the inmates the importance of checking every diarrhceal attack however mild. Very many lives might be saved every summer in our cities, if mothers could be informed that the diarrhoea of their infants is not conservative on account of dentition, and that what they think lightly of is the beginning of a most fatal malady which will inevitably bring desolation to their homes in a few weeks, if it be not checked. Whenever unusually severe cases occur, requiring superior 272 MORTALITY OF YOUNG CHILDREN IN CITIES. nursing, the woman visitor might frequently become the nurse, under the direction of the physician, though it might be quite impossible, as a rule, for the nurse to be in constant attendance on the sick. Her attendance would in general supplement that of the physician. The effect of such care of the sick, both upon the sick and the family, cannot be fully computed. Experience shows, that among the poor, sick in their homes, receiving the care of a physician, and the nursing of the family, simple diseases not infrequently become severe and complicated, from negli- gence or other cause, a result which the presence of a skilled nurse might have prevented. But when medical skill is aided by expert nursing in the homes of the poor, the most severe diseases usually run quite as favorable a course as in the homes of the wealthy. Even the aid of diet kitchens, which furnish selected and well prepared food to the sick poor, tends to diminish, it is believed, the mortality among this class, in the dispensary districts of New York. The influence of the presence and services of the nurse in the homes of the sick poor, during severe sickness, is as, has been intimated, not limited to the welfare of the patient, but is felt by all and impresses itself upon the future life of the family. There is a discipline of the whole household, which under the circumstances, is lasting. Whatever may be the special temperament of the members of the family, all are rendered peculiarly susceptible, by anxiety, to the impressions which the acts of a patient, intelligent, sympathizing nurse will make. Cleanliness and ventilation are now, perhaps, first enforced, disinfection is now practiced, and foods are carefully selected and prepared. In a word, all the simple rules by which the apartments of the sick are rendered healthy, cloth- ing made clean and wholesome, food cooked so as to be di- gestible, are now silently but effectively taught. It is scarcely too much to say that when sickness among the poor results in the elevation of the family in the scale of healthy living, it is a blessing rather than a curse. MORTALITY OF YOUNG CHILDREN IN CITIES. 273 II. Sanitary Care and Treatment of Children and their Dis- eases in Hospital. The necessity of hospital care of children suffering from surgical accidents and operations, and from chronic suppura- tive diseases, has been recognized as a part of medical chari- ties devoted to the poor of cities. It is impossible to treat this class of patients efficiently in their homes, though the surgical skill and nursing be of the highest quality. There will always be a want of proper appliances, of requisite floor space, of suitable bed and bedding, and of many other con- ditions essential to their successful treatment. It is found, therefore, that where hospital care is provided for these cases, lives are saved which would otherwise have been lost, a vast amount of suffering is prevented by the better methods of treatment and the diminished length of time required, and in- validing deformities of limbs cured that would have pauper- ized the unfortunate subjects of hereditary diseases. The child's hospital may be a very simple and inexpensive branch of the service. It should be located at the " Home," and, if the surroundings are favorable, should be an indepen- dent building, one story in height, with wards properly ex- posed to the sun and air. The wards should be two or more in number to accommodate the sexes. The general details of construction should make the hospital a model of good venti- lation and heating. If it is not practicable to build a new structure, wards may be constructed in the Home which will serve the purpose, though not as suitable as in a well ar- ranged isolated building. The rooms selected should be on the second floor, to avoid dampness, and to secure a free flow of external air, and escape of the emanations of the living rooms. If the building have a southern extension, this portion may be made available. In the arrangement of rooms for wards, all the conditions for the health of the inmates should be even more carefully studied and provided for, than in the separate hospital, because unheal thful conditions are more numerous and difficult to meet. 18 274 MORTALITY OF YOUNG CHILDREN IN CITIES. The matron of the Home becomes the matron of the hos- pital, and the trained visitors the nurses. The surgical and medical attendance would be gratuitously supplied by appoint- ment from the profession of the city. III. Sanitary Care and Treatment of Children and their Dis- eases in a Sanitarium. In the organization of a sanitarium it must be borne in mind that neither the donor nor trustees promise that it shall fulfill the conditions of a hospital. The primary motive of Mr. Wilson in establishing a sanitarium is given in his will as follows : " I have observed for many years with much con- cern, the great and alarming mortality which occurs each summer among young children deprived by misfortune of their parents of all opportunity for removal from the heated and fatal atmosphere of the city." He therefore gave to the corporation appointed to administer the funds bequeathed, the title of " The Thomas Wilson Sanitarium for Children of Baltimore City." The trustees " at their first meeting, pre- liminary to the formation of any definite plan of procedure," determined to correspond with persons " eminent for their success and experience in the treatment and care of sick chil- dren." In requesting essays or contributions from their cor- respondents, the trustees stated that they had " in mind the consideration of the best method of establishing a sanitarium (not a hospital but a summer retreat) for sick children." The trustees also desire an " opinion regarding the regula- tions suitable for receiving and administering medically and otherwise to those who shall be the proper subjects of their care, with suggestions as to the character of the buildings that may be requisite, their grouping or isolation, and how best to provide for mothers and nurses accompanying their children." From these statements it appears that the sanitarium should have a twofold plan in its organization : — (1.) " For well children among whom a great mortality occurs each summer, because they are deprived of all oppor- MORTALITY OF YOUNG CHILDREN IN CITIES. 275 tunity for removal from the heated and fatal atmosphere of the city. (2.) " Provision for a summer retreat for sick children from the heat and unhealthfulness of the city." These two objects are so different, both in regard to the children to be relieved, and their special wants, that it neces- sitates the division of the sanitarium into two departments, one to be devoted to well and the other to sick children. Be- fore the plan can be projected for care of these two classes of beneficiaries in a sanitarium, an approximate estimate must be made of the number of persons to be provided with homes. Number of Well Children. It may, we think, be justly es- timated that of the annual average of 743 deaths of infants in Baltimore referred to in the prefatory note, at least 60 per cent, belonged to the families unable to remove " from the heated and fatal atmosphere of the city." Accepting this ratio as a basis of calculation, the number of deaths by heat of those who would properly become beneficiaries of this charity is about 450, or to make a more liberal provision we will allow 500. But this is by no means the actual number of well per- sons for whom provision must be made. Every child under one year of age, nursing its mother, must be accompanied by its parent and her other children too young to be separated from her care. On an average, it may be stated that one such child must be added to the list for every nursing moth- er's child. Orphan children and those fed by the bottle, will require only a nurse for two or three children. If we esti- mate the nurslings at 400, their attendants would be 800, and if the bottle-fed are 100, their attendants would be at least thirty. The total number of persons would be 1,200 of the former, and 180 of the latter, or a grand total of 1,330. But it is not necessary that each well child of the 500 should remain at the retreat during the entire heated term or twelve weeks. On the contrary it may be estimated that an average residence of sixteen days during the hot months for each child will suffice to prevent the fatal effects of heat in 276 MORTALITY OF YOUNG CHILDREN IN CITIES. the city. It is true that some children will require more time, bat others would require less, and the average may be fixed as above. From this statement we are able to fix the average popula- tion of this branch of the retreat during the three hot months at 100 children, the mothers and nurses at 100, and the addi- tional children at 100, making a total of 300 souls. Number of Sick Children. The annual average number of cases of sickness among the children of Baltimore, of five years or under, for the four years 1875, 1876, 1877, 1878, may be estimated at about 100,000. The estimate is based upon the calculation of Mr. Playfair that for every death in a community there have been 28 cases of sickness. To be more exact, the annual average death rate of children of that city during the four years mentioned was 3,494, which would give a total annual average of sickness of 97,832. If 90 per cent, of these cases were in part in better families, or not so severe but that convalescence followed without special after- treatment, there would still be not far from 8,000 cases of severe illness, requiring more than ordinary care during con- valescence. This number would be a monthly average of 650 cases. It would be a safe estimate that of this number not more than 200 monthly would become beneficiaries of this sanitarium. For the purpose of this computation we will fix the number of sick children to be provided for at 200. Distribution of Children. In the distribution of the chil- dren and their attendants regard must be had to the fact, that the family relation of each group should be as far as possible maintained. In order to do this one hundred domi- ciles are to be provided, each having the conveniences neces- sary for domestic privacy and comfort of at least three per- sons ; namely, the mother and her two children. The arrangement of the individual homes so as to secure the best conditions for health, with economy in their con- struction and facility of administration, is not a difficult prob- lem when considered with reference to the objects to be ob- tained, the large tract of ground to be utilized, and the climate MORTALITY OF YOUNG CHILDREN IN CITIES. 