COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64074714 RA61 N48 Infant's milk depots RECAP INFANTS' MILK DEPOTS AND THEIR RELATION TO INFANT MORTALITY THE NEW YORK MILK COMMITTEE OF THE NEW YORK ASSOCIATION FOR IMPROVING THE CONDITION OF THE POOR 105 EAST 22 nd STREET Columbia 3Hmuer£ttp mtfjeCttpof JBtetoPorfe College of $i)pgtctan* ano burgeons Reference lUbrarp BORDEN'S MILK Is the result of more than fifty years' careful study and experience in the dairying- industry, through the use of such methods as have been proved practical for the production of a milk supply representing" the highest degree of cleanliness, purity and quality. Our milk is supplied from dairies where cleanliness is a science, where all cows are regularly examined by our competent veterinarians, where the herd and all details connected with the dairy work are under our control and the constant supervision of our carefully- trained inspectors, and where all conditions are such as contribute to a milk supply that cannot be surpassed in real merit. We keep in constant touch with the health conditions of all persons having to do with the dairies. All cases of contagious or infectious disease are immediately reported to us, and the supply of milk from such sources is withheld at our own financial loss. This one feature of our plan is of inconceivable value to our patrons, and alone should commend our products to every thoughtful user of milk. Our Peerless Buttermilk is especially prepared daily from this same supply of fresh, pure, clean milk. The process of preparation converts the milk sugar into lactic acid, making it very beneficial for use as a food and beverage. In the light of recent investigations, which have shown the great value of lactic acid ferments as an aid to digestion, Borden's Peerless Buttermilk is a product of great merit. BORDEN'S CONDENSED MILK CO. "Leaders of Quality" Est. 1857 The Sterilizing Bottles used by the New York Milk Committee are furnished by JEANNETTE GLASS CO. J E ANNETTE, PA. Manufacturers of Flint Glass Bottles, Perfumers' Ware, Druggists' PrescriptionWare and Specialties NEW YORK OFFICE 2 BARCLAY STREET SHARLOW BROTHERS 442 West 42nd Street and 439-441 West 41st Street NEW YORK CITY Manufacturers of Crates for Infants' Milk Bottles Also Milk Dippers, Milk Kettles, Measuring Rods, Cream Stirrers, and other Milk Bottle Carriers Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/infantsmilkdepotOOnewy INFANTS' MILK DEPOTS AND THEIR RELATION TO INFANT MORTALITY THE NEW YORK MILK COMMITTEE OF THE NEW' YORK ASSOCIATION FOR IMPROVING THE CONDITION OF THE POOR 105 EAST 22nd STREET N THE NEW YORK ASSOCIATION FOR IMPROVING THE CONDITION OF THE POOR OFFICERS AND MANAGERS 1908-1909 President R. Fulton Cutting Percy R. Pyne Howard Townsend Treasurer Robert Shaw Minturn Secretary Leonard E. Opdycke Counsel John L. Cadwalader Vice-Presidents John Seely Ward, Jr. George W. Wickersham General Agent Robert W. Bruere Supt. Relief Dept. Mrs. Helene Ingram Supt. Fresh Air Dept. Alice Page Thomson BOARD OF MANAGERS Elected 1877 R- Fulton Cutting 1880 T. Franklin Smith, M.D. 1891 De Witt J. Seligman 1892 Robert Shaw Minturn 1893 Howard Townsend 1893 George W. Wickersham 1894 Andrew Mills 1895 Percy R. Pyne 1895 John Bancroft Devins, D.D 1896 Leonard E. Opdycke 1899 John Greenough 1899 Isaac Townsend 1899 Herbert Parsons 1899 Henry G. Barbey 1899 Charles Wisner Elected 1900 John Seely Ward, Jr. 1900 Eugene Delano 1900 George S. Brewster 1902 B. Ogden Chisolm 1904 Albert G. Milbank 1905 George Blagden 1905 Augustine J. Smith 1906 Charles C. Burlingham 1906 Victor Morawetz 1906 Frederick Trevor Hill 1907 John G. Agar 1907 Linsly R. Williams, M.D. 1907 R. Bayard Cutting 1907 Frederic P. Moore 1908 Franklin B. Kirkbride THE NATION PRESS. 20 VESEY STREET THE NEW YORK MILK COMMITTEE GEORGE W. WICKERSHAM, Chairman. Ernest Hamlin Abbott Hugh D. Auchincloss E. H. Bartley, M. D. Pres. Nicholas Murray Butler Henry Dwight Chapin, M. D. Henry Ives Cobb Lewis A. Conner, M. D. R. Fulton Cutting Richard Harding Davis Simon Flexner, M. D. Joseph N. Francolini Rt. Rev. David H. Greer E. Eliot Harris, M. D. Frederick Trevor Hill L. Emmett Holt, M. D. Loton Horton Edward F. Hurd, M. D. John S. Huyler A. Jacobi, M. D. Walter W. Law, Jr. Ernst J. Lederle, Ph. D. V. Everit Macy A. J. Milbank Cleveland Moffet Robert C. Ogden Percy R. Pyne Joseph H. Raymond, M. D. Mortimer L. Schiff Samuel Sloan, Jr. Charles Sprague Smith John Spargo Frederick T. Van Buren, M.D. E. H. Van Ingen Prof. H. T. Vulte Rev. William J. White EXECUTIVE COMMITTEE: Stephen G. Williams, Chair-man David Bovaird, M. D. Robert W. Bruere Haven Emerson, M. D. Alexander Lambert, M. D. Charles E. North Godfrey R. Pisek, M. D. Charles T. Root DeWitt J. Seligman Linsly R. Williams, M. D. Wilbur C. Phillips, Secretary. 