rnLUMBlA LIBRARIES OFFSITE HEALTH SCIENCES STANpAFID HX64074625 RA61 V26 Ifi'a"' mortality and RECAP Ingen, P» V, and Taylor, Emmons ..•Infant Mortality and Milk Stations RA610-V26 ; i-^"lirt1inJi Columbia (Bmtiem'tp mtljeCtlpotHmgork CoHese of ^f^v^icmna anb ^urgeonsi INFANT MORTALITY AND MILK STATIONS SPECIAL REPORT OF THE COMMITTEE FOR THE REDUCTION OF INFANT MORTALITY OF THE NEW YORK MILK COMMITTEE 1912 THE NEW YORK MILK COMMITTEE 105 EAST TWENTY-SECOND STREET NEW YORK Columtiia Wini'btvJiitp CoUege of ^fjpgitiansJ anb burgeons l^eference ILihvaxv Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/infantmortalitymOOvani INFANT MORTALITY AND MILK STATIONS INFANT MORTALITY AND MILK STATIONS SPECIAL REPORT DEALING WITH THE PROBLEM OF REDUCING INFANT MORTALITY. WORK CARRIED ON IN TEN LARGEST CITIES OF THE UNITED STATES TOGETHER WITH DETAILS OF A DEMONSTRATION BY PUBLIC AND PRIVATE AGENCIES IN NEW YORK CITY DURING 1911 TO DETERMINE THE VALUE OF MILK STATION WORK AS A PRACTICAL MEANS OF REDUCING INFANT MORTALITY D n D Edited by PHILIP VAN INGEN, M.D. Member of the New York Milk Committee and Medical Director of the Committee for the Reduction of Infant Mortality and PAUL EMMONS TAYLOR Secretary of the New York Milk Committee and Director of the Committee for the Reduction of Infant Mortality PUBLISHED BY THE NEW YORK MILK COMMITTEE 1912 Infant mortality statistics presented in this report were prepared By Philip Van Ingen, M.D. Price, One Dollar The New York Milk Committee ORGANIZED BY THE NEW YORK ASSOCIATION FOR IMPROVING THE CONDITION OF THE POOR IN 1906 INCORPORATED IN 1910 Create ttjrougb education and publicitp a public bemanb for a clean anb jsafe mtlfe jiupplp for an. pretoent unneces^ar? XzH of infant life. OFFICERS Stephen G. Williams, Chairman Thomas S. McLane, Vice-Chairman and Treasurer Paul E. Taylor, Secretary ACTIVE MEMBERS The Officers and Haven Emmerson, M.D. Stephen Francisco Mrs. J. Borden Harriman Philip Van Ingen, M.D. Miss Alice Lakey Charles E. North, M.D. Mrs. a. M. Palmer Godfrey R. Pisek, M.D. Marshall L. Warrin Ira S. Wile, M.D. ADVISORY COUNCIL E. H. Bartley, M.D. Henry Dwight Chapin, M.D. Henry L. Coit, M.D. Henry Ives Cobb Lewis A. Conner, M.D. Mrs. Arthur M. Dodge Rt. Rev. David H. Greer A. Jacobi, M.D. Rev. Walter W. Laidlaw Walter W. Law V. EvERiT Macy Franklin D. Roosevelt John G. Saxe DeWitt J. Seligman John Spargo Mrs. Henry Villard Arthur E. Wakeman George W. Wickersham Committee for the Reduction of Infant Mortality Godfrey R. Pisek, M.D., Chairman Mrs. J. Borden Harriman, Vice-Chairman Paul E. Taylor, Director EXECUTIVE COMMITTEE The Officers and S. Josephine Baker, M.D. Eli Long, M.D. Mrs. J. J. MooRHEAD Mrs. a. Gordon Norrie E. B. Phelps Mrs. Nathaniel Bowditch Potter Mrs. Belmont Tiffany Ira S. Wile, M.D. Philip Van Ingen, M.D. GENERAL Mrs. Felix Adler Reuel a. Benson, M.D. Homer Folks Miss Alice P. Gannett Robbins Oilman John A. Kingsbury Rev. a. W. McCurdy Thomas M. Mulry COMMITTEE Prof. M. I. Pupin Mrs. V. G. Simkhovitch Miss M. deG. Trenholm Morris D. Waldman Miss Marianna Wheeler Gaylord S. White Egerton L. Winthrop, Jr. MEDICAL COUNCIL Abraham Jacobi, M. D., Chairman L. Emmett Holt, M.D. Walter Lester Carr, M.D. L. E. LaFetra, M.D. Henry Dwight Chapin, M.D. C. G. Kerley, M.D. Floyd M. Crandall, M.D. William P. Northrup, M.D. Rowland G. Freeman, M.D. N. R. Norton, M.D. S. S. GoLDWATER, M.D. JOHN A. Wyeth, M.D. Table of Contents PAGE Introduction Chapter I. — The Problem 17 Statistics of Infant Mortality (a) In Foreign Countries. (b) In the Registration Area of the United States. Conditions Afifecting Infant MortaUty. Poverty and Ignorance, Resulting in — (a) Unsanitary Housing. (b) Neglect of Babies and Expectant Mothers. (c) Impure Milk. (d) Bad Methods of Feeding. (e) Crime and Illegitimacy. Relation of Meteorological Conditions to Infant Mortality. Chapter II. — The Campaign Against Infant Mortality in New York City (Prior to 1911) 22 Beginning and Growth of the Movement. Work of Various Charitable Organizations. Work of the Health Department. Co-operation Between Organizations. Development of Prevention. Chapter III. — The Campaign in New York City in 1911 27 Work of the New York Milk Committee. (a) EstabHshment of Thirty-one Milk Stations. (b) Plan of the Campaign. (c) Tremendous Growth of Movement. (d) Appropriation Granted by Board of Estimate and Apportionment for Fifty- five Milk Stations in 191 2. Work of the Health Department. Work of Other Organizations. Chapter IV. — Results of the Campaign in New York City as Shown by Comparative Tables 36 A Study of Infant MortaUty by Years, Trimesters, etc., for Manhattan, Brooklyn, and the "Rest of the City," Showing Gross and Percentage Changes. Weather Conditions. Chapter V. — Results at the Milk Stations of the New York Milk Committee. A Statistical Study of the Records 52 Comparison of Records of "Station" Babies and "Station District" Babies. Feeding Records of Station Babies. Deaths of Station Babies viii TABLE OF CONTENTS PAGE Chapter VI. — Campaigns in other Cities 84 Statistical Study of Infant Mortality. Weather Conditions. Efforts at Reducing Infant Mortality. Chicago. Philadelphia. St. Louis. Boston. Cleveland. Baltimore. Pittsburgh. Detroit. Buffalo. Chapter VII. — General Conclusions 122 Summary of Infant Mortality in Various Cities. Comparison of Weather Conditions in Various Cities. Comparative Summary of Campaigns Against Infant Mortality. General Deductions. Chapter VIII. — ^The Extension of Relief Through Milk Stations. ... 131 Method of Handling Free Milk Problems. Statistical Study of Milk Relief Applications. Other Forms of Relief. Ice. Hospital Care. Outings. Conclusions. Chapter IX. — Establishment and Operation of Milk and Health Stations 147 Survey of Needs. Cost and Equipment of Station Plants. Organization and Operation. Cost of Operation. Physicians. Nurses. Matrons. Chapter X. — Extension of Milk Stations' Activities 165 Education of Expectant Mothers. Control of Midwives. Supervision of Boarded-out Babies. Care of Children Under School Age. Appendix 1 74 Tables Showing the Quality of Milk Dispensed by the Committee's Stations and that Dispensed by City Stations. Summary of Milk Committee's Work for Season. Exhibits Illustrations Introduction The purpose of this report is to make available to every one having an in- terest in the campaign against infant mortality the information acquired by the Committee for the Reduction of Infant Mortality of the New York Milk Com- mittee during the summer of 1911, when it undertook a demonstration to deter- mine the value of infants' milk stations as a means of reducing that mortality. It is not intended as a general report of the work done by the Committee, which is contained in the Fifth Annual Report of the New York Milk Committee. Statistics were carefully kept and tabulated. They are here presented, with the deductions drawn from them, together with the opinions derived from the ex- perience of those who organized and directed and carried on the work. In the first chapter is given a very brief summary of the problem, to help in the solution of which the milk station was called upon. A frightful tragedy, costing the lives of some 1600 men and women, horrifies the entire world, and yet every year many thousands of babies die unnecessarily. Tables are given show- ing that in the civilized world from one in every ten to one in every three babies born die during the first year of life. The various factors concerned in this waste of life are very briefly discussed. In the next chapter is given a resume of what has been done in New York city during recent years for the prevention of this high infant mortality. An attempt is made to trace the development of the activities working together today toward this end. Chapter IV deals with the results obtained in New York city as a whole, and its different subdivisions. Tabulations of the official figures of the Health De- partment for a number of years are given. These tables show a most remarkable reduction in infant mortality for the year, and chiefly during the summer months. They show that, with a low total infant mortality, only 28 per cent, occurred during the three summer months in Manhattan, as against an average for the preceding ten years of 33.8 per cent. A tabulation and brief discussion of weather conditions in New York is also given, which shows that in the first half of the summer conditions were very un- favorable for a low infant mortality. The first part of July was the most un- favorable since 1901, and yet the deaths during that month were the lowest since 1901, not even taking into consideration the increase in population. Chapter V deals with the results obtained at the milk stations. Careful records were kept containing all data which could be used to any advantage. The feeding records of 3182 babies under two years are analyzed and studied in some detail. Of these babies, only 158 died, and of them, 58 were never treated in any way by the station physician or nurses, being immediately sent to a hospital X INTRODUCTION or private physician. The milk stations were carried on to prevent sickness among babies. Many facilities exist for treating sick ones. Every baby who died, how- ever, if it once came inside the station, was charged against that station, in order to avoid possible charges of selecting cases. The results show the entire feasibility of teaching the mother to modify the milk at home. Detailed studies of mortality in a large portion of the borough of Manhattan were made by one of the Committee, in order to try to show the relation of the mortality among the station babies to that in the blocks surrounding th^ stations and from which the babies came. The results are rather striking. In order to determine whether results in New York, especially the boroughs of Manhattan, wliere the Committee was working, and Brooklyn, where the Health Department was most active, were better than in other cities, as complete records of their vital statistics as possible were made, together with an attempt to find out what was being done there. The nine largest cities after New York were selected. More could not be attempted, owing to the difficulty of securing in- formation. The lack of published statistical records makes it very difificult to make a thorough study of conditions. Comparatively few cities outside of the largest ones publish monthly bulletins of vital statistics. Of those that do, the data printed in regard to infant deaths are often scanty and classified entirely differently in different cities. Even the Census Bureau, in its splendid yearly reports on mortality, does not tabulate infant deaths by months of occurrence, though it does adults. For many of the data the Committee is indebted to health officers, who supplied them on written request. In Chapter VI the various data collected are tabulated and summarized, and an attempt is made to compare results fairly and impartially. The Committee believes the value of the milk station as a means to reduce infant mortality through educational prevention is proved. In the chapters that follow, the organization of the stations and the central office is shown for the benefit of any communities planning to organize such a work. The cost of maintenance is most carefully and fully worked out. The problem of relief and the details of its management are given fully. A chapter is devoted to the future of the milk station and its possibilities of usefulness. The work of the Committee was carried on to help the Department of Health demonstrate the value of milk stations in reducing infant mortality. The city appropriated funds in 1910 to maintain 15 municipal milk stations. When the Board of Estimate and Apportionment met to pass on the appropriations for 1912, the Committee submitted a report to each member stating what had been ac- complished, and illustrating results with maps, charts, and tables. It also was represented at the public hearing on the budget, and that the city increased the previous appropriation so that the Department of Health could maintain 55 in 1912, they feel sets the official seal of approval on the work of milk stations, — not theirs, — but what is far more important, milk stations as a means for the pre- vention of infant mortality through education. The Committee wishes in this way to acknowledge the help and cooperation of many — it is impossible to mention them by name, they were so many. The INTRODUCTION xi various relief organizations, settlements, and hospitals gave much assistance; without it the work would have been impossible. The cooperation of the Health Department and the Bureau of Municipal Research was much appreciated. The ice companies did their share in generously supplying free ice to those unable to buy it. Our thanks are due to the many health officers who provided statistical ma- terial and information. Many physicians and private individuals also furnished valuable information. And, finally, we wish to express our thanks and appreciation to the staff of physicians, nurses, matrons, and the office force, who worked in season and out of season, early and late, under most trying and almost impossible conditions, giving their very best to their work. Without such a spirit on the part of all we could not have accomplished what we did. I And U Thor Ssy< Boa I NOISE '■->• JH TO Commii Ma Keeii 365 RULES 'FOR THb i.ARE OF SICK BABIES IN SUMMER DR.JACOBI URGES CITY TO SAVE. LIVES OF BABIESI VcniTflble Dean of American Me i Pleads with Board of Est - — Mother TclfsErenins M;i ij How Pure Milk Has Saved I Exhibit 1 How Newspapers Help CHAPTER I The Problem "A baby who comes into the world has less chance to live one week than an old man of ninety; and less chance to live a year than one of eighty." So said Bergeron some years ago, and it is practically true today. In 1900, 2.2 per cent, of the total population of the Registration Area* were under one year of age. Assuming the same proportion to hold good in 1910, among 2.2 per cent, of the population occurredf 19.2 per cent., or nearly one-fifth, of all the deaths. The infantile mortality ratet in eight States having fairly complete birth registration varied in 1910 from 108 to 168 (f) ; that is, from one in every six to one in every ten, babies died before they were one year old. These figures are not exceptionally high, as will be seen from the following table :§ TABLE 1.— SHOWING GENERAL AND INFANT DEATH-RATES IN FOREIGN COUNTRIES IN 1909|| General Death-rate Infant Death-rate England and Wales 14.5 109 Scotland 15.3 121** Ireland 17.2 92 New South Wales 9.6 74 Victoria 11.2 71 Queensland 9.7 72 S. Australia 9.3 61 W. Australia 9.9 78 Tasmania 10.0 65 New Zealand 9.2 62 Denmark 13.1 123** Norway 13.5 76** Sweden 13.7 85** Prussia 17.0 164 Hungary 25.1 212 Austria 22.3** 204tt Servia 29.3 158 Netherlands 13.7 99 Belgium 16.5** 147** France 19.3 135tt Switzerland 16.2** 108** Spain 23.4 173tJ Italy 21.4 153** Chili 31.5 320** * The registration area in 1900 comprised 40.5 per cent, of the population of continental United States. It embraces those States and cities which have adequate laws for registration of vital statistics. t Census Bureau Bulletin, 109. X Infant mortality rate is deaths of infants per 1000 living births for same period. § From Seventy-second Annual Report of Registrar General of Births, Deaths, and Marriages in England and Wales (1909). 11 General death-rate is number of deaths at all ages per 1000 of population. Infant death- rate is number of deaths under one year per 1000 births. *♦ 1908 figures. ft 1907 figures. %% 1906 figures. 2 17 1 8 INFANT MORTALITY AND MILK STATIONS Ireland, Norway, Sweden, The Netherlands, and the great Australian colonies. New Zealand and Tasmania, alone fall below 100; while in Prussia, roughly, one in every six; Austria and Hungary, one in every five; and Chili, one in every three, babies die before they are a year old. In order to understand the problem we must analyze these figues still further. It is necessary to know when the babies die, and from what causes. The follow- ing tables show the age at death and the cause of death (general groups of dis- eases) in England and Wales in 1909: TABLE 2— INFANT MORTALITY IN ENGLAND AND WALES. NUMBER OF DEATHS PER 1000 BIRTHS AT VARIOUS AGES AND FROM VARIOUS GROUPS OF DISEASES, BASED ON FIGURES FOR 1909* I. Common infectious diseases II. Diarrheal diseases III. Wasting diseases IV. Tuberculous diseases V. Miscellaneous All causes Bi ■< 10.14 1.41 5z« . 0.04 0.04 0.18 0.28 10.68 2.46 11.55,13.18 0.07 0.30 2.08 3.823.16 0.01 0.01|0.04 1.69:1.84 1.50 5.70|5.33i3.99 I « H H O Z g 0.11 0.80 29.88 0.06 8.90 39.20 Under One Year 6.97, or 6.4% 12.64, or 11.6% 41.69, or 38.3% 4.00, or 3.6% 43.43, or 39.9% infant deaths 108.73 By Months. 1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 Under 1 Year I. 0.11 0.36 0.36 0.33 0.32 0.42 0.54 0.74 0.85 0.93 0.97 1.04 6.97 IL 0.80 1.47 1.63 1.50 1.47 1.23 1.02 0.89 0.81 0.72 0.56 0.54 12.64 III. 29.88 4.30 2.35 1.46 1.02 0.71 0.52 0.40 0.32 0.30 0.23 0.20 41.69 IV. 0.06 0.20 0.32 0.34 0.44 0.41 0.38 0.36 0.40 0.39 0.35 0.35 4.00 V. 8.90 5.26 4.12 3.44 3.18 2.93 2.89 2.76 2.72 2.58 2.35 2.30 43.40 All causes 39.75 11.59 8.78 7.07 6.43 5.70 5.35 5.15 5.10 4.92 4.46 4.43 108.73 I. Includes smallpox, chicken-pox, measles, scarlet fever, diphtheria, whooping-cough. II. All gastro-intestinal diseases except gastritis and gastric catarrh. III. Includes premature births, congenital defects, want of breast milk, starvation, atrophy, de- bility, marasmus. * Compiled from Annual Report of Registrar General, England and Wales, 1909. It should be noted here that in Group V are included "meningitis, not tuberculous," and "convulsions," which amount to 10.43 under one year, and "gastritis, gastric catarrh," amounting to 1.83. The latter, in our classification, would probably be included in Group II, and the former are probably largely digestive in character. This should be remembered in comparing the above table with Table 4. THE PROBLEM 19 TABLE 3— INFANT MORTALITY IN ENGLAND AND WALES. PERCENTAGE TOTAL DEATHS UNDER ONE YEAR OCCURRING AT VARIOUS AGES, BASED ON FIGURES FOR 1909 Of the infant deaths — 10.6% occurred under 1 day. OF 12.1% ' ' 1 day and less than 1 week. 5.2% ' ' 1 week and less than 2 weeks. 4.9% ' ' 2 weeks " " " 3 " 3.6% ' ' 3 " " " " 1 month. 36.5% ' ' under 1 month of age. 10.6% ' 1 month and less than 2 months 8.0% ' ' 2 months " " ' ' 3 6.5% ' 3 " " " ' ' 4 5.9% ' 4 " " " ' ' 5 ' 5.2% ' 5 " " " ' ' 6 4.9% ' 6 " ' 7 ' 4.7% ' 7 " " " ' ' 8 4.6% ' 8 " " " ' ' 9 ' 4.5% ' 9 " " " ' ' 10 ' 4.1% ' 10 ' ' ' 11 4.0% ' 11 " " " ' ' 12 Of these deaths, 10.6 per cent, occur under one day old, 22,7 per cent, under one week old, and over a third during the first month of life. From then on the proportion steadily decreases. The above tables also show that 38.3 per cent, of these deaths under one year occur from the so-called "wasting diseases," and 11.6 per cent, from diarrheal diseases. As noted above, the proportion of the latter is probably too low, but practically 50 per cent, are due to these two classes. The following table shows the proportion of deaths under one year in the Registration Area of the United States due to these causes: TABLE 4.— PERCENTAGE OF DEATHS UNDER ONE YEAR OF AGE IN THE REGIS- TRATION AREA OF THE UNITED STATES DUE TO DIARRHEAL AND WASTING DISEASE* 1900-4 Diarrhea and enteritis (II) 23.72 Wasting disease (III) 25.61 49.33 1905-9 26.41 27.79 54.20 1900-9 25.23 26.83 52.06 It will be seen that in the United States also a little over one-half of all the deaths under one year are due to these two classes of disease. Further, the pro- portion has shown a steady increase from year to year, as will be seen from the following figures: TABLE 5.— PERCENTAGE OF ALL DEATHS UNDER ONE YEAR DUE TO DIARRHEAL AND WASTING DISEASES IN THE REGISTRATION AREA OF THE UNITED STATES* 1900 48.80 per cent. 1901 48.40 1902 47.57 1903 49.96 1904 51.84 1905 52.46 per cent. 1906 53.21 1907 54.23 1908 55.59 1909 55.03 Such, then, in brief is the problem which confronts us. When we look still * " A Statistical Survey of Infant Mortality's Urgent Call for Action," Phelps. for Study and Prevention of Infant Mortality, Annual Meeting, 1910. Amer. Assoc. 20 INFANT MORTALITY AND MILK STATIONS further and try to discover the causes of this appalling state of affairs, we are brought face to face with practically the entire social problem of today. Conditions Affecting Infant Mortality Ignorance and poverty are written all over the situation. As has been said, one-quarter of all the deaths in babies are due to the so-called "wasting diseases." Poverty forces married women to be wage-earners. It forces the expectant mother to work long hours, often in the factory, under unsanitary conditions, with poor food and with her family at home to take care of after working hours. This is a poor preparation for the ordeal through which she must go. She is less likely to give birth to a baby who has a fair start in the world. Further, her own physical condition is such that she is less likely to be able to give the baby the food that nature intended it to have. Even if she can give the baby the breast, poverty again drives her to return to work immediately after her confine- ment. This forces her not only to feed the baby artificially, but to leave it to the care and tender mercies of a "Little Mother," often a mere child herself, or to confide it to the care of a day nursery. Poverty forces the poor to live in overcrowded, unsanitary tenements. Exhibit 2 shows graphically the distribution of infant deaths along the East Side of Manhattan — New York city. In some of these blocks as many as 5000 people are herded together, and it is in these districts that the infant deaths occur in such large numbers. Compare the black dots near the river with those near Fifth Avenue. We are here confronted with the problem of congestion of population in all its phases. Another quarter of the deaths among babies is due to diarrheal disease. This means bad food and bad methods of feeding. Deprived of its mother's milk, the baby must be artificially fed, and milk should be the chief article of diet during the first year. This brings us face to face with the entire milk problem. How is the city to be insured a clean milk supply? About 2,000,000 quarts of milk a day are brought into New York city from 44,000 farms in seven different States. To the average mother milk is milk. She is ignorant of the necessity for clean, pure milk. Poverty forces her to buy the cheapest milk she can get. Pure milk costs more to produce than dirty milk, but if buying food for the older members of the family, she would not willingly buy decomposing meat or vege- tables. She is ignorant of the fact that impure milk is a poison to her baby, just as decomposing food is to the rest of the family. Bad methods of feeding, even when the milk used is a good milk, are respon- sible for a vast number of deaths. The mother is ignorant of how to feed her baby, and it is not only the mother, but unfortunately often the physician as well, who is ignorant. When her baby is sickly, in desperation she tries anything her neighbors suggest — condensed milk, proprietary foods, or even solid food. Artificial feeding diminishes tenfold the baby's chance to survive the first year. Finally, crime and illegitimacy come in as causes. The figures for England and Wales for 1909 show the death-rate among illegitimate children under one year of age to be 2U.1, as against 104.8 for legitimate children — more than twice as high a mortality. V^^ ■... . ^vii^'. u z u:! o c "n , M c H u m ^ O w U) :mv ""..... ' "-y ■";■;■■ ~ -"" , •• •»' "L ::::::::: 'tH^ [I^u::: • /i- •H-T 1 .. t"-^ L • "• 11 •::: •::in :::::1B E=! •= ::: !:::::H: /•/IJ^ 9 6 ^^^ ^ X cyj OJ H ^ 'J-i <:•;*; ■ ■ ■.■:'"■'"' '■"..■•*:■■■ ■1 -!,.--_ _ „ 3 ' ^.- o w'a y u s ^is^ lit-' •V' /y ,. ^ ^'ay '^.^ 0'::^f-^y-::-/-^ --r- Exhibit 3 In Less Than One-half of Brooklyn's Total Area Occurs Ninety-five Per Cent, of the Borough's Infant Mortality THE PROBLEM 21 In general, then, the two great fundamental causes of infant mortality are poverty and ignorance. Among the more remote causes meteorologic conditions are considered to play a large part in producing infant deaths. From one-third to almost one-half of the baby deaths in some cities are recorded during the third quarter of the year — July-September. In a recent careful study of conditions in Berlin Lieflfmann and Lindemann have drawn certain conclusions as to the effect of atmospheric temperature. They have constructed charts showing the daily deaths in Berlin, together with the course of the temperature for a number of years. They show that for the winter and spring months there is a sort of normal mean daily curve for deaths. In early summer, with the advent of hot days, there is a sharp rise in the number of deaths; with the fall of temperature there is an almost immediate fall in the deaths to the so-called normal. In midsummer and in late summer, while the sharp rises occur with each hot day, the fall does not recur to the "normal," but the basal curve tends to remain high. It is only after a considerable period of cool weather that it does so return. They conclude, from their studies, that atmospheric heat above 23° C. (73.4° F.) has a directly injurious effect upon infants. They consider that a great number of deaths in hot weather are due to "heat-stroke" ("Hitzschlag"), just as in adults. While admitting that many babies, during the hot weather, do suffer from diarrheal disease, they consider that this is not the real cause of death. Artificial feeding, to their mind, is usually faulty in quality and quantity in hot weather. Cow's milk under these conditions causes an injury to the intestinal tract which makes such babies particularly susceptible to the effects of heat. Certain experiments on animals seem to bear out this theory. This fact seems to explain the failure of the death-curve to return to the "normal" in later summer during cooler days. Many babies die from diarrhea each day, regardless of the temperature, and on each very hot day the "heat cases" are added. Whether this is a true explanation or not; whether the theory that the heat diminishes the baby's resistance, acts unfavorably on the milk or food it gets, and so renders it an easy prey to the diarrheal disease brought on by faulty feeding or filthy milk, is accepted — the fact is not altered that the daily deaths do rise sharply in hot weather, and tend to remain high throughout the late summer. Exhibits 4 and 5, showing the daily deaths under one year in Manhattan in 1909 and 1910, and Exhibit 7, showing the same for Brooklyn for 1910, illustrate this very clearly. Relative humidity has been less studied, and it is somewhat difficult to give its proper place. It is to be noted that humidity in dwellings is probably quite different from that recorded at weather bureaus. Rainfall — the amount and distribution of the rain throughout the summer — is thought to have an influence. Dry summers and long periods without rain, even when the total rainfall is large, are supposed to increase the infant mortality. All these factors will be discussed more in detail in studying the conditions and results in 1911 compared with other years. CHAPTER II History of the Campaign Against Infant Mortality in Greater New York Before describing in some detail the story of the campaign in New York in 1911, it will be well to take a brief glance at what was done in previous years. The New York Milk Committee is convinced that the phenomenal decrease in infant mortality in 1911 can in large part be laid to improved methods, and a view of the development of these methods will not be out of place. In 1873 the New York Diet Kitchen Association was founded, its object being to distribute nourishing food to the sick among the very poor. "Good milk" was, of course, distributed to old as well as young. In 1891, at the Good Samaritan Dispensary, milk was dispensed in summer to sick babies. It was modified to a set formula, suited to a definite age, and pasteurized. For several years this part of the work was carried on only in sum- mer. Since 1898 it has distributed milk all the year. In 1892 Mr. Nathan Strauss founded his well-known Pasteurized Milk Laboratories. Any baby in need of milk could obtain the day's supply, already prepared, and needing only to be warmed before using. Mr. Strauss's depots were situated in various parts of the city. As his plan grew summer stations were added to meet the demand. A safe, well-prepared milk was provided, the formulae being provided by the best medical authorities in the city. This was a great step in advance, and paved the way for most later developments. In Brooklyn, in 1901, the Children's Aid Society entered the field, following the lines of the Strauss stations. Their depots were open only a couple of months the first year and were in charge of a matron. The Health Department provided a physician to supervise the preparation of the milk. Eleven stations were opened, chiefly in settlements or hospitals, and 1087 babies were fed the first summer. In 1889 and 1890 the Brooklyn Bureau of Charities had started this work, which was later taken over by the above-mentioned society. Before 1901 the work of the Health Department had been small in the field of infant mortality. As far as the annual reports show, until 1902 it consisted in a small summer corps who visited sick babies in the tenements. In 1902, however, the work was reorganized, and a house-to-house canvass of the worst tenement districts was carried on. Nurses followed up the cases and carried out orders. Dispensaries were established at recreation piers; 206,121 families were visited. The inspection of the milk supply was undertaken — at the farm, in transit, and in the city. Funds were not available for a very exten- sive campaign, but the work was begun. The Brooklyn Children's Aid Society continued their work, adding another Exhibit 4 Exhibit 5 Exhibit 6 < -J 2: s;. >- — 1 _ isi — o CD cs: CD Exhibit 7 Exhibit 8 CAMPAIGN AGAINST INFANT MORTALITY 23 station, and caring for 1197 babies. This year they were open from June 24th to September 5th. The same general principle was followed, dispensing milk according to age, already modified. The Henry Street Nurses' Settlement began this year to dispense milk to the poor in their neighborhood in connection with their visiting work. In 1903 the Health Department broadened out its work considerably. The summer corps of physicians and nurses began visiting the families of every baby whose birth was registered with the department between August 1, 1902, and June 30, 1903, A circular on "How to Keep the Baby Well" was mailed to each address. After three days it was found that 30 per cent, of the families had moved, and so many unregistered babies were found that a house-to-house canvass was started, and a report made on every child under one year found. Literature was distributed, and, when necessary, sick babies were treated by inspectors and nurses. Six inspectors chosen for their fitness were specially assigned to this. In Brooklyn the Children's Aid Society increased their stations to 14, feeding 1547 babies from June 17th to September 5th. In Manhattan the Strauss laboratories, the Good Samaritan, and the Diet Kitchen continued their work as before. In 1904 the department continued its work along the same lines, visiting the tenement districts, tabulating all cases, and treating the sick children. The physicians visited 159,726 families and treated 1428 sick babies. Thirty-three nurses were doing district work, and visited 56,271 families and cared for 437 sick babies. They distributed orders for milk and ice as needed. In Brooklyn the Children's Aid Society improved on their method by attempting seriously to carry on some instruction. The matrons visited among the sick babies, and a corps of volunteer physicians (nine) followed up the sick cases. Again, 14 stations were maintained and 1233 babies fed from June 27th to September 3d. In 1905 the Health Department increased its activities, employing 31 nurses in Manhattan, 14 in Brooklyn, 1 in the Bronx, and 2 each in Queens and Rich- mond. The families visited numbered 289, 1 14, and 1985 sick babies were treated. The New York Diet Kitchen Association had been paying more and more atten- tion to babies and to tuberculosis work, and in their reports only milk and eggs are mentioned as being distributed. In Brooklyn 15 stations were maintained by the Children's Aid Society from June 26th to September 9th, feeding 1649 babies. In 1905 the milk problem was energetically handled. The New York Association for Improving the Condition of the Poor carried on a very extensive investigation with the cooperation of the Health Department. As a result of this investigation many violations of the law were discovered and offenders punished. It was the beginning of a vigorous campaign. In 1906 a new agency came into the field. Mr. John D. Rockefeller accepted the suggestion made by the A. I. C. P. that the land adjoining the Rockefeller Institute be utilized for a summer hospital for sick babies, where mothers could be taught that they can "save their own babies, in their own tenement homes, if they will give them clean milk, clean air, and clean bodies." 