211 of the locality. The several questions which are to be deter- mined are as follows : — The Site and its Preparation. That portion of the grounds especially devoted to the residences of this colony should em- brace an area of at least twenty-five acres. It should have an elevation equal to and if practicable greater than the sur- rounding country, in order to secure the free flow of the air. It should have a south-southwestern surface-inclination in order to be well exposed to the prevailing winds and to the sunlight. If there is an opportunity to select soils, that should be preferred which is least retentive of water and even moist- ure, such as soils free from compact clay strata near the sur- face. Alluvial and sand formations are especially dry, and if rendered fertile by proper admixture of loam should be se- lected. Whatever the soil may be, deep drainage will be a necessary expedient to prevent the soil soakage during pro- tracted rains and even dampness at all times. The selection of shade trees and their arrangement on the grounds, while largely a subject for the skill and taste of the landscape architect, must still be subordinate to the sanitary conditions to be secured. The trees selected should, in part, be such varieties as have special medicinal properties which are diffusible in the air, as the aromatic trees and shrubs, or which purify the air by absorbing greedily deleterious miasm floating in it, as the linden, the maple. The selection should include trees and shrubs which flower successively during the summer. The shade should not be so dense as to make the ground damp, even in small areas as groves. Nor should the trees be grouped so as to obstruct the south-southwesterly and westerly winds. Arbors should be provided in which hammocks and swings can be suspended : shaded walks should be laid out with hedge rows at intervals so dense as to secure isolation and privacy. Fruit-trees should not be al- lowed on any grounds devoted to children. Fountains with spray, ponds through which fresh water constantly flows, and running streams, are desirable features of the landscape both for beauty and healthful purposes. 278 MORTALITY OF YOUNG CHILDREN IN CITIES. The Administration Buildings and Domiciles. The admin- istration requires one building for offices, a second for the kitchen and dining halls, and a third for the laundry. The building for offices should be in the front portion of the grounds where it will be of easy access to those who visit the sanitarium, and conveniently located to the several branches of service. This building should be the residence of the su- perintendent, and should be constructed accordingly. The kitchen should be located on the northern part of the grounds, centrally as to the colonies, but quite beyond the limits of grounds occupied by the residents. In arranging dining-rooms, and in the distribution of food, it must be borne in mind that there will be two classes of per- sons to be provided: (1.) The bottle-fed, and those under five years of age accompanying their mothers. (2.) The mothers aiad nurses. The nursing infant does not enter into the ac- count. The first class are evidently to be chiefly supplied with good milk. This milk may be given out two or three times a da}^ on tickets issued to the mother or nurse, from the kitchen, or other more convenient depot, where it is kept in proper coolers, — the milk being taken to the domicile, where it is to be consumed. Older children, who require a miscellaneous diet, can accompany the mothers and nurses to the general table. The second class should dine at common tables located in the wings of the kitchen, or in separate din- ing-rooms adjoining the kitchen. The laundry should be located at a distance from the kitchen, still farther to the northward of the colonies, and in a wooded ravine, where all its outflowings will be from the occupied grounds, and to the leeward of the residences. If its sewerage is a part of the system provided for the entire grounds, the waters that flow from the laundry should enter the main at such point as will secure .its uses for flushing drains containing much excreta. Domiciles and their Arrangement. The domiciles for both branches of the sanitarium should be constructed chiefly of tenting cloth, but with substantial raised wooden floors, and >opif»g-cougft. Mumps. Scale of feet. MORTALITY OF YOUNG CHILDREN IN CITIES. 279 ample materials for flies as a protection against the sun and rain, and every convenience for comfort should be provided. In order to accommodate families of various conditions, the tents must vary in size and form. Some families desire to live entirely isolated, others prefer to live in apartments im- mediately adjoining friends, and still others are willing to take rooms in a large apartment dwelling. The tents may be therefore assorted so as to accommodate one, two, three or more families. But in addition to tents for families there must be wards for well and sick children, having no parents, or who are under the charge of nurses. These wards should be arranged on a long axis running north and south, and should have not more than thirty beds each, fifteen on each side. Smaller tents for four to ten children, under the care of one nurse, should be provided in addition to two or three single, large wards. But there will always be some families of the well and sick, who should live in wooden structures, and hence it will be important that several cottages be con- structed. They may be single or two story buildings, and have apartments for four to ten families. In addition to these buildings, there should be a central one in each group, con- taining a long ward exclusively for children in charge of nurses. The grouping of these structures admits of an un- limited amount of taste and skill. It will suffice to say that the important fact to be kept in mind, and that which should dominate every plan, is purity of air for each individual. To this end the most important point to be considered, in placing the various structures, is to give ample ground space to each individual person. As a rule, not more than twenty-five per- sons should be placed on an acre. The position of tents, and other structures, with regard to each other should be such as to admit of free circulation of air, without violent draughts during storms. This will be principally accomplished by avoiding long straight avenues, and requiring, in pleasant weather, when the wind is light, the raising of the sides of the tents. The closure of tents during storms is a regulation readily enforced, because thereby the comfort of the occu- pants is best secured. 280 MORTALITY OF YOUNG CHILDREN IN CITIES. Water Supply and Drainage. Among the most important conditions affecting the salubrity of the sanitarium is the sup- ply of pure water, and the rapid and complete removal of all sewage. Although these are questions to be finally deter- mined by the engineer and architect, it is proper to state : 1st, that the supply of pure water should be so abundant as to meet every demand, whether for the uses of the colony, or the administration buildings, or for flushing ; and 2d, that the sewage will be most effectually disposed of by employing it as a fertilizer by sub-irrigation. If the flow of water cannot obtain sufficient head by natural means, machinery should be used which will give the requisite pressure upon all of the conduits so as to secure rapid and powerful currents. As a part of the system of sub-irrigation the "trough water-closet" affords the most effectual method of removing the excreta of people aggregated on the grounds of a sanitarium. When they are thoroughly cared for by a competent person, this closet has been found the simplest, cleanest, and most effec- tive method of disposing of excreta, of large populations of poor people, yet devised. The system of sub-irrigation with which the trough-closets should be connected consists of a number of lines of tile-pipe laid at a depth of twelve or more inches below the surface of the ground. Through these pipes the sewage is distributed underground over any desirable area, and becomes a valuable fertilizer, while it is in that process rendered innocuous. Cottages for the Reception of Acute Infectious Diseases. As stated in Part I., it is very difficult to prevent the out- break of contagious diseases from time to time, where any considerable number of children congregate. Therefore sepa- rate buildings or tents should be provided, at least one eighth of a mile away from the cottages and tents of the sanitarium, and to the leeward of the prevailing winds, to which every case that presents a suspicious appearance can be immedi- ately removed. Frequently the nature of an infectious dis- ease is not apparent until it has continued a day, or a part of a day, and often symptoms from some transient indisposition MORTALITY OF YOUNG CHILDREN IN CITIES. 