105 East 22d St. Telephone 348 Gramercy. "J^( ? § c ft c i I r 1 L 8S i * H § f * j ^ IS 1 ^ [ J ^ J * tf J ^ 1 5 _4_ FOREWORD. ^e The following report is intended for all persons interested in saving the lives of infants. While it deals with conditions in New York City, the principles which it illustrates and their method of application are, with such modifications as individual communities may require, feasible elsewhere. Experience is a great teacher, and those who build upon the experience of others are fortunate. The Milk Committee has so built, and it now offers its failures, its successes, and its ideas to those who care to profit by them. Any information about its work not found in this report, will gladly be sent to any one applying to Wilbur C. Phillips, Secretary, New York Milk Committee, 105 East 22d Street, New York City. Robert W. Bruere, General Agent. The New York Association for Improving the Condition of the Poor. CONTENTS. Page Introduction 9 The Organization of the Milk Depot Work ( i ) Preliminary steps 13 (2) The milk; its selection, production, transportation and tests. 14 (3) The formulae 20 (4) The modification of the milk 21 (5) Sanitary methods at the laboratory 22 (6) The location of the depots 24 (7) The engaging of the nurses 26 (8) The preparatory work of the nurses 27 The Conduct of the Milk Depots 28 The Conduct of the Consultations 32 The Statistical Side of the Work 36 The Physicians ; Their Work and Organization 47 The Finances of the Depots (1) Initial expenditures, equipment, etc 49 (2) The business maintenance of the depots 52 (3) Relief ; its method of dispensation 53 (4) Cost of the educational work 54 (5) Financial statement 55 The Work of the Nurses Not Connected with Milk Depots 57 A Study of the Results Obtained by the Nurses in the Milk Depots and by the Nurses Not Connected with Milk Depots. ... 59 The Experimental Program — Facts Shown by the Summer's Work Experiment No. 1. — What are the comparative results obtained by the continued use of pasteurized and of raw milk? 63 Experiment No. 2. — Which is the more economical and satisfactory method of saving infants' lives — the purely educational program carried on in connection with the ordinary milk supply, or the sale of modified milk dispensed by nurses who ^Jso do instructional work ? 65 Experiment No. 3. — Can infants' milk depots be run on a business basis, and if not, in how far will philanthropy be needed to support their "work" ? 69 This question is considered under the following heads : (1) The production, handling and sale of the milk (business) 70 (2) The investigating and relief of necessitous cases (philan- thropy) 74 (3) The feeding, instructional and statistical work (medical) 76 (4) The "follow-up" and statistical work (social or muni- cipal) 77 Summary 80 INTRODUCTION. Infant mortality, in the opinion of most physicians and social workers, remains one of the biggest problems that confronts society. For years, it has been the object of serious concern to governments and municipalities, and has won the attention of physicians, philanthropists, milk dealers, sanitarians, and social workers, not only in this country, but also in France, Germany and England. In spite of everything that has been done, how- ever, the total number of deaths among infants has not appreci- ably decreased. Isolated agencies have produced results in cer- tain quarters, but, as directed against the whole problem, their efforts have been like those of scattered whippers in a forest fire — apparently in their own section of the forest they have the fire under control, but the wind, the sparks, the heat, the draught, and a hundred other factors still remain, each to assume at any moment the leading role in the program of conflagration and death. That this is so, is shown clearly in New York City. Here, in unusual abundance, are found elements to combat infant mortal- ity. Yet in spite of all that has been done by philanthropists, milk dispensing