24 INFANT MORTALITY AND MILK STATIONS The old Schermerhorn mansion, in a state of apparently hopeless decay, was rejuvenated by soap and water and plenty of whitewash. Five open-air shacks were provided, capable of accommodating 60 babies. Everything was of the simplest. A large shelter tent was provided, and "Junior Sea Breeze" was ready for work. Mothers were allowed as free access as possible to the shacks in order that they might learn that the simplest articles were sufficient to care for the baby ; also how much had to be done when a baby was sick. With the hospital work proper was combined an educational campaign. In the shelter tent there were given, twice a week, simple lectures and demonstrations to the mothers in the care of their babies, the importance of maternal nursing, "clean milk, clean air, clean bodies." A nurse did follow-up and district work. The Health Department coiltinued its work on much the same lines, always increasing in amount: 350,618 families were visited, and 3331 sick children treated. The Children's Aid Society in Brooklyn continued as before, feeding 1620 babies at its 15 stations from June 25th to September 8th. There was little change other than Junior Sea Breeze. In 1906 the appropriation for milk inspectors for the Health Department was doubled, and a vigorous inspection was carried on. In 1906 the New York Milk Committee came into existence as a result of a conference called by Dr. Darlington, then Commissioner of Health. This com- mittee was formed to investigate the milk problem, especially in its relation to infant mortality. The Mayor also appointed a committee to investigate the problem of insuring a safe milk supply. In 1907 the work of the Health Department, Diet Kitchen, Strauss labora- tories. Good Samaritan, and Children's Aid Society of Brooklyn was continued with little change. The chief feature of the summer work was the enlarging of the scope of the work of Junior Sea Breeze. A very vigorous educational cam- paign was carried on. Nineteen nurses were employed in district work. This work was confined to the nineteenth ward, extending from Fortieth Street to Eighty-sixth Street, and from Sixth Avenue to the East River. A house-to- house canvass of the district was made ; mothers were urged to feed their babies on wholesome milk if nursing was impossible, and watch was kept on the babies of the district. It was a piece of intensive work of great importance. While the summer deaths were higher in the rest of the city, in the nineteenth ward they were lower than the previous year. The Association for Improving the Condition of the Poor also started this summer its Caroline Rest, where mothers and babies were sent as soon after the confinement as possible. Here the mother had a chance to recuperate and fit herself to nurse her baby. She was given the most careful instruction in the care of babies and older children. The year 1908 marks the beginning of a very vigorous campaign, with emphasis on the educational factor. Up to this year the Department of Health had carried on its summer corps work as part of the Division of Contagious Diseases. In August, 1908, the Division of Child Hygiene was formed, in charge of a chief and 5 assistant chiefs, 16 supervising inspectors, 1 superintendent of nurses, 5 supervising nurses, and 195 district nurses. This was a very great step CAMPAIGN AGAINST INFANT MORTALITY 25 in advance. The summer work was carried on by 83 nurses and 20 doctors. Visits were made to all new-born babies as the births were reported. Lectures were given at various places by Health Department inspectors, and it is noticeable that this year there was a very marked decrease in infant deaths and in the infant death-rate. Early in the spring the Commissioner of Health issued an invitation to all organizations interested in any way in the campaign against infant mortality to attend a conference at the Health Department. This conference was held and was largely attended, and the cooperation of all agencies was earnestly asked for. In Brooklyn the department increased its cooperation by detailing inspectors and nurses to the stations of the Brooklyn Children's Aid Society. The work of this organization was, therefore, greatly increased, and the educational factor became very pronounced. The physicians and nurses were provided with simple medicines which were given to any sick children. From their 16 stations 2296 babies were fed. Seventy mothers' meetings and clinics were held, in charge of a physician and nurse. Literature was distributed in the homes, and free ice- tickets, provided by the Herald Free Ice Fund, were given when needed. On June 17, 1908, the New York Milk Committee opened seven stations, from which they dispensed milk modified at the stations according to set formulae. Volunteer physicians had charge of all the consultations, and trained nurses were employed to prepare the milk and supervise the babies in their homes. No mother was permitted to obtain milk from the station until it was proved that she was unable to nurse her baby, and she was allowed to obtain milk then only on condition that she would bring her baby once a week to be weighed during consultation hours. A careful record of all cases was kept as a basis for further work. From three of the depots pasteurized milk was dispensed, and from four, raw milk. Consultations were also held at the Union Settlement in East One Hundred and Fifth Street and in West Ninety-third Street, though milk was not dispensed from these places. Junior Sea Breeze continued its work as in the past year, although not so many nurses were employed in visiting work as in the previous year. In 1909 the work of the Division of Child Hygiene was increased. It was made to include the supervision of midwives, boarded-out children, nurseries, and other institutions caring for children. From April 15th to September 1st the summer campaign was carried on. A great step in advance was made by beginning the campaign early. The summer corps visited 57,059 mothers of new-born infants. Another important step in advance was the formation of the so-called "Little Mothers* League." There were 54 centers for this league, which enrolled the little mothers in the public schools, giving them lessons and demonstrations in the care of the baby and general hygiene. An inspector and a nurse held these meetings once or twice weekly in each center. The New York Milk Com- mittee maintained seven stations throughout the year. This organization was originally a special committee of the New York Association for Improving the Condition of the Poor. In October of this year it became an independent organ- 26 INFANT MORTALITY AND MILK STATIONS ization, in accordance with the poHcy of the Association in allowing its offspring to become independent as soon as they were able to care for themselves. In Brooklyn the Children's Aid Society continued its cooperation with the Health Department. Sixteen stations were maintained, caring for 2142 babies. Physicians and nurses w^ere provided by the Health Department, and there was also cooperation by the District Nursing Committee. Increased emphasis was laid on educational work, maternal nursing, and the care and preparation of milk. Three hundred and twenty meetings were held during the year. In 1910 the work continued as before. The New York Milk Committee was able to maintain only four stations, owing to lack of funds. These were con- ducted also along different lines. The distribution of already modified milk was discontinued, and the policy of teaching mothers to prepare the baby's food themselves, under the supervision of the nurse, according to the doctor's direc- tion, was carried out. It was with considerable hesitation that this work was undertaken, but the results soon proved its value. The mothers were more regular in their attendance, and took greater personal interest and pride in the progress of their babies when they themselves prepared the food. During this year the Health Department cooperated with the New York Diet Kitchen, providing physicians and nurses for eight of their nine stations. The ninth station was managed. by the association itself. Physicians and nurses held at first weekly clinics, then semi-weekly, and, finally, during the summer, daily clinics. Expectant mothers were also cared for. In Brooklyn the Children's Aid Society continued as before. The importance of small classes and individual instruction was brought home to them, and greater attention was paid to this detail. From 18 stations 2182 babies were fed, of whom half were sick on admis- sion, and only 32 deaths occurred. It will be noticed that of late years, especially since 1908, prevention has been playing a greater and greater part in the attempts at the reduction of infant mortality. What has been given above is merely a very brief outline of certain phases of the work which has been carried on. It is impossible to give in detail everything that has been done. One of the most important agencies in the pre- vention of the waste of infant lives has been the adoption of the so-called social service work of Dr. Cabot, of Boston. Most of the hospitals and dispensaries of this city now have a social service department. It interests itself, among other things, with the care of babies and the prevention of disease among them. Another very important step has been the increasing cooperation developing among various agencies. The Health Department has been ready and willing to make the work which is being done in every way more efficient. In 1907 the depart- ment turned over practically all the work of visiting new-born babies in the nineteenth ward to Junior Sea Breeze Hospital. A list of births was provided to the Junior Sea Breeze nurses, just as to their own. This cooperation increased in a most encouraging way, as will be seen in the report of what has been done in 1911. NEW YORK MILK COMMITTEE EXECUTIVE COHnilTEE CQMMSREDUffl'IfflTtlDRlJIY HNANCE COMMITTEE EXECUTIVE COMMITTEE MEDICAL COUNCIL DIRECTOR I REUEFAGEMT SUPERVISE NURSE AS ST. SUP. NURSE SECRETARY TO UIRE CTDR 1 STATISTICAL CLERKS BOOK-KEEPER _ TELEPHOME DPERATER SPECIAL NURSES INVESTIGATORS MESSENGERS GENERAL COMMinEE VOLUNTEEK SUPERVISING PHYSICIAN STATION PHYSICIANS STATION NURSES INTERPRETERS ASSISTANTS MATRONS Exhibit 9 Organization Chart of the Committee for the Reduction of Infant Mortality of^the New York Milk Committee CHAPTER III The Campaign in New York City in 1911 The year 1911 marks the beginning of the most extensive and efficient campaign for the reduction of infant mortaUty ever undertaken in New York city. The lessons of past years had apparently been learned. Here were a number of organizations, each working independently, with practically no general cooperation, though many worked well with the Health Department. Campaign of the New York Milk Committee In the fall of 1910 the Board of Estimate and Apportionment appropriated sufficient funds to maintain, during the entire year, 15 infants' milk depots under city control. These stations were put under the control of the Division of Child Hygiene. The New York Milk Committee realized that this was a new venture, and that the extension of this system of milk depots depended on the success of the year's work. They also realized that the summer months were the ones when the greatest reduction ought to be obtained. To make the experiment a strongly convincing one, a sufficiently large number of stations must be provided to cover thoroughly a large portion of the city. The Health Department decided to place only five in Manhattan, one in the Bronx, and nine in Brooklyn. It was felt that the mortality of the city could not be demonstrably affected by the existing stations, so a subcommittee of the New York Milk Committee, known as the Committee for the Reduction of Infant Mortality, was formed. They were authorized to plan a campaign, raise money, and conduct their demonstration, subject to the approval of the Executive Committee of the parent body. The new subcommittee selected an Executive Committee and a Finance Committee. The former committee thoroughly canvassed the city, studying the available records of population and mortality, and the presence of other similar organizations in given districts. As a result of this study it was decided to start, as soon as funds could be raised, 22 stations, in addition to the 4 already maintained by the Committee. It was thought that these stations could care for most of the worst portions of the city. The Finance Committee started in on a whirlwind campaign. The city was divided into districts, each district being in charge of a leader. Mrs. J. Borden Harriman was chairman of the Committee, and she associated with her a number of prominent and active women as district leaders. Each district leader divided her district into streets, and appointed a street leader for each. These latter approached the residents in their vicinity with a personal letter of appeal. The result was quite startling. The financial campaign did not start 27 28 INFANT MORTALITY AND MILK STATIONS until April, but enough money was obtained to open 11 stations of the 22 on the second of May. By the twentieth of May 10 more were ready to open, and on May 22d a meeting was held at Seward Park, officially opening the campaign. At this meeting Borough President McAneny, the Rt. Rev. David H. Greer, the Rt. Rev. Monsigneur McMahon, the Rev. Rabbi Wise, and Commissioner of Health Lederle spoke. On May 31st the last 2 of the 23 stations were opened; with the original 4 stations, this made 27. Realizing that the problem was a large one, and that every energy of all who were interested was needed to do the necessary work, a scheme of cooperation was devised to prevent unnecessary duplication of work. The Association of Infants' Milk Stations was organized in May. Its objects were briefly: 1. To prevent duplication of work by districting the city, and giving each milk station a distinct area for its activities. 2. To establish some uniform system of record keeping, so that the work of the various agencies could be put together at the end of the season. 3. To render the information in the possession of one group available to all. 4. To conduct a publicity campaign in the interests of the reduction of infant mortality. At the invitation of Commissioner Lederle a meeting was held, and such an association was formed May 24 1911. Eight organizations, maintaining 79 milk stations, comprised the Association, and an Executive Committee, composed of a representative of each, was organized, as follows: S. Josephine Baker, M.D., Chief Division of Child Hygiene Department of Health. Reuel a. Benson, M.D Babies' Dairies Assn. Maria L. Daniels, R.N N. Y. Diet Kitchen Assn. Arthur R. Green, M.D Nathan Strauss Pasteurized Milk Labora- tories. Jane E. Hitchcock, R.N Nurses' Settlement. G. N. McCurdy Morningside Milk Dispensary. Paul E. Taylor, Director N. Y. Milk Committee. Arthur E. Wakeman Brooklyn Children's Aid Society. Through the courtesy of Dr. Baker office room, with use of a stenographer and clerk, was provided at the headquarters of the Division of Child Hygiene. Dr. H. H. Hart, of the Child-Helping Department of the Russell Sage Foundation, provided funds for the salary of a secretary. Mr. Charles J. Storey was appointed to fill this position. By a committee of the Association the city was districted, thus preventing two nurses from visiting the same family and wasting time and effort. Whenever possible, a baby applying at a station living outside the district was referred to the station located in that district, but, owing to the price of the milk varying in different sets of stations, this was not always possible to bring about. No can- vassing was done, however, outside the district assigned to each particular station. Each station sent in a weekly report in detail showing its enrolment and EDUCATION THROUGH PRINTED MATTER Exhibit 10 Distributed to Thousands of Homes by Public and Private Agencies THE CAMPAIGN IN NEW YORK CITY IN 1911 29 all details of importance, which were tabulated and made accessible to the other organizations. The 27 stations founded by the Milk Committee were situated in the most congested parts of the city. The object of the Committee's campaign was to make a demonstration of the value of milk stations in reducing infant mortality; to show that these stations should be situated in the most densely populated dis- tricts of the city; and that the ordinary store was suited for a milk station. Many of the situations selected were far from ideal ; vacant stores had to be utilized, and they were sometimes not situated just where desired, and, as was afterward proved, were often too small. The Union Settlement in East One Hundred and Fourth St., the Vanderbilt Clinic, the Wilson Industrial School, and the Alfred Corning Clark House gave room rent free for the stations. The plan of campaign was as follows: Each station was in charge of a graduate nurse specially chosen for her knowledge of infant hygiene, for her interest in the problem, and her willingness to give herself, as well as her time, to the work. She was assisted by a matron. In certain districts where the popu- lation was almost entirely foreign, and where English was spoken and understood as rarely as in Italy or Russia, a matron was selected, when possible, who was able to talk the language of the district. Where two or more languages must be spoken, an interpreter was provided in addition. Each nurse canvassed her district from house to house, looking for babies, leaving the folder of the station with the mother, and offering to help her keep her baby well. That was the great thing the stations tried to teach — to prevent sickness. The windows of each station were adorned with placards in various languages inviting mothers to make use of it. The outside of each station was painted a light, bright blue, and the "Blue Fronts" became a regular expression of the district, being incorporated into many foreign tongues. The Milk Committee stations tried first and foremost to encourage maternal nursing. Mothers were told how necessary it was and how it would save the baby many of the dangers of the hot weather. Not only were they urged to nurse their babies, but they were taught to care for themselves so that they could nurse them. They were told what to eat and, more important, what not to eat and drink. When breast-milk seemed to be failing, they were provided with milk, and, if necessary, nourishing food, to try to increase the ability to nurse. When nursing was impossible, artificial feeding was ordered by the doctor in attendance at the station. Each baby was treated as an individual, and the food ordered according to its individual needs. Let us trace a baby through its whole progress at the station. The doctor was in attendance at definite hours twice or three times a week. If a new baby was brought to the clinic, it was seen by the physician, and its food ordered by him. If brought in at another time, after a preliminary talk from the nurse in which the whole system was explained, the mother was asked if she wanted to enroll her baby. If so, it was stripped and weighed by the nurse and the weight recorded on the individual chart. The nurse's record and the history card were then filled out, and the nurse ordered a temporary feeding for the 30 INFANT MORTALITY AND MILK STATIONS child, according to instructions very carefully prepared by the supervising phy- sician and indorsed by the Medical Council. If the baby was sick, it was sent to a station where a doctor was in attendance that day, or the station doctor was communicated with and arranged to see the baby. Its food having been ordered, the mother procured her supply of milk, bottles, barley-flour, etc., and returned to her home, whither the nurse speedily followed her. At this visit she was taught how to prepare the food; and in her own home, where existing conditions could be most readily appreciated, she was given a lesson in general hygiene. The formulae ordered for the babies were of the simplest kind possible. Whole milk mixtures were used almost exclusively. She was then told to bring the baby back to the station on the next clinic day, and to come every morning for her supply of milk. She was also urged, at the first sign of illness, however slight, to report at once to the station. On clinic days every baby was stripped, weighed, and examined by the station physician, its progress discussed with the mother, any necessary changes ordered, and the nurse instructed what to do. Very sick babies were referred to hospitals or to private physicians. If the mother was unable to buy milk, through an arrangement with the Charity Organization Society, the Association for Improving the Condition of the Poor, and the United Hebrew Charities, such cases were immediately reported to them, and were at once investigated. In almost every case — probably in every deserving case — milk relief was promptly ordered by these organizations. Regularity in attendance at clinics was demanded from the mothers. If they refused to attend, they were not allowed to obtain milk. It was hoped that as many as 75 babies might be enrolled at each station. By the fifteenth of July many of the stations began to cry for help. They were so overcrowded they could not properly carry on their work. So many babies were brought to the clinics that they could not all get in and blocked the side- walk. The nurses were unable to do the follow-up visiting essential to a suc- cessful campaign. The situation was carefully considered, and, although July is not a favorable month to try to raise money, funds were procured, and 4 new stations were opened to relieve those most urgently in need of assistance. The full list was as follows: Old Stations 306 E. 21st St. 73 Cannon St. 244 Mulberry St. 438 W. 48th St. Opened May 2d 248 E. 105th St. 722 E. 9th St. 1391 Avenue A. 229 E. 4th St. 114 Thompson St. 307 Tenth Ave. 35 Norfolk St. 174 Eldridge St. 325 E. 5th St. 239 W. 69th St. 56 Leroy St. >4' EDUCATION THROUGH PRINTED MATTER Exhibit 11 Publicity and Information THE CAMPAIGN IN NEW YORK CITY IN 1911 31 Opened May 20th. . . .37 Washington St. 326 E. 11th St. 316 E. 56th St. 512 Second Ave. 873 Second Ave. 1705 Second Ave. 235 E. 81st St. 315 E. 112th St. 3E. 115th St. Vanderbilt Clinic. Opened May 31st .... 165 Ludlow St. 200 E. 97th St. Opened July 8th .... 331 Stanton St., to relieve 73 Cannon St. Opened July 10th 223 E. 75th St., to relieve 1391 Avenue A. Opened July 12th .... 78 Ninth Ave., a new station where the summer deaths were high. Opened July 14th 1457 Madison Ave., to relieve 200 E. 97th St. The dates given above are those on which milk was first distributed. The nurse and matron had been at work in the district for several days. Not only was the scope of work increased by adding four new stations, but every station whose enrolment passed the 100 mark was provided with an extra nurse. This was essential if the purpose of the station — instruction — was to be carried out. In August, therefore, 31 stations were in operation. Doctors were on duty, holding clinics, and often visiting the sick babies in their homes; nurses were daily at the stations and visiting in the homes, watching, advising, encouraging, scolding, teaching, as the case demanded. As the nurse went about from house to house, from family to family, she found many expectant mothers. Part of the campaign was to get in touch with these women and to try to advise and teach them so that they might pass successfully through their pregnancy and be in physical condition to nurse their babies. It was soon found that this was a large undertaking, and in August a special nurse was delegated to take charge of this work. Her salary was kindly provided by Dr. Hastings H. Hart, of the Russell Sage Foundation. During the summer, 964 expectant mothers were under observation. The cooperation existing between the Milk Committee and the various charitable organizations, especially those already mentioned, was of the closest kind. Whenever tired-out mothers were found whose babies were doing well enough to be sent away, through the cordial relations existing an outing was easily arranged. The Association for Improving the Condition of the Poor offered to receive any baby needing hospital treatment at Junior Sea Breeze Hospital. This offer was gladly accepted, and during the summer months 43 babies were admitted there. At discharge or death a report of the case was made to the Committee. Discharged babies were immediately referred back to the milk station from which they came. Figures showing that a large percentage of deaths among babies occur in found- ling institutions, the Committeeoffered the services of its milk stations to the New York Foundling Hospital and the New York Infant Asylum. They explained to those in authority at these institutions the purpose of the stations. The offer 32 INFANT MORTALITY AND MILK STATIONS was gladly accepted, and during the summer 110 babies were enrolled from these institutions. The fact that so many of the foster mothers lived in the outlying boroughs prevented a greater number from being able to make use of the stations. The milk which was used during the summer was provided by the New York Dairy Demonstration Company.* It came from tuberculin-tested herds and was of the highest standard. It was sold for seven cents a quart. The contract for this milk was awarded after bids had been asked for from the chief milk- dealers of the city. A constant watch was kept on the quality of this milk. Bacterial counts were made daily from samples taken at various stations, and control bacterial counts were made frequently by the Research Laboratory of the Health Department, through the courtesy of Dr. W. H. Park. The milk was used raw. These counts were compared with those made by the Health Department of the milk dispensed at their stations and compared favorably. The table showing the bacterial counts will be found at the end of this report. The central office of the Committee was in charge of the Director, Mr. Paul E. Taylor, who was selected by the committee because of his proved executive and constructive ability and his knowledge of the problem from his active parti- cipation in the Philadelphia campaign of 1910. He was associated with the Philadelphia Bureau of Municipal Research, who kindly granted him leave of absence to undertake the work here. The general supervision of the whole work was in the hands of the Director ; a supervising nurse was at the office constantly; station nurses were instructed to report by telephone to headquarters every difficulty or complication which arose; an assistant to the supervising nurse was constantly in the field, visiting and inspecting the stations; and a special assistant was appointed during the summer to keep track of the relief cases. The work of the physicians was supervised by a volunteer supervising phy- sician, who visited the various stations as often as possible, and especially diffi- cult cases when asked, and was general adviser on all strictly medical work. Much of the supervising work was done by the assistant supervising physician. The entire scope of the work was submitted to the Medical Council in consid- erable detail and was indorsed by them. Work of the Health Department The Department of Health conducted a very vigorous campaign. Fifteen stations were maintained by them at the following locations: Manhattan 108 Cherry St. Brooklyn 185 Bedford Ave, 31 Roosevelt St. 296 Bushwick Ave. 209 Stanton St. 128 Dupont St. 2287 First Ave. 994 Flushing Ave. 207 Division St. 698 Henry St. 651 Manhattan Ave. Bronx 511 East 149th St. 176 Nassau St. 129 Osborn St. 303 Williams Ave. u- u *^Y^^ company was organized by the New York Milk Committee to demonstrate that a high-grade milk from healthy herds can be produced by the ordinary farmer with ordinary equipment, and sold at a price usually charged for bottled milk of uncertain quality. (See Fifth Annual Report of New York Milk Committee for details of this experiment.) Jew York Milk Committee*. )HP.