281 simulate closely those of an infections malady. Several hours or a day or two may be required to ascertain the exact char- acter of the affection ; for such cases a cottage for observa- tion seems indispensable. The stay of any one in this build- ing would be transient. Apart from it, and apart from each other, there should be three or four additional cottages for the reception of the contagious maladies, namely, one for cases of scarlet fever, another for cases of measles, a third for those of diphtheria, and, perhaps, a fourth for those of whooping- cough. No intercourse should be allowed between these cot- tages, when they are occupied, for the eruptive fevers espe- cially are often communicated by the clothing and persons of nurses, and if a child have one of these maladies, he is ren- dered no less liable to contract another. In these cottages all the precautions should obviously be taken as regards isola- tion and disinfection, which are recommended and enjoined by boards of health in the care of cases in the cities. The Gymnasium and Bath. These buildings are readily located, and should be provided with every convenience and appliance. PART III. THE SANITARIUM. Hygienic Rules for the Management of Children in the Sani- tarium as well as at their Somes. — Facts with which the Visitors among the Poor should be familiar. Since, as we have seen, one of the chief causes of the in- creased death-rate of children in the cities during the summer months is dietetic, it is obvious that the subject of feeding de- mands careful consideration in every plan or project designed to reduce this mortality; and since in' the future manage- ment of the sanitarium, and in the wider operations of the Thomas Wilson Association, it seems probable that children of all ages, will, to a certain extent, be cared for, I have thought best to devote a chapter to the consideration of the diet not 282 MORTALITY OF YOUNG CHILDREN IN CITIES. only of infants, among whom the mortality from improper feed- ing is greatest, but also to that of older children. I shall en- deavor then to point out the kinds of food and the mode of feed- ing, which are required for the wants of the system, and are most conducive to the healthy development from birth till the close of childhood ; and though I may state facts which do not seem immediately useful or pertinent to the object for which this essay is prepared, I am persuaded that every scientific fact relating to this important subject will in the end have a practical bearing. DIET. Obviously, the best food for the infant until it has attained a certain age, is that which is provided naturally, and in conse- quence of the danger which attends artificial feeding, moth- ers should always be encouraged to suckle their infants unless they are physically unfit for the task. If they are thus inca- pacitated and reside within the city limits, healthy wet-nurses should if possible be employed rather than incur the risks of ar- tificial feeding, even if the increased expense require retrench- ment and rigid economy in other particulars. The infant of the city artificially fed during the months in which he should be nourished at the breast, is not only the first to suffer from the summer complaint when the hot weather arrives, but is more apt to acquire a faulty constitution, a rachitic or scrofulous diathesis, with its many unpleasant manifestations, than is one who has the natural aliment until the time when weaning is proper. But there are certain states of ill-health in the mother which contra-indicate suckling, states in which it should not be allowed, both for her sake and the infant's. Among these may be mentioned tuberculosis, incipient or confirmed, a de- cidedl} r scrofulous state, any chronic disease which reduces the strength in a marked degree and renders the milk thin, innutritious, and insufficient, and acute constitutional conta- gious diseases, which take away the appetite and exhaust the strength, as typhoid fever, and severe erysipelas. In other acute diseases, not so severe as to endanger life, destroy the MORTALITY OF YOUNG CHILDREN IN CITIES. 283 appetite, or cause much suffering, lactation should be supple- mented, if need be, during the continuance of the disease by artificial feeding. In acute maladies of the mother of a grave type, attended by pain, loss of appetite, and prostration, but which will probably soon terminate favorably, it is commonly best to allow the infant to suckle two or three times in twenty-four hours, sufficiently often to prevent the breasts from drying, until convalescence is established. But whether or not under such circumstances of ill health, lactation should be continued, or to what extent, depends upon the particulars of each case, and must be determined by the attending phy- sician, who should be fully aware of the importance of pre- serving the milk. The return of the catamenia, which in some women is as early as the third or fourth month after parturition, but is not in the average till the sixth or eight month, affects the composition of the milk, diminishing its nutritive properties. Charles Marchand found in three chemical analyses of the milk during menstruation, a diminution of two to four parts in the butter, of two to five parts in the sugar, and a diminu- tion in the casein and albumen of two to five parts. This seems but a trifling change when we recollect that human milk in the state of health contains, according to the analysis of M. Robin and others, 25 to 37 parts of butter, 37 to 49 parts of sugar, and 29 to 39 parts of casein, in 1,000 of milk : still the alterations in the milk during the catamenial flow, some of which have not perhaps been detected, produce in ex- ceptional instances more or less indigestion in the nursling and even diarrhoea. But these ill effects are transient, sub- siding when the flow ceases. The return of the catamenia does not therefore contra-indicate lactation in ordinary cases. Suckling should in general be discontinued if the mother have good reason to believe that she is pregnant. Regard for her own health and the development of the foetus require this, but if the family remain in the city it is safer for the infant to continue nursing during the first two or three months of her gestation, if the weather be hot, and no indi- 284 MORTALITY OF YOUNG CHILDREN IN CITIES. gestion or diarrhoea occur, than to be taken from the breast and placed on artificial food, for weaning in the city in mid- summer nearly always causes the much dreaded summer diarrhoea. The proper way under such circumstances is the employment of a wet-nurse, or removal to the country and weaning there. In the salubrious locality of the ordinary farm-house, or in a sanitarium, gradual weaning will probably be safe, even in the season of greatest atmospheric heat. Sometimes there are insuperable obstacles to lactation in the state of the mother's breasts or nipples. The breast may be small, so as to secrete very little milk, or there may have been a previous inflammation so near the nipple as to occlude the milk ducts, or there may be an acute inflammation with induration and suppuration of the breast, or the nipple may be small and depressed, so that it cannot be seized by the in- fant's lips. This last obstacle may sometimes be remedied by the use of the artificial nipple, but if the milk be drawn with difficulty, such appliance does not fulfil the indication. The frequency of cracks and sores upon the nipples which se- riously interfere with nursing is known to all practitioners. In these various ways lactation is interfered with or pre- vented, and the family may not be in such circumstances that a wet-nurse can be employed. But the rule is imperative, admitting no exceptions, that the infant remaining in the city should be wet-nursed through the first year, for the fact needs to be repeated and emphasized, that the infant under the age of one year, if taken from the breast, though it may do well in the cool months, will in all probability be seriously sick during the hot season, with indigestion, followed by diar- rhoea. In New York we are compelled every summer to wit- ness the melancholy spectacle of infants pining away and dying upon the bottle, when we are convinced that this great waste of life might be prevented or greatly reduced by early removal beyond the city limits, to a sanitarium or farm house, where pure air and fresh milk can be obtained. A large proportion of the mothers of America need de- tailed instruction in regard to the suckling and feeding of MORTALITY OF YOUNG CHILDREN IN CITIES. 