agencies, hospitals, sanitarians, physicians, social workers and the municipality, the number of deaths of infants under one year of age in 1907 was 17,437; — that is to say, con- sidering the whole population, rich as well as poor, for the space of the entire year, between 140 and 150 babies out of every thou- sand born died before they reached the first year of age from causes which were largely preventable; whereas, considering the poor population during the hot weather alone, the rate in con- gested quarters was from 200 to 400 deaths per thousand births. io A. I. C. P. These striking figures, which as far as actual percentages are con- cerned, are exceeded in many other cities, give some statistical idea of the relation of infant mortality to our civic and national life, but they can never portray the pain, the loneliness and the wretched- ness of which they are merely the numerical index. To appreciate their full meaning is impossible ; it is beyond human capacity, and can only be understood in part by those who have suffered bereavement through the death of some little one. In order to help reduce infant mortality, and to throw light upon important matters connected with it, the Milk Committee last spring decided upon a year's campaign, of which the following is the first quarterly report. Its purpose, apart from the actual good which it hoped to accomplish through the saving of lives was educational and constructive. It aimed to build upon founda- tions already laid, to take advantage of all demonstrated facts, rules and principles, and with them as a starting point, to see if, by any improvement, combination or arrangement, a better plan of reducing infant mortality, than that which had hitherto exist- ed, could be worked out. Of the truths on which the Committee built, the following may be cited, as demonstrated by isolated effort of other agencies. i. The paramount importance of breast feeding, demon- strated by all physicians everywhere. 2. The necessity of clean milk for infants (where breast feeding is impossible), demonstrated by Mr. Nathan Straus, Dr. George Goler of Rochester, the Gouttes de Lait of France, etc. 3. The importance of educating mothers in infant hygiene, demonstrated by the late Dr. Budin and the French Con- sultations de Nourrissons. New York Milk Committee ii 4. The value of field work by nurses, demonstrated by the New York Association for Improving the Condition of the Poor in its Junior Sea Breeze Campaign of 1907, and by the New York Health Department. 5. The necessity for philanthropic aid, demonstrated by all relief and charitable agencies. It had also been demonstrated that the danger of over-feeding was fully as great as that of under-feeding; that the question of bottle and breast-fed babies is often a question of the mother's nourishment; and that social and economic conditions are an im- portant element in the problem. Yet in spite of all this know- ledge, which in itself would seem to contain the solution of the question, few, if any, agencies, engaged in saving the lives of in- fants, combined all or even a large number of these ideas ; indeed, there was much disagreement, some experts claiming that one factor and some another was of chief importance, so that not only they, but the public as well, had only a confused idea of the true significance of the educational, medical, sanitary, social, and economic aspects of the problem of infant mortality. The Committee's program for 1908-9 was divided under two heads : (A) The actual field work. (B) The experimental work. (A) In its actual field work the committee planned to estab- lish and maintain seven milk depots with trained nurses in charge of each, and to employ in addition three trained nurses to do in- structional field work, not connected with milk depots. The ob- ject striven for was: 1. The encouragement and assistance of breast feeding. 2. The education of mothers in infant feeding and hygiene (prevention by education, carried on by physicians and 12 A. I. C. P. doctors and based on the idea of the French Consulta- tions de Nourrissons). 3. The providing in the depots of the best possible substi- tute for breast milk, namely, certified milk, modified in individual "feedings." 