\RTMEN'T OF.HEALTH* i'athan Strauss Laboratories! . . . , Tew York Diet Kitchen* rx. (_N -li. <=> lL/1 C3 c_n <=> o s <=> 8 s g CO s C5 ■ ^^ ^^ - - H .ROOBO-YN' Children's Aid SociETYf •GOD Samaritan DiSPENSARvt lENRY Street Settlement*. ENSON Dairies! loRNiNGsiDE Milk Dispensary!. • • • Home modification of milk taught. Milk dispensed modified. Exhibit 12 Number of Babies Registered at Milk Stations September, 1911 THE CAMPAIGN IN NEW YORK CITY IN 1911 33 The same general policy was carried out in the stations of the Health Depart- ment as in those of the New York Milk Committee. Individual formulae were ordered, — almost always whole milk formulae, — and the food was prepared at home under supervision of the nurse. Careful records were kept and the cases were followed up. The work of the summer corps was coordinated with that of the milk stations. The district nurses and inspectors received lists of sick babies from the stations each day, and visited and cared for the sick children of those unable to pay a physician. The department cooperated with the other organi- zations, sending their inspectors to see any sick child in the care of a milk station on request. The " Little Mothers' League" continued its active and most valuable work in teaching the future mothers of the city how to care for the little brothers and sisters left in their charge. The efficient cooperation of the Health Department was further shown by the assignment of physicians and nurses to the stations of the Brooklyn Children's Aid Society and the New York Diet Kitchen stations. The milk used at the stations was the Sheffield Farms Slawson-Decker pasteurized milk, and was sold in quart and pint bottles, unmodified, for seven cents per quart. Work of Other Organizations The New York Diet Kitchen maintained 8 stations in Manhattan and one in the Bronx, as follows: Manhattan 146 E. 7th St. 205 E. 66th St. 451 E. 86th St. 209 E. 103d St. 169 Mott St. 437 W. 41st St. 205 W. 62d St. 152 W. 100th St. Bronx 583 Courtlandt Ave. Daily clinics were held at their depots in charge of the Health Department physicians and nurses. Formulae were ordered according to each baby's indi- vidual needs, and mothers were taught by the nurses to prepare the food at their homes. Certified milk in bulk was dispensed, the daily quantity being "dipped." It was sold at six cents a quart. The same records and system were employed as at the Milk Committee and Health Department stations. The Nurses' Settlement station was continued as before. Two physicians were in charge of the consultations, and the settlement nurses did the home visiting. Milk was tuberculin tested and shipped to the settlement in cans, where it was bottled and sold in quart and pint bottles at eight cents a quart. Modifi- cation was carried out at the homes according to individual prescription under the supervision of visiting nurses. All the above-mentioned organizations worked along similar lines, laying 3 34 INFANT MORTALITY AND MILK STATIONS special emphasis on instruction, in the belief that permanent results are more likely to follow teaching a mother to care for her baby and its food herself, than by simply giving her the food already prepared. The campaign was also parti- cipated in by other organizations, who did their share along slightly different lines. The Nathan Strauss Pasteurized Milk laboratories maintained eight stations : 322 E. 59th St. 348 E. 32d St. 303 E. 111th St. 402 W. 37th St. 38 Macdougal St. Tompkins Square Park 45 Monroe St. Educational Alliance Roof Garden, 197 East Broadway From these stations pasteurized milk, already modified to set formulae, was dispensed in 3- , 6- , and 8-ounce individual feeding-bottles, at ten cents a quart modified, or for older children at eight cents a quart unmodified. There was no home instruction or visiting and no compulsory medical supervision. The Babies' Dairies provided tuberculin-tested milk in individual feeding- bottles, modified at the station on individual prescription, at ten cents for a day's feeding. Home supervision was not carried out. Medical supervision at the station was provided. The stations were located at — 416 E. 65th St. 523 E. 78th St. 511 W. 41st St. 117 W. 63d St. (St. Cyprian's, colored) The Good Samaritan Dispensary, at the corner of Broome and Essex Streets, continued its work, dispensing pasteurized milk modified to set formulae. The Morningside Milk Dispensary, at Morningside Avenue and 122d Street, dispensed pasteurized milk, modified to set formulae, in individual bottles of 4, 6, and 8 ounces, at two and three cents the bottle. In Brooklyn the Children's Aid Society maintained 14 stations. Through the active cooperation of the Health Department in providing the physicians and nurses, follow-up work at the home was carried on, and consultations were held. Considerable attention was paid to the educational side. Pasteurized milk, modified to set formulae, was sold in 3-, 6-, and 8-ounce bottles, at one and two cents a bottle; unmodified milk in 8-ounce bottles at two cents. The stations were located as follows : 105 Fleet St. 190 Fourth Ave. 608 Fourth Ave, Pitkin, cor. of Watkins St. 159 Wyona St. 148 Jackson Ave. 817 Park Ave. 165 Johnson Ave. 106 S. 3d St. 85 Java St. 27 Columbia Place 201 Hoyt St. 146 Union St. 15 Garnet St. These stations were open from June 15th to September 15th. The various dispensaries and hospitals continued their follow-up work through visiting nurses. Bellevue Hospital, Presbyterian, Roosevelt, St. Luke's, Mt. Sinai, The Babies', University and Bellevue Medical School Dispensary, j u a ■r-l f a 3 ^ > Exhibit 14 The Committee Provided the Board of Estimate and Apportionment With the Facts- The Number of Municipal Stations was Increased From Fifteen to Fifty-five THE CAMPAIGN IN NEW YORK CITY IN 1191 35 Vanderbilt Clinic, and many others have visiting nurses who instruct mothers in the care of their babies, and all are factors in the campaign. There was, however, no particular change from previous years in their methods. The same applies to the St. John's Guild and Junior Sea Breeze, except as already noted in regard to cooperation with the milk stations. Cooperation was earnestly sought from all the special agencies. The New York Milk Committee sent out an information card, giving the list of all milk stations and information regarding kind of milk, method of preparation, cost, etc. This card was sent to hospitals, dispensaries, social workers, nurses' settle- ments, and many physicians. Police Commissioner Waldo distributed lists of the milk stations, provided by the Milk Committee in size suitable for carrying in the pocket, to all patrol- men of the police force, and issued instructions to give the address of the nearest station to any mother with a sick baby seen in the parks or on the recreation piers. The cooperation of the press was active. Articles appeared frequently in many newspapers in New York and throughout the country. Editorial help was also frequently given. Toward the latter part of the summer the committee prepared to back up the Commissioner of Health in his request for funds to maintain 75 milk stations in New York in 1912. All summer special statistics had been compiled through the courtesy of Dr. Guilfoy, Registrar of the Health Department, who allowed access to the records. These statistics were put together in as striking a manner as possible, with charts and tables. A detailed study of the location of the high mortality centers was made by a member of the Executive Committee, and the results of this study were embodied in a report which was delivered to each member of the Board of Estimate and Apportionment before the hearings. The Committee was represented at the public hearings ; only one protesting voice was raised there against the appropriation, and in this case it was evident that the protester did not understand what the money was to be used for. The Board finally appropriated money to maintain 55 stations, which, although 16 less than the number urged by the Milk Committee, was a very great advance over the 15 provided for the previous year; and there is hope that if these are efficiently carried on in 1912, the full number will be provided for in 1913. CHAPTER IV Results of the Campaign in New York City In the pages that follow an honest attempt is made to discuss fairly the facts shown by vital statistics. As already mentioned, the factors in infant mortality are many and complicated, and at the present moment many statistics are still unavailable. Only the most obvious facts can be more than briefly touched upon. In studying the mortality among infants in this country we are sadly handi- capped by lax registration ordinances — lax themselves or laxly enforced. The recognized method of rating yearly infant mortality is to record the number of deaths in infants under one year of age per 1000 births during the same year. In New York the registration of births has been incomplete up to the last few years; therefore comparisons of infant mortality rates (deaths per 1000 births) cannot be made between widely separated periods. The years 1901 and 1911, for instance, cannot be compared. The greater the number of unreported births, the higher will be the rate, of course. A glance at Table 6 will show that in 1901 the rate was 191.5, while in 1911 it was 111.6. Nobody believes this really hap- pened. So inaccurate is this method that the Census Bureau has only in 1910 begun to record these figures, and then (Bulletin No. 109) only for 35 large cities. Only 5 of the 10 largest cities in the country have sufficiently complete registra- tion of births to be includea. Chicago admits that not more than one-third of the births are registered, but steps are being taken to remedy this state of affairs. Another method of rating infant mortality is on the estimated population under one year, based on the percentage at that age according to the last United States Census, and assuming this percentage to remain constant. The results are, of course, only approximate. Again, the number of deaths under one year of age in proportion to all deaths is an approximate method of estimate. Tables 6, 7, 8, and 9 show in some detail the infant mortality by months and groups of months, in the city of New York as a whole, the boroughs of Man- hattan and Brooklyn, and the " Rest of the City" (comprising Bronx, Queens, and Richmond), for the years 1901 to 1911 inclusive, with five- and ten-year averages- It also shows the relation to total mortality and to births. It will be noted that there is a steady tendency to increase from 1901 through 1907, with the exception of 1903. The year 1903 shows the lowest gross total mortality of any year in the decade 1901-10. Again it will be noted that in 1908 there was a sharp fall of 1206 deaths in New York city from the record of 1907; a further decrease of 255 in 1909; a rise of 239 in 1910; followed in 1911 by a fall of 1198. 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(fi ^ nj XI o > ;_, >, u u 2 O g g c o 6 o a. o > u OI >s "> o 4) C o o C IS o o o 0) o ) 01 -M 3 u O. > r c r r c I? "u C >< > ^ C, - u 0. X E a c X c ■• t C X > c 2 1. i E a, c a. C I. cti a. < C 3 U Cm 1 < 1 _>> 3 •— 1 d c o c ^ o C OI Cl, o > _c tr X X ■v +-» 0) c CIS 40 Exhibit 15 Infant Deaths Occurring in New York City by Weeks (1909, 1910, 1911) RESULTS OF THE CAMPAIGN IN NEW YORK CITY 41 As already mentioned, in 1908 there was a very great increase in activity in the campaign in New York. That was the year of the formation of the Division of Child Hygiene in the Health Department; the cooperation of the Health Department with the Children's Aid Society; the effort to bring about general cooperation, as shown by the first conference on the summer care of babies; the opening of seven milk depots by the New York Milk Committee; in other words, a great extension of the campaign and the coming to the front of educational prevention. The year 1911 was another one of great extension in the work, especially along educational lines. It must be remembered that the special efforts were confined largely to the summer months ; also it must be remembered that the problem is very different in different boroughs, owing to their different physical characteristics. The following tables illustrate the changes that have occurred since 1908: TABLE 10.— MORTALITY UNDER ONE YEAR IN NEW YORK CITY OCCURRING DURING THREE SUMMER MONTHS 1908 1909 1910 1911 Actual Percentage of year . . 5739 35.3 5154 32.2 5574 34.3 4593 30.5 It will be noticed, from Table 10, that while the total year's mortality in 1908 was low, the summer mortality was quite high — higher than either 1909 or 1910—35.35 per cent, in 1908, as against 32.26 per cent, in 1909, and 34.37 per cent, in 1910. It was, however, below previous years, except 1903. In 1911 the summer mortality was low, being only 30.58 per cent, of the year's total. Table 11 shows the difference between these years and 1911. TABLE 11.— DIFFERENCE BETWEEN MORTALITY UNDER ONE YEAR IN THREE SUMMER MONTHS OF 1911 AND CERTAIN OTHER YEARS From 1908 From 1909 From 1910 Actual —1146 —19.9 —561 —10.8 —981 Percentage —17.6 The summer mortality in 1911, compared with the three previous years in the different boroughs, as shown in Tables 12 and 13, is worth noticing. TABLE 12.— MORTALITY UNDER ONE YEAR DURING THREE SUMMER MONTHS IN DIFFERENT SECTIONS OF NEW YORK CITY 1908 1909 1910 1911 Manhattan Brooklyn Actual Percentage of year Actual 3043 33.63 1835 36.6 861 37.9 2640 29.61 1733 35.2 781 36.5 2952 32.96 1768 34.9 854 38.7 2294 28.00 1499 Rest of City . . Percentage of year Actual Percentage of year 32.3 800 34.8 42 INFANT MORTALITY AND MILK STATIONS T\BLE 13 —DIFFERENCE BETWEEN MORTALITY UNDER ONE YEAR IN THREE ■ SUMMER MONTHS OF 1911 AND CERTAIN OTHER YEARS From 1908 From 1909 From 1910 Manhattan Actual —749 -34.6 —336 —18.3 —61 —7 —346 —13.1 —234 —13.5 + 19 +3.4 —658 —33.3 Actual —269 —37.8 Rp^T OR CtTV Actual —54 —6.3 It will be seen that while there was a very great actual and percentage reduction in 1911 from the figures in 1908 to 1910 in both Manhattan and Brook- lyn, in the Rest of the City this was not so marked. There was an actual increase over 1909 figures. The proportion of deaths occurring in the third quarter of the year was very low. Table 14 shows the distribution of the mortality by trimesters for the years 1901-1911, with five- and ten-year averages for the boroughs of Manhattan, Brooklyn, and the "Rest of the City." It will be noted that in Manhattan only 28 per cent, of the year's mortality occurred during the third quarter, while the ten-year average is 33.8 per cent., and the five-year average, 1906-1910, is 32.8 per cent. In no single year was so low a figure reached, and in only one, 1909, did it fall below 30 per cent. This occurred in connection with a very low total mortality for the whole year. The figure for Brooklyn ''s 32.4 per cent., as against the ten-year average of 38 per cent. It is also the lowest of any single year by 2.5 per cent. The "Rest of the City" shows 36.4 per cent., the ten-year average being 41.9 per cent. But in 1909 the proportion was 36.5 per cent. The lower figure and the proportionately greater reduction seem to make the inference fair that the more extensive and active campaign in Manhattan was responsible, in part, at any rate. i| The New York Milk Committee opened its stations in 1911 in the latter part of May. The campaign did not really come into full swing until June. So far as the Milk Committee was concerned, it ceased its work on the first day of November, when the Health Department took over 22 of the 31 stations which it had maintained during the summer. In order to estimate the effect of the campaign during these five months, tabulations have been made of the deaths in the various parts of the city for a number of years and the births occurring during corresponding twelve-month periods ending October 1st. In the summer of 1911 there were in Manhattan 57 milk stations; in Brook- lyn, 23; and in the Bronx, 1. These tabulations have been made for Manhattan, Brooklyn, and the "Rest of the City." This last area has been taken because in all three boroughs there was practically no milk station work. The regular summer corps work of the Health Department was carried on as heretofore. Table 15 shows the results. , «B to «s Tt O ^ ii "T* o© Os'^* UI © lO© ^ 9 o«* oe 2 i2^ sa 215 -^ so • ^!5 S^ so • Pi o §2 so t^ N o eoq MO woo ©Tf ^.o 00 00 ©00 00*^ ©o\ r»so s2 is Is §2i ®2 «^ n " Os ^ u .^ td o2 ?SiO ^ ^ 1100 r*'* w* m-r-i ©o M "0 «Os MSO ©Os © 10 Pi W w Pi o gr4 So ^2; 5^ s^ l-H J^I U-) tt (M 11 o^ o\ w ^QO 00© 00© CN UB so© '*ao OQO o isi 2S ^CO 00 • o o> O l« OC9 ^o ^eo '^'^ fO N lOlH ^1H so© ^liS ■rt'* o Hi o ?3n 2^ 2li 2§ S^ 2« -s ^i ^e »-i© CO iS roi* '-H© ^ N lO© CM © 00 © C^4 © ^© or* 00 o 00 • ro 50 00 • 2« so • 2« 3;© ^i u t^ w O lO 00 iH -^ 11 OS© CN r» ^00 •^us so© tO^ ^w i~~r» 1* 2 00 • 2S CN W Is ^ii -s 12 o fOGO t^e* c^ © CN^ Ot© Os^ rt* © ^© r--GC o© Osi-< LO N 2m 0\ © :2© ^2-5 O 00 o2 °6 S3 tHOO Pi 5 o Sm rrj W Sn ^e« ■rt N CN W ^'H 1-* iH l-H^ lH » in 12 H e 5 ;9 ON 1H O ^H 00 ©t^ «(N ^t- ■*o rj*'^ iH 00 U5 0s «00 00 "^ ss 00 _; ^o^ ^2 ^2 ^^- «2 P5 W <- H 0» t^^• Tjl © Tt r^ "0 © Os« ^ « CN© OsQO PD © ^® t^« "^«*; S" 2S = S CN M -S -s ^S Sgji -J; 2 h > t^ CO C<1 GO •* © Tj" 00 fO'* 1-^ la CN tH ro© CM© m ut OsiH t^ Iffl o 2S« 2^J 2* 1-1 *5 o^ s© ^4 o u» 00i-( »-< r^^ r^« o© CN © lO© '^OO ^os ^US SOS* JiS"* Pi < 1 2" on rs \o © OS © OS • M §5 CO* 10 • 00 us t-^ o« Ov''* cs© o© ^■^ o© OM CO r» r^M rt. >. >» >, >> >. >, >s >. >. >, >. (/) -)-> _-i-i -M +-> +-> -UJ X a rt CiJ cfl OJ 03 OJ 03 a 03 03 OS H Va t t t: u -t-> i« u ■(-> Ul < o o O o o O o O o O S s a e S 6 s S S 6 s s 1 U3 03 03 03 jn "u 03 _U3 o! 03 03 03 c3 1-1 (U OJ o u 0) > >. >. >. >i >> >, >, >. >s >. >s "o OJ "o 1^ "o 01 "o 'o 4) "o u 'o 0) "o : 'o 0) 'o u "o 01 "0 ki 0) 3 T3 = (U 03 3 0> 01 ">< 'r 0) 03 3 TJ = 4) 01 1i o3 3 g bO g §a^ bo 03 ■t-i g bo 03 g I-. 3 — as bO 0! g bO 03 +-> g -i C O lU ■l-> -l-> Ui a ■!-> o U '-' ■!-> 1- c •'-' ^- -a *I> u -M -w u- t- O 4> V- O 0) u w 6 " Rest of City" 1196 1295 The actual and percentage differences from these estimated mortalities are: AcTV.u. Percentages 1910 1911 1910 1911 Maxhattax -f288 —718 +7.0 —17.0 Brooklyx -f 67 — 414 -f 2.6 — 15.5 ••RESTOFCmr" - —214 -fO.O —16.5 There has been in the "Rest of the City" a steady tendency downward during the l^t three years. In 1910, when Manhattan and Brooklyn were in excess of the estimated mortality', the "Rest of the City" maintained the same proportion. In 1911 it fell more than Brooklyn, and almost as much as Manhattan. It is possible that the influence of the campaign in New York city may have had something to do with this result. Conditions in these outlying boroughs are very different from Manhattan and Brooklyn. If, now, we look at the infant mortalitj' rates for these years, we find that, based on the total births for the year, the proportion of infant deaths in the months of June to November Ist was: TABLE 20.— INFANT MORT.ALITY R-\TE FOR MONTHS TUNE TO NO\^MBER FOR DIFFERENT SECTIONS OF GREATER NEW YORK 19-08 1909 1910 1911 Maxhattax 65.2 62.9 66.2 52.5 Brooklyx 61.6 59.2 61.4 49.0 "Rest OF City" 65.9 61.3 59,7 48.5 Table 21 shows the actual and percentage difference in these rates compared \Nnth the years preceding, during the period discussed : TABLE 21.— DIFFERENCE IN INFANT MORT.\LITY R.\TE FOR MONTHS JUNE TO NOVEMBER. BETWEEN 1909. 1910, AND 1911, AND YEARS PRECEDING, FOR DIFFERENT SECTIONS OF GREATER NEW YORK 19W as Compared Wilh 1908 Actual Pee Cekt. Maxhattax — 2.3 — 3.52 Brooklyx — 2.4 — 3.89 " Rest of City " — 4.6 — 6.98 1910 as Compared With 1908 and 1909 AcTUAi Per Cent. 1908 1909 1908 1909 Maxhattax -rl.O -3.3 -1.53 +5.24 Brooklyx —0.2 -2.2 —0.32 +3.71 "Rest OF City" —6.2 —1.6 —8.16 —2.6 1911 as Compared With 1908, 1909, and 1910 Actual Per Cekt. 1908 1909 1910 1908 1909 1910 Maxhattax — 12.7 —10.4 —13.7 —19.4 —16.5 —20.7 Brooklyx —12.6 —10.2 —12.4 —20.4 —17.2 —20.1 Rest OF City" —17.4 —12.8 —11.2 —26.4 —20.8 —18.7 I ;' '. 1 I / ^Vl AM/ y \ ^^ h /\ ApJf f«g Exhibit 16 Deaths of Infants, 1909, 1910, 1911, by Weeks Upper Chart — Manhattan; Lower Chart — Brooklyn RESULTS OF THE CAMPAIGN IN NEW YORK CITY 47 Comparing the percentage change in the infant mortality rates in consecutive years we find: TABLE 22 1909 1910 1911 Manhattan —3.5 +5.2 —20.0 Brooklyn —3.8 +3.7 —20.1 "Rest OF City" —6.9 —2.6 —18.7 The mortahty rate of the "Rest of the City" fell in 1909 much more than that of Manhattan and Brooklyn. In 1910 it fell, while that of the other two boroughs rose. In 1911, in Manhattan and Brooklyn, the mortality fell more than in the "Rest of the City." The tables given above would seem to show that — (i) In the city of New York during the summer and early fall of 1911 there was a very great diminution in infant mortality. (2) That the diminution is demonstrable both in the gross infant mortality and in the infant mortality rate. (j) That the diminution is slightly but distinctly more marked in the bor- oughs of Manhattan and Brooklyn, where the greatest efforts were put forth, than in the "Rest of the City. " It is a well-known fact that infant mortality tends to vary from year to year in given localities. This is usually explained on the ground of varying weather conditions. Summers of intense heat and scant rainfall have usually been followed by a high infant mortality. It remains now to investigate weather conditions which have existed in New York during certain years, and to see how they compare with the mortality rates. Table 23 shows the number of days on which the maximum temperature and mean temperature reached or passed certain figures. TABLE 23.*— NUMBER OF DAYS MAXIMUM AND MEAN TEMPERATURES IN NEW YORK REACHED CERTAIN FIGURES Maximum Temperature was Mean Temperature was 95° or + 90° or + 85° or + 85° or + 80° or + June 1901 2 5 10 1 5 1903 1908 18 4 1909 4 9 6 1910 2 6 3 1911 2 July 1901 2 9 19 2 12 1903 1 6 12 5 1908 2 7 21 2 18 1909 2 10 3 1910 4 19 10 1911 6 10 18 6 9 August 1901 17 2 1903 3 1908 4 10 3 6 1909 ' 4 7 2 1910 1 1911 5 12 3 * New York Meteorological Observatory Reports. 48 INFANT MORTALITY AND MILK STATIONS Maximum Temperature was Mean Temperature was 95° or 4- 90° or + 85° or + 85° or + 80° or + September 1901 4 1903 3 1908 1909 1910 12 1 1911 3 June-September 1901 4 15 40 3 19 1903 1 6 18 5 1908 2 12 39 5 28 1909 10 26 11 1910 7 28 14 1911 6 15 35 6 12 The years 1901 and 1903 are included in the above table, because the latter showed the lowest year's mortality on record since 1901. The annual meteorologic summary for 1911, issued by the Weather Bureau (New York), contains the following statement: "July, period hot weather exceeded only by that of July, 1901, in duration and intensity, prevailed during the first thirteen days of the month." The highest temperature was only one degree below the highest ever recorded at the station, and for thirteen days the average temperature was 81°. These records were taken 400 feet above the street. Not only was the number of days when the temperature reached the high point greater in 1911 than in these other years, but the duration of the heat was greater, as will be seen in Table 24. TABLE 24.*— NUMBER OF HOURS TEMPERATURE WAS AT OR ABOVE CERTAIN ^ FIGURES Temperature was 95° or + 90° or + 85° or + June 1901 3 23 66 1903 1908 5 38 1909 14 65 1910 5 34 1911 10 July 1901 10 40 134 1903 1 26 80 1908 3 33 149 1909 6 41 1910 20 100 1911 25 67 151 August 1901 3 35 1903 11 |908 24 76 909 10 34 1910 5 1911 , 15 59 September 1901 12 1903 11 1908 1909 1911 8 * New York Meteorological Observatory Reports. RESULTS OF THE CAMPAIGN IN NEW YORK CITY 49 June-September 1901 1903 1908 1909 1910 1911 Temperature was "or + 90° or + 85" or - 13 86 247 1 26 102 3 62 263 30 140 30 153 25 82 228 This table shows a very much greater duration of heat than in any other of the years tabulated, especially in regard to temperatures of 90° or over. In 1908 a temperature of 85° or over was maintained longer than in 1911, but in 1909 and 1910 weather conditions were much less severe. The years 1901 and 1903 will be discussed later. The mean temperature for the month taken alone is deceptive in making comparisons, a long period of hot weather being often balanced by a long cool period, or short hot and cool periods following one another. The following table (Table 25), taken in conjunction with Table 24, shows the records for the four months of June, July, August, and September, and the average monthly mean over a period of forty-two years : TABLE 25— MEAN MONTHLY TEMPERATURES AND INFANT MORTALITY RATES, JUNE-SEPTEMBER* Average Mean Temperature for Month FOR Forty-two Years June 70.3 July 75.3 August 73.3 September 67.1 Infant mortality Rate 70.5 77.7 74.9 68.1 7311 (90.5) 1903 64.2 74.6 69.0 67.0 6210 (65.5) 1908 72.9 79.8 75.7 68.3 6909 54.4 1909 72.1 73.5 72.2 66.8 6256 50.8 1910 68.7 77.2 72.0 69.4 6871 53.2 1911 69.8 77.5 72.8 67.6 5627 41.8 Table 25 shows that the mean monthly temperature in 1908 for all four months was distinctly above the average for the forty-two years. In this year the summer mortality was high, being 54.4. In 1909 June alone was above the average mean, July and August being considerably below, and September slightly below; the infant mortality was low, the rate being 50.8. The records for 1910 and 1911 were very similar. In June both were below the average mean, espe- cially 1910. July was nearly two degrees above the mean in both years; August was below in both, 1911 being the higher of the two. September shows con- siderable excess in 1910 and a slight excess in 1911, In the death-rates for the two years there is a difference of 1.4 in favor of 1911. So far as temperature was concerned, it would seem that 1911 was a bad year. The year 1903 was the remarkable one of the decade as to low infant mortal- ity, both for the year and for the four months June, July, August, and September. Its death-rate, based upon births for the entire year and for the summer months, was also much below the years preceding and following; in fact, the yearly rate was not equaled again until 1907, when there was a very great increase in the re- ported births. In 1903 there can be no question as to the remarkable weather 4 * New York Meteorological Observatory Reports. 50 INFANT MORTALITY AND MILK STATIONS conditions that prevailed. June was over 6° below the mean; July, 0.7° below; August, over 4° below; and September, about the average. On only one day of the four months did the temperature reach 95° or over, and it remained there for only one hour. For only nine hours did it reach 90° or over, and for only 102 hours was it S5°+. The mean temperature never reached 85° and was only 80° or over on five days. There has been no such record as this in any year since IQOO, the nearest approach being 1909, as already mentioned. The years 1901 and 1911 each had a prolonged hot spell in July. In the former year, at 6 a.m. on July 1st, the temperature was 81° and did not fall below 80° until 2 P.M. on the third, a period of fifty-six hours, when between 1 p.m. and 6 P.M. there was a hard storm, the thermometer falling from 94° to 77° in one hour. From 11 a.m. to 9 p.m. on the first, from 9 A.M. to 6 p.m. on the second, and from 10 A.M. to 1 p.m. on the third, the temperature registered 90 or over and reached 100° on the first and second. Then followed cooler weather. There was a period of high temperature from July 14th to 17th inclusive; August 21st to 24th inclusive, and August 29th and 30th, but the temperature did not reach such great heights, nor did it remain so high during the entire twenty-four hours. During the month of July, 1901, there were 2404 deaths under one year of age. In the week ending July 6, 1901, 617. In July, 1911, during the first thirteen days, there was a period of extreme heat. From 10 a.m. on the morning of the second to 7 p.m. on the evening of the seventh, a total of one hundred and twenty-nine hours, the temperature was recorded below 80° for only twenty-six hours. From 3 p.m. to 9 p.m. on the second, 9 a.m. to 9 p.m. on the third, 11 a.m. to 8 p.m. on the fourth, 12 m. to 9 P.M. on the fifth, 11 a.m. to 8 p.m. on the sixth, it was continually at 90° or over; then came thirty-nine hours of relief, to be followed by another period of extreme heat. From 10 a.m. on the ninth, to 10 p.m. on the thirteenth, a total of one hundred and eight hours, the temperature was below 80° only twenty-three hours. From 3 p.m. to 8 p.m. on the ninth, 11 a.m. to 5 p.m. on the tenth, 12 m. to 9 P.M. on the eleventh, 4 p.m. to 9 p.m. on the twelfth, it was continually 90° or over, and yet during the month of July, 1911, only 1530 babies died, compared with 2404 in 1901. In the week ending July 8, 1911, only 347 babies died, com- pared with 617 in 1901. This remarkable failure of the infant deaths to rise promptly and markedly during the hot weather is even more strikingly shown in Exhibits 6 and 8, which show the daily deaths in Manhattan and Brook- lyn during this hot period. On no day in the entire summer did the deaths in Manhattan reach 40. In 1909, on the other hand, 57, and in 1910, 65, deaths were recorded in a single day. The hot period in 1901, while it lasted a shorter time, was a little more intense in that the temperature did not fall below 80° for fifty-six hours. In 1911, in the early mornings, between 2 and 7 or 8 a.m., the thermometer registered 77° to 80°, but its effect on the thoroughly baked tene- ments could not have been great. When we come to consider the subject of rainfall and the number of rainy days occurring during these years, several points must be emphasized. The total rainfall for the month, so far as its bearing upon health conditions may be con- RESULTS OF THE CAMPAIGN IN NEW YORK CITY 51 cerned, must be considered as to its distribution throughout the month, as well as its total amount. For instance, August, 1911, had a total rainfall of 9.28 inches, as against 1.07 in 1910, but up to and including the twenty-third only 1.95 inches had fallen in 1911, as against 0.89 in 1910. Table 26 shows the monthly rainfall and the number of rainy days in each month for the years we have been considering, and also the rainfall from July 1st to August 23d inclusive. TABLE 26.— RAINFALL AND RAINY DAYS, NEW YORK CITY RAINFALL, INCHES Average, Forty-two Years June 3.29 July 4.38 August 4.54 September 3.62 1901 LOO 7.64 6.55 2.42 1903 9.78 3.93 7.85 4.31 1908 L27 3.80 6.01 1.91 1909 3.02 2.17 8.50 2.65 1910 6.03 0.49 1.07 1.42 1911 5.67 2.16 9.28 1.70 Total. .15.83 17.61 25.87 12.99 NUMBER OF RAINY DAYS 16.34 June 9 July 10 August 9 September 8 Total . .36 RAINFALL,* JULY 1ST TO AUGUST 23D, INCHES 9.01 5 18 3 10 12 16 10 7 5 6 9 11 10 8 11 12 6 3 7 5 42 45 23 30 34 18.81 14 11 12 9 46 July August 7.64 4.05 3.93 3.66 3.80 2.59 2.17 8.50 0.49 0.89 2.16 1.95 Total 11.69 7.59 6.39 10.67 1.38 4.11 It will be seen that during the entire period, 1911 had a greater precipitation than any of the three previous years, slightly greater than in 1901, and less than in 1903. The number of rainy days was greater than in any of the five other years considered, although during the period July 1st to August 23d the rainfall was lower than in any of the five years except 1910. We must, therefore, admit that in 1911 the rainfall and number of rainy days were in favor of low mortality, as compared with 1910, during the latter part of the summer. During July and the first part of August climatic conditions were unfavorable. In a general way summers having bad climatic conditions had a high infant mortality. During 1911 these conditions were unfavorable, especially during July. This Committee believes that the reduction in the mortality in the summer of 1911 was not due to "chance" variation in mortality, but to increased effi- ciency in the methods used to combat it. New York Meteorological Observatory figures. CHAPTER V The Results at the Milk Stations of the New York Milk Committee The results of the work of the Milk Stations may be gauged to a certain extent by the response of the communities in which the stations were located ; by the mortality among the babies within their spheres of influence; and by the mortality among the station babies. In order to obtain these figures a vast amount of statistical work had to be done, and it was impossible to carry it out for all the stations in Greater New York. The work was, therefore, limited to the stations maintained by the Milk Commit- tee. It has already been stated that the response to the work was so great at most of the stations that extra nurses and sometimes extra matrons had to be provided. In 20 stations an extra nurse was provided, and in 15 an extra assistant. Table 27 shows the enrolment of babies actually under supervision at the end of each week from May 20th to the end of the season. In order to estimate the mortality among the babies in the areas under the influence of the milk stations, the following method was adopted: A map was made and plotted out showing the location of the station and the number of babies enrolled in each block surrounding the station. In this way the actual sphere of influence of the station was determined. A few babies came from longer distances, and, therefore, from outside the district. In order to determine the mortality in the district thus established a search of the records at the Health Department and a tabulation of all deaths occurring in the months of June to November were made for the years 1910-1911. In order to determine the infant mortality rates it was necessary to tabulate the births by blocks in the same areas. The Committee originally intended to close its work on October 1st, so that the births were tabulated for the years October 1, 1909, to September 30, 1910; and October 1, 1910, to September 30, 1911. The deaths were originally tabulated from January 1st to September 30th, but it seemed more accurate to take only the five months of active work, and this tabulation was made a second time. It was, however, impossible to go through the birth figures again. The following table shows the deaths under one year for the "Station Areas" in the months June to October inclusive in 1910, before, and in 1911, after, sta- tions were maintained. It should be remembered that the stations at Mulberry, Cannon, East 21st, and West 48th Streets had been running for several years. This table also shows the births for the twelve months ending September 30th, and the infant mortality rate based thereon. For comparison the death-rate 52 1" 00 O ■<* C^ NO 00 O '-I 00 I ■^ -^ lO •<* 00 ^^ NO 00 •^ O 00 fO On T-i lO ON ■>* CN lO 00 O O 00 (T) i-< 00 -^ 'rt O 00 ■rt rc lO •rt CM lO i-i O O O l^ fD nO ^ _ _( _4 _ T-l T-H ^ -. i-i •^ O O 00 rO NO i-i ^ ,_( _H ^ ^ _4 ^ i-( ,-H CSCM CS 1-1 1-1 1-H 1-1 i-( CS CS i-( ^ i-l(M 1-1 1-1 i_| cs ,_i i_Hi_( o o 00 r^ ■* t^ 00 T-H lO lO ro -^ On -^ CO t^ t^ lO »* O lO ^ ON 00 ■* On CN O ■^ NO J^ i-h O 00 O "O On ro CN lO On On O NO ■* i-< NO "0 ^H 1-1 in O fO "* "-1 ^^ r^ i-i •rt O O t^ fO NO 1-1 ,_, T-l ^ i-( i-H •^ 1-1 1-1 (N CS CS i-< ■^ i-( 1-1 i-( CM CN 1-1 •rH i-( CM i-l i-( ^ CN i-l tH i-( On ro •^ r*5 ■* ■^ '-I -H «^ 00 1-1 O 1^ r<0 ro ■<* *^ fO NO O 00 lO CN lO 00 •* t^ 00 r^ t^ •«* lO On 1-1 lO On •* CN lO On 00 i^H NO ro •rt NO lO 1-1 i-( lO O CM -* 1-1 O NO •^ ■•-( O O t~- CN iD ,_| ,_| i-H T-l 1-1 1-1 ■^ ^H •^ (M CN On rj CO ^H 00 00 i-i -^ On O i-i i-i ■«*< NO ON rfi •^ 00 CO CC* 00 O On NO -^ ID ■^ t^ OMD -^ lO O !>• ID CNH^ •># 00 00 * 1-1 O lO 00 ■^ CO On 00 i^ i-i i-i 00 O i-< O "# 00 NO lO NO ■<* t^ On t-- ■* NO t~- NO 00 lO NO CM CM CO NO O •* O •* CO O !-» NO On lO CM no iD CO 00 O lO ON CM 00 CO NO uo 00 rt CM ^ Tt< •* 1-1 O -^ t^ i-< CM 00 NO NO O O 00 On O O CO rHrHi— li-li-l i-li— li-li-HCMCMi— ItHi-Ii-Ii— ICMi— ItHi— 1 1-* i-li-l»-li— 1 i— li-Hi-H 1^ ID •<* 1^ iOOOOOOOOOioOn*^coiOOconOOnOncOO- Om-i On (M NO ■* 00 O CM ■^ CO CO O O CO NO O CM t^ •* NO O O OO 00 O O co 1-1 1-1 ■^ 1-1 1-1 ^H T-H i-( CM IM 1-H 1-1 r-H 1-1 1-1 CM 1-1 -^ 1-1 1-1 1-1 -^ 1-1 i-H i-| i-| ,_( O CM 5 1^ NO ■^ On CO lO »0 CO CO CO NO 00 O •* O ON CM NO C4 On 00 CMO Osl^ lO ON rO O O NO 00 O 1^ O NO CO NO J>. CO 00 O (M O ■rt CO On On NO th CM 00 CM O ■* ON t^ 00 ■* •<* O •* O ■* On lO 00 00 NO t^ CO l>- ON "* 00 CO On lO NO !>. 00 * CM (M (M CM NO On On CM 00 00 no On CO r~- lO t-» ■rt t^ On CO r~ CD ON CO CM SIN )— 1 NO t^ CO -^ r^ NO 00 ■<* •^ ■^ On On 00 "0 (M 00 NO On •<* NO PN) O CO On CM ^h i-i lO lO On O •>* NO i-H>- 1^ CM NO ■^ On CM t^ 1-1 NO O 00 NO t-» lO On NO lO CM CM i-i t^ On <0 Jr^ 00 00 -"^ 1-|1-(1-I i-(i-li-(i-(»-H 1-1 1-1 tH 00 CM >— 1 Ttl ID On NO t^ CM CM UO O lO CM r^ 00 1-1 CM 1-1 ■* ID f^ O 00 O Tti CO O t-~ 1-1 CM NO tJh NO 0\ T) NO CM NO On O th NO O lO Oi 00 1^ NO •^ t^ NO 1-1 1-1 • PNl nO 00 CM t^ t^ 1^ • 1— (1— < 1-1i-Hi-Hi— t 1-H .1— )i— 1 CO 00 CM ON ID T-i rti 00 00 es Tt< NO On ■* ■^ •* O 00 CO •>* t^ lO On ,-< ,-h co co -^ 00 J>- CM -^ 00 t^ to i-< lO NO On 00 '^i 00 ID NO ID ID •* O lO •* • • • O iD t^ CM NO ■>* iD • 1-1 1-( 1— 1 1-1 ... 