285 their children, and I will therefore state somewhat fully, at the risk of writing upon matters which may not seem exactly pertinent to the wants of the Wilson Association, facts which every mother and wet-nurse should know, and a knowledge of which will tend to diminish infantile sickness and insure a more robust development of body. The subject of the diet from birth to the end of childhood is so important that it can- not, I think, be treated of too exhaustively. After the birth of the infant the mother needs to rest a few hours, — four or five, or a little longer in tedious and exhaus- tive cases, — and then it should be applied to the breast. There is frequently a little milk at this time, and the act of nursing promotes the secretion and increases the quantit}'. The full secretion is not, however, established before the third day, and though the infant should be applied to the breast about every second hour by day and fourth hour by night on the first and second days, it obtains but little nutri- ment. Babies are so constituted that they need little food until it is naturally provided for them, and the common prac- tice of feeding them to repletion with various sweetened mix- tures almost as soon as life begins, because they obtain so little breast milk, is to be regretted. Filling their stomachs in this way has a tendency to prevent their drawing upon the nipples with the avidity which is required to stimulate a free flow of milk. Besides, as I have many times observed, indi- gestion, diarrhoea, and sprue, are common results of this injudicious feeding. If therefore the infant be applied to the breast every second hour when the mother is awake till the third day and be fed nothing besides, there need be no anxiety as regards its nutrition. If on the third day the breasts do not begin to fill and the secretion be delayed, a little fresh cow's milk, diluted with double its quantity of warm water, and slightly sweetened, should be given every fourth hour, but should be withheld as soon as the flow of milk occurs. Infants under the age of one month should nurse about every hour and a half by day and at longer intervals by 286 MORTALITY OF YOUNG CHILDREN IN CITIES. night, or about ten times in twenty-four hours, for the stom- ach of the new born holds but little, and therefore receives but little at each nursing, and its digestion is active. The interval should be longer at night than in the day-time, so as to allow the mother more sleep. In the second month the interval should be about two hours, and it should be gradu- ally lengthened as the age increases, so that after the fourth month nursing should be about every third hour, and after the sixth month, when the use of some artificial food is proper, every fourth hour. The infant should be habituated to nursing at regular in- tervals, and when it is, it will ordinarily awaken at about the proper time. The practice on the part of the mother of ap- plying the babe to the breast whenever it frets, and as a means of quieting it, although it have but just nursed, is pernicious and should be forbidden. Giving the stomach no time to rest, or filling it to repletion, tends to produce indigestion and diarrhoea, and to increase the fretfulness. The cause of the fretfulness should be sought for that the proper measures may be applied. In ignorance of the cause, it is better to quiet the restlessness by carrying the child, or even by rocking it, than to increase the task of the digestive function. Fretfulness of infants is often due to colic or griping in the bowels from gas or food that has not fully digested, and the addition of more food has a tendency to increase rather than to diminish it. If the mother have sufficient breast milk, no other food need be given before the fifth month, but many for various reasons find it necessary to supplement the nursing before that time. If other food be required, a little cow's milk, diluted for young infants with water in the proportion stated hereafter, may be given two or three times daily. After the fifth month cow's milk should be given without dilution. If for any reason the cow's milk disagree, one of the farina- ceous preparations described hereafter may be added to it or substituted for it. A fixed rule in regard to the proper time for weaning is impossible, for robust mothers with abundance of milk MORTALITY OF YOUNG CHILDREN IN CITIES. 287 should suckle longer than those who are less favorably cir- cumstanced. But in the ordinary condition of health, lacta- tion should continue till about the age of twelve months, when the first molars have pierced or are about piercing the gums. The fact heretofore alluded to should be emphasized in this connection, namely, that weaning should never occur during or just before hot weather, within the limits of the city, where the atmospheric conditions are such that there is a strong liability to intestinal catarrh in infants, so that slight dietetic changes, as the substitution of a food which is not so easily digested as the breast milk, may produce it. In New York the second summer is greatly dreaded by mothers, on account of the known liability of their infants to diarrhceal ailments, but the greater risk in the second summer over that in the first, which is known in all the tenement houses, is due solely to the fact that so many infants have been recently weaned, and placed upon new diet when the second summer begins. I have frequently advised mothers to suckle their in- fants of twelve, fifteen, or eighteen months through the period of atmospheric heat, rather than incur the risks of weaning at such an unfavorable time, and without apparent detriment to either party concerned, when I was convinced that weaning, even with judicious selection of artificial food, would result disastrously. In a salubrious rural locality, the change from the natural to artificial food involves little danger even in the hottest weather. Unfortunately, there are not a few mothers who, from causes enumerated above, are unable to suckle their infants, and find it necessary to make use of artificial feeding. Many such cases will doubtless come under the care of the Wilson Association, either in the sanitarium or elsewhere, since infants thus fed from birth, as we have already shown, are very liable to disease, either of the digestive organs or of a general character, as rachitis or struma. It is important therefore to have some rules for guidance as regards the diet of such infants. There is no food which so closely resembles human milk, 288 MORTALITY OF YOUNG CHILDREN IN CITIES. and which under ordinary circumstances is so good a substi- titute for it, as the milk of animals, particularly, since it is so readily obtained, that of the cow or goat. Infants under the age of six months should take it through the nursing bottle at the temperature of about 98i°, and the bottle as soon as used should, with the India rubber tip and attachment, be put in a quart or two-quart bowl of cold water, to which a teaspoonful of bicarbonate of sodium has been added ; and this water should be drawn through the tube and nipple by suction with the mouth. As the infant under the age of one month, when in the normal state, nurses the breast about ten times in twenty-four hours, it should have the bottle about every two and a half hours. The stomach during the first six weeks of life is very small, as we have stated above, resem- bling more a dilatation of the intestines than a separate organ, not receiving more than one or two ounces of liquid without distention. Therefore, while it is fed so often, it is evident that the quantity given each time should be small and such as will be quickly digested and absorbed. In the first month after birth the cow's milk should be diluted with half its quantity, or sometimes an equal quantity, of water, from the second to the fifth month with one third to one fourth its quantity, and after the sixth month it should be employed without dilution. The shops contain many substitutes for human milk, but cow's milk, if it can be obtained fresh from healthy grass-fed or hay-fed cows, is to be preferred to any of them for ordinary feeding. Condensed milk possesses no advantages which ren- der it superior to ordinary milk if the latter can be obtained directly from the animal and sufficiently often. When shall other food be allowed in addition to cow's milk, and what kind of food? Cow's milk, given unmixed with other kind of food, does not always agree with the infant. Possessing nearly the same chemical constitution as human milk, it nevertheless behaves differently, in some re- spects, in its digestion. The casein of human milk coagulates in light flocculi in the stomach of the infant so as to be read- MORTALITY OF YOUNG CHILDREN IN CITIES. 289 ily acted on by the digestive fluids, while that in cow's milk is apt to form large and firm coagula, which are with difficulty digested, and which therefore may cause colic and fever and make the infant restless, or cause vomiting, by which the mass is expelled ; or it may pass the bowels only partially digested, and appear in the stools as whitish masses. More- over, much of the cow's milk in market gives a more or less acid reaction, as we shall see hereafter. Now the casein of milk, which is already acid when administered to the infant, coagulates more rapidly and in larger masses than the casein of breast milk, which is alkaline. But if we mix with the cow's milk some bland and easily digested food, which by me- chanically separating the caseous particles, prevents the forma- tion of large masses, and which, while it has nutritive proper- ties, dilutes the milk and enables the digestive fluids to act more readily upon it, the desired effect is attained of facilitat- ing digestion without impairing the nutritive properties of the milk. Experience shows that this object can be effected, and that cow's milk, which disagreed with the feeble digestive function of the infant, can be made to agree by the admixture of certain dietetic preparations. The belief has prevailed in the profession that infants, prior to the third or fourth month, can digest only a very small amount of starch, since the pancreatic and salivary glands, whose secretions convert starch into glucose, a