4. The gathering of important statistics bearing upon the problem of infant mortality. (B) In its experimental work the committee endeavored to find some answer to those questions which had been raised most frequently by persons interested in the milk situation, and which until there was some unanimity of opinion concerning them, bid fair to prevent successful effort in the saving of infants' lives. These questions reduced themselves to the three following exper- iments : Experiment No. 1. What are the comparative results obtained by the continued use of pasteurized and of raw milk. Experiment No. 2. Which is the more economic and satisfactory method of saving infants' lives — the purely educational program carried on in con- nection with the ordinary milk supply, or the sale of modified milk, dispensed by nurses who also do instructional work? Experiment No. 5. Can infants' milk depots be conducted on a business basis, and if not, in how far will philanthropy be needed to carry on their "work"? INFANTS' MILK DEPOTS AND THEIR RE- LATION TO INFANT MORTALITY. THE ORGANIZATION OF THE MILK DEPOT WORK, (i) Preliminary Steps. The production of certified milk, its modification, delivery, and sale from infants' milk depots, means the investment of a great deal of money and labor. The amount of this expenditure varies with the magnitude of the undertaking. To establish and main- tain seven modified milk depots, were the agency so doing to own its own farm, cows, laboratory, horses, delivery wagons, etc., would involve certainly an outlay of between seventy-five and one hundred thousand dollars, not to mention the anxiety and labor incidental to every step in the planning and equipment of the enterprise. To equip a smaller laboratory is less difficult, but even this involves all the difficulties of conducting a milk busi- ness, plus many which the ordinary milk business does not em- brace. In opening its depots, the Milk Committee, as has been stated, aimed to build upon foundations already laid. This applied not only to accumulated social, hygienic, and medical experience, but also to the experience of men actually engaged in the milk busi- ness. Even had the Committee been able to purchase its own dairy and build its plant, it would not have done so for the reason that it is not a milk enterprise, but a social organization. But be- cause no other modified milk dispensing agency was doing in New York City exactly what the Committee wished to do, it was compelled to assume responsibility for the theoretical part of the undertaking — planning out and demonstrating the nezv work on the foundations of the old. Previous to the commencement of the undertaking, Mr. Loton Uorton, President of the Sheffield-Farms-Slawson-Decker Milk Company, had been elected a member of the Milk Committee by the Association for the Improvement of the Milk Supply of New 14 A. I. C. P. York City — an organization of about fifty milk dealers, of which Dr. Ernst J. Lederle, formerly Health Commissioner and a mem- ber of the New York Milk Committee, is a leading supporter, and of which Mr". Horton is president. Mr. Horton had for some time thought of opening a number of stores on the lower east side, where whole milk would be sold at reduced prices to poor people, and he consequently was ready to accept the proposition later embodied in the contract entered into by the Sheffield-Farms- Slawson-Decker Milk Co., and the Milk Committee in May, 1908. By this contract (which is still in force) the Milk Committee purchased its own equipment, while the Sheffield-Farms-Slawson- Decker Milk Company gave floor space at its plant in West 57th Street as a laboratory, contracted for the milk, furnished horses and truck wagons, and rendered monthly a true bill for the cost of purchasing, modifying and delivering the milk without profit and exclusive of interest on invested capital. (2) The Milk: Its Selection, Production, Transportation, and Tests. Owing to the exodus of people from the city in summer time, a quantity of certified milk is always left on the hands of the dealers who sell it. This is usually sold at a loss, mixed in with the ordinary milk. By taking advantage of this surplus, the Milk Committee was able at the outset to secure as much certi- fied milk as it needed, while the contracting company, by selling this milk at cost, saved any loss which might otherwise have been incurred through a shortage of customers. The milk chosen, and which is still in use, comes from Tully Farms in Onondaga County. Here nature and enterprise have