1—1 i-H ID CM o CM 1-1 NO O'^CMf-'* OOO O NO NONO CO CM Wr-Ht^O OnnO no 00 ^ CO •rt ■* ■rt CM ■* t^ NO •* 1-1 CO tD On NO CO NO ■* r^ TjH -^ CO t-- CO CO • ■ • On "* NO i-h UT* tJh ■ IT) 1-H NO CO 00 On ON 00 Or^ O CM On 00 00 •* O iDt^ NO O ID r^ i-i NO t- iD 00 0\ CM CO ID "0 •^ 1-t CO CO ON NO CM lO CM ■* rj< CO CM ID CO CM ■ • • no ■<* iD O Tf CM i-i • 1-1 1-1 1-1 ... .,—1 . >-> On CM 1-1 00 ID On 00 P<1 CM CO On CO >D CO ID O 00 ID O NO O ro ■<* "* 00 NO i-i •rt CO "* ID CO 1-1 CM CO 00 ID ■^ Tj* CM Tf CM CM 1-1 CO CM •rt - . . i* CO ■^ O CM i-l t-< • ID CM H ZO 1-5 CM ID NO CM CO t^ On 1-H CO NO NO 00 1-H NO t^ O On CM CM rfl O 00 1-- •rt t^ O O 1-H CM CO ID CM 1-1 ■^ CM t^ •^ 11 CO CM CM 1-1 CM 1-1 CM 1-1 1-1 • • • CO CM tH O CM i-l »-l • 1-1 1—1 1-1 ... ,_H . CO ID O 1— > On CM On 00 O t^ ■^ ■^ CNl 1^ 1^ NO CO CM OO ID O iD -* t-h ro ■* O ■^ CM NO O CM CM ID (M 1-1 ■^ CM t-^ ■* O CO 1-1 CM i-l tH • ... ID CM -^ O CO CM NO On On CO On t^ NO 1-1 CO ID 00 NO O O »h CM rji (M •.* CM i-H^ -^ t^ CO •* O CM CS ID ■rt CM 1-1 'H NO CO 00 1-H ■ 1-H . . .... rf CM 1-1 On CM CO • CO 1-1 -^ • -00 ID 00>OiD OCM OnCM NO ■^ O OnOn-^OOtJh CO NO ^ tH U n z o H C/3 - H O H :::::::::::::::::::::: : S ;:::::: : <^ ::::.. : ::::::: 'Q ::::::: : ,"^i-HCMrO-*iDNOt^OOONOi-HCMCO-<*iDNOJ>.OOONO^CMcO ^i-iCMCO'tHDNOt^tJO \3i ^ ,_, _l 1-1 1-1 ^ 1-H -^ 1-1 1-1 CM CM CM CM !> 53 54 INFANT MORTALITY AND MILK STATIONS among babies under one year, based on the enrolment, is given for each station; also the totals for East and West Side stations and for the total area. TABLE 28.— STATISTICS OF STATION AREAS AND STATIONS 1910 1911 Station Mortality Station Area East Side Deaths, June- Oct. Births, Oct.- Sept. Infant Mortal- ity Deaths, June- Get. Births, Oct.- Sept. Infant Mor- tality Deaths, June- Oct. Enrol- ment Death- rate 1. Mulberry 42 16 39 78 65 58 33 55 53 53 90 92 20 47 37 30 24 53 110 13 '27 27 1307 601 1305 1909 1130 1219 883 1011 598 831 1678 1568 358 554 568 505 378 834 1593 349 373 738 32.1 26.6 29.8 40.8 57.5 47.5 37.4 54.4 88.6 63.7 53.6 58.6 55.8 84.8 65.1 59.4 63.4 63.5 69.0 37.2 72.3 36.5 54 11 34 52 30 40 29 36 34 50 83 70 14 31 39 23 21 40 84 10 'i4 25 1343 580 1374 1777 1013 1199 830 911 561 786 1663 1556 366 553 605 471 397 783 1631 338 366 776 43.4 18.9 26.6 29.2 29.6 33.3 35.3 39.5 60.6 63.6 49.9 44.9 38.2 56.0 64.4 48.8 52.8 51.0 51.5 29.5 38.'2 32.2 12 2 6 1 7 3 5 6 14 5 1 4 9 5 6 6 8 2 "2 356 133 307 430 155 153 143 158 187 305 399 383 111 176 170 135 135 367 198 134 ioi 189 46.8 2. Norfolk 0.0 3. Eldridge 9.6 4. Cannon and Stanton (21) 5. Ludlow 13.9 0.0 6. East 3d 6.5 7. East 5th 49.3 8. East 9th . .:i. 9. East 21st 18.9 26.7 10. Avenue A 29.2 11. East 105th 46.8 12. East 11th 17.6 13. East 56th 9.0 14. 512 2d Ave 22.7 15. 873 2d Ave 52.9 16. E. 81st St 37.0 17. 1705 2d Ave 44.4 18. E. 97th 22.4 19. E. 112th 40.4 20. E. 115th 14.9 21. Combined with 4 22. E. 75th 19!8 23. Madison Ave 0.0 Total East Side . . 1062 20389 52.3 824 19668 41.8 104 4314 24.6 1910 1911 Station Mortality Station Area West Side Deaths, June- Oct. Births, Oct.- Sept. Infant Mortal- ity Deaths, June- Get. Births, Gct.- Sept. Infant Mor- tality Deaths, June- Get. Enrol- ment Infant Mor- tality 1. Thompson 42 40 54 127 32 33 59 44 917 550 639 1360 375 333 545 373 45.8 72.7 85.8 93.3 85.3 148.5 108.2 117.9 47 32 46 101 25 24 44 19 861 555 534 1409 378 242 481 365 54.5 57.6 87.7 71.7 66.1 99.1 91.4 52.0 4 10 8 7 2 5 2 3 236 129 117 198 91 121 139 134 16.9 2. Leroy 77.5 3. 10th Ave 68.3 4. W. 48th 35.3 5. W. 69th 21.9 6. Washington 41.3 7. Vanderbilt Clinic 8. 9th Ave 14.3 22.3 Total West Side . East Side 431 1062 431 4971 30289 4971 86.6 52.3 86.6 338 824 338 4815 19668 4815 70.2 41.8 70.2 41 104 41 1165 4214 1165 35.1 24.6 West Side 35.1 All Areas 1493 25260 59.0 1162 24483 47.4 145 5379 26.9 It will be seen that in the station areas on the East Side there was a reduction of 10.5 over 1910, and on the West Side, 16.4. The infant population affected on the West Side, however, was about one-quarter that of the East Side. This THE RESULTS AT THE MILK STATIONS 55 would seem to point either to less efficient station technic or to a poorer class of patients, i. e., needing the stations more. Comparing the station rate and the district rate, the latter conclusion is borne out, for on the West Side the station rate was just half the district rate. The testimony of the nurses and physicians in charge of the stations also points to this being the case. Another noticeable fact is that in the Mulberry Street, East 5th Street, and Leroy Street stations the station mortality is in excess of the district mortality. This is explained by the fact that the nurses in these districts were particularly active in seeking out sick babies; also by the particularly bad character of the neighborhood in which at least two of the stations (East 5th Street and Leroy Street) were situated. Although many of these babies were seen only once and cannot be fairly charged against the station, the Committee adopted the policy of accepting the responsibility for the death of every baby enrolled, even if seen only once, in order to avoid criticism, and it stands on these records as given. The West Side figures show the great need of stations in this part of the city. The areas of intensely congested population are more scattered ; there is not the long stretch that is seen on the East Side, and this part of the city has been neg- lected. In only 4 of the 23 East Side station areas does the death-rate equal or exceed the lowest one on the West Side. In 4 of the West Side districts the rates are higher than those of the worst East Side district. Some of the figures are very striking. In the Washington Street district, among the Syrian population, the death-rate in 1910 was 148.5, and fell in 1911 to 99.1, a net difference of 49.4. This little strip of densely populated territory extends from Battery Place to Cedar Street, from West Side to Greenwich. The people rarely speak English, and an interpreter was needed almost all the time. Two hundred and forty-two babies were born in the year, and the enrol- ment was 121, or exactly 50 per cent., while the station death-rate was 41.3, or 41.6 per cent, of the district mortality. Table 29, while not strictly accurate, is suggestive for purposes of compari- son. If the enrolment be deducted from the district births, and the station deaths from the district deaths, the comparison is even more striking. This is not strictly accurate, because the enrolment was not absolutely con- fined to the station area of influence. For instance, at the East 105th Street station several enrolled babies lived in the Bronx. The station where the figures did most closely correspond was probably Washington Street, which shows a mortality of 41.3 as against the "corrected" rate of 157 for the district. Another suggestive table, again not strictly accurate for the same reason, but not more than 1 or 2 per cent, out, is Table 30, showing the percentage of births enrolled at the stations and the percentage of the district deaths among babies enrolled. One of the objects of the demonstration carried on by the New York Milk Committee in cooperation with other organizations was to show that home modi- fication was practicable among the very poor and ignorant, among whom the work was done. The Committee felt very strongly that not only was this a more practical way, because less expensive, but that it accomplished more in that it taught something. 56 INFANT MORTALITY AND MILK STATIONS TABLE 29— STATISTICS FOR STATION AREAS, DEDUCTING STATION ENROL- MENT FROM DISTRICT BIRTHS, AND STATION DEATHS FROM DISTRICT DEATHS, COMPARED WITH STATION FIGURES Station Districts Stations Deaths Births Rate Deaths Enrolment Rate IE 42 11 32 46 30 39 22 33 29 44 69 65 13 27 30 18 15 34 76 8 12 25 987 457 1067 1347 857 1046 678 753 374 581 1364 1273 255 377 435 336 262 516 1433 204 265 587 42.5 24.0 29.9 34.1 35.0 27.2 32.4 43.8 77.5 75.7 50.5 51.0 50.9 71.6 68.9 53.5 57.2 65.8 53.0 > 39.2 45.2 42.5 12 2 6 1 7 3 5 6 14 5 1 4 9 5 6 6 8 2 2 256 123 207 430 155 153 142 158 187 205 299 283 111 176 170 135 135 267 198 134 101 189 46.8 2 E 0.0 3 E 9.6 4 and 21 E 13.9 5 E 0.0 6E 6.5 7 E 49.3 8 E 18.9 9 E 26.7 10 E 29.2 HE ^ 46.8 12 E 17.6 13 E 9.0 14 E 22.7 15 E 52.9 16 E 37.0 17 E 44.4 18 E 22.4 19 E 40.4 20 E 14.9 22 E 19.8 23 E 0.0 Total East Side 720 15454 46.5 104 4214 24.6 1 W 43 22 38 94 23 19 42 16 625 426 407 1211 287 121 342 231 68.8 51.6 93.3 77.6 80.1 157.0 122.8 69.2 4 10 8 7 2 5 2 3 236 129 117 198 91 121 139 134 16.9 2 W 77.5 3 W 68.3 4 W 35.3 5 W 21.9 6 W 41.3 7 W 14.3 8 W 22.3 Total West Side 297 3650 81.3 41 1165 35.1 Summary East Side 720 297 15454 3650 46.5 81.3 104 41 1 4214 1165 24.6 West Side 35.1 Total 1017 19104 53.2 1 145 5379 26.9 With this point in view, careful records were kept of each case, and from the individual records the following tables (Tables 31 to 42) have been compiled, showing in some detail the feeding history of 3182 babies. The period of observa- tion extended from June 1st to September 15th. The latter date was selected in order that something definite might be compiled for the Board of Estimate and Apportionment. If the full time — June 1st to November 1st — could have been utilized for these records, the results might have been even better, as many babies were recorded as well at the end who showed no gain in weight. THE RESULTS AT THE MILK STATIONS 57 TABLE 30.— RELATION OF ENROLMENT AT STATION TO BIRTHS IN DISTRICT AND STATION DEATHS TO DISTRICT DEATHS Station Districts Percentage of Percentage of District Births Enrolled Deaths Among Enrolled East Side 1.... 20.5 22.2 2 21.2 0.0 3 16.2 5.8 4 and 21 24.2 11.5 5 15.3 0.0 6 12.7 2.5 7 17.3 24.1 8 17.3 8.3 9 33.3 14.7 10 26.0 12.0 11 17.9 16.8 12 18.1 . 7.1 13 30.3 6.8 14 31.8 12.9 15 28.0 23.0 16 28.6 21.7 17 34.0 28.5 18 34.0 15.0 19 12.1 9.5 20 39.6 20.0 22 27.5 14.2 23 24.3 0.0 21.4 12.6 West Side 1 27.4 8.5 2 23.2 31.2 3 22.3 17.3 4 14.0 6.9 5 24.0 8.0 6 50.0 20.8 7 28.9 4.5 8 36.7 15.7 24.2 12.1 Grand Total 21.9 12.4 With reference to the condition of "well" or "sick" at the close of the period, the criticism may be made that overenthusiasm of the physicians and nurses may have made the well too many, and the sick too few. This criticism cannot be disproved, but even leaving out of all consideration the statement of "well" or "sick," the weights, which show pretty conclusively the success or failure of feeding, cannot be questioned. They must be regarded as accurate and as free from error due to the personal equation. In considering the following tables, noting the "condition at close," it must be remembered that the period of observation was short, — an average of six weeks. — and many babies classed as well did not have a chance to gain in weight. Every baby enrolled more than a week is included in this record. Fatal cases are in- cluded in the tables, although no data are given. These cases are considered in detail elsewhere. As no babies who did not attend a week or over are included in the table, the number of deaths is only 74 instead of 119, as 45 babies were seen only once and immediately referred to a hospital or private physician, or else the mother refused to attend. o > w CQ O U. 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Bi^ 00 ^ o fO 00 o CO Tt* Ov Ov 00 o o '^ 1— 1 o VO CN CO CN o CN o ^ 1 g o ro rJ lO ro r>. CO CO VO lO CO ^ 00 o lO Ov Ov 00 o CN VO CN VO CN 'rf 0\ cs tN vH es (N CN t-H CN 1-H 1-H 1-H 1-H 1-H 1-H y-t 1-H 1-H to O u w CO CO Tt< ro On VO O VO lO Ov OO 00 o o VO Ov CN ^ 00 r^ OO O 00 o .^_l H ro vO •* ^ VO CO 00 VO lO tJh o o CO VO t- CN 1^ VO t^ to o o < n ^U ID ■* "* lO lO ■* Tt< "* Tl^ VO >o VO lO "■3 CN Tl< to rf VO '^ cs 00 to to M ,_! rt< lO 00 o CO Tf VO CO ID CO lO >o CN r- J>. i-H 1-H r^ i-H CN Ov 'Tt^ OO s cs rs rs rs CO cs CN tH CN CN CN 1-H 1—1 CN 1-H 1-H 1-H ^-H 1-H o W ^ Ti< CN 00 T)H ^-H 1^5 O lO CO Ov 00 CN »o o T-l VO VO 1-H CO 00 CO 00 ,^_^ 00 »* TVlOl CO >o lO lO in »o l/> CO rlt CO ■<* CN CO ■* CN CO CN CM 1-H CN " CN 1-< 00 •1H30 ts t^ \o es 00 l-H 00 Ov O 00 CO VO t^ t^ O ^ u nzd ts «s o ■^ o CN o o o ■^ •^ ■^ ■^ ■^ CN ^ aaia ■* t^ •1-H CN y-< CO -^ 1-1 CN ^ -^ ^ ^ ^ CN ) CS Tjf t^ VO o *^ 00 «o Ov CN iTi t-<. l>- 1-H »-~ t^ lO CO VO to ro iT) fn >rt cs »-l CO fS VO CN CN ■<* CO Tj< Ov 1-H 1-H •* VO 1-H CO VO CN CO •< Ui O '* >o CN CO cs lo CO VO CO CO rfH CO lO VO 1-H ,_! CN CO .,-1 .,-1 CN CN CO H -•— ( 00 § w ^ >o c^ CN VO o lO I/O lO O »o CN lO 00 00 Ov t^ t^ Ov CO CO to t^ ■* •>* rf ,-1 >o t~- t^ VO lO VO '* lO f^ lo •* lO 00 VO VO CO CO 00 VO CO 1^ to a < n O o o Os Ov Ov Ov Ov Ov ov o\ Ov Ov ov CO Ov ov Ov Ov Ov Ov Ov Ov Ov J i ■>* 00 o ■<1' o t^ VO O ^ lO VO VO CO lO VO Ov 00 VO (VI t^ 00 O ^ 00 t^ fo lO o CO CO CN t— ( Ov O o cc J-^ 1-H to to to rt^ Tf to CN CO t^ to ^ CN ▼H " " " CN cs i •>* o VO OO -* CN CN rh o o Ov o 1^ o CO ^ o Ov to 00 Ov CN VO 00 H CO rt* *— ( o O ov t^ CN VO VO VO ■* '^ lO CN CO t^ VO o *— 1 CN ^-H T-H »-t T— ( t-H «— t T-H ^-H 1-H CO H CN u o .^ CS f*; ■* lO VO t^ 00 Ov o ^ CN CO Tf to VO *^ 00 Ov o (N CO ►J < o < i-H y-< 1-1 y-* CN CS CS CN H 72 THE RESULTS AT THE MILK STATIONS 73 It is also to be remembered, in studying these tables, that the period of ob- ervation was during the hottest summer weather. The gain in weight is very triking. This is most marked among the breast-fed babies, as would be ex- lected. It is also interesting to note the average weights of the babies under one ear. In the group over one year it will be noted that they were practically all rery much under normal weight when admitted, and that the gains were con- iderable. Summary Tables 44 and 45 show the condition of babies at the close of the )eriod of observation, grouped according to age, sick or well on admission, and otal, expressed in gross and percentage figures. I As would be expected, the results for babies well on admission are much r^etter than for sick babies. In the former group, 87.5 per cent, showed gain in veight, as against 76.8 per cent, in the latter, the average being 84.8 per cent. «\gain, 95.4 per cent, of the well babies were well at the close, 3.5 per cent, were iick, and 1.1 per cent, had died. Of the sick babies, 50.1 per cent, were well, 44.1 per cent, were still sick, and mly 5.8 per cent, had died. That over-optimism did not make the "well" too ligh may be gathered from the relation of gain in weight and "well" among the iick babies. A more detailed discussion of the deaths will be given later on in this chapter. The following table shows the condition of babies on admission, grouped iccording to feeding history, and further divided into groups of babies under )ne year and over one year of age. FABLE 46.— SUMMARY OF FEEDING HISTORIES AND CONDITION ON ADMISSION Feeding Under One Over One Total Breast Well Sick Total Well Sick Total WeU Sick Total 608 140 54 83 24 16 691 164 70 60 23 31 17 3 3 77 26 34 668 163 85 100 27 19 768 Breast to mixed 190 Breast to artificial 104 Total breast on admission 802 123 925 114 23 137 916 146 1062 Mixed 329 26 108 9 437 35 98 19 60 13 158 32 427 45 168 22 595 Mixed to artificial 67 Total mixed on admission 355 117 472 117 73 190 472 190 662 Artificial 451 284 735 529 194 723 980 478 1458 Total 1608 524 2132 760 290 1050 2368 814 3182 74 INFANT MORTALITY AND MILK STATIONS Of 3182 babies at end of period — 2697, or 84.87 per cent., showed gain in weight. 2666, or 83.8 per cent., were well. 74, or 2.3 per cent., had died. Of 3182 babies on admission — 2368, or 74.4 per cent., were well. 814, or 25.6 per cent., were sick. Of 2368 babies well on admission, at end of period — 2072, or 87.5 per cent., showed gain in weight. 2258, or 95.4 per cent., were well. 27, or 1.1 per cent., had died. Of 814 babies sick on admission, at end of period — 625, or 76.8 per cent., showed gain in weight. 408, or 50.1 per cent., were well. 47, or 5.8 per cent., had died. TABLE 47.— NUMBER OF BABIES GROUPED ACCORDING TO FEEDING HISTORY, NUMBER SICK AND WELL ON ADMISSION, AND PERCENTAGES OF TOTAL ENROLMENT FOR EACH GROUP AND CONDITION Breast-fed Breast-fed TO Mixed Fed Breast-fed TO Artifi- cially Fed Mixed Fed Mixed Fed TO Artifi- cially Fed Artifi- cially Fed Totals No. Per Cent. No. Per Cent. No. Per Cent. No. Per Cent. No. Per Cent. No. Per Cent. No. Per Cent. Well Sick 668 100 21.0 3.1 163 27 5.1 0.8 85 19 2.7 0.6 427 168 13.4 5.3 45 22 1.4 0.7 980 478 30.8 15.0 2368 814 74.4 25.6 Total 768 24.1 190 5.9 104 3.3 595 18.7 67 2.1 1458 45.8 3182 99.9 TABLE 48.— FEEDING HISTORY AND PROPORTION OF EACH GROUP, SICK OR WELL ON ADMISSION Breast-fed Breast-fed TO Mixed Fed Breast-fed TO Artifi- cially Fed Mixed Fed Mixed Fed TO Artifi- cially Fed Artifi- cially Fed Totals No. Per Cent. No. 163 27 Per Cent. No. Per Cent. No. Per Cent. No. Per Cent. No. 980 478 1458 Per Cent No. Per Cent. Well 668 100 87.0 13.0 85.8 14.2 85 19 81.7 18.3 427 168 595 71.8 28.2 45 22 67 67.2 32.8 67.2 32.8 2368 814 74.4 25.6 Sick Total 768 100.0 190 100.0 104 100.0 100,0 100.0 100.0 3182 100.0 Nearly one-quarter of the entire enrolment, therefore, were breast-fed throughout, and 30 per cent, were entirely or partially nursed. The ratio of sick to well increases from breast-fed to mixed fed to artificially fed. THE RESULTS AT THE MILK STATIONS 75 ^ABLE 49— PROPORTION OF TOTAL BABIES BREAST-FED, MIXED FED, AND ARTIFICIALLY FED ON ADMISSION Breast No. 1062 Per cent. 33.4 Mixed No. 662 Per cent. 20.8 Artificial No. 1458 Per cent. 45.8 Of 1062 babies breast-fed on admission — 768, or 72.3 per cent., were breast-fed throughout; at end of period — 704, or 91.7 per cent., showed gain in weight. 699, or 91.0 per cent., were well. 5, or 0.47 per cent., had died. 190, or 17.9 per cent., were changed to mixed feeding; at end of period — 171, or 90.0 per cent., showed gain in weight. 167, or 87.9 per cent., were well. None had died. 104, or 9.8 per cent., were changed to artificial feeding; at end of period — 90, or 86.5 per cent., showed gain in weight. 97, or 93.3 per cent., were well. None had died. Of 662 babies mixed fed on admission — 595, or 89.9 per cent., were mixed fed throughout; at end of period — 497, or 83.5 per cent., showed gain in weight. 460, or 77.3 per cent., were well. 19, or 3.2 per cent., had died. 67, or 10.1 per cent., were changed to artificial feeding; at end of period — 51, or 76.1 per cent., showed gain in weight. 53, or 79.1 per cent., were well. 6, or 9.0 per cent., had died. Of 1458 babies artificially fed on admission; at end of period — 1184, or 81.2 per cent., showed gain in weight. 1190, or 81.6 per cent., were well. 44, or 3.0 per cent., had died. TABLE 50.— PROPORTION OF TOTAL BABIES WELL OR SICK ON ADMISSION AC- CORDING TO FEEDING ON ADMISSION Breast-fed Mixed Fed Artificially Fed No. Per Cent. No. Per Cent. No. Per Cent. NeW 916 146 86.3 13.7 472 190 71.3 28.7 980 478 67.2 iick 32.8 rOTAL 1062 100.0 662 100.0 1458 100.0 Of 916 babies well and breast-fed on admission — 668, or 72.9 per cent., were breast-fed throughout; at end of period — 624, or 93.4 per cent., showed gain in weight. 647, or 96.8 per cent., were well. 3, or 0.45 per cent., had died. 76 INFANT MORTALITY AND MILK STATIONS 163, or 17.8 per cent., were changed to mixed feeding; at end of period — 146, or 89.6 per cent., showed gain in weight. 150, or 92.0 per cent., were well. None had died. 85, or 9.3 per cent., were changed to artificial feeding; at end of period — 73, or 85.0 per cent., showed gain in weight. 83, or 97.6 per cent., were well. None had died. Of 472 babies well and mixed fed on admission — 427, or 90.5 per cent., were mixed fed throughout; at end of period — 371, or 86.9 per cent., showed gain in weight. 400, or 93.7 per cent., were well. 8, or 1.9 per cent., had died. 45, or 9.5 per cent., were changed to artificial feeding; at end of period — 34, or 75.5 per cent., showed gain in weight. 38, or 84.4 per cent., were well. 4, or 9.1 per cent., had died. Of 980 babies well on admission and artificially fed throughout; at end of period — 824, or 84.1 per cent., showed gain in weight. 940, or 95.9 per cent., were well. 12, or 1.2 per cent., had died. Of 146 babies sick and breast-fed on admission — 100, or 68.5 per cent., were breast-fed throughout; at end of period — 80, or 80 per cf^nt. showed gain in weight. 52, or 52 per cent., were well. 2, or 2 per cent., had died. 27, or 18.5 per cent., were changed to mixed feeding; at end of period — 25, or 92.6 per cent., showed gain in weight. 17, or 63.0 per cent., were well. None had died. 19, or 13 per cent., were changed to artificial feeding; at end of period — 17, or 89.5 per cent., showed gain in weight. 14, or 73.7 per cent., were well. None had died. Of 190 babies sick and mixed fed on admission — 168, or 88.4 per cent., were mixed fed throughout; at end of period — 126, or 75.0 per cent., showed gain in weight. 60, or 35.7 per cent., were well. 11, or 6.6 per cent., had died. 22, or 11.6 per cent., were changed to artificial feeding; at end of period — 17, or 77.3 per cent., showed gain in weight. 15, or 68.2 per cent., were well. 2, or 9.1 per cent., had died. \ Of 478 babies sick on admission and artificially fed throughout; at end of period — 360, or 75.3 per cent., showed gain in weight. 250, or 52.3 per cent., were well. 32, or 6.7 per cent., had died. The above figures are for babies under two years of age. It may be well to study the results of the feeding in the 2132 babies under one year of age. THE RESULTS AT THE MILK STATIONS Of 2132 babies under one year of age, at end of period — 1844, or 86.5 per cent., showed gain in weight. 1796, or 84.2 per cent., were well. 68, or 3.2 per cent., had died. Of 2132 babies on admission — 1608, or 75.4 per cent., were well. 524, or 24.6 per cent., were sick. Of 1608 babies well on admission, at end of period — 1449, or 90.1 per cent., showed gain in weight. 1534, or 95.4 per cent., were well. 22, or 1.4 per cent., had died. Of 524 babies sick on admission, at end of period — 395, or 75.4 per cent., showed gain in weight. 262, or 50 per cent., were well. 46, or 8.8 per cent., had died. n TABLE 51.— PROPORTION OF TOTAL BABIES UNDER ONE YEAR WHO WERE BREAST-FED, MIXED FED, OR ARTIFICIALLY FED ON ADMISSION Breast-fed Mixed fed Artificially fed No. Per cent. No. Per cent. No. Per cent. 925 43.4 472 22.1 735 34.5 Of 925 babies breast-fed on admission — 691, or 74.7 per cent., were breast-fed throughout; at end of period — 648, or 93.8 per cent., showed gain in weight. 634, or 91.8 per cent., were well. 5, or 0.72 per cent., had died. 164, or 17.7 per cent., were changed to mixed feeding; at end of period — 148, or 90.2 per cent., showed gain in weight. 144, or 87.8 per cent., were well. None had died. 70, or 7.6 per cent., were changed to artificial feeding; at end of period — 64, or 91.4 per cent., showed gain in weight. 63, or 90.0 per cent., were well. None had died. Of 472 babies mixed fed on admission — 437, or 92.6 per cent., were mixed fed throughout; at end of period — 375, or 85.8 per cent., showed gain in weight. 353, or 80.8 per cent., were well. 18, or 4.1 per cent., had died. 35, or 7.4 per cent., were changed to artificial feeding; at end of period — 27, or 77.1 per cent., showed gain in weight. 27, or 77.1 per cent., were well. 6, or 17.1 per cent., had died. Of 735 babies artificially fed on admission, at end of period — 582, or 79.2 per cent., showed gain in weight. 575, or 78.2 per cent., were well. 39, or 5.3 per cent., had died. 78 INFANT MORTALITY AND MILK STATIONS i TABLE 52.— PROPORTION OF BABIES UNDER ONE YEAR WHO WERE WELL OP SICK ON ADMISSION ACCORDING TO FEEDING ON ADMISSION Breast-fed Mixed Fed Artificially Fed H No. Per cent. No. Per Cent. No. Per cent. U Wei! Sick 802 123 86.7 13.3 355 117 75.2 24.8 541 284 lil 1 Total 925 100.0 472 100.0 735 100.0 ■ Of 802 babies well and breast-fed on admission — 608, or 75.8 per cent., were breast-fed throughout; at end of period- 577, or 94.9 per cent., showed gain in weight. 591, or 97.4 per cent., were well. 3, or 0.49 per cent., had died. 140, or 17.5 per cent., were changed to mixed feeding; at end of period- 126, or 90.0 per cent., showed gain in weight. 129, or 92.1 per cent., were well. None had died. 54, or 6.7 per cent., were changed to artificial feeding; at end of period — 50, or 92.6 per cent., showed gain in weight. 52, or 96.3 per rent., were well. None had died. Of 355 babies well and mixed fed on admission — 329, or 92.7 per cent,, were mixed fed throughout; at end of period — 294, or 89.4 per cent., showed gain in weight. 308, or 93.6 per cent., were well. 7, or 2.1 per cent., had died. 26, or 7.3 per cent., were changed to artificial feeding; at end of period — 20, or 76.9 per cent., showed gain in weight. 20, or 76.9 per cent., were well. 4, or 15.4 per cent., had died. Of 451 babies well and artificially fed on admission; at end of period — 382, or 84.7 per cent., showed gain in weight. 434, or 96.2 per cent., were well. 8, or 1,8 per cent., had died. Of 123 babies sick and breast-fed on admission — 83, or 67.5 per cent., were breast-fed throughout; at end of period — 71, or 85.5 per cent., showed gain in weight. 43, or 51.8 per cent., were well. 2, or 2.4 per cent., had died. 24, or 19.5 per cent., were changed to mixed feeding; at end of period — 22, or 19.7 per cent., showed gain in weight. 15, or 62.5 per cent., were well. None had died. 16, or 13 per cent., were changed to artificial feeding; at end of period — 14, or 87.5 per cent., showed gain in weight. 11, or 68.7 per cent., were well. None had died. THE RESULTS AT THE MILK STATIONS 79 Of 117 babies sick and mixed fed on admission — 108, or 92.3 per cent., were mixed fed throughout; at end of period — 81, or 75.0 per cent., showed gain in weight. 45, or 41.7 per cent., were well. 11, or 10.2 per cent., had died. 9, or 7.6 per cent., were changed to artificial feeding; at end of period — 7, or 77.8 per cent., showed gain in weight. 7, or 77.8 per cent., were well. 2, or 22.2 per cent., had died. Of the 284 babies sick and artificially fed on admission, at end of period — 200, or 70.4 per cent., showed gain in weight. 141, or 49.6 per cent., were well. 31, or 10.9 per cent., had died. The above figures prove pretty conclusively that the home modification of lilk is possible among the very poor and ignorant, and that the results, when this jeding is carefully ordered and careful supervision insures the instructions being arried out, are as good as when modified milk is dispensed. As has been already stated, every fatal case which was seen once by the hysician or nurse at the station has been charged against that station. This 5 obviously unfair, for in practically every case the mother was referred to a hysician or advised to take the child to a hospital, arrangements usually being lade at once by the nurse, and a card given to the mother. However, in order hat no charge of selecting cases could be made, all were credited to the stations, nd the general mortality rates for each station and for the stations as a whole iclude these deaths. Of the 158* deaths occurring among the station babies during the entire ■eriod June to November, the method of feeding, condition on admission, dis- position of the case, place of death, average interval elapsing between last visit nd date of death, and age at death, are shown in the following detailed tables, rouped according to diagnosis and number of clinics attended. In studying these tables it must be remembered that the diagnoses are those iven on the death-certificates by the reporting physician. It will be noted that iarrheal disease is credited with 79, or exactly 50 per cent, of the total deaths ; lalnutrition, 21, or 13.3 per cent.; respiratory diseases, 17, or 10.8 per cent.; ontagious diseases, 14, or 8.9 per cent.; all other diseases, 27, or 17 per cent. In his last group there are included: Diseases of cerebrospinal system 14 Congenital debility 2 Tuberculosis 3 Congenital syphilis 1 Mastoiditis 1 " Choked to death " 1 Unknown 5 Total 27 * The deaths given in connection with the feeding tables are for the period June 1st to Sep- ember 15th. w < u < < O Z Pi w u o u < < Q I <* i tN O O C5 CN 1 - ^OOth CN --lO'-lT-l CO CO CN 1-H T-H t^ N O Tl -^ tN t^ O O '-(■^ ID ID O »-i "D ^ ■* CN O CO CN CN O OlO *» 2 ^ CM '"' o :? fS t-~ rO t^ CN ; O O CN CN Ti< tH OCN '-I '^ OOOO o COOO-* t^ 2 U < n t^Tt mco t- CN ro CO '-I Ov OOOO o OOOO O CO"-! O"-! ID ! u, JS V i> *^ •o c e «S CN o o Tf CN O O O CN OOOO o i-HtHOO CN i-iOOO y-{ o d^. o ^ o *— < o lO O O CN ID O OO o OOOO o OOOO O iisa 00 CO CNTj; IT) t^ O lO '-t "^. •^ O CO ID CN ■^. ^. ^. 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(n . . • (/> . . . l/i . . . tn . en 7 . . o ■ • .y • • .^ . . o . . o . • c . -'c • 'is • ._'S • .'B . i^ Z • ;:2 t/) ■ ■ a tn u) S 'S'S ^ i H O o H ■ • Si tn 05 o yog < H O > O • ■ £i tn en o yog C C '=' < H o 2 '- o'c . '. "o . . (U tn en ^ O O g 'c'S « o . '. "o . . 0) U) tn n o o g 'S'c '^ < K u: ;i; :^ u. oi u u u o H ;^ u o u o H Pi O O (J o H H o o o o H W o o y o H CN r^ rf CN o t-C »-l , (n . tn CS al. riti tor ou rs a .. .- 1- ^ u ^ c c c "= LIN rrhe nut Dira tagi 3the < o O rj — — — ^ ^ o u u o H ^•22S§ = H ►J,-, (SCO'* < 8i 82 INFANT MORTALITY AND MILK STATIONS It is possible that, as only four died in the hospital, some of the "cerebro- spinal diseases" may have been diarrheal in nature. The above figures give a death-rate from the different groups of causes as follows, based on the enrolment of 7919 babies: TABLE 54.— DEATH-RATE FOR EACH GROUP OF DISEASES Diarrheal 8.0 per thousand Malnutrition 2.6 || Respiratory 2.1 Contagious 1-8 Other causes 3.4 In order to get a really accurate view of what was accomplished it is necessary to deduct the deaths of babies seen only once and referred to hospitals or physi- cians, numbering 58, or 26.7 per cent. This leaves exactly 100 deaths to be credited to the stations. We, therefore, have 100 deaths among 7861 babies (deducting 58 from enrol- ment totals under two years of age), a death-rate of 1.27 per thousand. There were charged against the stations 145 deaths among babies under one year, and 13 deaths among babies between one and two years. Of these cases there attended only one clinic, or were seen but once, 51 under one year and 7 over one year and under two years. Deducting these figures from the deaths and enrolment at the different age periods we have — 94 deaths among 5328 babies under one year, or 17.6 per thousand. 6 deaths among 2533 babies over one year, and under two, or 2.4 per thousand. The deaths under one year in Manhattan for the same months, based on the births of the preceding twelve months, were 52.5 per thousand — almost exactly three times as many. If, in addition to the deaths among babies attending only one clinic, we ex- clude everything except diarrheal and malnutrition deaths, we shall have the startling total of 66 deaths among 5287 babies, or 12.5 per thousand. This is, of course, putting the matter in its most favorable light, and is mentioned only as an interesting statement. It is of interest to study the percentage of the deaths in each group in rela- tion to the number of clinics attended: TABLE 55.