necessary change in digestion, are almost rudimentary in the first months of infancy. Therefore it was held that farinaceous or starchy food is unsuitable for young infants, and the re- nowned Baron Liebig, wishing to subserve the cause of in- fantile hygiene, prepared a food in which, by the action of malt, the starch of wheat flour is converted into glucose. Liebig's food is extensively used, and mixed with milk or given separately it commonly agrees with the youngest in- fant, but when given unmixed and in considerable quantity, it has in my practice proved too laxative, especially in hot weather, from the amount of glucose or grape sugar which it contains. I consider it on account of this quality one of the 19 290 MORTALITY OF YOUNG CHILDREN IN CITIES. best foods for constipated infants, and for all infants except in the hottest weather when there is a marked tendency to diar- rhoea. But now it is ascertained that the salivary and pan- creatic secretions are not the only agents by which the sac- charifaction of starch is effected in digestion. The mucous surfaces furnish an " epithelial ferment," which aids in the change, so that the secretions from the buccal and intestinal surfaces assist materially in the digestion of starchy food. 1 Therefore the theory seems now established that young in- fants can digest starch, though not to the extent of those who are older. The following are preparations containing starch which may be given, mixed with milk, to infants during the period of summer heat : Select the best wheat flour, bake it in an oven at a slow heat till it has a light fawn color, stirring it occasionally. This is very similar to the Ridge's Food of the shops. Another way of preparing flour is to press and tie it snugly in a bag, which should be boiled four or five hours in water sufficient to cover it. It is then like a piece of chalk, except the outside, which is moist and must be removed. Grate the flour from the mass as it is wanted for use. Flour prepared in this way, boiled with water in a gruel and mixed with more or less milk according to the age, agrees with most infants. It is somewhat constipating, and is therefore espe- cially useful in the summer diarrhoea. If it be too constipa- ting, it can be mixed with one third its quantity of oatmeal or Liebig's Food. Barley-flour is also a useful dietetic article, agreeing with most infants. But there are not a few cases of infantile diarrhoea in which milk given at each feeding, however judiciously mixed with farinaceous or glucose preparations, does not agree. Many such will no doubt be received from time to time in the sani- tarium ; cases, in which diarrhoea with symptoms of indigestion occurs, and though temporarily checked by treatment, re- turns. Under such circumstances it is better to give the milk at longer intervals, at each second or third feeding, or it i See resume' on Recent Discoveries in Digestion, by Charles Richert, Review Medicale, 1879 ; also remarks by Professor Flint, Jr. MORTALITY OF YOUNG CHILDREN IN CITIES. 291 maybe omitted entirety for a few days and the gruel be given alone, or mixed with the white of the egg, or with the ex- pressed juice of meat. A gruel made of flour and water is not sufficiently nutritive for prolonged use, and if the milk disagree and cause colic or diarrhoea so that it is necessary to withhold it from most of the feeding, take the white or albu- minous part of half a fresh egg, beat it in a saucer or cup, and add it to the gruel after the latter has become cool. This is usually taken readily by young infants, and it has an excel- lent effect in diarrhoeal cases, while it is very nutritious. Two or three times through the day, if the infant show signs of insufficient nutrition, one or two teaspoonfuls of the ex- pressed juice of meat maybe added to the gruel. It is better to make only one of these additions to the nursing bottle at a time, but I have occasionally employed at the different feed- ings in the same day, the egg, milk, and juice of meat with advantage. Too little attention is given in families generally to the kind and quality of milk which their milkmen serve them with. In and near a great city much of the milk served to the people, all of that which is from cows constantly stabled, and from those that are fed on cheap and poor kinds of food, is apt to be acid even at the milking, and to disagree with the infant, causing diarrhoea. Therefore physicians who have had experience with sick children in the cities, emjihasize the fact that only milk should be employed of the best quality, and from cows that have the range of the fields with grass or clover for food, or if stabled in the cool months are fed with hay and grain. If milk disagree and be found to be decidedly acid when tested by litmus paper, the acidity can be removed by adding to it lime-water or a little soda or pot- ash, but it is far preferable to substitute for it other milk of the best quality that can be obtained, which is less acid. Milk should be the chief article of food during the first year, and one of the chief during the whole period of infancy, but after the age of six months it is proper to allow some solid food. The proportion of solid food should be increased and 292 MORTALITY OF YOUNG CHILDREN IN CITIES. that of milk diminished as the infant grows older, but during the second and third years as well as during the first, milk should be allowed each day at, at least, certain of the meals. At the age of twelve months, the artificial food already men- tioned may be made of greater consistence, so as to be given with the spoon. Crumbs of stale bread broken up should be boiled in water sufficient to cover them, for one or two hours, then removed, and to the pulp fresh milk be added. This may be given one or more times daily in addition to the nurs- ing, care being taken that all lumps be reduced to a pulp. Beef tea is laxative, on account of the salts which it contains, as is also chicken tea, but a small, or moderate amount of it may be given once a day. Stale wheat bread or soda cracker should be crumbled in it and soaked, so as to be soft. If there be diarrhoea, the ordinary beef tea should not be allowed to young infants on account of its laxative effect, but the ex- pressed juice may be given instead. Few vegetables are proper for infants under the age of one year, but the potato baked and mashed so as to be like flour, may be given at the tenth to twelfth month. It contains a large amount of starch, but appears to be readily digested by infants of the age mentioned, if given once a day in moderate quantity, with a little butter and salt added. In the second year a greater variety of food may be allowed, but the full diet of the table must not be given till after infancy, or the age of three years. In the beginning of the second year the infant is weaned. He has twelve teeth, the eight incisors, and four molars, which, with their broad surfaces, are designed for chewing. Let him have now, each day or second day, in addition to the food which has previously been employed, a small piece of roast beef, rare done and cut very fine. Other meat, as mutton, may sometimes be given instead. After the age of eighteen, months, light puddings of farinaceous substances, properly prepared, as of rice and corn meal, are proper additions to the dietary. All the teeth of the first set have appeared at the age of two years and five months, and the time has now arrived MORTALITY OF YOUNG CHILDREN IN CITIES. 293 when a more marked transition may be made from liquid to solid food. Certain fruits may be allowed, even before this period, as also the jellies of most berries, and of fruits, which being deprived of seeds and parenchyma are for the most part readily digested, while they give a relish to the farinaceous food with which they are eaten. Pastries as ordinarily made, whatever fruits they may contain, are too rich and in- digestible for young children. The following judicious rule for the preparation of fruits for children, copied in popular treatises on hygiene of infancy and childhood, is from " Mur- ray's Modern Cookery Book." .... " Put apples sliced or plums, currants, gooseberries, etc., into a stone jar, and sprinkle among them as much Lisbon sugar as necessary ; set the jar in an oven or on a hearth, with a teacupful of water to prevent the fruit from burning ; or put the jar into a sauce-pan of water till its contents be perfectly done." Berries and fruits thus prepared, and the fruit jellies, are best eaten spread on bread and butter, or on soda crackers. It is obvious, from what has been stated above, that no rules or measures for the preservation of infantile life in the cities, during the summer, can be effectual in the highest de- gree, that do not particularize in regard to the quantity, as well as quality of the food, and the mode of feeding ; and as in the future operations of the sanitarium it is probable that children of all ages will be cared for and fed, I shall detail, presently, observations, which show what quantity of food is required, both in infancy and childhood, to furnish the nutri- ment which is necessary for normal growth. There is la- mentable ignorance in community as regards the dietetic needs of young children. The belief that children on account of being so much smaller require much less nutriment than adults, leads many astray. The following statistics, while showing how much food children require to do well and how much they receive in the large and well conducted institu- tions of New York City, will surprise many. The fact is, the digestion of children is more active than that of adults, and they suffer more from hunger if their meals are delayed be- 294 MORTALITY OF YOUNG