worked hand in hand. The meadows, where the cows range at will during the spring, summer and autumn, slope down to the shores of the Tully lakes. A pure water supply, a soil peculiarly rich in grass, and a lay of land which favors cleanliness, meet the prime requisites of sani- tary dairying. Twice each month bacteriological tests and chem- ical analyses, on which the certification of milk depends, are made New York Milk Committee 15 by the Syracuse Academy of Medicine. In addition to these precautions, every cow is subjected to examination by a veterin- arian at regular intervals. Animals found unfit to be milked, from whatever cause, are immediately removed from the herd. To secure even further protection, Dr. \Y. H. Leonard of Tully daily analyzes samples of the milk taken at every stage of its pro- duction. If the milk shows a higher count than 1,000 bacteria per c. c, investigation as to the cause is immediately set on foot. Dr. Leonard also maintains a scrupulous oversight of the farm lands, the buildings, the fodder and the physical condition of the men who come in contact with the milk. The latter have for their special use a lavatory and a laundry, in the former of which they bathe and dress before they work ; in the latter the white suits and towels so extensively used at the dairy are laundered daily. No article is used a second time without being washed and sterilized. The dairy plant and the mechanical equipment at the farm are constructed according to the highest hygienic standards. The floors of the dairy building and the cow barn are laid in con- crete, making it possible easily to flush and cleanse them as many times a day as circumstances require. The interior fixtures of the cow barn are iron, and therefore impervious to liquids and solids likely to absorb unhealthful matter. As a precaution against the accumulation of dust in mows or bins, no hay or feed of any kind is stowed away in the cow barns, but is transported to the mangers by means of a trolley system con- nected with the adjacent building. The King system of ventila- tion and an effective sewerage system furnish pure air and clean- liness. In the cow barns as well as the other buildings, an ample supply of water, available from faucet and hose connection, is supplied by gravity from a chain of springs connected with a spring house. Before milking, the cows are thoroughly groomed and sprayed with pure water. The grooms then go down the line of cows, washing their sides and udders and wiping them dry with steri- lized, single-service towels. A second man again washes and Why Babies Die in Greater New YorK Year ending Sept. 5,1908 Causes Deaths under I Year Congenital Debility i ill-defined Causes Diarrheal Diseases Respiratory Sv Tubercular Diseases All other Diseases Rate per 1.000 Deaths 3 2 9 326 2 2 1 1 24 1,000 Urban Rural Infant Mortality not Confined fa Cities Rural and Urban Districts United States : Registration Area 13 06 Deaths under one year Rate per 1.000 total Urban Deaths 210.1 Rate per 1.000 total Rural Deaths IB5.8 > w 3 < m D go f" 1 g h 3 2 w < J3 New York Milk Committee 17 dries the udders, after which the milkers, in their white suits and carrying their metal stools, as clean as parlor furniture, begin their duties. The first streams of "fore milk" are taken in separ- ate utensils as a precaution against the retention of foreign mat- ter in the ends of the teats. Small topped pails are used and emptied into large covered cans previously sterilized, in which the milk is carried to the dairy building by uniformed assistants. As fast as it is received, the milk is strained through a pad of steri- lized cotton to eliminate any impurities which may have gathered in its transit. It is then run over a tubular cooler through which ice water is constantly passing to keep an even temperature of 36 degrees Fahrenheit. At this temperature it is put into forty- quart cans, which have previously been washed and thoroughly sterilized at the plant. A boiler and engine in the basement of the dairy building furnish the heat and power for this purpose. At all seasons the milk is subjected to a thorough refrigerating process, in which ice, cut from the pure waters of Tully lakes, is used. The room in which this process is carried out is accessible to the workers only ; is rendered dust proof by seals and windows ; and is moistened high and low by sprays of