— PERCENTAGE OF DEATHS IN RELATION TO DIAGNOSIS AND NUM- BER OF CLINICS ATTENDED 1 Clinic 2 Clinics 3 Clinics 4 OR MORE Diarrheal 36.7 19.0 41.2 42.9 44.4 22.8 14.3 0.0 21.4 11.1 12.7 28.6 17.6 7.1 3.7 27.8 Malnutrition 38.1 Respiratory 41.2 Contagious 28 6 All others 40 7 36.7 17.1 13.3 32.9 THE RESULTS AT THE MILK STATIONS 83 The interval elapsing between the time when the baby passed from under the observation of the station to date of death is shown by the following table : TABLE 56— PERCENTAGE OF DEATHS IN RELATION TO NUMBER OF CLINICS AND INTERVAL BETWEEN LAST ATTENDANCE AND DATE OF DEATH Days Elapsing One clinic , More than one clinic All cases I-IO 11-20 21-30 31-40 41-S0 si-60 61-70 71-80 81-90 50.0 3L0 10.3 1.7 3.4 0.0 0.0 1.7 1.7 48.0 24.0 17.0 2.0 3.0 4.0 2.0 0.0 0.0 48.7 26.6 14.6 1.9 3.2 2.5 1.3 0.6 0.6 Total 99.9% 100.0% 100.0% From the above the following conclusions seem to be warranted : First: That milk stations did have a distinct influence in diminishing the mortality among babies in the districts in which they were situated. Second: That the milk stations did not indirectly encourage artificial feed- ing — 32.4 per cent, of all babies under one year of age were entirely breast-fed throughout; 60.6 per cent, were partly breast-fed. Third: That home modification, even among the very poor and ignorant, is possible. Fourth: That the results, as shown by the mortality and by the condition of the surviving babies at the end of the period of demonstration, prove that as good results can be obtained as when already modified milk is distributed. CHAPTER VI Campaigns in Other Cities While the figures that have been given for New York prove conclusively! that there was a greater reduction in infant mortality in 1911 than in any pre- vious year ; that the weather conditions were not such as to explain this low mor-| tality, especially in the early summer; and that the diminution in Manhattan and] Brooklyn, where a very vigorous campaign was carried out, exceeded that of the I rest of the city, the question arises, Was the mortality in New York reduced morej than in other large cities? With this question to answer, a careful tabulation of mortality statistics has! been made for the nine largest cities in the country after New York. Study was] also made of the weather conditions, and, as far as data could be secured from pub- lished records and articles, and in many cases from personal letters from health! officers and lay and medical workers in those cities, a comparison was made of the] extent and efficiency of the campaign against infant mortality. It must be admitted tha', m-^st of the efforts at reducing infant mortality in I this country have been carried on spasmodically, being almost always confined entirely to the hot summer months. It is, therefore, these three hot months,; generally July, August, and September, that we shall discuss most fully, although i the figures for the entire year also give important information as showing the eflfects of the educational campaign carried on. The various cities will be dis-j cussed in the order of their population. CHICAGO The details of the mortality under one year of age in Chicago are shown ii Table 57. If we analyze these figures, we find that the total deaths in Chicago undei one year rise steadily from 1906 to 1908, and that the percentage of total deaths! at all ages occurring during the first year of life rises from 21.05 in 1906 to 22.67 inj 1908. In 1909 there was a diminution of 504 in the infant deaths for the yearj the proportion of total deaths being 20.4. In 1910 the total rose almost to the! figure of 1908, but the percentage of the total mortality remained about the same. I In 1911 the gross total reached the lowest figure since 1906, although it was onlyj 75 below 1909. A similar condition is noted in the deaths occurring during the three summer months. Again 1909 was a low year, 1911 being 60 less than 1909, and the pro-j portion of the year's deaths under one year of age occurring during these monthsl is smaller than in any of the five preceding years. The percentage of total deaths] 84 AROUSING GENERAL INTEREST IN Exhibit 17 Important Facts Brought to the Attention of THE PROBLEM OF SAVING BABIES Exhibit 17 Mayors. Health Officers, and Civic Organizations CAMPAIGNS IN OTHER CITIES 85 at all ages is in excess of 1910, but less than any of the other four years. The Assistant Registrar of Vital Statistics of Chicago states that about one-third of the births are reported, thanks to an inefficient ordinance, so that infant mor- tality rates cannot be compared. TABLE 57.— MORTALITY UNDER ONE YEAR IN CHICAGO January February March April May June July August September October November December Year Per cent, total mortality July, August, and September . . Per cent, year's infant mortality Per cent, of total deaths 1906 1907 1908 1909 1910 484 568 606 588 521 454 579 698 537 497 504 611 627 557 663 494 546 547 480 524 497 536 466 490 526 344 404 389 407 478 585 487 671 435 811 749 967 863 830 758 589 676 620 699 640 480 457 525 510 504 414 390 425 399 445 520 478 451 452 474 6114 6699 6888 6384 6841 21.05 20.81 22.67 20.40 20.58 1923 2130 2154 1964 2209 31.45 31.79 31.27 30.76 32.29 26.64 27.81 29.23 26.13 23.82 Average FrvE Years 553 553 592 518 503 404 597 833 644 495 414 475 6581 21.08 2074 31.52 27.55 1911 576 506 543 495 540 393 614 739 551 434 421 497 6309 19.31 1904 30.18 24.69 For the year 1911, then, in relation to 1910, there was a reduction of 7.7 per cent, of actual deaths and a reduction of 5.8 per cent, in the percentage of total deaths. Of deaths for July, August, and September, there was a reduction of 13.8 per cent, in actual deaths, but an increase of Z.Z per cent, in the proportion of total deaths. The proportion of the infant mortality for the year occurring during the summer months is less by 6.5 per cent. If, now, we estimate what the mortality would have been in the years follow- ing 1906 if the infant deaths had increased at the same rate as the population (2.87 per cent, yearly), and then compare the actual mortality in these years, we find the conditions which are set forth in the following table : TABLE 58.— MORTALITY WHICH SHOULD HAVE OCCURRED ON BASIS OF 1906 FIGURES, ALLOWING FOR INCREASE IN POPULATION, COMPARED WITH ACTUAL MORTALITY, IN CHICAGO 1907 1908 1909 1910 1911 Estimated mortality Actual mortality 6289 6699 +410 6464 6888 +424 6640 6384 —256 6815 6841 +26 6991 6309 Difference —682 Percentage difference +6.5% +6.5% -3.8% +0.3% —10.1% 86 INFANT MORTALITY AND MILK STATIONS The deaths in each year from 1907 on were in excess of this estimated rate by from 0.3 to 6.5 per cent., except in 1909, when they were 3.8 per cent, below the estimated figure. In 1911 there was nearly three times as great a reduction from the estimate as in 1909. The proportion of deaths occurring during the third trimester is the lowest of any of the cities considered except Manhattan and Buffalo. It may be of interest to tabulate these figures here for reference. TABLE 59.— DEATHS UNDER ONE YEAR BY TRIMESTERS, CHICAGO 1906 1907 1908 1909 1910 Average 1906-10 1911 First quarter: Actual 1442 23.6 1335 21.8 1923 31.5 1414 23.1 1758 26.2 1486 22.2 2130 31.8 1325 19.8 1931 28.0 1402 20.4 2154 31.3 1401 20.3 1682 26.3 1377 21.6 1964 30.8 1361 21.3 1681 24.6 1528 22.3 2209 32.3 1423 20.8 1698 25.8 1425 21.7 2074 31.5 1384 21.0 1625 Per cent, of year's mortality . . Second quarter: Actual Per cent, of year's mortality . . Third quarter: Actual 25.8 1428 22.6 1904 Per cent, of year's mortality . . Fourth quarter: Actual Per cent, of year's mortality . . 30.2 1352 21.4 Weather Conditions The weather conditions in Chicago during the last three years may be com- pared in the following tables : TABLE 60.— WEATHER CONDITIONS: NUMBER OF DAYS MAXIMUM AND MEAN TEMPERATURES REACHED OR EXCEEDED CERTAIN FIGURES, CHICAGO* 1909 Maximum Temperature was — Mean Temperature was — 95° or -H 90° or + 85° or + 85° or + 80° or + June 5 1 July 3 11 2 August 2 8 4 September 2 1 5 26 8 1910 June 3 7 6 July 2 6 13 9 August 10 .04 September 2 9 30 19 1911 June 3 6 9 2 5 July 5 9 15 6 10 August 4 7 4 September 1 8 19 32 8 19 * Monthly Meteorological Summary, Local Weather Bureau, Chicago, and Monthly Weather Review, Washington. CAMPAIGNS IN OTHER CITIES 87 TABLE 61.— MONTHLY MEAN TEMPERATURE, PRECIPITATION, AND NUMBER OF RAINY DAYS, CHICAGO* Average 39 Years 1909 1910 1911 June Mean 66.4° 3.56 in. 67° 5.09 in. 68° 0.91 in. 72° Rainfall 2.54 in. Rainy days 13+5 4+1 10+2 July Mean 73° 3.57 72° 1.77 76° 1.79 76° Rainfall 2.65 Rainy days 8+6 8+5 11+2 August Mean 71° 3.10 75° 6.20 73° 3.08 72° Rainfall 3.72 Rainy days 10+3 6+5 12+2 September Mean 65° 64° 65° 67° Rainfall 3.07 3.60 3.90 4.03 Rainy days 8 + 1 9+4 16+4 Total Mean 68.6° 13.30 69.5° 16.66 70.5° 9.68 71.7° Rainfall 12.94 Rainy days 39+15 27 + 15 49 + 10 Note. — ^Two figures are given for number of rainy days — the first, in front of the plus sign, I is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is ! number of days there was a trace of precipitation, but less than 0.01 inch. If we study these tables, we find that the maximum temperature for the four months, taken as a whole, reached 85°, 90°, and 95° on more days than in either 1909 and 1910. The thermometer never reached 95° in 1909, and on only five days did it reach 90°. In 1910 it registered 95° or + on only two days, and 90° on only nine days, as against eight and nineteen days respectively in 1911. Similarly, the mean temperature never reached 85° in either 1909 or 1910, while it did so on eight days in 1911. Only the month of August fell below 1909 and 1910 as to mean temperature for the whole month. The average for four months was decidedly higher than either year, and 3° higher than the average for thirty-nine years. In each month, however, the total rainfall was higher than in 1910, though it was above the thirty-nine-year average only in August and September. In July and Sep- tember it exceeded the figures for 1909. For the four months the rainfall was well above that of 1910 and well below that of 1909. In the number of rainy days 1911 is largely In excess of either year. The month of July Is particularly interesting. The mean temperature for the month was 4° higher in 1911 than in 1909, and the deaths were 170 more than in 1909. There was the same mean for 1910 and 1911, and the deaths in 1911 were 197 less than in 1910. Also the deaths in 1910 were 376 more (86 per cent.) than in 1909, as against 170 more (39 per cent.) in 1911. In 1910 and 1911 August was 2° and 3° below 1909, and the deaths were 72 * Monthly Meteorological Summary, Local Weather Bureau, Weather Review, Washington. Chicago, and Monthly 88 INFANT MORTALITY AND MILK STATIONS and 91 respectively below those of 1909. In September, on the other hand, 1910 was 1° and 1911 was 3° above 1909, and yet the deaths were respectively 59 and 148 below those of 1909. In July the rainfall was practically the same for 1909 and 1910, and 0.86 inch more in 1911. August showed less rainfall by 3.12 and 2.48 inches in 1910 and 1911 than in 1909, in both of the latter years the deaths being less. In September the rainfall was nearly the same, +0.30 inch in 1910 and +0.43 inch in 1911. The Campaign For a number of years Chicago had been getting ready for an organized effort for combating infant mortality. The United Charities, then consisting of two separate organizations, attempted to get mothers and babies out of the city, to care for the sick babies, and to educate the mothers in the city itself by means of public tents, in charge of a trained nurse and visited by a physician. The Chil- dren's Hospital Society established a Milk Commission to provide a modified and pasteurized milk for babies at a reasonable price. Milk was dispensed already modified to set formulae. In 1908 the Health Department first entered the field, putting 100 physicians at work visiting from house to house, instructing the mothers, during July and August. The work was not organized, and very little came of it; but a more comprehensive plan was worked out during the ensuing winter. In 1909 the United Charities, the Health Department, and the Visiting Nurses' Association cooperated. The Health Department mapped out the areas of the highest death-rate, furnished 20 nurses and 14 doctors, and spent $10,000 on the campaign. The United Charities furnished nurses, tents, and workers. The Visiting Nurses' Association supervised the tents, furnished nurses in the tents, and worked in the field. The general plan was a house-to-house canvass by nurses in the most crowded and unsanitary districts. Wherever a small child was found, instruction in feeding and care was given. At first the Health Department confined its activi- ties to locating and referring cases, the actual care of the sick babies being turned over to the Visiting Nurses' Association, the settlements, and the United Chari- ties. During July so much work had to be done that the Health Department had to take up part of the work of caring for the sick. Careful records were kept of all the cases, and information was acquired which was tabulated during the follow- ing months for use in the campaign of the next year. It will be noted that 1909 was the first year with a lowered mortality since 1906. The percentage of the total mortality was also low. Armed with the information obtained in 1909, the work was more active in 1910 and better organized. The activities of the Health Department were con- fined to one entire ward and parts of three others, as far as house-to-house visiting was concerned; and in 13 other wards they visited the homes of every baby that could be discovered from the records of the United Charities or the County Clerk's register of births. Ten public tents were located in centers having the highest (lARBAGE AND WaSTE FORTY-EIGHT HoURS IN THE STREET; OnE OF THE HANDICAPS OF A Summer Baby-saving Campaign CAMPAIGNS IN OTHER CITIES 89 death-rates. These were maintained by the United Charities. Dr. CaroHne Hedger spent her whole time in the work. An Infant Welfare Society was formed, consisting of representatives of all the various charities in Chicago. During the summer the mothers of 23,984 babies were instructed. Ice tickets were distributed, and relief was provided through the United Charities, Jewish Aid, etc. The nurses were on the lookout for violations of the Sanitary Code, and 500 complaints were made. The Civic Federation placarded the city fences and walls with a telling poster, "Don't Kill your Baby!" — with information how not to, and this was most effective. The well-known Bulletins of the Health Department featured the campaign, and its "Health Grams "and striking cartoons went far and wide. In 1911 there was much greater cooperation among the nurses of the De- partment and other organizations. The work of the Health Department be- came more definite, and in every way the campaign was more efhcient. The Infant Welfare Society maintained 10 milk stations, open all the year, each in charge of a nurse. Volunteer physicians carried on the consultations, of which 806 were held. Two thousand one hundred and twenty-nine babies attended these conferences. Home modification was taught "when possible"; when impossible, modified milk was dispensed. Six hundred and twenty mothers were taught. Certified milk only was used.* It will be noted that there was an increase in mortality in 1910 over 1909 nearly up to the figures of 1908, although this is only 0.3 per cent, greater than the mortality estimated on the 1906 figures. The work of the nurses, while more efficient, was not nearly so wide-spread as in 1909. In 1911, due to increased ex- perience and better cooperation, a great diminution was again obtained, especially marked during the summer months, in spite of unfavorable weather conditions. Dr. Hedger, who has had charge of the work in large part during the last three years, says: "The campaign should be a year-long affair; a few weeks of instruc- tion in the summer is not sufificient. It must be line upon line and precept upon pre- cept, year in and year out."t Chicago realizes the importance of continuous instruction to obtain permanent results, and not an ineffectual, short campaign. Since 1910 Chicago has been attempting to enforce the laws pertaining to a safe milk supply. Seventy-five per cent, of the city's milk is pasteurized. All the rest must be from tuberculin-tested herds. As thorough an inspection of pasteurization plants is carried out as available funds will permit. There is also inspection of dealers and depots, platform inspection, and a certain amount of country farm, creamery, and bottling plant inspection. It is interesting to note that, excepting that provided to restaurants, 95 per cent, of the city's milk is bottled. * The above facts are obtained from the report of the Department of Health of the City of Chicago for the years 1907-1910. and from personal letters. In 1912 we are informed that prac- tically all modification is done at the home. Through cooperation with certain milk dealers certified milk is delivered direct to the homes at 10 cents a quart. t Report of the Campaign Against Summer Diarrhea, Chicago, 1909, etc. 90 INFANT MORTALITY AND MILK STATIONS PHILADELPHIA We have been unable to obtain reports or records of infant mortality inij Philadelphia by months prior to 1909. The following table gives the figures as far as obtainable:* TABLE 62— MORTALITY UNDER ONE YEAR, PHILADELPHIA 1906 1907 1908 1909 1910 1911 January' 387 438 433 330 289 396 659 490 496 364 238 350 398 404 497 349 313 540 799 552 426 315 284 355 286 February' ■ ' 289 March 427 April 332 May 344 June 401 Tulv 587 August . September 556 394 October 313 November December 330 357 Total Per cent, total mortality 5781 31.1 5508 30.0 5291 30.1 4870 19.4 5232 19.3 4616 17.6 July, August, and September Per cent, year's infant mortality . . . Per cent, total mortality 1645 33.7 38.4 1777 33.9 37.9 1537 33.3 35.0 Births 34,771 166.3 35,142 136.7 36,641 144.1 37,540 139.7 38,676 135.3 41,000t Intant Mortality 113.5t In 1911, therefore, Philadelphia had less deaths by 254 than in 1909, the low record of the five-year period 1906-1910; 1165 less than in 1906, the high year; and 616 less than in 1910. The proportion of the total mortality for the year is 17.6 per cent., a fall of 1.8 from 1909; 3.5 from 1906; and 1.7 from 1910. The summer infant mortality was practically the same proportion of the year's infant mortality as in 1909 and 1910; but of the total deaths it was 3.4 per cent, and 2.9 per cent, lower. The infant mortality rate also shows a marked fall, although it is only estimated. There is a reduction of 22.8 and 17.2 per thousand from 1909 and 1910 respectively. In tabular form this appears as follows: TABLE 63.— DIFFERENCE BETWEEN MORTALITY UNDER ONE YEAR IN 1911 AND OTHER YEARS Year's mortality Per cent, total mortality July, August, and September Per cent, total year Per cent, total mortality Percentage Difference 1909 - 5.2 - 9.3 - 6.5 - 1.4 -11.9 1910 —11.7 — 8.8 —13.5 — 2.0 —10.3 • From figures supplied by Dr. S. W. Newmeyer, Philadelphia. t Estimated. CAIMPAIGXS IX OTHER CITIES 91 In 1903 there were 4597 deaths under one year of age in Philadelphia, which was 17.7 per cent, of the total mortality. This is the low record year of the decade in both respects. The following table shows the deaths which would have oc- curred had they increased in proportion to the population increase, and the actual and percentage differences from these figures: TABLE 64.— MORTALITY UNDER ONE YEAR, WHICH SHOULD HAVE OCCURRED IN DIFFERENT YEARS, BASED ON 1903 FIGURES, COMPARED WITH ACTUAL MORTALITY, PHILADELPHIA 1906 1907 1908 1909 1910 1911 Estimated deaths 4868 5781 + 913 +18.7 4959 5508 + 549 +11.0 5049 5291 +242 + 4.7 5140 4870 —270 — 5.3 5230 5232 + 2 + 0.0 5321 Actual deaths 4616 Difference Percentage difference — 705 —13.3 There is, therefore, a very great reduction in 1911 from every point of view. Weather Coxditioxs The weather conditions during the last three years are set forth in the follow- ing tables : TABLE 65.— NUMBER OF DAYS ON WHICH M.AXIMUM AND MEAN TEMPERA- TURES REACHED CERTAIN FIGURES, PHILADELPHIA* MAXniuii Temperature Me.'vx Temperature 95° or + 90° or + 8s° or + 85° or + 80° or + 1909 June July 1 1 2 8 5 3 16 10 17 13 40 1 1 1 3 8 8 August September . . . 3 19 1910 June 1 1 5 10 1 15 8 19 5 3 35 1 1 2 5 July August September . . . 17 2 24 1911 June 5 5 2 10 3 IS 9 19 13 2 43 6 6 3 July 12 August September . . . 5 20 * Monthly Meteorological Summary, Philadelphia; and Monthly Weather Review, Wash- ington, D. C. 92 INFANT MORTALITY AND MILK STATIONS TABLE 66.— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF; RAINY DAYS, PHILADELPHIA* Normal 1909 1910 1911 JVNE Mean temperature Rainfall 71.2° 3.30 in. 75.8° 4.33 in. 73.8° 4.61 in. 67.4° 3.38 in. 72.05° 15.62 in. 72.4° 2.26 in. 13 75.3° 2.19 in. 4+4 73.0° 1.95 in. 4+2 67.2° 3.55 in. 8 71.9° 9.95 in. 29+6 69.6° 5.40 in. 14 78.2° 1.84 in. 5 73.2° 5.70 in. 11 70.0° 3.05 in. 5 72.75° 15.99 in. 35 71.6° 5.10 in. Rainy days July Mean temperature Rainfall 14+3 78.5° 4.19 in. Rainy day^ August Mean temperature Rainfall 9+2 74.5° 12.10 in. Rainy days September Mean temperature Rainfall Rainy days Totals Mean temperature Rainfall Rainy days 14+3 68.6° 2.52 in. 7+6 73.3° 23.91 in. 44 + 14 Note. — Two figures are given above for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is number of days there was '■ Lisce of precipitation, but less than 0.01 inch. Except for extremely hot weather, that is, the number of days when very high temperatures were reached, there was very Httle difference in the temperature records for the three years. The mean temperatures for the month show 1911 above the normal in all four months, especially in July; 1910 was lower than 1911 in each month except September, although there was only 0.3° difference in July. July and September were above the normal; 1909 was below the normal in all months except June, although very slightly. In 1909 the heat was more uniformly distributed throughout the summer. In 1911 rainfall for the month and the number of rainy days were consider- ably in excess of 1910, especially in July and August. June and September, 1910, had a little more rain. During June, July, and August temperature conditions may be said to have been distinctly less favorable to a low infant mortality than in 1909 and 1910- In respect to rainfall and its distribution during the same period, conditions were more favorable. The Campaign Before 1909 there was very little effort made toward the reduction of infant mortality outside the ordinary work of the various charitable organizations. The Modified Milk Society was about the only special agency at work. It pro- * Monthly Meteorological Summary, Philadelphia; and Monthly Weather Review, Washing- ton, D. C. Any Place Will Do for a Milk Station I I CAMPAIGNS IN OTHER CITIES 93 ided milk modified at a central laboratory and distributed to infants from several (oints in the most congested sections of the city. In 1909 Dr. Neff, Director of the Department of Public Health and Charities, )rought about a revision of the milk ordinances after considerable publicity had »een given to the statement that 12 per cent, of the milk furnished the city was rom cattle infected with tuberculosis. A conference was held early in the summer, at which plans were considered or reducing infant mortality. As a result, the Modified Milk Society, various ettlements, and a number of women's clubs conducted work along independent ines. The Health Department placed its medical inspectors in the most con- jested parts of the city to canvass for sick babies and to instruct mothers in their are. Milk dealers were provided with bags upon which were printed simple lirections as to the care of milk and feeding of the baby. Bottled milk was sold n these bags. In 1910 a conference was called by the Mayor. This was attended by rep- ■esentatives of some 200 agencies, the object being to bring about a better work- ng relation between the various organizations engaged in summer work for nothers and children. As a result of this conference a Bureau of Registration md Information was established at the City Hall. A directory was published md distributed, giving the names of agencies and the kind of service each was prepared to render. The Modified Milk Society established 10 distributing stations and later jpened 8 more. The City Council appropriated funds to maintain a corps of 8 lurses, and, by utilizing the medical inspectors and district physicians, a tem- Dorary Division of Child Hygiene was established, with Dr. S. W. Newmayer in :harge. This division began intensive work in June in four of the most congested wards. Other organizations assisted by furnishing nurses who reported daily to the Health Department and worked with their nurses. Two nurses each were provided by the Bureau of Municipal Research, the Visiting Nurses' Society, Starr Centre, and the Light House, and one each by the Phipps Institute and the Baby Alliance. Previous to the closing of the schools in the four wards selected, demonstra- tions were given to girls in the grammar grades on the care of babies. This work was done by the medical inspectors and school nurses through the cooperation of the school authorities. A house-to-house canvass was carried on in the district by the Health Department nurses to instruct mothers in their homes. At the central office a careful system of record keeping for each case was in- stalled. Day and night telephone service was established for receiving requests for aid in emergency cases. The Police and Fire Departments cooperated by instructing all police stations and fire houses to forward, by telephone, any re- quest for medical or nursing aid. A large number of bulletins, posters, and cir- culars were distributed, chiefly through the police department. The Visiting Nurses' Society assumed supervision and care of sick babies. Piers were utilized for receiving and caring for babies and mothers. Special 94 INFANT MORTALITY AND MILK STATIONS hospital facilities were made available, the hospital at Redbank, N. J., cooperat- ing by receiving babies. Free ice was distributed, midwives were checked up, and several baby farms j were closed. The Philadelphia Association of Retail Druggists passed resolutions indors- ing the stand taken by the Health Department in regard to soothing syrup and comforters, and discouraging their sale by its members. There was a reduction of 40 per cent, in the deaths under two years in the four wards where the work was concentrated. In the city itself, during the three summer months, there was an increase of 132 deaths over those in 1909, though the proportion of the total deaths which occurred under one year fell 0.5 per cent. In 1911 a still more vigorous campaign was waged. A "Milk Show" was held May 20th-27th, which was attended by 110,681 people. Considerable in- terest in the problem was aroused. The City Council voted $5,000 for the summer work, and the nursing stafif was increased. The work was carried on in four wards. Sick babies were cared for at the recreation piers by night as well as by day. The Mayor appointed a strong commission to investigate and report upon the whole subject of the milk supply. The refrigeration of milk in transit was required for the first time. The experience of previous years bore fruit in a better organized campaign and a great reduction in the summer mortality, both from 1910 and 1909 figures. In the four wards where the nurses were working there was a reduction of 11.3 per cent, in all deaths under one year from the 1910 figures, and of 34.6 per cent, in diarrheal deaths under two years. CAMPAIGNS IN OTHER CITIES 95 ST. LOUIS Table 67 shows the infant mortality statistics for St. Louis for the five-year jeriod 1906-1910, the average for the five years, and the figures for 1911. TABLE 67.— MORTALITY UNDER ONE YEAR, ST. LOUIS 1906 1907 1908 1909 1910 Average Five Years 1911 ' anuary ■"ebruary vlarch ^pril \jla.y 143 112 122 132 100 U1 264 204 195 132 125 138 127 121 144 121 76 122 315 181 160 107 112 129 146 102 117 120 116 189 229 204 115 125 148 123 136 151 128 116 121 151 229 196 137 127 128 103 129 139 146 93 115 177 216 201 149 133 105 104 136 135 131 116 105 157 350 197 151 134 133 119 166 107 102 92 96 une ulv 160 228 \.ugust September 170 141 Dctober *Jovember 111 109 December 97 ^EAR 1814 17.91 1715 16.50 1734 17.73 1723 16.04 1707 15.67 1738 16.74 1579 Percentage total mortality 14.55 f une— September 810 36.5 34.3 778 38.3 23.4 737 31.6 33.8 713 33.6 30.8 113.3 743 33.3 31.4 112.1 756 34.5 22.7 699 Percentage deaths all ages 34.1 30.5 101.6 It will be seen that during the four years 1907-1910 there was very slight v^ariation in the total year's mortality under one year of age. The year 1906 was a high one, the low year being 1910. In comparing the proportion of total deaths which occurred under one year of age there is no very great difference between the first and third years of the five-year period. In 1909 and 1910, however, there is a distinct fall. The year 1911 gives the lowest gross total for the year, as well as the lowest percentage of all deaths. In comparing the summer mor- tality it will be noticed that the four months, June, July, August, and September, are given instead of July, August, and September. St. Louis mortality begins to increase earlier than the more northern cities, and in many years June is much higher than September. If we compare these figures, we will see that there has been a slight general decrease since 1906, and that this decrease was greater in 1911 than in any other year. * From figures provided by Mrs. Minnie D. Weiss. 96 INFANT MORTALITY AND MILK STATIONS The following table shows what the deaths would have been had they in- creased from 1907, the low year up to 1910, at the same rate as the population,! 1.94 per cent, per year. TABLE 68.— MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OCCURRED, B\SED ON 1907 FIGURES, COMPARED WITH ACTUAL MORTALITY, ST. LOUIS Estimated mortality . Actual mortality .... Difference Percentage difference . 1908 1748 1734 — 14 —0.8 1909 1781 1723 — 58 —3.2 1910 1814 1707 —107 — 5.8 1911 1848 1579 — 269 —14.5 Yearly rate of increase in population, 1.94 per cent. Allowing for the increase in population, then, there has been a steadily de- creasing mortality rate, and the percentage difference from the estimate has been greater each year up to and including 1911. Weather Conditions Comparing the weather conditions which existed in St. Louis during these years we find the facts set forth in the following tables : TABLE 69.— NUMBER OF DAYS MAXIMUM AND MEAN TEMPERATURE REACHED OR EXCEEDED CERTAIN FIGURES, ST. LOUIS* 1909 June July August. . . September 1910 June July August. . . September 1911 June July August . . . September Maximum Temperature 95° or + 6 2 1 17 90° or + 5 6 18 2 31 7 5 5 17 13 13 8 5 39 85° or + 14 15 27 64 14 15 13 6 48 22 21 15 15 73 Mean Temperature 85° or + 5 7 3 15 80° or 6 9 23 1 39 11 6 1 26 15 15 11 4 45 • From Monthly Meteorological Summary, Local Weather Bureau, St. Louis, and Monthly Weather Review, Washington, D. C. After a Coxslltatiox — Future Mothers are Being Taught CAMPAIGNS IN OTHER CITIES TABLE 70.— MONTHLY MEAN TEMPERATURE, PRECIPITATION, OF RAINY DAYS, ST. LOUIS* 97 AND NUMBER Average, Thirty- eight Years 1909 1910 1911 Tune Mean 75° 4.49 in. 79° 3.63 in. 78° 2.48 in. 70° 2.89 in. 75.5° 13.49 in. 75° 2.63 in. 10+5 77° 7.34 in. 13+4 81° 0.66 in. 4+3 68° 4.22 in. 00 + 75.2° 14.85 in. 00 + 72° 4.24 in. 11+0 77° 4.21 in. 14+0 75° 1.90 in. 7+3 70° 6.09 in. 10 + 2 73.5° 16.44 in. 42+5 79° Rain Rainy days Tidy Mean 1.34 in. 8 + 1 79° Rain 0.64 in. Rainy days iugust Mean 5+5 76° Rain 3.51 in. Rainy days September Mean 11 + 1 74° Rain 7.09 in. Rainy days Total j Average mean . . Rain 14+5 77° 12.58 in. Rainy days 38 + 12 Nntf.. — Two fi?i] res are e-iven for nu mber of rainv da\ ^s — the first, in fro nt of the dIus sien. 3 the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is the number of days there was a trace of precipitation, but less than 0.01 inch. i It will be seen that June, 1911, averaged for the month higher than either of che other years or than the thirty-eight-year average. The same is true for July. August, on the contrary, is 5° below 1909 and 2° below the mean, but August lad some very hot weather, the thermometer registering 95° on two days and the nean for the day being 85° -f 'on three days. September was hot, the mean Deing well above either year and the thirty-eight-year average. The rainfall ilso in 1911 was very scant through June and July, but above the average for \ugust and September, especially in the latter month. Extremely high tempera- ;ures were reached during the four summer months of 1911, remained high for onger periods, and the hot weather was continued throughout the summer more evenly than in any of the other years considered. In spite of very much worse conditions in June and July, the mortality in fune was 17 below 1910 and 9 above 1909. In July it was 1 below 1909 and 12 above 1910. * Monthly Meteorological Summary, Local Weather Bureau, St. Louis, and Monthly Weather leview, Washington, D. C. 98 INFANT MORTALITY AND MILK STATIONS The Campaign In 1904 the St. Louis Pure Milk Commission was incorporated for the pur- pose of distributing modified milk to poor babies. After two years of work Dr. A. S. Bleyer started consultations at one of the stations of the Commission. This work was founded with the idea of instructing mothers in the care of their babies, and modified milk was dispensed. In the spring of 1911 the "Save the Babies" League was formed, to cooperate with existing agencies for the prevention of sickness and death among the babies of St. Louis. In the previous summer the Pure Milk Commission had carried on some nursing work, but was financially unable to continue it. In 1911 the Visiting Nurses' Association had one nurse in the field. The object of this League was the maintenance of conferences where mothers were advised and instructed by the doctors in charge in the care and feeding of their babies; follow-up work in the homes by the nurses, especially in the case of sick babies ; and cooperation with the St. Louis Pure Milk Commission in furnishing safe modified milk for babies. On June 1st one nurse started in on her work, the number being rapidly in- creased to 9. Thirteen stations were in operation, 6 of them being opened for five months, — from May 1st to October 1st, — and 729 babies being enrolled. There were 17 doctors, 9 nurses, and 6 assistant workers engaged in the work. Particular stress was laid upon the home work, and during the latter part of the season a considerable number of the mothers were taught home modification of milk. This was the first year that any extensive campaign was carried out. Cooperation between various organizations was extremely good, and plans are in hand for a more extensive campaign in 1912. The Health Department did very little special work in connection with the campaign. Milk inspection in St. Louis is still far from thorough, owing to lack of available funds. CAMPAIGNS IN OTHER CITIES 99 BOSTON The following table gives the facts in regard to infant mortality in Boston for the years 1906-1911: TABLE 71.