CHILDREN LN CITIES. yond the usual time. The tissues undergo more active molec- ular change than those of adults, so that they need more nu- triment for the waste, and they require additional nutriment for the purposes of growth. The children upon whom the following observations were made are grouped according to their ages. New-born infants differ in some respects physiologically from those that are older, and they constitute the first group. The term " new- born " being applied to those under the age of five weeks. The second group embraces infants between the ages of two and ten months. These furnish a fair average of the dietetic requirement during the period of infancy after the second month. The observations embraced in the remaining tables relate to children who have passed beyond the age of lactation and been weaned. It will be seen from the statistics that new-born infants re- quire less milk than those who are older, and that after the first month the amount required is pretty uniform during the period of lactation. For the purpose of procuring accuracy in the following ob- servations, I obtained Fairbanks' Scales, weighing to the half drachm. The infants were accurately weighed before, and after each nursing, and the artificial food was weighed before and after each feeding. In this way the quantity taken at each meal was determined. The weights used were avoir- dupois. The observations were made, at my request, by Dr. Kate Parker, resident physician of the New York Infant Asy- lum, and by Dr. Chadbourne, resident physician of the New York Foundling Asylum, and I can vouch for their accuracy. The avoirdupois ounce contains 437.5 grains, and Dr. Chad- bourne ascertained, by very careful weight and measurement, employing the metric system for its greater accuracy, that one fluid ounce of human milk, with a specific gravity of 1,031, weighed 451.9 grains. With these data it was easy to determine the quantity in bulk of the milk from its weight. The observations in each case extended through twenty-four hours. MORTALITY OF YOUNG CHILDREN IN CITIES. 295 TABLE I. — Age under Five Weeks. Name. Age. to 3 S3 o sj Milk Nursed in 24 Hours. No. Quantitv in Quantity in fc Weight. Fluid Ounces. Oz Dr. 1 Josephine Folev . . . 17 d. 11 10 l 9.75 2 Henrv Cunningham 16 d. 9 13 5 13.24 3 Henrv Jackson . . . 19 d. 9 10 3 10.07 4 5 "RiL-p 5 d. 6 d. 12 12 22 7 15 54- 22.22 15.25 Henrv Benton . . . 6 Wm. Fletcher .... 5d. 12 10 1£ 9.88 7 Nora Has tie . . . . 14 d. 12 17 3 16.85 8 Carl Flask 5 d. 12 5 4 5.37 9 Clarence Humphrey- 1 m. 5 d. 8 11 H 10.84 10 Frederick Dighle . . 7d. 12 14 4 14.08 11 Edward Stace . . . 6 d. 12 8 1 7.74 12 Rosa Brown .... 3 w. 12 14 1 13.68 From these statistics, it is seen that each of these infants, who were all under the age of five weeks, and all but one un- der that of twenty days, nursed in the average 12.41 fluid ounces of breast milk in twenty-four hours, and as the average number of nursings for each during the day was 11.0, the quantity of milk received at each nursing averaged only a lit- tle more than one fluid ounce, 1.12, or to state the result of these observations in a different way, in 133 nursings of 12 in- fants in the twelve hours of day and twelve of night, the total quantity of milk received was 148.97 fluid ounces, with a daily average of 12.41 ounces for each infant, and 1.12 fluid ounce for each nursing. These infants were selected on ac- count of their healthy condition, none of them showing symptoms of imperfect nutrition. They were selected as fair examples of healthy infants under the age of five weeks. The practical benefit from these observations is apparent. We can do no better than imitate what is natural in the feeding of infants, and if, for any cause, lactation of a new-born infant be prevented, it should not be fed more than one and one fourth ounces, each two and a half hours, of cow's iriilk, pre- 296 MORTALITY OF YOUNG CHILDREN IN CITIES. pared as directed above, so as to resemble as closely as possi- ble, human milk. New-born infants, deprived of the natural mode of feeding, are apt to be over-fed by anxious mothers, with the inevitable result of indigestion, diarrhoea, and un- healthy stools, colic and sprue. Statistics like the above may assist in correcting such error. TABLE II. — Ages from Five Weeks to Ten Months. m u Milk Nursed in 24 Hours. Name Age. No. • 2P Quantity in Quantity in £'" Weight. Fluid Ounces. Oz. Dr. 1 Agnes Sunkle . . . 6 m. 8 26 H 25.3 2 Jessie Bradley 4 m. 9 38 i 36.8 3 Walter Gorman . 3£m. 8 24 2 23.5 4 Lottie Brooks . . 7 m. 10 27 3^ 26.6 5 Willie Leonard . 5} m. 11 28 7 28.0 6 John Clay . . . 5 m. 10 29 7 29.0 / Agnes West . . 3^m. 8 19 2 18.6 8 Freddy Van Buren 2 m. 10 d. 7 24 4 23 . 7 9 Eddie Wilson . . 6 m. 10 12 4i 12.2 10 Frank Smith . . 3i m. 8 26 7 26.1 11 Sarah White . . 4 m. 8 23 5 22.9 12 John Gafney . . 9 ra. 8 24 11 23.4 13 Bernhard Joseph 7 m. 8 27 4 26.6 14 Thomas Cole . . 6 m. 10 26 6-t 26.0 15 Astie Russel . . 6 m. 10 21 6 21.1 The average quantity of milk, which these infants, who were all well-nourished, received in the twenty-four hours, was 24.65 fluid ounces. The quantity received at each nurs- ing was 2.73 fluid ounces in the average. Comparing the statistics in the two tables we find that infants in the first month require only half the nutriment which is needed in the subsequent months of the first year. In other words, the nursling, after the first three or four weeks, requires about one ounce of milk, for each hour between the nursings. If there- fore it be bottle-fed, every third hour, with cow's milk, or other food, so prepared as to have about the same amount of nutriment as breast milk, three or three and a half ounces would be sufficient for each feeding. MORTALITY OF YOUNG CHILDREN IN CITIES. 297 The following observations, relating to the diet of children who have passed beyond the age of lactation, were made in the New York Foundling Asylum, with all possible care in order to avoid errors. In this institution children are not stinted in their eating, but those who eat little are reminded of their remissness, and are urged to eat more, so that no one leaves the table hungry. On the days in which Dr. Chad- bourne made the observations vegetables, except potatoes, were withheld, so that computation of the quantity of food consumed would be more accurate. TABLE III. — Observations Relating to the Diet during Twenty- four Hours, of Twenty-eight Healthy Children, between the Ages of Two and Three Years, with an Average Age of Two Years Eight Months. Total Amount. Average for each. Bread . Butter . Breakfast. 6 lbs. 4 oz. 1 dr. 13 oz. 5 dr. 22 lbs. 14 oz. 2 dr. 1 8 lbs. oz. 5 dr. 6 lbs. 13 oz. 7 dr. 17 lbs. 9 oz. 7 dr. 19 lbs. 12 oz. 1 dr. 7 lbs. 1 oz. 2 dr. 14 oz. 7 dr. 3 . 5 oz. .45 oz. Milk . " - - - 12.7 fl. oz. Meat . Potatoes Dinner. 4.6 oz. 3.9 oz. Milk . 9.4 fl. oz. Milk . Supper. 10.5 fl. oz. 4.0 oz. Butter . 53 oz. 1 354.6 fluid ounces. AVERAGE FOR EACH CHILD PER DAY. Bread 7.5 oz. Butter 98 oz. Meat (beef) 4.6 oz. Potatoes 3.9 oz. Milk 32.6 fl. oz 298 MORTALITY OF YOUNG CHILDREN IN CITIES. TABLE IV. — Observations upon Twelve Children between the Ages of Three and Six Tears: Average Age, Four Tears Ten Months. Total Amount. Average for each. Bread . Butter . Breakfast. 4 lbs. 6 oz. 3| dr. 5 oz. 2 dr. 280 fl. oz. 9 lbs. 1 oz. 3 dr. 1 lb. oz. 1 dr. 9 lbs. 12 oz. 7 dr. 112 fl. oz. 2 oz. 2£ dr. 2 lbs. 4 oz. H dr. 5 oz. 5| dr. 192 fl. oz. 5 . 86 OZ. .427 oz. Milk 23.3 fl. oz. Beef . Dinner. 12.1 oz. Bread 1 . 6 oz. Eice 13.0 oz. Milk 9 . 3 fl. oz. Butter Bread . Butter . Milk . Supper. 3 . oz. 16.0 fl. oz. AVERAGE PER DAT FOR EACH CHILD. Milk . Beef Bice . Bread Butter 48.6 fl. oz. 12.1 oz. (avoird. 13.0 oz. " 10.3 oz. 1.08 oz. " MORTALITY OF YOUNG CHILDREN IN CITIES. 299 TABLE V. — Observations relating to the Diet of Twenty-four Chil- dren, Twelve Boys and Twelve Girls, between the Ages of Four Tears and Ten Years : Average, Six Years Ten Months. Total Amount. Average for each . Breakfast. Bread Butter Milk 7 lbs. 13 oz. 3 dr. 12 oz. 3^- dr. 348 fl. oz. 18 lbs. 11 oz. dr. 15 lbs. 8 oz. 3 dr. 1 lb. 6 oz. \ dr. 192 fl. oz. 4|dr. 6 lbs. 2 oz. 3£ dr. 384 fl. oz. 11 oz. 5| dr. 5.21 oz. .51 oz. 14.5 fl. oz. Roast Beef Potatoes . Bread . . Milk . . Dinner. 12.46 oz. 10.30 oz. . 92 oz. 8.0 fl. oz. Butter .012 oz. Bread . . Supper. Milk 16.0 fl. oz. Butter .16 oz. AVERAGE PER DAT FOR EACH CHILD. Roast beef 12.46 oz. Bread 10.23 oz. Potatoes 10.3 oz. Butter .99 oz. Milk 38.5 fl. oz. Compare the above observations with those of Professor Dalton, who estimates that a healthy adult taking active ex- ercise requires each day, — Meat 16 oz. Bread 19 oz. Butter 3^- oz. Water 52 oz. while one leading a sedentary life needs considerably less. It will be seen by the above tables, that even more food appears to be needed during the period of childhood, than in adult life. We would suppose this to be so without statistical evidence, for the active exercise, and rapid and progressive growth of this period, would necessarily require a large 300 MORTALITY OF YOUNG CHILDREN IN CITIES. amount of nutriment. Moreover while adults do well with solid food and water, statistics show, that the best diet for children, who have passed beyond infancy, is one of milk with solid food, for at least breakfast and supper. Although we are able, by observations, to determine the average amount of food required in twenty-four hours, by children of various ages, it would be wrong to limit the diet to a fixed quantity, for some need more than others. A child should never go hungry after a meal. In some of the best conducted institutions of New York, the children eat of plain food all that they desire at each meal, while in other institu- tions, the food at supper is limited, but is abundant at the other meals. As children go to bed so soon after supper, it is proper to have this meal light, and of such food as is easily digested. I have obtained the following dietaries of three of the larg- est and best conducted of the New York Institutions, the children in which exhibit a healthy and contented appear- ance, and have little sickness. New York Orphan Asylum. This institution, of which Mrs. Alexander Hamilton, after the death of her distinguished husband, was during many years first directress, is located in West Sevent) fourth Street, and the children in it, about one hundred and eighty, eat all which they wish at each meal. BREAKFAST. Two or three thick slices of bread with milk ; no butter. DINNER. This always consists of hearty food, as corn beef, fresh meat, pork and beans, fish, potatoes, with other vegetables ; bread ; no soups. SUPPER. Bread and milk. New York Foundling Asylum. Inmates, about six hundred, all under the age of eight years. Those over the age of two and a half years have the following diet : — BREAKFAST. Bread and milk ; butter ; eggs for the delicate ; occasionally oat-meal porridge. MORTALITY OF YOUNG CHILDREN IN CITIES. 301 Eoast beef, potatoes, and four times each week other vegetables, as peas, beans, tomatoes, turnips, cabbage, and parsnips. Bread and milk for delicate children. On Monday rice, and on Friday eggs. SUPPER. Bread and milk ; butter; berries in their season ; apple-sauce; cake; syrup. The roast beef is sliced, passed through a machine chopper, so as to be made into hash, which is then moistened by the gravy, or juice of the meat. In the form of hash it is easily digested, while it contains all the nutritive properties of the beef. It would be well if this mode of preparing beef were imitated in other institutions and in families. Protestant Episcopal Orphan Asylum. BREAKFAST. One pint of milk; five to seven large slices of bread (two thirds of a pound to one pound.) DINNER. Monday. — Indian meal and syrup, or rice and sugar ; bread ; at times pota- toes and codfish. Tuesday. — Strong beef soup, containing onions, carrots, potatoes, turnips, parsley, celery, and rice ; bread. Wednesday. — Codfish and potatoes ; bread. Thursday. — Same as on Tuesday. Friday. — Corned beef, corned pork ; bean soup. Saturday. — Bice or Indian meal ; hominy; potato stew. Sunday. — Cold corned beef; boiled potatoes; bread. SUPPER. Same as breakfast. All the ordinary berries and fruits are also liberally used in their season. BATHHTG. Bathing is now recognized in all civilized countries as one of the chief promoters of bodily comfort and health. The first bathing of the infant, which is immediately after birth, should be in water at a temperature a little below that of the blood, namely, at about 96°, after which the general bath is inadmissible until the navel string is detached. In the infant reaction of the surface when chilled is tardy and uncertain, and therefore there is great danger of catching cold when the surface is cooled by water, and does not quickly react. It is a matter of daily observation that infants become chilly and 302 MORTALITY OF YOUNG CHILDREN IN CITIES. their extremities remain cool in a medium, whether air or water, in which older children and adults would have com- fortable warmth. Therefore they are liable to contract bron- chitis, sore throat, intestinal catarrh, or other inflammation from very slight exposures. This fact must be borne in mind in considering the subject of bathing. During the first year after the detachment of the navel string, the bath should be employed daily, but not longer than three minutes, during which time thorough ablution can be performed. Different authorities disagree in regard to the proper temperature of the bath during the first months of infancy. Steiner of Prague, a high authority in children's diseases, says," During the first nine months the infant should have a daily bath a little above blood heat," .... but most state a temperature a little below blood heat. In my opinion it should be 92°, which is considerably below blood heat, but which communicates a moderately warm sensation to the hand. After the age of ten months or even of eight months for vigorous children, the temperature of the bath may be re- duced to 90°, and it should not be lower than this during the remainder of infancy, or if it be used a little lower, care should be taken to produce reaction by brisk rubbing and exercise after a short bath. At the close of infancy, namely, at two and a half years, the temperature may be still farther reduced, but it should not even for the most robust children of eight or ten years be below 78°, which is recorded on our thermome- ters as the temperature of summer heat, and is about that of our northern lakes during midsummer. The rules given in the books not to bathe or direct a child to be bathed immediately after eating, or after much exercise, when the pores of the skin are perspiring, should be heeded. The head should first be wet with the water, and castile soap should be applied over the surface to insure cleanliness. The strongly scented toilet soaps sometimes contain rancid fats, or other deleterious substances, and should be regarded with suspicion. In hot weather a daily bath is advisable, but in the cooler months it is sufficient if the child bathe twice or three MORTALITY OF YOUNG CHILDREN IN CITIES. 303 times in the week. If from lack of conveniences, or for other reason, general bathing be dispensed with and the surface be washed from a basin or bowl, cooler water may be used than would be proper for the general bath, and a longer time to complete bathing would evidently be required. The bath- room should be comfortably warm, and after the bath the surface should be briskly rubbed with flannel, or in case of the older children with a suitable coarse towel, and exercise afterward encouraged to insure full reaction. In NeV York, in one of the largest and best managed asylums, both boys and girls are allowed to bathe in bath houses in the Hudson, when the water and weather are not too cool. It may be well to add to these general remarks on bathing the recent remarkable statement of a high authority on ther- mometric observations and temperature, that during hot days a bath in hot water employed in the hours of greatest at- mospheric heat, tends to reduce the heat of body and to pre- serve its normal temperature during the remainder of the day. Wun derrick says, " in tropical countries and in very hot sea- sons, no means of cooling is so lasting as a bath or a douche of very warm water. CLOTHING. One of the most important duties of the mother or nurse, is the selection of clothing for children which will be suitable for their age and the season. In the matter of dress as in that of diet, many errors are unconsciously committed. In a room of proper temperature, which during the cool months should be 70° for infants and 68° for children old enough to run about, the head should never be covered unless in case of young infants, the sides of whose heads as well as their necks and shoulders may be lightly covered in sleep. It is the common practice to leave off the " belly band " which is ap- plied after birth, when the infant has reached the age of three or four months, but from the fact that infants so often take cold, especially at night by throwing off bed clothes, both in cool weather, when the temperature of the apartment 304 MORTALITY OF YOUNG CHILDREN IN CITIES. may fall below 70°, and in summer when there are currents of air through open windows, I advise the continuance of the band during the first year or eighteen months. In the summer it should be made of light merino, and in the winter of flannel. It should never be so thick and heavy as to be uncomfortable, or so snug as to interfere in the least with the free movements of the chest and abdomen in respiration. It should extend to and not over the ribs, and should be se- cured either with safety pins or a few stitches. If excoria- tions or prickly heat appear on the skin under the band in hot weather, a very common eruption in infancy, the surface should be dusted with subnitrate of bismuth or a mixture in equal parts of lycopodium and oxide of zinc, and a single layer of linen should be applied over it and under the band. If the eruption be severe, it might be best to substitute a linen or soft muslin band for a time in place of the merino. A cardinal principle in the clothing of children is that the garments should always be so loose as not to interfere in the least with the functional activity of organs. The fitting and putting on of the dress is left too much to the discretion of the nurse, who is usually ignorant of the important facts in physiology, and, unwittingly and with the best inten- tions, injures her charge. I have often interposed to loosen the dress of young infants, which was so tight as to sensibly embarrass respiration, and the case of a new-born infant has been reported to me in which it seemed probable that death resulted from this cause. Infants especially who are so liable to pulmonary collapse and intestinal hernia, should have loose covering of both chest and abdomen. Pressure over the stom- ach always feels uncomfortable, and this organ, almost as much as the lungs, needs full expansion and free movement, in order to perform its function of digestion properly. The same is true also of the intestines, but they tolerate compres- sion better, and their movements are less impeded than those of the stomach by too tight dressing. Another part, where too snug an application of the dress does very great harm, is the neck, since moderate pressure in this region may retard MORTALITY OF YOUNG CHILDREN IN CITIES. 