— MORTALITY UNDER ONE YEAR, BOSTON 1906 1907 1908 1909 1910 Average Five Years 1911 187 168 186 201 197 152 240 357 271 186 165 158 177 138 96 156 185 151 172 356 282 229 147 187 197 198 208 198 182 150 305 405 300 222 186 191 175 157 192 161 146 117 188 313 240 159 124 153 163 183 189 163 140 168 225 254 270 225 148 121 179.8 168.8 174.2 175.8 170.0 147.6 226.0 337.0 272.6 204.2 154.0 162.0 163 February 175 March 196 April 191 May 180 June 129 Tulv 280 August 260 September 224 October 172 November 138 December 137 Year 2468 21.62 2276 19.47 2742 23.28 2125 19.20 2249 19.45 2372.0 20.62 2245 Percentage of total deaths 19.08 July, August, September 868 35.17 30.62 810 35.58 29.88 1010 36.83 34.04 741 34.87 29.25 749 33.30 27.18 835.6 35.22 30.27 764 Percentage of year' s infant mortality Percentage of all deaths 33.58 25.10 Births 17,284 142.8 18,436 123.4 18,521 *il48.0 17,728 119.8 17,741 126.7 17,942 132.2 1258 126.0 It will be noted that, excepting 1908, a very high year, there has been little striking change in the gross figures. In percentages of total mortality 1907, 1909, 1910, and 1911 remain practically the same, differing only in a small fraction of 1 per cent. In the totals for summer mortality the last three years have been very nearly the same, being slightly higher each year. The infant mortality rate shows an increase in 1910 and 1911 over both 1907 and 1909. The rate for 1911, as fur- nished by the Registrar of Vital Statistics for Boston, Dr. Davis, is given at 126, practically the same as in 1910. If we estimate the deaths which would have occurred if they had increased in the same proportion as the population, 1.96 [per cent., yearly, taking 1909, the low year for the five-year period, as a basis, and then compare these figures with actual deaths, we find the following: TABLE 72.— MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OCCURRED ON BASIS OF 1909 FIGURES, COMPARED WITH ACTUAL MORTALITY, BOSTON 1910 1911 Estimated mortality 2166 2208 Actual mortality 2249 2245 Difference +83 +37 Percentage difference +3.8 +1»7 100 INFANT MORTALITY AND MILK STATIONS Estimating for the three summer months, taking 34.87 per cent, as the pro- portion of deaths occurring during these months in 1909, we have the figures shown in the following table: TABLE 73.— MORTALITY UNDER ONE YEAR IN THREE SUMMER MONTHS WHICH SHOULD HAVE OCCURRED ON BASIS OF 1909 FIGURES, COMPARED WITH ACTUAL MORTALITY, BOSTON 1910 1911 Estimated mortality 755 769 Actual mortality 749 764 Difference 6 5 Percentage difference — 0.79 — 0.65 Boston, therefore, shows almost no improvement in infant mortality for the year compared with three of the five preceding years. The summer mortality has not been reduced in the last three years. The percentage of the year's in- fant deaths occurring during the three summer months is still fairly high, as is the proportion of all deaths during this period. Taking the high figure, 2742, in 1908, and estimating the deaths which should have occurred on the basis of a yearly increase of 1.96 per cent., there is only a decrease of 22.7 per cent., while New York shows for the year 1911 a decrease of 20.4 per cent, from the lowest, allowing for increase in population. Weather Conditions The weather conditions in Boston during the last three years are shown in the following tables: TABLE 74.— NUMBER OF DAYS ON WHICH MAXIMUM AND MEAN TEMPERA- TURES REACHED CERTAIN FIGURES, BOSTON* Maximxjm M EAN 95° or + 90° or + 85° or + 85° or + 80° or + 4 9 6 1 4 8 4 3 6 4 1 11 23 14 1 6 2 6 16 5 4 7 26 7 2 8 9 14 7 10 3 6 1 1 8 12 23 7 11 1909 June July August. . . . September Total 1910 June July August. . . September Total 1911 June July August . . . September Total * Monthly Meteorological Summary, Local Weather Bureau, Boston, and Monthly Weather Review, Washington, D. C. fiii i^ ^^^:^i nip -iVi J n 1 ■ill! lir ^.^ ca ^; ^ ^ >< o W ^; Q Z w H H < 1 t/1 H 7 Z W i Q U) H cy^ o o ^ UO 3 rn O H CAMPAIGNS IN OTHER CITIES lOI TABLE 75.— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF RAINY DAYS, BOSTON* Normal 1909 1910 1911 June Mean temperature Rainfall Rainy days July Mean temperature Rainfall Rainy days August Mean temperature Rainfall 66° 3.08 in. 72° 3.18 in. 70° 3.84 in, 63° 3.33 in. 69° 4.45 in. 8 72° 0.97 in. 5 + 7 69° 3.55 in. 8+3 63° 5.15 in. 12 + 1 65° 4.89 in. 12+2 75° 1.15 in. 6 + 1 69° 0.98 in. 7+2 63° 2.14 in. 11 + 1 66° 3.67 in. 8+7 77° 4.65 in. 4+3 69° 4.18 In. Rainy days September Mean temperature Rainfall 9+4 63° 2.95 in. Rainy days 10+1 Totals Mean temperature Rainfall 68.7° 13.33 in. 68.2° 14.12 in. 32 + 11 68.0° 9.16 in. 36+6 68.7° 15.45 in. Rainy days 31 + 15 Note. — Two figures are given for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is num- ber of days there was a trace of precipitation, but less than G.Ol inch. Except for the month of July, the conditions are very similar. In this month the temperature reached 95° or over on eight days in 1911, and the mean temperature was 85° or over on seven days. The high figures are all crowded into the first two weeks of July; August was cool. In summing up the monthly figures compared with the normal, June was exactly the same. July was 5" over; August was below; September was the same. The rainfall the first three months is in excess of the normal; September, somewhat below. Compared with 1910, June was 1° hotter; July, 2° hotter; August and Sep- tember were the same. In 1909 June was 3° hotter; July, 5° cooler; August and September, the same. The rainfall in 1911 was less in June, much more in July and August, and less than 1909 in September, but more than in 1910. It was less evenly distri- buted throughout the summer than either year. The Campaign In Boston practically the only organization doing purely baby work, and laying particular stress on prevention, is the Boston Milk and Baby Hygiene Association. In 1905 a group of public-spirited citizens organized a "poor people's" modified milk service. They distributed milk already modified to * Monthly Meteorological Summary, Local Weather Bureau, Boston, and Monthly Weather Review, Washington, D. C. 102 INFANT MORTALITY AND MILK STATIONS various settlements, day nurseries, etc. In 1907 a committee on modified milk stations was organized to take charge of the work. After a year this committee came to the conclusion that its poHcy was unintentionally encouraging weaning, and a new method was adopted. In 1909 they opened 10 milk stations, under the control of the Committee on Milk and Baby Hygiene. A director was appointed, and consultations were inaugurated, under volunteer physicians, a medical director, and trained nurses. In 1910 the association was incorporated, and has been carrying on the work since. Twenty volunteer physicians have charge of the 10 stations; consulta- j tions are held from once to three times a week ; modified milk is dispensed ; earnest 1 efforts are made to encourage breast-feeding ; mothers receive home instruction ; all sick babies are referred to physicians or dispensaries ; sick babies are referred also to the Instructive Visiting Nurses' Association, whose nurses care for the babies while sick. In 1911, 9 stations were maintained; 10 nurses were in the field; 13 volunteer physicians had charge of consultations. Home modification was taught "where possible." In 1909 and 1910 the Women's Municipal League carried on a demonstration of prenatal and postnatal instruction to mothers. They have since discontinued their postnatal work, which was planned as a demonstration. The work in Boston in 1911 showed no increase except in efficiency, perhaps, over that done in the three previous years. The work of the Milk and Baby Hygiene Association has been excellent, but it cannot reach more than a small proportion of those who need its aid. The Health Department had two nurses in the field doing prophylactic work, including prenatal instruction. CAMPAIGNS IN OTHER CITIES 103 CLEVELAND In considering the mortality returns for Cleveland, it must be remembered that, with the exception of Detroit and the three boroughs of Bronx, Queens, and Richmond in New York, the percentage increase in population during the past decade has been greater than in any of the other cities considered. The following table shows the details of the infant mortality for the years 1906 to 1911 inclusive: TABLE 76.— MORTALITY UNDER ONE YEAR, CLEVELAND 1906 1907 1908 1909 1910 Aver- age 1906-10 1911 January February March April May June July August September October November December Year Percentage of all deaths July, August, and September Percentage of year's infant mortality Percentage of all deaths Births Infant mortality rate 108 145 180 194 123 215 272 176 145 122 121 124 166 162 170 150 137 124 164 304 188 175 113 135 153 144 171 135 119 104 240 209 142 142 128 114 133 148 170 142 117 99 204 213 137 126 108 114 134 141 194 132 147 157 322 278 174 128 127 123 139 148 177 150 128 140 140 136 157 138 119 123 163 147 147 148 140 137 225 199 145 124 92 121 1925 26.1 1988 25.9 1801 25.7 1711 24.5 2057 25.6 1896 25.5 1788 23.4 593 30.8 30.2 656 33.0 30.1 591 32.8 33.2 554 32.4 30.3 774 37.6 35.3 634 33.4 32.7 569 32.0 38.5 11,201 171.9 10,700 185.8 12,010 150.0 13,100 130.6 13,456 152.9 12,093 156.8 12,589 142.0 During the years 1906-09 inclusive there was a steady diminution in the total number of deaths under one year and in the proportion of all deaths. The year 1910 showed a sharp rise both in the year's total and during the summer months, the proportion of the mortality occurring during the summer months being the highest in any of the years considered. On the other hand, 1911 had a lower total mortality than any year except 1909, The same is true of the summer mortality, and the percentage of all deaths both for the year and for the summer months ; the proportion of the year's deaths occurring during the three summer months is also lower than any year except 1906. The greatest reduction, therefore, occurred during the summer months, but there is a marked fall for the entire year. In the following table is shown the compari'^on of 19irs figures with those of other years: 104 INFANT MORTALITY AND MILK STATIONS TABLE 77— DIFFERENCE BETWEEN MORTALITY UNDER ONE YEAR IN 1911 | AND OTHER YEARS, CLEVELAND Year Percentage all deaths July, August, and September . . Percentage of year's infant mortality Percentage all deaths 1906 1907 1908 1909 —137 —210 —13 +77 —3.7 —3.5 —3.3 —2.1 —24 —87 —22 + 15 + 1.2 —1.0 —0.8 —0.4 —1.7 —1.6 —4.7 —1.8 1910 If, now, we compare the results in 1911 with those in 1909, allowing for the ' increase in population, we find results shown in the following table: TABLE 78.— MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OCCURRED, BASED ON 1909 FIGURES, COMPARED WITH ACTUAL MORTALITY, CLEVE- LAND Estimated mortality Actual mortality. . . Difference, actual . . - Per cent, difference . Yearly rate of increase in population, 4.69 per cent. The year 1910 showed 266, or 14.8 per cent., above 1909's figures, allowing for the increase in population; whereas 1911 was 83, or 4.4 per cent., less. There was, therefore, a distinct improvement in the infant mortality condi- tions in Cleveland, although if the registration of births is anywhere near com- plete, the death-rate is still very high, and there is not the same degree of im- provement noted as in a number of other cities. Weather Conditions The weather conditions in Cleveland are shown in Tables 79 and 80. In 1909 in no month was the temperature above the normal. On only one day did it reach 90°, and the mean daily temperature reached 80° only on one day. In 1910 the temperature for the month was 1° higher than the normal in September. The mean for the four months was 0.5° below the normal; and again there was only one day when 90° or over was recorded. The mean was 80° or + on four days. In 1911 all four months were above the normal, and the mean for four months was 1.3° above. Individual days of high temperature also were more numerous; 95° or over was reached once, 90° or over seven times. Twice the mean daily temperature was 85° or over and 9 times 80° or over. The high temperatures were scattered through the summer, except in July, when on four consecutive days 90° or over was reached (July 2d to 5th). The rest of July was cool. CAMPAIGNS IN OTHER CITIES 105 TABLE 79.— NUMBER OF DAYS ON WHICH THE MAXIMUM AND MEAN TEM- PERATURE REACHED CERTAIN FIGURES, CLEVELAND* 1909 June July August. . . September Total 1910 June July August. . . September Total 1911 June July August . . . September Total 95° or + Maxiitum 90° or + 85° or + 20 11 7 8 1 16 6 7 2 6 1 Mean 85° or + 80° or + TABLE 80.— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF RAINY DAYS, CLEVELAND* Normal 1909 1910 1911 June Mean temperature Rainfall 67° 3.51 in. 73° 3.56 in. 70° 3.87 in. 64.1° 3.33 in. 67° 3.72 in. 13 70° 3.12 in. 9+5 70° 2.31 in, 10+3 62° 3.40 in. 10+3 64° 2.01 in. 9+3 72° 0.94 in. 9+3 70° 1.08 in. 6+0 65° 4.09 in. 11+2 69° 2.88 in. Rainy days July Mean temperature Rainfall Rainy days August Mean temperature Rainfall 10+5 73° 1.71 in. 7+5 71° 5.18 in. Rainy days September Mean temperature Rainfall Rainy days 11+5 65° 4.67 in. 11+3 Totals Mean temperature Rainfall 68.3° 13.30 in. 67.2° 12.55 in. 42 + 11 67.7° 8.12 in. 35+8 69.5° 14.44 in. Rainy days 39 + 18 Note. — Two figures are given for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or ^more; the second, after the plus sign, is the number of days there was a trace of precipitation, but less than 0.01 inch. * Monthly Meteorological Summary, Local Weather Bureau, Cleveland, and Monthly Weather Review, Washington, D. C. io6 INFANT MORTALITY AND MILK STATIONS The weather conditions were less favorable for a low infant mortality in 1911 than in 1909 or 1910, except in regard to rainfall, the most marked advantage in this respect in 1911 being in August. The Campaign In 1899 a Milk Fund Association was formed, which distributed clean milk in bulk to any one who desired to buy it. In 1906 the Infants' Clinic was established by the Milk Fund Association and the Visiting Nurse Association, to provide, during the summer, medical counsel, nursing care, and instruction in the homes pnd clean milk for sick babies in its neighborhood. The clinic was so ! successful that it became evident that a permanent organization was needed. The value of the home nursing was demonstrated beyond question. In December, 1906, the Babies' Dispensary and Hospital of Cleveland was incorporated. A medical director was appointed, and Dr. Gerstenberger has continued from its founding to devote his time and thought to the undertaking. It is largely due to him and his clear conception of the problem that the work has succeeded as it has. In May, 1907, the dispensary and the milk laboratory were opened. Three visiting nurses were provided, and two dispensary physicians appointed. Milk was modified at the central plant and distributed by hand. In 1908 an out-physician was added to the staff to visit cases too sick to come to the dispensary. Four nurses were employed, who made 8503 visits. Milk was still delivered to tlie homes with a wagon. Considerable modification of milk was done at the home by mothers; those incapable of doing so received already modified milk. Particular stress was laid on the educational side and to the encouragement of maternal nursing. In 1909 four branch dispensaries were formed. Great cooperation existed between the Milk Fund Association, the Visiting Nurses' Association, the Health Department, and various settlement houses. An outdoor ward was established where sick babies were treated — at first from 8 A. M. to 6 p. m., and later day and night. The Milk Fund Association became amalgamated with the dispensary, thus putting the work on a more rational basis. In 1910 there were 6 branch dispensaries. A vigorous campaign of education for reduction of infant mortality was carried out, and was participated in by a large number of civic and philanthropic organizations. In 1911 the New Central Dispensary was built and in operation. The City Council appropriated $10,000 for the reduction of infant mortaUty, and 5 new stations were opened, making a total of 11 with 60 distributing stations. Two were managed by the Health Department, but, owing to the wonderful coopera- tion which existed, the Babies' Dispensary and the Health Department worked together. In October, 5 of the branch dispensaries were taken over by the city. A Bureau of Child Hygiene was formed, and in September Dr. Gerstenberger became its head. Cleveland is a fortunate city in the complete, broad coopera- tion that has marked its infant mortality work, especially in recent years. CAMPAIGNS IN OTHER CITIES 107 BALTIMORE In the following tables is set forth the infant mortality by months and groups of^months, with the percentage of all deaths occurring under one year of age for the years 1907 to 1911: TABLE 81— MORTALITY UNDER ONE YEAR, BALTIMORE January February March April May June July August September October November December Year Percentage all deaths July, August, September Percentage of year's infant mortality Percentage all deaths 1907 167 153 182 134 139 140 397 370 239 215 145 162 2443 31.84 1908 180 160 166 157 157 201 399 233 184 138 123 117 2215 31.36 1909 155 139 161 162 173 168 317 264 215 172 157 144 2227 31.43 176 170 148 132 114 183 306 266 180 190 138 145 2148 19.97 1911 143 138 165 141 152 125 280 254 182 132 109 137 1958 18.83 1006 41.10 34.01 816 36.84 31.14 796 35.74 39.35 752 35.01 38.05 716 36.57 38.33 From this table it will be seen that the gross figures for the years have had a steady tendency to diminish, and that this tendency has been increasingly marked in 1910 and 1911. The relation of the deaths under one year to total deaths re- mained practically constant during the first three years shown in the table, but has steadily fallen in 1910 and 1911. Comparing the summer mortality, there is the same steady decrease in the gross figures. The decrease, however, has been slow. The proportion of the year's deaths under one occurring during the three summer months in 1911 was higher than in either 1909 or 1910. There is also a slight increase in the propor- tion of all deaths during the three summer months which are under one year of age. In other words, there was a greater proportionate decrease during the rest of the year than during the summer months. The population of Baltimore increased 9.7 per cent, in the decade 1900-10, or 0.97 per cent, yearly. If we estimate the deaths which would have occurred had the total increased 0.97 per cent, yearly from 1908, which was the low figure up to 1910, and then note the difference between this estimate and the deaths that did occur, we shall have the results shown in the following table : io8 INFANT MORTALITY AND MILK STATIONS TABLE 82.— MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OCCURRED, BASED ON 1908 FIGURES, COMPARED WITH ACTUAL MORTALITY, BAL- ^ TIMORE 1909 1910 1911 2236 2227 —9 —0.4 2257 2148 —109 —4.8 2279 1958 —321 —14.0 Yearly average increase in population, 0.97 per cent. The results, as shown by the yearly figures, are therefore good. The re- duction in the summer mortality, however, is slight, and there is still a very high proportion of the year's infant deaths occurring during the summer months. Birth statistics for Baltimore are of no value. Weather Conditions The following tables show weather conditions in Baltimore: TABLE 83.— NUMBER OF DAYS ON WHICH MAXIMUM AND MEAN TEMPERA- TURES REACHED CERTAIN FIGURES, BALTIMORE* Maximum Temperature Mean Temperature 95° or + 90° or + 85° or + 85° or + 80° or + 1909 June 1 1 1 1 2 1 7 2 10 9 7 6 22 4 15 1 2 22 7 11 6 24 13 16 13 42 10 23 9 5 47 10 20 14 6 50 1 1 1 3 1 2 1 4 1 7 2 10 9 July 9 August 6 September Total 24 1910 June 6 July 16 August 3 September 3 Total 28 1911 June 4 July August 14 9 September Total 1 28 * Monthly Meteorological Summary, Local Weather Bureau, Baltimore, and Monthly Weather Review, Washington. CAMPAIGNS IN OTHER CITIES 109 TABLE 84— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF RAINY DAYS, BALTIMORE* June Mean temperature Rainfall Rainy days July Mean temperature Rainfall Rainy days August Mean temperature Rainfall Rainy days September Mean temperature Rainfall Rainy days Totals Mean temperature Rainfall Rainy days Normal 73° 3.84 in. 77.3° 4.82 in. 74.7° 4.31 in. 68.6° 3.85 in. 73.4° 16.73 in. 74.1° 4.38 in. 13+8 76° 1.31 in. 5 + 7 74.4° 0.86 in. 5+3 67.6° 3.97 in. 5 + 5 73.02° 10.52 in. 28+23 70.4° 5.3 in. 14+1 78.8° 0.95 in. 7+2 74.3° 1.37 in. 11+3 71.6° 2.13 in. 4 + 7 73.7° 9.75 in. 36 + 13 73.4° 5.52 in. 16 79.2° 3.53 in. 6+4 76.2° 12.28 in. 15+4 70.4° 1.6 in. 7 + 1 74.8° 22.93 in. 44+9 Note. — Two figures are given for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is the number of days there was a trace of precipitation, but less than 0.01 inch. For maximum temperatures below 95° and mean temperatures below 85° there is a very close resemblance between the three years. But temperatures of 95° or over were recorded 10 times in 1911, as against twice in 1910 and once in 1909. Mean temperatures of 85° or over were also recorded 10 times in 1911 as against 4 times in 1910 and 3 times in 1909. The monthly mean temperatures in 1911 were well above the normal in each month, while in 1909 only June, and in 1910 only July and September, exceeded the normal. The year 1911 had a higher monthly mean than 1909 in each month except June, and higher than 1910 in each month except September. Rainfall, on the other hand, was much greater in 1911 than in either 1909 or 1910, except in September, and exceeded the normal in the months of June and August. August had the remarkable rainfall of 12.28 inches, which is 2.79 inches greater than any recorded in August since the establishment of the Weather Bureau. The Campaign The chief agencies engaged in work for the reduction of infant mortality in Baltimore are the Babies' Milk Fund Association and, to a much less extent, the Mothers' Relief Society. The latter society was founded in the early nineties, its purpose being the assistance of the mothers during and after confinement. The Babies' Milk Fund was started in 1904, when the Thomas Wilson Sani- tarium established four milk stations in distant parts of the city. The work was * Monthly Meteorological Summary, Local Weather Bureau, Baltimore, and Monthly Weather Review, Washington, D. C. no INFANT MORTALITY AND MILK STATIONS shown to be of such value that, after a few years, the Babies' Milk Fund Associa- tion was incorporated. Funds were raised by popular subscription, the Thomas Wilson Sanitarium being the largest contributor. Babies were referred to the stations from hospitals, dispensaries, and private physicians. Milk modified to set formulae was dispensed, and special formulae could be secured. Milk was dispensed by trained nurses, who gave the greater part of the day to visiting at the homes, instructing and demonstrating. In 1910 the two above-mentioned organizations united to form the Maryland Association for the Study and Prevention of Infant Mortality. It was managed by a committee composed of representatives of both organizations. After one year the Mothers' Relief Society withdrew. In 1911 the work done increased considerably in efficiency and also in extent. Nine stations are now maintained, open all the year round. They are in charge of a trained nurse. Babies are referred by physicians and organizations, and there is little or no house-to-house canvassing. Milk already modified is supplied from six of the stations. From the other three home modification is practised and taught, tuberculin-tested milk being delivered directly to the mothers' homes, and the modification taught by the nurse. At the first two visits she modifies for the mother, and at the last visit watches the mother do it. This latter work — home modification — was started in 1911. A weekly clinic is held at each station, when babies are weighed and mothers instructed. Great emphasis is laid on breast-feeding. Instruction is individual, not in classes. Attendance is not compulsory; milk is delivered whether they attend or not. During the year Dr. Henrietta Thomas has been conducting follow-up work for cases discharged from the Johns Hopkins Maternity ser- vices. She has had 500 babies under her care. They are also visited by the association nurses from time to time. Milk is not dispensed to these babies. The work of the association is being widened in its scope by the establish- ment of welfare clinics at six of the stations, and by prenatal work among ex- pectant mothers referred by three hospitals in Baltimore. The number of babies supplied with milk by the stations has been as follows: TABLE 85.— NUMBER OF BABIES FED AT MILK STATIONS IN BALTIMORE AND MORTALITY AMONG SAME Deaths Rate February, 1908, to February, 1909 1073 103 96.0 per 1000 1909, to " 1910 1217 105 86.3 " " 1910, to " 1911 1356 188 138.7 " " 1911, to " 1912 1194 50 41.9 " " Of these 1194 babies in 1911-12, 927 were supplied with modified milk; 267 with whole milk modified at home. The Department of Health has done little active special work, owing to lack of funds. During the last two years considerable interest in the problem has been aroused by the annual meeting of the American Association for the Study and Prevention of Infant Mortality in 1910, and by general exhibits on Baby Hygiene, etc. CAMPAIGNS IN OTHER CITIES III PITTSBURGH The following table shows the infant mortality statistics for the years 1907-1 1 n Pittsburgh: TABLE 86— MORTALITY UNDER ONE YEAR, PITTSBURGH 1911 fanuary February March '^pril May June [uly August September October November December Year Percentage all deaths July, August, September Percentage years infant mortality Percentage all deaths 1907 1908 1909 1910 129 223 177 162 146 259 157 176 137 183 120 185 139 172 131 169 148 142 140 148 148 160 153 166 244 251 273 338 189 214 184 231 127 176 164 178 126 144 143 191 112 143 134 157 159 127 147 150 1804 2194 1923 2251 24.45 24.29 23.04 23.43 560 641 621 747 31.04 29.20 32.29 33.18 29.83 31.08 31.19 33.33 171 134 151 142 131 116 250 197 144 132 118 124 1810 22.33 591 32.65 27.75 It will be seen that in 1911 the year's total is the lowest since 1907, which year was 6 below 19irs figures. The percentage of the total deaths occurring under one year of age is lower than in any year, including 1907. During the summer months the deaths were 591, the lowest total of the five years except 1907. The percentage of the year's mortality which occurred during these three months was lower than in 1910, but higher than in 1907, 1908, or 1909. If, now, taking as a basis the figures of 1907, the lowest year up to 1911, we estimate the deaths as increasing at the same rate as the population, and compare the actual deaths with these figures, we find the results shown in the following table : TABLE 87.— MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OCCURRED, BASED ON 1907 FIGURES, COMPARED WITH THE ACTUAL MORTALITY, PITTSBURGH 1908 1909 1910 1911 Estimated mortality 1836 2194 +358 +19.5 1869 1923 +54 +2.8 1902 2251 +349 +18.3 1935 Actual mortality 1810 Actual difference —125 Per cent, difference —6.4 Average yearly increase in population, 1.82 per cent. 112 INFANT MORTALITY AND MILK STATIONS These figures show that in each of the years 1908, 1909, and 1910 more deaths occurred than the estimate, while 1911 alone shows a decrease of 6.4 per cent, from the estimate. There has, therefore, been a very decided improvement this year over pre- vious years. The proportion of infant deaths occurring during the three summer months has not, however, fallen as much as in other places. Weather Conditions Weather conditions are shown in Tables 88 and 89. TABLE 88.- NUMBER OF DAYS ON WHICH MAXIMUM AND MEAN TEMPERA- TURES REACHED CERTAIN FIGURES, PITTSBURGH* 1909 June July August. . . September 1910 June July August . . . September 1911 June July August . . . September Maximum Temperature 95° or + 90° or + 2 1 1 4 4 8 6 18 85° or + 24 10 13 10 1 34 5 17 18 3 43 Mean Temperature 85° or + 80° or + 3 3 2 9 7 18 Extremely high temperatures were reached more often in 1911 than in either 1910 or 1909, especially as compared with the latter year. In neither 1909 nor 1910 was 95° recorded. The same general relation is true for the daily means. The hot weather was especially severe in July and August, 1911 (during forty- eight days beginning July 1st the thermometer reached 85° or over on thirty-two days). In neither 1909 nor 1910 did the mean reach 85°, against six and four days in July and August, 1911. The monthly mean temperatures are very much the same in 1910 and 1911, differing only in August, when in 1911 it was 1° hotter, and June, when it was 4" hotter. All four months of 1911 are above the normal averages. June, 1909 and 1911, were the same, but all other months were much below in 1909. * Monthly Meteorological Summary, Local Weather Bureau, Pittsburgh, and Monthly Weather Review, Washington, D. C. The Station Nurse Insists Upon Maternal Nursing Wherever Possible CAMPAIGNS IN OTHER CITIES 113 TABLE 89.— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF RAINY DAYS, PITTSBURGH* Normal 1909 1910 1911 June Mean Rainfall Rainy days Mean Rainfall Rainy days August Mean 70.7° 3.71 in. 74.8° 4.39 in. 73.8° 3.07 in. 66.7° 2.48 in. 71° 4.92 in. 16 71° 1.22 in. 9+6 72° 3.33 in. 9+5 65° 0.76 in. 8 67° 1.94 in. 13+3 75° 1.26 in. 9+4 73° 2.47 in. 8 + 1 68° 5.5 in. 10+4 71° 2.63 in. 9+6 75° 2.17 in. 7+6 74° Rainfall Rainy days September Mean 6.3 in. 13+4 68° Rainfall Rainy days 6.36 in. 13+4 Totals Mean 71.2° 13.65 In. 69.7° 10.23 in. 42 + 11 70.7° 11.17 in. 40 + 12 72° Rainfall Rainy days 17.46 in. 42+20 Note. — Two figures are given for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is num- ber of days there was a trace of precipitation, but less than 0.01 inch. The rainfall in August and September, 1911, was above the normal, and also above either 1909 or 1910, especially in August. June and July were below the normal, but in excess of 1910 in June and in excess of both years in July. It has been impossible to obtain information first hand in regard to the work being done in Pittsburgh. * Monthly Meteorological Summary, Local Weather Bureau, Pittsburgh, and Monthly Weather Review, Washington, D. C. 114 INFANT MORTALITY AND MILK STATIONS DETROIT In studying the mortality figures for Detroit it must be remembered that the population has increased 63 per cent, in ten years. The following tables give the statistics of infant mortality for the years 1906 to 1911: TABLE 90.— MORTALITY UNDER ONE YEAR, DETROIT 1906 1907 1908 1909 1910 Average 1906-10 1911 97 113 137 147 145 134 221 172 154 136 116 107 124 107 153 114 119 103 186 198 166 133 100 95 126 141 165 180 119 117 206 207 162 131 91 89 130 126 149 150 140 114 211 220 171 149 114 127 148 132 200 196 141 198 275 251 182 125 118 129 135 134 161 157 133 133 330 309 167 135 108 109 160 154 March 138 April 104 May 150 133 Tulv 244 August 215 September 179 October 130 November 121 December 134 Year 1679 38.0 1598 36.4 1734 39.5 1801 38.5 2095 38.1 1781 28.1 1862 Percentage of all deaths 36.1 July, August, and September Percentage year's infant mortality 547 33.6 33.3 550 34.4 35.8 575 33.6 38.5 602 33.4 36.0 708 33.8 35.3 596 33.5 35.7 638 34.3 34.0 Births 7752 216.5 8341 191.5 9572 181.1 9617 187.2 11,509 182.0 9358 190.3 13,373 Infant mortality rate 139.2 TABLE 91.— DIFFERENCE BETWEEN MORTALITY UNDER ONE YEAR IN 1911 AND PREVIOUS YEARS, DETROIT 1906 1907 1908 1909 1910 Year Percentage all deaths + 183 —1.85 +91 +264 —0.24 +88 —0.16 —1.83 + 128 —3.36 +63 + 1.10 —4.51 +61 —2.42 +36 +0.84 —3.03 —233 —1.99 July, August, and September —70 Percentage year Percentage all deaths + 1.32 +0.74 +0.47 —1.36 It will be seen that from 1907 through 1910 there has been a slowly increasing gross total infant mortality. The proportion of total deaths which occurred under one year of age was higher than in 1907 during the three years following it, although it has slowly fallen each year after 1908. The year 1911, however, shows the lowest percentage of all deaths of any of the six years, being even lower than 1907. Comparing the summer mortality, the total has slowly increased, but not in CAMPAIGNS IN OTHER CITIES 115 proportion to the population. The year 1911 shows a lower total than 1910, but higher than the four previous years. The percentage of the year's mortality which occurred during these three months is also higher than in any year except 1907. In other words, the summer mortality is not reduced quite so much as that for the rest of the year. The percentage of all deaths occurring during the summer months is, however, lower than any since 1906. If we take deaths in 1907, the low year, as a basis, and estimate the increase on the same basis as increase in population, the mortality should have been: TABLE 92.— MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OCCURRED ON BASIS OF 1907 FIGURES, COMPARED WITH ACTUAL MORTALITY, DETROIT 1908 1909 1910 1911 Estimated mortality 1698 1734 +36 +2.1 1799 1801 +2 +0.1 1900 2095 + 195 +9.3 2000 Actual mortality 1862 Difference — 138 Per cent, difference —6.9 Average yearly increase in population, 6.3 per cent. Applying the same method to the summer mortality we find : TABLE 93.— MORTALITY UNDER ONE YEAR DURING THREE SUMMER MONTHS WHICH SHOULD HAVE OCCURRED ON BASIS OF 1907 FIGURES, COM- PARED WITH ACTUAL MORTALITY, DETROIT 1908 1909 1910 1911 Estimated mortality 584 575 —9 —0.15 619 602 —17 —3.7 654 708 +54 +8.3 688 Actual mortality 638 Difference Per cent, difference —50 —7.3 The summer reduction has, therefore, kept pace with the yearly reduction, allowing for increase in population. The infant mortality rate also shows a very marked fall to 139.2, but it must be remembered that the great increase in births during 1910 and 1911 is probably partly due to a more efficient registration. Weather Conditions Weather conditions in Detroit are shown in Tables 94 and 95. The most striking differences occur in 1909 and 1911. August was hotter in 1909 than in either 1910 or 1911. The mean for the month was higher, and also above the normal. In the other three months 1911 was in excess of 1909 by from 2° to 3°. Ninety-five degrees was never reached in 1909, while it was reached three times in 1910 and five times in 1911. The daily mean was never 85°, and only 80° or over three times in 1909, while in 1911 it was 85° three times and 80° or over thirteen times. ii6 INFANT MORTALITY AND MILK STATIONS TABLE 94.— NUMBER OF DAYS ON WHICH THE MAXIMUM AND MEAN TEM- PERATURE REACHED CERTAIN FIGURES, DETROIT* 1909 June July August. . . September 1910 June July August. . . September 1911 June July August. . . September 95° or + Maximum 90° or + 3 3 1 7 3 8 1 12 85° or + 3 5 8 2 18 15 7 30 6 12 7 2 27 Mean 85° or + 80° or + 3 3 1 7 3 8 2 13 TABLE 95.— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF RAINY DAYS, DETROIT* Normal 1909 1910 1911 June Mean 67.4° 3.80 in. ■ 67° 4.95 in. 13 66° 1.47 in. 9+0 69° Rainfall Rainy days July Mean Rainfall Rainy days August Mean Rainfall Rainy days September Mean 1.48 in. 9 + 7 72.1° 3.50 in. 70.1° 2.73 in. 63.5° 2.55 in. 71° 5.94 in. 9+2 72° 3.75 in. 9+5 61° 0.75 in. 8+2 74° 1.48 in. 6 + 5 71° 1.11 in. 7+3 63° 2.02 in. 10+2 74° 0.79 in. 9+0 71° 1.31 in. 9+6 64° Rainfall Rainy days 4.32 in. 14+4 Totals Mean 68.2° 12.58 in. 67.7° 15.39 in. 39+9 68.5° 6.08 in. 32 + 10 68.5° Rainfall Rainy days 7.9 in. 41 + 17 Note. — Two figures are given for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is nuiU'- ber of days there was a trace of precipitation, but less than 0.01 inch. * Monthly Meteorological Summary, Local Weather Bureau, Detroit, and Monthly Weather Review, Washington. CAMPAIGNS IN OTHER CITIES 117 June, 1910, was cooler than 1911 by 3°, and September by 1°. The other two months had the same mean, 1911 being above the normal in all four months. Except in September the rainfall in 1911 was scanty, being well below the normal in each month. The first three months were drier than in 1909. July was much drier than 1910, and had very slightly greater rainfall in June and August. It is in the months of July and August that the greatest reduction in infant deaths occurred. The Campaign Until 1910 very little was done in Detroit for preventing infant mortality outside of the ordinary relief work done by charitable organizations. The Babies' Milk Fund distributed good milk, whole or modified, to patients referred by the various clinics and hospitals. No attempt was made to follow up these babies, nor was any home instruction given. In 1910 the Health Department began a "mothers' clinic" under the charge of Dr. Duffield. The Visiting Nurses' Association assigned one nurse to this clinic, which attempted to secure proper feeding for babies and instruction for their mothers. The milk was distributed unmodified, and was prepared at home under supervision. The "Children's Bureau" was organized this same year, composed of repre- sentatives of 18 different organizations; a trained social worker was employed, and cooperation and greater efficiency resulted. In 1911 the Babies' Milk Fund started two milk stations in charge of a Med- ical Director, Dr. Cooley, with nurses in attendance. The Milk Fund gave up the modification of milk except in very exceptional cases, teaching home modification instead. Home visiting by the nurses is made a great feature of the work, and cooperation exists with the Visiting Nurses' Association. Consultations are held at the stations, attendance by the mothers being demanded. Classes have been started for mothers and young girls in infant hygiene, making of clothes, etc. Obstetric clinics are being started in connection with the stations, and promise to be valuable additions to the work. The Mothers' Clinic of the Health Department increased its activities very largely in 1911. The school nurses were detailed to its work in the summer months. Births reported by midwives were visited, and the mother instructed. A campaign of publicity was started to try to improve the milk supply. A milk exhibit was held under the auspices of the Board of Commerce and the Health Department, which resulted in greatly improving the supply through the raising of the standards required. A considerable amount of work has been done, and very nearly all of it dur- ing the years 1910 and 1911. The educational prevention of infant mortality is being emphasized. Ii8 INFANT MORTALITY AND MILK STATIONS BUFFALO The mortality under one year for Buffalo is shown in the following table: TABLE 96.— MORTALITY UNDER ONE YEAR, BUFFALO* I January February March April May June July August September October November December Year Percentage all deaths July, August, and September Percentage of year Percentage all deaths Births Infant mortality rate 1906 84 85 92 97 80 77 130 221 67 99 93 121 1246 19.6 418 33.5 23.7 8075 154.3 1907 39 118 114 109 100 79 290 242 152 92 73 87 1495 33.5 684 45.7 38.8 8891 168.1 1908 107 110 96 100 77 73 154 174 141 144 77 74 1317 31.1 469 35.6 39.9 9171 143.6 1909 110 101 77 70 89 64 136 192 117 98 85 114 1253 19.8 445 35.5 37.5 9027 138.8 1910 109 76 111 135 123 67 139 254 173 109 91 95 1482 31.3 566 38.3 33.0 10,008 148.1 Average 1906-10 90 96 98 103 94 73 170 316 130 108 84 1358 20.9 516 38.0 30.5 9373 146.5 1911 96 82 94 97 88 104 97 103 90 70 63 66 1050 30.7 290 37.6 30.0 10,546 99.5 The difference between 1911 and the other years is shown in the following table : TABLE 97.— DIFFERENCE BETWEEN MORTALITY UNDER ONE YEAR IN 1911 AND PREVIOUS YEARS, BUFFALO 1910 Year Percentage all deaths July, August, and September Percentage of year's infant mortality Percentage all deaths Infant mortality rate 1906 1907 1908 1909 —196 —445 —267 —203 + 1.1 —1.8 —0.4 +0.9 —128 —394 —179 —155 —5.9 —18.1 —8.0 —7.9 —3.7 —13.8 —9.9 —7.5 —54.8 —67.6 —44.1 —39.3 —432 —0.6 —276 —10.6 —12.0 —48.6 It will be seen at once that there was a most phenomenal decrease in the infant mortality in 1911. Only January and June are above the five-year aver- age. The decrease is all in the second half of the year. The figures for the first and second half-years are: * These figures are taken from the monthly bulletin of the State Department of Health. They will be found to differ considerably in some cases from the Census Bureau figures, and from those of the Buffalo Department of Health Annual Reports, owing apparently to different methods in tabulating still-births. CAMPAIGNS IN OTHER CITIES 119 TABLE 98.— MORTALITY UNDER ONE YEAR BY HALF-YEARLY PERIODS, BUFFALO 1906 1907 1908 1909 1910 Average 1906-10 1911 First half-year 515 731 559 936 553 764 511 742 621 861 553 806 561 489 Second half-year The striking situation exists of the second half of the year having a lower mortality than the first half ; even more striking are the figures by trimesters : TABLE 99.— MORTALITY UNDER ONE YEAR BY TRIMESTERS, BUFFALO First trimester. . Second trimester Third trimester . Fourth trimester 1906 261 254 418 313 1907 271 288 684 252 1908 303 250 469 295 1909 288 223 445 297 1910 296 325 566 295 Average 1906-10 384 368 516 390 1911 272 289 290 199 The percentages of the year's total deaths occurring in each of the four trimesters in 1911, as compared with the average for five years, are: TABLE 100.- -MORTALITY UNDER ONE YEAR BY TRIMESTERS, AGES, BUFFALO IN PERCENT- First Second Third FOURTH 1911 25.91 30.91 27.52 19.73 27.62 38.00 18.95 Average 31.36 A difference of one-tenth of 1 per cent, is shown between the second and third quarters in 1911, as against 18.27 in the average. The third quarter in 1911 is 10.38 less than the average. The percentage of all deaths for the year, however, is only 0.6 lower than 1910, and is 1.1 per cent, higher than 1906. For the summer months it is 12 per cent, lower than 1910, and 3.7 per cent, lower than 1906. The infant mortality rate is from 39.3 to 67.6 lower than the pre- ceding years, being 99.5, a very low figure. If we estimate the deaths that would have occurred if the mortality had in- creased at the same rate as the population, based on the figures of 1906, the low year, we find: TABLE 101.— YEAR'S MORTALITY UNDER ONE YEAR WHICH SHOULD HAVE OC- CURRED, BASED ON 1906 FIGURES, COMPARED WITH ACTUAL MOR- TALITY, BUFFALO 1907 1908 1909 1910 1911 Estimated mortality 1271 1495 +224 + 17.6 1296 1317 +21 + 1.6 1321 1253 —68 —3.1 1347 1482 + 135 + 10.0 1372 Actual 1050 Difference —322 Percentage difference —23.5 Average yearly increase in population, 2.02 per cent. 120 INFANT MORTALITY AND MILK STATIONS Estimating in the same way the summer mortality we find: TABLE 102.— MORTALITY UNDER ONE YEAR, DURING THREE SUMMER MONTHS, WHICH SHOULD HAVE OCCURRED, BASED ON 1906 FIGURES, COM- PARED WITH ACTUAL MORTALITY, BUFFALO 1907 1908 1909 1910 1911 426 684 +258 +60.6 435 469 +34 +7.8 443 445 +2 +0.5 452 566 + 114 +35.3 460 290 —170 —36.9 There has been a most phenomenal decrease in infant deaths in Buffalo. The infant mortality rate has fallen to 99.5, and the actual figures for births are only 546 more than 1910, so that there cannot have been a very greatly increased reporting of births, in all probability. Weather Conditions Weather conditions in Buffalo are shown in the following tables: TABLE 103.— NUMBER OF DAYS ON WHICH MAXIMUM AND MEAN TEMPERA TURES REACHED CERTAIN FIGURES, BUFFALO* Maximum Temperature Mean Temperature 95° or + 90" or + 85° or + 80° or + 85° or + 80° or + 75° or + 1909 June July August September . . 1 2 1 2 7 10 3 1 3 6 1 Total . . 1910 June July August September . . 4 1 2 5 22 6 9 12 11 1 3 7 Total . . 1911 June July August September . . 1 2 2 8 6 6 27 2 11 11 1 1 3 3 11 10 9 Total . . 1 4 12 25 1 6 19 * Monthly Meteorological Summary, Buffalo, and Weather Review, Washington, D. C. CAMPAIGNS IN OTHER CITIES 121 TABLE 104.— MONTHLY MEAN TEMPERATURE, RAINFALL, AND NUMBER OF RAINY DAYS, BUFFALO* Normal 1909 1910 1911 June Mean 65° 3.03 in. 70° 3.33 in. 69° 2.95 in. 63° 3.09 in. 66.7° 12.39 in. 64.6° 1.05 in. 5 + 7 68.6° 2.49 in. 10+3 69.4° 1.69 in. 8 61.7° 2.61 in. 11+4 66.07° 7.84 in. 34+14 62.8° 1.05 in. 8+5 70.1° 5.33 in. 8+4 69.4° 2.72 in. 8+3 62.0° 2.16 in. 10+4 66.07° 11.26 in. 34+16 66.3° 2.23 in. 12 + 6 71.6° 4.41 in. 8 + 7 69.8° 4.61 in. 11+4 62 2° Rainfall Rainy days Mean Rainfall Rainy days August Mean Rainfall Rainy days September Mean Rainfall Rainy days Total j^ Mean 3.81 in. 11+6 67 4° P Rainfall * Rainy days 15.06 in. 42+23 Note. — Two figures are given for number of rainy days — the first, in front of the plus sign, is the number of days precipitation was 0.01 inch or more; the second, after the plus sign, is number of days there was a trace of precipitation, but less than 0.01 inch. Temperatures above 90° are unusual in Buffalo. They were not recorded during the years 1909 and 1910. Figures for a maximum of 80° and a mean of 75° are, therefore, included in the table. The year 1911, therefore, stands out as a year when there were periods of extreme heat, 90° or more being recorded on two days in both July and August. A mean temperature of 80° or more was also recorded in both July and August, which did not occur in either 1909 or 1910. A mean temperature of 75° was reached nineteen times in 1911 as against eleven times in the two previous years. The monthly means show 1911 above the normal in each month except Septem- ber, and higher than either 1909 or 1910 for each month. The rainfall except in June was above the normal in each month, and was greater than the corresponding months in 1909 and 1910, except in July, when less rain fell than in 1910. Except in rainfall, weather conditions were unfavorable for a low infant mortality. The Campaign It has been difificult to obtain exact information in regard to the activities being carried on in Buffalo. In a general way everybody seems to be agreed that during the last year some very active work has been done by the Health De- partment and social organizations. The problem of the milk supply is being very actively handled by the Health Commissioner, Dr. Fronczak. The Children's Welfare Society and the Babies' Milk Dispensary are both very active in their campaign. Considerable cooperation exists between the various agencies, and the Health Department is doing all in its power to increase this cooperation. * Monthly Meteorological Summary, Buffalo, and Weather Review, Washington, D. C. I CHAPTER VII General Summary For convenience in reference the mortality in the various localities studied is summarized in the following tables. Table 105 shows the highest, lowest, and difference between same, for the years 1906-10 inclusive, in the year's actual mortality under one year; the percentage of all deaths, and the infantile mortality rate; the actual deaths, percentage of all deaths, and proportion occurring in this period for the third quarter; and the relation of the 1911 figures to the highest, lowest, and 1910 figures in each of \ these groups. ^ Table 106 shows the same thing expressed in percentages. By "Extremes" is meant the difference between highest and lowest in the period 1906-10 ex- i pressed in percentage of the highest. The yearly average increase in population " is also noted. A consideration of these tables shows that: 1. In actual yearly deaths — Manhattan, Brooklyn, City of New York, Philadelphia, St. Louis, Baltimore, and Buffalo show a decrease in 1911 from the lowest actual mortality recorded in the previous five-year period. In the amount of this decrease from lowest figures, expressed in percentages, the figures for Manhattan are exceeded only by j Baltimore and Buffalo. "Rest of City," Chicago, Boston, Cleveland, Pittsburgh, and De- troit show an increase in 1911 from this lowest figure. 2. In the ratio of infant deaths to total deaths for the year, in 1911 — All but Buffalo show a decrease from the lowest figure recorded. In actual figures the proportion of decrease is greater in Manhattan i than in any of the other localities except Cleveland, Pitts- burgh, and Detroit. In the percentage decrease from the lowest previous figure, Man- hattan is exceeded only by Philadelphia and Cleveland (8.8 and 8.6 respectively, as against 7.8 for Manhattan). 3. In infant mortality rate for 1911 — Manhattan is higher than any other city in actual figures except Boston, Cleveland, and Detroit. ! A decrease from the lowest previous rate is noted in all except \ Boston, which is 6.2 higher than its lowest previous figure, and Cleveland, which is 11.4 higher. 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O "^ On re On On O iDr^ O t^ O re NO re CM o On re D t^ t~ i ^ <; 1-1 re m TM ^^ re nO t^ ■* O ■* re t^ ^H ID NO re •* ti) »-l 1-1 U H vOOOrJ-r* ON cs cs -^oi^ On 00 ON CS "* CM CM O NO >D ID ^OOt^O 00 ID 1* to t^ NC CM O t~ 4 CS CN CS ro -* re es cs cs CM r-H •* CS •rt 00 Z B! J O H < 5l »-^ tS <*y •<*i to \0 t~- 00 ©■ o ^ PNl re"*"- nO»>.00CnO -H tM re Tj< »D nOJ^OO Ov o H 1-H ■-H 1-1 1-1 CV CM CM CS CM CM O 11 44 The Bearer, .— New York,- .1911 is entitled to receive Ten Pounds of Ice for each of the attached coupons when this book is presented to the Weigh- master of any of the Ice Depots named on back of book, or to the Driver of any retail ice wagon of the Knickerbocker Ice Company when countersigned by an authorized ageht of the NEW YORK MILK COMMITTHE. By. -Agent Ooly one coupon will be honored each week day and two Saturday. Exhibit 22 Book No.44h44~ Coupon No. !L__ This Coupon when not detached is good for TEN POUNDS OF ICE according to terms stated on front cover of this book. HEW YORK MILK COMMITTEE. Exhibit 23 The ice-box problem has already been solved, as very few homes visited by the station nurse during the demonstration were found not to have facilities for 144 INFANT MORTALITY AND MILK STATIONS keeping the ice. The education of mothers as to the importance of keeping the babies' milk cold, and the established custom of the agencies, already mentioned, of distributing free ice, has caused the poor mothers to solve the ice-box problem satisfactorily. To the ice-distributing agencies much credit is due for their efforts to aid the mothers in keeping the babies' milk supply sweet and wholesome. Relief in the Form of Hospital Care The relief extended in the form of hospital and dispensary care of the sick babies during the period of this demonstration contributed in no small way to its success. However, the difficulties in placing sick babies in hospitals seriously lessen the effectiveness of the hospitals. During the summer a careful canvass of the hospitals in New York city was made, and the result shows that, for the care of infants under two years suffering from general diseases, there are approxi- mately 800 beds which are not restricted by requiring a legal commitment or a permit from the Department of Charities. These beds are not all available for the use of infants under two years because of the requirements for admission — none will receive cases complicated by mild contagion ; some do not receive babies under one year of age ; some require mothers to accompany babies ; others have no accommodation for nursing mothers, while some receive no cases during the summer and others receive cases only during the summer ; most of these beds are for what are known as pay or part-pay patients. Only 21 per cent, are reserved exclusively for free patients. Again, these 800 beds are not available at all times, as often a hospital is in quarantine with some contagious disease. The existing facilities, though inadequate, cannot be properly utilized under the present system, as no one knows the total number of available beds at any given time, and to place a case one must telephone from hospital to hospital until accommodations are found. A central hospital bureau prepared to give prompt information as to available beds at any time would make possible a better utilization of the present hospital facilities, which are generally known to be woefully inadequate. Because of the difficulty in placing sick babies under proper hospital care comparatively few of those registered at the Committee's stations were sent to hospitals. Junior Sea Breeze, which has special facilities for the treatment of gastro-intestinal diseases, responded promptly and satisfactorily in every case brought to its attention. Relief in the Form of Outings Through the cooperation of various agencies maintaining seaside and country homes for sick mothers and children the station nurses were liberally provided with tickets to distribute to those in need of this kind of relief. In the case of the St. John's Guild Floating Hospital, tickets were good only for sick children or mothers recommended by either the family or station physician. In very few instances did the station nurses encourage mothers to take their babies to seashore and country homes if the baby was well and gaining in weight under the station supervision. This is particularly true of babies artificially fed, o EXTENSION OF RELIEF THROUGH MILK STATIONS 145 because the change in milk and feeding formula had been found in a number of in- stances to prove detrimental, at least for a time. However, special effort was made by the station nurses to obtain for the mother a rest in her own home by having relief agencies provide a country or sea- shore outing for the older children. This plan proved far more beneficial to all concerned, and was keenly appreciated by the overworked mother. TABLE 116— SHOWING FOR 2156 FAMILIES HAVING BABIES REGISTERED AT MILK STATIONS, RENTAL, INCOME, AND LIVING CONDITIONS NtJMBER OF Persons IN Family Total Families Total Number of Persons Total Number of Rooms Total Number of Dark Rooms Average Yearly Rental PER Family Average Yearly Income per Family 2 3 1 541 2 1623 1 1627 408 $108 145 $260 641 4 379 1516 1182 355 145 621 5 429 2145 1398 372 147 633 6 304 1824 1019 300 151 631 7 205 1435 720 250 156 599 8 143 1144 499 137 164 626 9 76 684 270 92 151 546 10 45 450 177 39 183 678 Over 10 33 396 141 50 196 740 Total 2156 11219 7034 2003 $150 $628 Number of Families Living in 1 Room 2 Rooms 3 Rooms 4 Rooms 5 Rooms 6 Rooms 7 Rooms 8 Rooms 2 3 1 7 118 297 104 i3 i 4 6 70 199 82 21 1 5 8 74 195 111 35 4 2 6 4 39 131 112 13 4 1 7 15 100 67 18 3 2 8 1 10 71 45 13 1 2 9 4 38 25 6 3 10 2 12 22 7 1 1 Over 10 6 20 4 1 2 Total families 27 119 332 1479 1049 5250 588 3381 130 778 19 120 8 58 3 Total number of persons 34 Total number of rooms 27 10 664 227 3147 920 2352 640 540 160 114 19 56 19 24 Total number of dark rooms 8 Average yearly rental per family* . . . 182 $124 $138 $171 $211 $258 $229 $384 Average yearly income per family* . . $433 $516 $602 $678 $852 $918 $921 $1716 * Cents omitted in amounts given. ID 146 INFANT MORTALITY AND MILK STATIONS In conclusion: L The milk stations can be successfully conducted without making the distribution of free milk a prominent part of the work. 2. The organized relief agencies should be called upon to handle every case needing free milk. If a family is too poor to buy milk for the baby, the case is not one for free milk alone, but for general relief, and as such should be dealt with by an agency prepared to deal with the situation. 3. Whatever relief is extended in the way of free milk should be given in a quiet way. The desire for free milk is contagious with milk-station mothers. 4. Arrangements should be made to have some agency undertake to furnish needy cases with the necessary ice to keep the baby's milk sweet and wholesome. The mothers can and will solve the ice- box problems. 5. Hospitals with many so-called free or part free beds do not mean available hospital service for sick babies. The standardizing of requirements for admission and the establishment of a Central Hospital Bureau for information will insure a better utilization of exisiting hospital facilities. 6. The older children may be sent away for a country or seashore out- ing, but the baby should be left at home with its mother. Travel and change of milk and feeding formula may be disastrous to the bottle-fed baby. 7. The milk station should be made a place where mothers will come with their troubles. The nurse should be prepared to know what to advise; if she shows good judgment, she will win the confidence and friendship of the mother. CHAPTER IX Establishment and Operation of Milk and Health Stations Survey to Determine the Needs of Each Locality A preliminary survey was made in 1910 to determine how many milk stations would be necessary to carry on an intensive demonstration in Manhattan. In- formation and experience obtained in operating six milk stations during 1909 and census figures served as the basis for this study. The records of these milk sta- tions were analyzed, a map of the district in which the stations were located was made, and in each block was indicated the number of babies registered at the station. The number of babies was then considered in relation to area and density of baby population. As the six stations were located in different sections of Manhattan it was thought that their experience could be taken as an index of what might be ex- pected if additional stations were opened in similar districts. Accordingly, it was estimated that the average sphere of influence in acres of a station on the lower East Side was 16; on the upper East Side, 24, and on the West Side, 22. By considering station enrolment in relation to baby population it was esti- mated that in districts with more than 25 children per acre 25 per cent, might be expected to come under the supervision of milk stations; in districts with 15 to 25 children per acre, 10 per cent.; and in districts with less than 15 children per acre, 5 per cent. — might be expected to come under the supervision of stations. Allowing 100 babies as a maximum enrolment for a milk station, it was estimated that, to provide for the entire number of babies needing milk-station supervision in Manhattan, 60 stations in addition to those already in operation would be required. In April, 1911, after the Committee had secured sufficient funds to begin a demonstration, another survey was made to determine the number of babies under two years who might be brought under the influence of the milk stations. This study was made by wards or parts of wards, in which the block population was used as the basis for estimating the number of children under two years of age. From this, together with the experience of the stations already in opera- tion, it was estimated that a minimum of 13,137 babies under two years could be brought under the influence of milk stations if these were properly located. In- formation from organizations already conducting milk stations showed that 4500 of the total estimated number were already under the supervision of estab- lished stations, leaving 8637 babies to be provided for. After a thorough canvass of the districts not covered by milk stations it was decided that if 28 stations were established by this Committee in addition to the 5 to be maintained in Man- hattan by the Department of Health and 22 by other agencies, it would be pos- 147 148 INFANT MORTALITY AND MILK STATIONS sible, by employing extra nurses, to care for the remaining 8637 babies needing supervision. With the tentative locations for new stations indicated on a map of Man- hattan, a careful inspection of each district was made. The clergy of all denomi- nations, as well as social workers and representatives of hospitals and dispensaries in the locality, were interviewed, and many valuable suggestions were obtained relative to the proposed location of the station in their district. Once having determined the vicinity in which the station was to be opened, a canvass was begun for suitable quarters; in selecting these, an endeavor was made to have the stations placed on streets which were most used by the mothers of the neighborhood. Kind of Quarters Selected In all but five instances stores were selected for quarters for the milk sta- tion, and an effort was made in each case to obtain at least 600 square feet of floor space, although in certain districts this was not possible, as nearly all the stores were the so-called single stores, having a width of 10 feet and extending back 40 to 45 feet. Wherever possible stores were obtained having partitions so arranged as to give one large room in front with two smaller rooms in the rear. (See Exhibit 24.) Free quarters were provided for five of the stations by different organiza- tions — two of these were in settlement houses ; one in an industrial school ; one in a dispensary, and one in the room adjoining the vestibule of a chapel. It became necessary, however, to remove the station from the chapel after occupying the quarters for six weeks, owing to the refusal of mothers to bring their babies to a station located in a church not of their religion. No difficulty was encoun- tered in obtaining a large enrolment at stations located in settlements; in fact, with one exception, the settlement stations had the largest enrolment throughout the summer of any of the Committee's stations. Equipment and Cost A careful list of the equipment necessary for the station was compiled, taking into consideration the economy of floor space and the amount of money available. The following is a complete list of the furniture and equipment purchased for each station, as well as the cost of same: LIST OF EQUIPMENT OF STATIONS Folding chairs (24) wooden $15.50 Stool (1), white enamel, wooden 87 Cabinet (1), white enamel, wooden 16.25 Mirror (1), white, size 123^ x 16 inches 60 Blackboard (1), size 24 x 36 inches 32 Chairs (2), white enamel 3.90 Table (1), size 24 x 30 inches, white enamel, wooden 3.75 Table (1), size 20x48 inches, white enamel, wooden, with drawer 213^^ X 19 inches 6.50 Table (1), size 24 x 60 inches, white enamel, wooden, 5 drawers — 4 side, 1 long 7.75 Desk (1), size 24 x 40 inches, white enamel, wooden, 5 drawers — 4 side, 1 long 10.25 ESTABLISHMENT AND OPERATION 149 Wash-stand (1) . $ 3.50 Refrigerator (1), size 27 inches x 5 feet, oak 34.00 Linoleum (to measure), 65 cents per yd., made and laid Pan for refrigerator 55 Folding screen, enamel, wooden, muslin filling, size 5 ft. 83^ inches x 193^ inches 5.00 Howe scales with special pan (1) 9.00 Pad for scales 22 Double boiler (1), 1 quart, enamel 57 Strainer (1), large, to fit quart measure, enamel 25 Quart measure (1), enamel 30 Spoon (1), enamel, white, size 14 inches 10 Jars (4), glass, 1 quart, with tops 88 Funnel (1), glass 09 Bath-tub (1), baby's 1.05 Graduate glass (1), 16 ounce 20 Kettle (1), 1 quart, enamel 80 Tea-kettle (1), 4 quarts, enamel 78 Pitcher (1), gallon, enamel 65 Saucepan (1), gallon, white enamel 80 Dishpan (1), size 16 x 5 inches, enamel 60 Mop (1) and handle 30 Boiler (1), No. 6 Kramer 1.12 Irons (2), 6 pounds, each 44 Ironing-board with cover, size 43^ feet 80 Scrub-pail (1) and wringer (1) 1.00 Washboard (1) 32 Bottle-cleaners (2) for small nursing bottles 50 Bottle-cleaner (1), large, with wooden handle 25 Nail-brush (1) 04 Scrub-brush (1) 11 Soap-dish (1), enamel 15 Towel-rack (1), nickel 42 Clothes-line (1) 45 Broom (1) 30 Ice-pick (1) and hammer (1) 25 Dust-pan (1) and brush (1) 31 Slop-pail (1), enamel 63 Hand-basin (1), enamel 24 Bowl and pitcher for wash-stand, enamel 97 Window-screening 25 White dotted muslin (20 yards) 1.90 Towels (12), hand, 1 yard each, hemmed 1.38 Towels (12), dish, 1 yard each, hemmed 1.32 Floor-cloths (6), 3^ yard each, hemmed 66 Scrap-basket (1), wire 35 Clock (1), New Haven alarm 60 Inkstand (1), with 2 bottles and pen-holder 75 Cash-box (1), tin, size 7x9x2 inches, 6 compartments 55 Thermometer for refrigerator 48 Dairy thermometer 17 Tongue depressors 60 Clinical thermometer (two-minute) 50 Breast-pump (1) 30 Pyoscope (1) 45 Letter-index, files (2) for charts, at $1.40 2.80 Card-drawer files (daily record cards), at 80 cents 1.80 The average cost of equipment was $184.72 per station. All the furniture was white enamel, with the exception of the folding chairs, and was made to order for the Committee. With the exception of the refrigerators, the equipment selected proved well adapted to the needs of the milk station. The refrigerators, although of well-known make, did not prove satisfactory, as it was impossible to keep the temperature of the milk below 55° F. unless the bottles were placed 150 INFANT MORTALITY AND MILK STATIONS in direct contact with the ice. It is doubtful if any refrigerator will give as satis- factory results in keeping milk at a low temperature as an ice-chest in which the bottles can be buried in cracked ice. Arrangement of Interior of Station Wherever possible, as has been said, stores with three rooms were obtained for milk stations — the front room, being the largest, was used for a class-room and for the dispensing of milk. In the exhibit showing floor plan of a three-room station the milk-dispensing table is in the fore part of the front room. In some places a rail and gate, togetlier with the table, separated the remaining part of the room used for class purposes from the milk-dispensing portion. A three-paneled screen is utilized to separate the class-room from the view of the street. The refrigerator, with a capacity of 200 quart bottles of milk, is placed alongside of the cabinets. These cabinets contained nursing bottles of various sizes, barley, milk-sugar, nipples, borax, and other supplies which were sold to the mothers at cost. A portion of the front room utilized for class work or as a waiting-room for mothers on consultation day with the physician is provided with 24 to 36 folding camp- chairs and a table for the use of the nurse or physician conducting class work. The adjoining room is known as the "demonstrating room" — this is the smallest of the three; here mothers were instructed in the modification of milk, bathing and dressing of babies, etc. It is provided with a large demonstrating table, a sink with running water, wall shelves on which were kept the utensils used in demonstrating the modification of milk, a cabinet for supplies, and a cloak closet. The third or rear room is nearly twice as large as the demonstrating room, and is known as the "consultation room," in that it is used almost exclusively for in- dividual consultation work with mothers. The station physician and nurse are each provided with a desk. At the side of the room nearest the nurse's desk is a table holding the scales used in weighing babies, and on the opposite side is the cabinet containing medical supplies used in the station work. The arrangement, as per the plan outlined, makes it possible for a station with apparently small quarters to handle quite conveniently a great many cases. The use of that part of the front room nearest the street door for receiving mothers or older children coming for milk, without interfering with the work carried on in the other part of the station, is particularly advantageous. The class-room makes it possible for the general lessons in hygiene and care of the baby by the station nurse and the special talks by the station physician to be given without interruption from persons coming in for the sole purpose of obtaining the day's supply of milk. By having the consultation room in the rear, a good light is assured for the examination of babies by the physician. The room affords a certain amount of privacy, and the mother feels that the station is giving her baby individual attention and that she is being granted a personal consultation, rather than being instructed as one of a group. The character and amount of individual attention given to each baby and mother by the station physician and nurse determine largely the influence which the station is to have upon that mother. DOCTDR^ DESK a nURSE s DESK CONSULTATION Roon □an aaoana DOCDCa " □□□□□ . ucacnn' □□noD □□□DO D M»< DISPENSER'S TABLE a a CLASS MILKDISPEHSING Exhibit 24 Floor Plan of Milk Station Stores Are Used For Milk Stations ESTABLISHMENT AND OPERATION 151 All records with the exception of the ledger for recording the milk dispensed are kept in the consultation room. On the walls of the front room of the station are placards giving advice or warnings to mothers. A blackboard in the milk- dispensing portion of the station affords a means of notifying mothers of changes in clinic hours and other important notices, such as announcements or reminders of clinics and classes to be held, excursions to parks or seashore, "little mothers' " meetings, etc. Painting and Decorating the Station A blue-and-white color scheme for both th,e city milk stations and the Com- mittee milk stations was adopted. The exterior of the station was a light blue LOOK FOR THE BLUE FRONTS BABIES' PURE MILK STATIONS Every Summer thousands of Babies die We can save your Baby Ask us how Coinniittee tor Reductioii of Infant Mortality New York Milk Committee Exhibit 25 Placards Used to Advertise the Stations (Printed in Five Languages; Size, 22 x 28 inches) with white trimmings around the windows. White calcimine was used for the ceiling, and a white-enamel paint for the side walls — in some cases white-enamel paint for the side walls was used up to a height of 5 feet, and the remaining por- tion of the wall calcimined. In some of the city stations blue was used in mark- ing borders in the interior. Having the exterior of the station a striking blue, this being an unusual color for fronts of buildings, served at once to attract the attention of the neighborhood, and it was soon known as the "House with the 152 INFANT MORTALITY AND MILK STATIONS Blue Front," and greatly aided the nurses in directing the mothers to the milk station, by simply giving the street upon which it was located and telling them to look for the "House with the Blue Front." In most of the stations there were signs, either at right angles to the front of the station or painted upon the large plate-glass window. The interior of the station being in white, its white- enamel furnishings and linoleum floor-covering gave the visitor the impression of clean, sanitary surroundings. Building up the Station Enrolment The location of the station was determined, quarters secured, and the prem- ises renovated and painted, furniture and equipment installed, and the organiza- tion was completed by engaging a nurse, matron, and a physician for carrying on the work of the station. With this personnel, work was begun immediately to build up a station enrolment. The nurse visited the dispensaries, hospitals, settlements, clergy, social workers, private practitioners, and druggists of the district to make known to them the aims and purpose of the station, and to obtain their cooperation, urging them to refer babies to the station for feeding supervision. The following postal-card form was distributed to facilitate referring cases : Date We have this day temporarily referred for feeding to Milk Station No Street of the NEW YORK MILK COMMITTEE Name Address _ Remark: Physician Exhibit 26 Wall-cards and convenient pocket-cards, giving the locations of all the milk stations of the city and the organization conducting the work, were left with those who were willing to cooperate. Large printed signs were placed in the window of the station, to announce the work that was to be carried on, and to notify mothers to bring their babies for examination by the station physician. These were also placed in store windows, and not infrequently were to be seen in corner saloons. Hand leaflets, showing contrasts between sick and well babies, and urging mothers to bring their babies to the stations, were distributed by druggists and shopkeepers, with good results. ESTABLISHMENT AND OPERATION 153 After making this announcement of the opening of the stations, the nurse began canvassing systematically the tenements on each street of her district. From the janitors she obtained information as to the families having babies under two years of age, and these homes were visited and the mothers urged to come to the stations with their babies. They were told the purpose of the station and the kind and price of the milk dispensed. As the babies became registered the mothers were given circulars to distribute among their neighbors and friends ; they were asked to bring with them other mothers whose babies were sickly, to get them well; and those whose babies were well, to learn how to keep them well. Each home having a baby under two years of age needing supervision was visited, and the following card form was filled out: Name Jf' ELIGIBLE BAB^' FUght O^ frt. h^-^\it. rr. house Address 'Ty l^-%'<^%/l/^^ tpy . Breast Fed Partly Breast Fed. Artificially Fed f^.. j^jjLfT- Raw... Pasteurized /Modified. Bottled ... Loose ^<^ondensed. Date fkf.. Condition '>^ Supplied by Pat. Food Action Taken — Remarks "llr^ij ^t3!Zi^ ^^^^^_/;^^^^fci2 "L^y XAELE Food N.Visit Mf i 2 I »5 V M ^ Id lU^HtP^U^^- U'li/^^^^ ^^^^xJ^ ^ % H Jt^ j^ ^aA4^^^^ ^-^^^^^t^ZJ ^ OJoi^-^iu i^'^- ^i^^*i^^ g j/ ^ H ^iicj liroT^^ ^^^^^ /"<^i^;L^ Exhibit 27 This is a salmon-colored card, 3x5 inches, punched so as to carry in a loose- leaf cover, and is known as the "Eligible Baby" record. The term "eligible babies" refers to those babies who live within the district which the station is supposed to serve, and who, in the judgment of the nurse on visiting the homes, need the care and supervision of the milk station. In other words, every home visited in which conditions were unfavorable, due either to poverty, ignorance, or neglect, the baby was considered a candidate for registration at the milk station. The above record shows that this particular baby lives on Cornelia Street, second flight, back hall, and apartment to the right. The baby was born on April 1, 1911, and artificially fed on "loose" (dipped) milk purchased at a gro- cery store. The date of the first visit to the home was August 15th; the con- dition of the baby indicated was "poor." The nurse urged the mother to attend the clinic, and instructed her in the care of bottles, nipples, and milk. The nurse revisited the home on August 19th, 23d, 27th, and 31st; the last was for the pur- 154 INFANT MORTALITY AND MILK STATIONS pose of bringing the mother to the station to have the baby examined by the station physician. A Registered Baby Once a mother brings a baby to the station and the baby is examined by the station physician, and the mother promises to follow the instructions given to her by the physician and nurse and attend the consultations as directed, the baby becomes a "Registered Baby," and the following card record is made: t i ^ I t^ z B0RN.,4~.l.::'.i f REGISTERED BABY Flight 2j frt. bck. rt^ [ft. rr. house Relief Case ...k ^asr I.4r..l Name L Attendance at Medical Consultation Case. Address 2>5 Govncl \0i St Date ^/i 31 Condition Hi Action B.W.die.t J(ohr3 Home Visits Date 8 V51 Action Taken Instructed mothc .r Next Visit % \m ipnm'A how to m(it{e R W y. ^+ 7. Irncjoted bowcJ. ^/< ^A z\ VprM m ^ Saline. % 01^ % Taucjht miikma d |i£al] ion Mll bh sta l h Tion ^/l9 Rnhi j has dm ^ q /con . on ar\d Ran, diet % £2 Sal n^ Attendance at Medical Consultation | Home Visits Next Visit Date Condition Action Date Action Taken 7l8 Imbrovec So me. disConTin. e.d Saline, ivvigntion %4 '75 gcod Honp, %4 II •• %5 '% ■ '^ ] __4: £ 3 5 i '^11 _ 2 ^ _, _i 3- o a 2 j 'o" 1 ^ rr s a, y "^ 0. ^ £■ • 1 CO ^ "T- r^ 1 ^ t ^:::::::_i J i! '^ X > 4: ■ ■^ s:::: l 1 > ^ i' III ^ ?; ] I S ^ ^;;; _ ■!____ ____ ^ z ^ < a i ■I £ 5 S i ^ ^ Vj o 1. ^^^ 5^ i\^ i\^V 0-v. ^ > :^ s z;:_\ ^ .• 1^ ^ '^S]: i \ = ^t X \ ^ 7 "^s :[:::::::__i % ^ -) w £ > i^ ^ ^ ,^^^\>L V^ ^v. ::v ^s i: \ js,, 2 E I ^ V OQ ^ V i: * '-* ^ii __ _L \ _ _. " ^ ^ - «> «^ S ij -Jr^^j-l/TS^r) ( ;J i S \ ^^ 4\t ^V o r r>^ ^^ ?' V'Zi:^ v--^'^-— '.--—- ■-11 t; iS 5^^ :$ s i?^^u^= ■•^*^'^5'5-"7-^e' V X 1% It' < S i OC D T 3 > £H*^\^ ^\^ ^- ro ->;; L- -^"^t • ''''"5V~^ '-^^^ \ ? ^ S u ;^ o j-.-:^-«>cT-^^ -J ■V-'-S k i I ■^ A^^A'^ A^ ^0, O «!« !> 9 2 ~- r"^*""- -It •^■•-■^•f •! -j?»j» 1 V en 4 L y ^ o o LU UJ Ll llI C- Ll. - W Q ' < UJ S i Z 2 o o K -1 -J , ^^ Cx >vi; » ""t-?q vrjfn '~>r'7(j> , A r- ^^e\l> '-;7?p'^S| --p,^7P r 1 - ^- -'52^Jii^'^n]\^^57 i. ^'«f^' b^w^i ^^^^'^'^^-wv'hi: ->^p^^-/£ Vt p ^ «^ "l^'? rvrdg^ , ^^^ "^^ ►; ^ JV ( -Uo, 4* ^M" ^ >* ;> r/ r^ J^ j' \ -^- -'^«^^*^^ /^^«^a' r't'^H>/f \| "" " - " "^ " i^'^Tn^^^ -^^L o ^'Jr»'«0;f.'';» J^-v^n^jj'ry -1 j^:»;1r i,^^^ ■y>^'' woo LLl I I en ' o. -^--^ .rH't2T-z^.V J " » "i""iz"" _^,__, •^j^c-^t"^?^^- " ^7^':i'B^--i^><'r'^t7 y^^^?*^"'^'!?' ^*/' y2_ar'^>«^''"^, '■^' ? -T»"'^-'/r^'*r[ \'7'i-^ M.' ^■^ ^ .^i^^fff^f^v^' A.*-f j3j^r) ■i'M\*?ifu'i ^ --'yiai^f-^ny^l^h.^^-'j^r^li .'■^Kyiyy^^y^ff) c 2 J Ll < 2 C^ 1- o - S3L0rJ M\'IDISAHd "^^ " - '~~ _ z___ q i' ^~- 1- LL cr o m > V- t < -J i§ 5 1 5 5 r. < ^ M 1 \t o °- ^ O z c - JC ^ — ?| "5 £ 1 z S IJ^J (Jooicor^u^Lnt^f^CN^oa^oOf^tX)^ 5 O 5 5 SQNnOd Nl 3AanO-iHDI3M ! ' N0liVNIl/^VX3 NO NOIiiaNOO "IVaiN30 a3IJiaOlN 31AI0H t- < UJ IX. CO OOOi lai 1 l-t-8 O "X " S J p ESTABLISHMENT AND OPERATION 155 I This card contains the important information shown on the "Eligible" card of the baby, and the current information as to the clinic consultation, the action taken by the station physician, the home visits, and notes of the station nurse. It forms the working memorandum which can be conveniently used by the nurse in exercising supervision and control over the case. This card form also has punched holes for carrying in the loose-leaf binder whenever the nurse makes her home visits upon the case. Both the "Eligible Baby" and the "Registered Baby" card forms are filed at the station in a tickler file, under the date on which the case is to receive further attention. When the "Eligible Baby " becomes a " Registered Baby," the " Elig- ible" card record is then filed alphabetically, in a terminated record file, and the "Registered" baby card beomes the active record. When the registered baby is attending clinic regularly, with no unusual conditions prevailing which would require home visiting and special work on the part of the nurse, this record is filed by street and numerically by the house number. If home visiting, etc., is necessary, the card is filed in a tickler file according to the date on which further action regarding the case is to be taken. Upon termination of a case by removal, transfer to hospital, or other agency, etc., the record is then filed alphabetically in a file for terminated cases. The registration card gives information as to the name of the baby, the address, date of birth, whether the case is one in which relief is extended, and the case number. The form also provides for recording the attendance of the baby at the medical consultations, its conditions, and the action taken as a result of the medical examination. It further provides for recording the home visits made by the nurse by giving the date of the visit, the action taken, and the date of the next visit, if such is necessary. The date indicated for the next visit determines the date under which the card is to be filed in the tickler file by the nurse upon her return to the station. Individual Weight Chart and Medical Record of Baby In addition to the foregoing card record maintained for each registered baby, a weight chart and medical record is kept in each case. This record is a 9^ x 1234 inch card, printed on both sides. One side is used for recording information relating to the baby if under one year of age ; the other side, if over one year of age. This record is made up at the time the baby is first examined by the station physician, and the mother agreed to follow the instructions of the physician and nurse. (See Exhibit 29.) This record provides for recording the name and address of the case, the date of birth, the number of the case, the station at which the baby is registered, sex, whether full-term or premature birth, reported weight at birth, length of time breast-fed, length of time mixed fed, the reason for artificial feeding, the kind of food given, nationality of mother, and the names of the station physician and nurse. All this information relates to conditions existing at the time the baby is registered. The major part of the form provides for recording information relating to the case, as noted by the station physician, and the kind of action taken. In the 156 INFANT MORTALITY AND MILK STATIONS upper part of this space provision is made for recording the month and the date the case comes under the observation of the station physician, the kind of formula for home modification if artificially fed, instructions regarding the number and intervals of feeding if breast-fed, and the weight of the baby in pounds and ounces for the age in weeks. The lower part of the chart records the general condition upon medical examination at entry, the physician's notes regarding the case, the average weight curve for normal babies, and the weight curve of the particular baby under ob- servation. The reverse side of the card records similar information for the baby in its second year, the main difference being in the normal weight curve. These chart records are filed alphabetically, according to the clinic or the consultation day on which the mother is instructed to bring her baby to the station. Whenever a case is transferred to another station, the chart record, together with the other records pertaining to the case, is forwarded to the station to which the baby is being transferred. If the case is terminated for whatever cause, the chart is filed alphabetically under terminated cases, and the reason for termination is reported to the central office. Case History Card In addition to the registration card and weight chart and medical record, a case history card is made out for each baby registered. This gives information concerning conditions which prevailed previous to admittance to the station, and takes the character of a social record of the case. This is a 5 x 8 inch card, printed on one side ; the following shows the form of this record : Exhibit 30 ESTABLISHMENT AND OPERATION 157 The information relates largely to a history of the baby and its home condi- tions. The record is compiled as soon as possible after the baby becomes regis- tered, generally on the first visit of the nurse to the house after registration. The arrangement of items provides a convenient way for recording data by checking the items upon which information is desired. The purpose of this history card was to ascertain the character of the homes which the milk station was able to reach, and the previous history of cases coming under their influence. It greatly facilitated matters in looking up a case whenever application for relief was made. Artificially Fed Babies When artificial feeding is prescribed for a registered baby, the mother re- ceives the daily supply of milk from the station. If it is not a case of extreme poverty, she is required to pay seven cents for a quart bottle and four cents for a pint bottle of milk. If the case deserves relief, milk is furnished upon instruction from the central office after the case has been investigated and some organization or individual has agreed to reimburse the station for the amount of the value of the milk dispensed in the form of relief. For the purpose of control over mothers coming to the station for their milk supply a ledger, providing a page for recording information relating to each case, is maintained ; the case is identified by the case number given the registered baby. The quantity of milk dispensed each day, also the feeding formula, as prescribed by the station physician, is here recorded. All this affords an important means of control over mothers having babies registered at the station and artificially fed, as the matron dispensing the milk promptly reports to the nurse cases where the mother fails to come for her daily supply. These are immediately followed up by the station nurse, to determine the cause; usually, if the baby is well, mothers are apt to be negligent or careless in making their station purchase, and, through motives of economy, substitute cheap grocery milk. The ledger has column-rulings with the following headings : Date Milk Dispensed Quarts Pints Cash Received Relief charged to Formula prescribed (oz.) Whole Milk Oatmeal Water Lime Water Barley Water Boiled Water Plain Water Milk Sugar Cane Sugar Feeding Intervals By having recorded the feeding formula of the baby receiving the milk, the nurse and the matron have conveniently at hand information as to the feeding and the quantity of milk the mother should buy for her baby. It is further used for 158 INFANT MORTALITY AND MILK STATIONS questioning the mother in regard to the feeding formula prescribed. If no change has been made in this for several weeks, it is an additional means of bringing to the nurse's attention the failure of the mother to bring the baby to the consulta- tions for the purpose of having any necessary changes made in the feeding formula, as no formulas are supposed to be written for a longer period than three weeks. Character of Reports Rendered by Station Employees During the demonstration daily reports were made out at the close of each day's work, by both physician and station nurse, and mailed to the central office, where daily tabulations were made and the results used for general supervision and control. Nurse's Daily Report Card The nurse made her daily reports on the card form, 4x6 inches, as shown in Exhibit 31. This report provides for reporting the name of the nurse, the date, station number, hour of arrival, and hour of her departure; information relating to changes in the station enrolment by giving the cases brought forward from the previous day; the new babies received, and from where they were received; the registered cases terminated, and the reason for termination, with the total number of active cases carried forward to the next day; the first visit, and revisits of well babies and sick babies to the station; the number of first visits and revisits made by the station nurse to homes of well babies, sick babies, babies not found; the number of visits and revisits of cooperation to dispensaries, hospitals, settlements, private practitioners, charitable organizations, etc., and the total number of first visits and revisits, and total for all visits. The form also provides for recording the number of mothers instructed indi- vidually, once or more than once, in the modification of milk or other matters relating to the care of the baby ; the number of mothers instructed in classes for the first time and for two or more times, and the total number instructed. In the lower right-hand corner of the report is recorded the number of babies fed, the number of mothers fed, and the others fed, and the total individuals to whom milk was dispensed; the number of requests for relief, the number of cases where instruction had been received to extend entire relief, partial relief, or to refuse or to discontinue relief. Space is also given to the daily accounting of milk received and dispensed by the station, recording the number of quarts and pints carried forward from the previous day's supply; quantity received on the date to which report relates, and the total amount to be accounted for; the quantity dispensed to babies, mothers, and to others; quantity transferred to other stations, spoiled, or left over, and the total quantity accounted for. The reverse side of the report provides for recording the name, address, time of visit, and recent action taken, and the date of the next visit for each home. Information is also recorded relating to cases transferred to hospitals by giving the name, home address, reason for transferring, name of hospital, and the date on which the case entered the hospital. For deaths among station babies the ESTABLISHMENT AND OPERATION 159 form provides for the name, the home address, the cause, the place where the death occurred, and the date of death. Form N— 10-/)-ll-3000 i \ NEW YORK MILK COMMITTEE Attendance First Visk Re- visit Total Date VV.f.fr^* /...../ ,9,, station Nun F»/^^. Mothers y f A3 Babies, well 4 7 // ARRIVAL /rrr. J ^ Babies, sick -a/ ^ DEPARTURE /^^/r^ ' ./^....y'^:"jL^ ^fi^Fr^. NURSE Visits to well babies . . / 4^ ^J" CASES BROUGHT FORWARD \/J'^ Visits In sick babies . . d y Cases Received Terminated Visits to babies not found / / Ref. Trans. Other To-.al Trans. Other " Total Visits of co-operailon . . Re-admilled Total visits /^ Hos. or Disp n^ -2^ Mothers Instruct. Iiidiv. .r J Board of Health .... Other Organization . . / / Mothers Instruct. Classes Other N.Y.M.C. Station Babies Fed . . 3! Milk QUI. Pts. Private Practitioner . . / / Mothers Fed . 3 Carried forw'd -• Canvass ^ ^ Others Fed . . .-^ deceived . . . /zi^ a-ij' { 7 7 // «?^ },i£a^>-i <^a^ -7" d-J lo^ ^<.^>^.0^j ^^ •sCc^yi. jiri C.J 3 Jll ykc2^Se^_£c/iJU{lu<^ 5 /Ig /Uc-<_< ^iC C.y3 .^ Ccco/ &£j&it^ OQ^ti. W.-Cfc-fafc«.> «^Co-<^ ^^/y C. 7 J /> /y^ M. CtdUij^i^^*^^ -^ ' 7/uC^r A^'O-^'^ ^21 ^-^ C 'P^ 3^ hcJ %C^li^.UcA JJuMj j^lLfc, flU*, X,j>,.-.o^ /-ZK-. C. ') £> >//" :^>^i^*^ Uh:^ aZlt^e^^^ ^■p^ aft //- /jT /t/**— <>»»?S?Z>;>4«/ ^ 10 Ax^i^ /US I CbtJ ^ ^1^ ^.^ ^ CiUf. Ju/f-^.*^£^ K. /o AaSENT TO it., a Ji-^ye.^^^ home Address c*^&.^«^^*-^ .k-. Name of Hospital ^jJLJL /Xfc*-*^ ^ ^ DeTtms (^j.v/ r;^ ♦ o '/ ^ ■. % '">, 1 1 1 1 1"^ $1.90 i 1 1 1 g o 3 Bo^ s ^ ^sS < kl^ < ita < <%& k ila < ^£q < i.'ia •^ hour after milk. SECOND MEAL-DXmiNG FORENOON. Milfc alone or with zwieback. NOON MEAL. (1) 6 ounces soup 3 ounces beef juice. NOTE: Soup msy be made of chicken, beef or mutton. (2) Stale bread may be added to the above. FOURTH MEAL- AFTERNOON. Milk or toasted bread and milk. EVENING HEAL. (I) 4 ounces thick gruel mixed with 4 ounces top half milk. NOTE: Crutlr hominy „« be made ol oa , whcatina. or ric nicji. farina, barlev. (2) Apple saJce Prone jelly. Total milk i o I.' J quarts. n 24 hours. 1 NOTE. 8 ounces IS equ a haJl Pint. DIET FOR CHILD FROM J8TH TO 24TH MONTH BREAKFAST. Jttice of I sweet orange Pulp of 6 stewed prunes Pineapple juice (fresh or bottled) I ounce. A rereal such as cream of wheat, oatmeal, farina, o hominy preparations with top milk (top 16 ounces sweetened or salted. A glass of milk, bread and buttei NOTE: If constipated give the fruits ' , hour before break- , they I either ' 1 duri r before FORENOON. A glass of milk with two toasted biscui graham crackers. ts or zwieback or DINNER. . 1 1 Broth or soup made of beef, mutton, thickened with peas, farina, sago or or chicken, and Beef 'juice with stale bread crumbs; c soup with yolk of egg r clear 7CgetabIe Egg soft boiled, with bread crumbs, or with a glass of milk- the egg poached. t2i Dessert: apple sauce, prune pulp, with or graham wafers stale lady-fingerB Plain pt<3dings; rice, bread, tapioca, blanc-mange, junket ,or baked custard. SUPPER. Glass of milk, warm or cold; iwieback and fruit. custard or slewed rts. Total milk ih 24 hours. I > . qu. COMMITTEE FOR THE REDUCTION OF INFANT MORTALIIY NEHf YORK MILK COMMITTEE DIET FOR CHILD FROM TWO TO THREE YEARS 'BREAKFAST. Juice of I sweet orj^rtgc Pulp of 6 stewed prunes I ounce pineapple juice (fresh or bottled) A cereal such as oatmeal, farina, cream of wheat, hominy or rice, slightly sweetened or salted as preferred, with the addition of top milk (top 16 ounces) A soft boiled or poached egg with stale bread or toast. A glass of milk. NOTE: If constipated kJvc the fruits ].i hour before break- erj if not. they may be given during tte fOT€ 7 fruit DINNER. Broth or soup made of chicken, mutton or beef, thickened with arrowroot, split peas, rice, or with addition of the yolk of an egg or toast squares. Scraped beef or white meat of chicken or broiled fish all , nt) Mashed or baked potato with fresh peas or spinach or Dessert: apple sauce, baked apple, rice pixdding, Jtinket or custard. SUPPER. A cereal or egg (if egg is not taken with breakfast) with stale bread or toast Bread and milk or bread and cocoa or bread and custard. Stewed fruit. COMMITTEE 'FOR THE PEDUCTION OF INFANT MOPTAtlTY' .VEW YORK MH-K COMMITTEE DIET FOR CHILD FROM THREE TO SIX YEARS BREAKFAST. Fruits: an orange, apple, pear or stewed prunes. Cereal : oatmeal, hominy, rice or wheat preparations, well cooked and salted, with thin cream and sugar Egg: soft boiled, poached, omelet or scrambled. Mjlk or cocoa. DINNER. Soup: beef, chicken or mutton. Meat: chicken or beefsteak or roast beef or Iamb chops or fish. Vegetables: spinach or carrots or si ring -beans, peas. cauIiHowcr tops, mashed or baked potato, beets or lettuce (without vinegar). Macaroni, spaghetti. Bread and butter not fresh bread or rolls. Dessert: custard, rice or bread or tapioca pudding, icc cream (once a week), cornstarch pudding (chocolate or other flavor), slewed prunes, or baked apple. SUPPER. A thick soup, as pea. butler A cereal and thin creai Stewed Iruit: cusljrd i ■earn of celery with bread and (.Ih bread and butler. I plain puddinR: jam or jelly.. Exhibit 38 Suggestions for Diet for the Older Children, Distributed Through Milk Stations EXTENSION OF MILK STATION ACTIVITIES 173 of these were distributed by the milk station nurses. (See Exhibit 38.) These special diet cards gave suggestions for each meal for children of different ages; for example, the diet card relating to children from twelve to eighteen months gave suggestions for the first meal on rising; the second meal during the fore- noon; the noon meal; the fourth meal during the afternoon, and the evening meal, and the total amount of milk which should be given during the twenty- four hours. Similarly, the diet is prescribed for children from the eighteenth to the twenty-fourth month, two to three and three to six years of age. For the child of two to three years the mother is told that the breakfast should consist of fruit, cereal, and milk, or fruit with soft-boiled or poached egg, with stale bread or toast and milk. She is told that if the child is constipated, to give fruits one-half hour before breakfast with water, and if not, the raw fruit may be given during the forenoon, and that milk and raw fruit- juice must not be given at the same meal. That the diet of the midday meal should consist of broth or soup, meat or fish, vegetable, and dessert. The kinds of soup or broths are given, as is also suggested the kind of meat, vegetable and dessert. For the evening meal, a diet of cereal or eggs with stale bread or toast ; or bread and milk ; or bread and cocoa; or bread and custard and stewed fruit are prescribed. It is difficult to estimate the amount of good the distribution of these diet-cards did, but the mothers seemed glad to receive them, and in many instances followed the direc- tions explicitly, particularly in those cases where the children were in delicate health. The influence of the milk station in promoting the health and welfare of the older children cannot be overestimated. Appendix COMPARISON BETWEEN THE BACTERIA CONTENT OF MILK DISPENSED BY THE MUNICIPAL MILK STATIONS AND THAT DISPENSED BY THE NEW YORK MILK COMMITTEE STATIONS Period, August 22 to September 9, 1911 The municipal stations dispensed pasteurized milk and the New York Milk Committee dispensed raw milk from tuberculin-tested herds. In both cases samples were collected and examined by the same laboratory. New York Milk Committee Stations Municipal Milk Stations Date Aug Sept Bacteria content per c.c. Bacteria content per c.c. 22 28,500 15,000 22 8,900 22 12,500. 22 12,000. 22 6,200. ,000 12,500 37,000 16,000 17,000 22,000 1 1 1 1 2 2 25,000 2 2 5 5 5 5 5 14,000 9,500 6,000 24,000 8,300 10,000 5,500 15,000 10,500 6,000 5,800 5 5,500 6 12,000 6 40,000 6 15,000 6 12,000 6 135,000 150,000 8,300 , 22,000 7,500 , 60,000 6,000 , 24,000 12,500 , 15,000 6,500 , 7,000 24,000 . 10,000 70,000 . 7,200 26,000 . 12,000 45,000 . 8,500 50,000 . 20,000 11,000 . 12,000 12,000 . 23,200 25,000 . 15,000 10,000 . 20,000 24,500 174 APPENDIX 175 STATEMENT SHOWING BACTERIA CONTENT OF SAMPLES OF MILK TAKEN FROM NEW YORK MILK COMMITTEE STATIONS AND EXAMINED BY DR. NORTH'S LABORATORY AND DEPARTMENT OF HEALTH (Samples taken four to ten hours after delivery of supply to station and two to three hours after the mothers had received their day's supply.) Number OF Samples Under 5000 Bacteria Content per c.c. 1911 5000 TO 10,00 10.000 TO 20,000 20,000 TO 30,000 30,000 TO 50,000 50,000 TO 75,000 75,000 TO 100,000 OVER 100,000 May June 11 23 23 35 37 9 6 10 1 1 2 4 6 3 12 14 3 1 4 7 5 12 2 1 7 5 5 1 1 2 2 1 1 1 1 2 2 July August September .... October 1 9 2 1 138 20 42 31 19 6 5 2 13 STATEMENT SHOWING A SUMMARY OF THE WORK OF NEW YORK MILK COM- MITTEE STATIONS, AS PER TABULATION OF DAILY REPORTS Period, May 20 to October 31, 1911 Number of babies on hand May 20th 634 Number of babies received 7,951 Received by transfer 291 Hospital or dispensary 24 Board of Health stations 35 Other New York Milk Committee stations 180 Other organizations 52 Received by reference 636 Hospital or dispensary 80 Board of Health stations 216 Private practitioners 193 Other New York Milk Committee stations 27 Other organizations 120 Received by canvass 6,538 Readmitted 486 Number of cases terminated 3,648 Refused to continue to attend 1,657 Removed 1,053 Transferred 780 To other New York Milk Committee stations 367 To Board of Health stations 24 To hospital or dispensary 218 To other organizations 92 To private practitioners 79 Died 158 Gastro-intestinal diseases 79 Other causes 79 Total number of babies on hand October 31st 4,937 176 INFANT MORTALITY AND MILK STATIONS Statement Showing a Summary of the Work of New York Milk Committee Stations, AS per Tabulation of Daily Reports, — {Continued.) Attendance at milk stations for advice 43,739 Mothers' first visits for advice 7,921 Mothers' revisits for advice 35,818 Well babies' first visits 5,876 Well babies' revisits 28,500 Sick babies' first visits 1,785 Sick babies' revisits 3,425 39,586 Home visits To well babies' first visits 7,463 To well babies' revisits 12,803 To sick babies' first visits 1,551 To sick babies' revisits 3,778 To babies' (not found) first visits 1,572 To babies' (not found) revisits 2,060 29,227 Visits of cooperation, first visits . 318 Visits of cooperation, revisits 206 524 Number of mothers instructed first time 12,401 Number of mothers instructed two or more times 9,964 Total number of mothers instructed individually 21,471 Total number of mothers instructed in class 894 22,365 Total new requests for free milk (relief) 903 Number given free milk (relief) Milk dispensed (quarts) 420,451 To babies 344,694 To mothers 36,377 To others 33,275 *Milk dispensed (quarts) from May 20th to May 31st 6,105 Total number of physicians' consultations 1,243 Total number of babies examined 27,095 Well babies examined (cases) 23,788 Sick babies examined (cases) 307 Number of cases referred to hospital or dispensary 562 Surgical treatment 138 Medical treatment 424 * Not itemized. C2e(251 ) lOOM 1,^ U. BINDERY 2 81948 Ul_ "iBBWS KM*' ^"-'-^ NA^, RESERVE sfelF (plO .'^rX: b t\'i l&i;