305 the circulation of blood through very important vessels, namely, those which supply the brain, or return blood from this organ. The dress about the neck should always be so loose that the four fingers of the nurse can be readily intro- duced underneath it. Skirts upon girls are sometimes sup- ported by being tied tightly around the waist and over the stomach. This should never be allowed, but skirts should always be supported by shoulder straps, and be loose around the waist. Clothing protects the body according to its thickness and the feebleness of its power of conducting heat. Woolen, fur, and feather garments have very low conducting power, and wool, from its plentiful supply and cheapness, must always be the material which is chiefly worn in the winter season ; while cotton, and in still greater degree, linen, are active conductors of heat, allowing its quick escape from any part of the body which it covers, and they are therefore the proper material for summer clothing. The color of a garment matters little as regards the escape of heat from the body, for whatever its color its surface next the body is necessarily dark from the exclusion of light ; but the color is important as regards the absorption of heat from the atmosphere and the solar rays. Black has the highest absorptive power, while white has the least, and the mixed colors have absorptive powers which are intermediate. In ex- periments made with shirtings of different colors, while white received 100° F., black received 208° F. A light color is therefore the best to dress children in in the hottest weather. The covering, which is proper for the head of a child when out-door, must evidently vary considerably in different sea- sons, and in different states of weather. Many a young child, with scanty growth of hair, has contracted that painful dis- ease, inflammation of the ear, followed perhaps by a pro- tracted discharge, and more or less impairment of hearing, in consequence of taking cold from insufficient covering of head and ears in inclement and changeable weather. Even leaving 20 306 MORTALITY OF YOUNG CHILDREN IN CITIES. off accidentally a band or tie, to which a child is accustomed, will sometimes give it a cold. In this connection, I wish to call attention to the common and dangerous practice among the poor of allowing children to go bare-headed in the sun, during the season when the at- mospheric heat is highest. Not a summer passes in which I do not meet cases of inflammation of the brain, which I be- lieve to be largely due to exposure to the sun's rays. There is no better and safer covering of the head of a child, who is allowed to go in the open air during the hot weather, than the light, cool, and inexpensive straw hat. The feet should always be warm and dry, the shoes worn in wet weather being water-proof ; and special care should be taken in the selection of shoes, that they be pliable and loose, so as to allow freedom of growth without compression of any part. If during the period of growth, proper precau- tions are taken in this respect, the chiropodist would have little to do in subsequent years. Corns, bunions, and ingrow- ing toe-nails originate from shoes, hard and unyielding, or too tightly fitting. SLEEP. The new-born infant requires from fifteen to eighteen hours sleep each day. If it do not have this amount and be wake- ful, it is probably not well. It sleeps therefore most of the time when not awake for nursing, bathing, and change of clothing. As it grows older, a less and less amount of sleep is required. At the age of three years, about nine hours are needed, and it is better, in my opinion, for healthy develop- ment, to allow children of this age one or two hours of sleep in the middle of the day. They indeed often take it by fall- ing asleep on the sofa, or floor, or in places where they are liable to take cold through currents of air, and scant cover- ing. Immense harm has been done to children, who were wake- ful, by nurses and mothers too, who have given them active and dangerous drugs, as laudanum or morphine, under some MORTALITY OF YOUNG CHILDREN IN CITIES. 307 enticing name as soothing syrup or cordial. A wakeful and fretting child is not well. Its ailment may be trivial or grave, but it should never, under such circumstances, receive from mother or nurse any of those proprietary mixtures hav- ing seductive names which the shops contain. If it need medicine, it should be examined and prescribed for by the phy- sician. It is scarcely necessary to call attention to some ac- cepted and important facts, regarding the dormitory of chil- dren. A free ventilation is required either through ventilators, or open windows, and a sufficient number of cubic feet of air should be allowed for each sleeper. A small room should not contain more than two children. Curtains should not as a rule be employed, and no open vessels of foul water should stand in the room, or anything else, which may contaminate the air. The garments worn through the day must be en- tirely removed and hung up away from the bed. In the asylums of New York, where from long and abun- dant experience the management of children is systematized, infants and the younger children are usually put to bed be- tween six and seven, and the older children between seven and eight o'clock, the last meal or supper, as I have stated else- where, being light and easily digested. EXERCISE. Exercise is an important hygienic requirement. Harm often results from modes of exercise which are not adapted to the age. Occasionally I meet cases of permanent bow-leg, which has manifestly resulted from attempts to make the infants stand at the age of four or five months. They should never be encouraged to walk or stand till about the age of one year, and if they do at the age of nine or ten months let it be voluntary, and not taught by standing them upon their feet. In case of infants with rachitis, which disease is com- mon in the cities, and is characterized by a lack of lime-salts in the bones, and can be detected by great backwardness in teething, attempts to stand or walk for any length of time should be discouraged, till by the use of lime-salts and cod 308 MORTALITY OF YOUNG CHILDREN IN CITIES. liver oil, and improvement of the general health, the rachitis is cured. Much of the permanent deformity which mars the beauty and symmetry of adult life originates in rachitis and might have been prevented. The infant before he is old enough to stand takes sufficient exercise in a way that is natural and harmless. Let him lie upon his back in the crib, or on the floor with a blanket under his body and a pillow under his head, and all his clothes loose so as not to restrain the free movements of his limbs. A healthy infant seems to enjoy this attitude, moving all his limbs sufficiently to give them the required exercise, and evincing his delight and exuberance of life by utterances which are as expressive as words. In the cool months of our latitude infants should not be taken out-door until the age of three months, and then only for a brief time in the warmest part of the day, but in the summer they should begin to receive out-door air and exer- cise at the age of one month. In warm weather the face should never be covered by a veil or otherwise, and air and light should have free access to it. The rays of the sun, however, from a clear sky should be excluded either by a par- asol, or the shade of trees or houses or the carriage in which the infant may be carried. In cold weather, or when there is a strong wind, the protection of a veil is needed. Rude toss- ing of infants, which is common in families, should always be forbidden. Its effect on the cerebral circulation is likely to be bad, and it involves risk of a serious accident. In one instance to my knowledge, death resulted from such acci- dent. Walking, as it is the natural, so it is the best, exercise for the older infants and during the period of childhood. It pro- motes digestion when not carried to the extent of fatigue, and gives gentle exercise to all the muscles. The baby-carriage answers a useful purpose, when combined with walking. With the ordinary hired nurse it is safer for the infant to be taken out in this vehicle than in the arms, for if the nurse in careless walking should trip, great harm might result. In MORTALITY OF YOUNG CHILDREN IN CITIES. 309 one instance which came under my notice convulsions and idiocy were plainly referrible to the fall of an infant from the nurse's arms upon its head. The ordinary lawn sports of childhood, as croquet for both sexes, playing ball or quoits for boys, which are rendered more exciting by the spirit of rivalry, are also useful for mus- cular exercise and development, while they involve little dan- ger. Swinging is a pleasant pastime to most children, and with the propulsion required it gives gentle but efficient ex- ercise to the muscles. Many of the gymnastic exercises are too severe, and involve too much risk of ruptured tendons, sprained joints, and even of dislocated or broken limbs. But with all the ingenious inventions to procure sports and pastimes for children, there are none better than gardening and farming, where facilities will allow it, conjoined with, the ordinary household duties. The healthy and robust develop- ment of the farming population, — their almost complete im- munity from rachitic and scrofulous ailments, is attributable to their out-door mode of life, and the many kinds of health- ful work which farm life requires. Such work is always in the highest degree beneficial for children old enough to par- ticipate in it, while it develops the habit of productive in- dustry. ■ m mm ^■■W m m m