spring water after first being sterilized by live steam. The milk leaves Tully at noontime, reaches New York City at eleven o'clock at night, and arrives at the laboratory at a uniform temperature of between 45 degrees and 48 degrees shortly after twelve o'clock. Thus it is thirty hours old before it is modified, having been drawn from the cows the morning and evening pre- ceding its departure. This is not an ideal condition* — yet of the eleven farms supplying the 12.000 quarts of certified milk sold in Manhattan out of the two million quarts of milk which come to New York City daily, the Tully Farms bottled milk, on bacteriological counts made by the Health Department, ranks on an average, fourth best. Tests of the modified milk did not T* The requirements for both guaranteed and certified milk are that such milk shall come from tuberculin tested cows, shall not contain more than 30,000 bacteria per cubic centimeter, and that such delivery shall be within 36 hours after milking, in sealed bottles, which have been filled at the dairy, and which bear the name of the dairy and the date of the earliest milking.] 18 A I. C. P. begin until August ioth, * when Dr. Park of the Health Department very kindly offered to test twelve samples weekly, six samples of the pasteurized and six of the raw, one of each formula, including the whole milk. Thanks to these tests, the Committee was able subsequently to discover and eliminate cer- tain defects in its laboratory work, which in spite of the excellent character of the milk used had, on one occasion particularly, re- sulted in the appearance of several "sick babies" on its list. At present each separate process in the modification and pre- paration of the milk in the laboratory is tested regularly by a bacteriologist. The sanitary precautions described on page 22 have also been adopted, reducing the danger of infection to a min- imum. The fact that it is necessary to bring this milk to the city in cans, however, renders the problem of keeping down the bacteriological content of the raw milk extremely difficult. Tests of the milk, made by the Health Department on August 24 and August 31, after modification in the Committee's labora- tory, were as follows : Colonies Per Cubic Centimeter. Raw Milk Pasteurized Formulae Modified Milk Mod. Test on Aug. 24, 1908. I 19,000 IO,400 II 460,000 IOO III 41,600 IOO IV 240,000 300 V 45,200 500 Colonies Per Cubic Centimeter. Raw Milk Pasteurized Formulae Modified Milk Mod. Test on Aug. 31, 1908. I 23,500 no growth II 90,000 200 III 29,900 1,000 IV 23,400 300 V 33,ooo TOO [* Owing to the fact that the Committee on June 17th found itself en- gaged in managing a retail milk business, in conducting a small Health Department, in experimenting with a new system of relief for necessitous cases, in establishing and supervising a very complex and difficult statisti- cal work, in ordering machinery, leaflets, ledgers, score cards, charts, lit- erature, etc.] New York Milk Committee 19 This milk with its high bacteriological count is the same milk, treated in the identical manner up to the moment when it is canned, as the bottled milk, the tests of which, made by the Milk Commission of the New York County Medical Society for the three summer months run as follows : Rank arnong certified milk farms sending samples same week. Date Count June 15 1,950 22 400 29 45o July 6 1,400 4th 13 IP50 20 1,100 2.7 1,250 August 3 1,900 10 900 17 4,000 24 500 31 500 Sept. 7 750 14 950 21 1,200 28 1,100 This marked difference between the canned and the bottled milk was due not only to the difficulties of shipment, but to improper washing of bottles (one of the greatest sources of infection), and by the delay in building the Committee's new bottle filler, which necessitated the filling of the bottles by hand. With the comple- tion and use of this machine ; the cleaning of the washing machine (the plungers of which, it was discovered, had become clogged) ; the substitution of new cans for the old and somewhat worn cans used at the start, and the protection of the milk in these cans from dust by the use of a paper cap under the cover, the main causes for a high bacteriological content were subsequently removed. bth 111 11 3rd in 12 3rd m 13 4th in II 3rd in II 2nd n II 2nd 111 II 2nd in 12 3rd in II 6th in 10 2nd n 10 3rd n 12 2nd n IO 3rd n IO 4th n 10 2nd n II 20 A. I. C P. The last tests of the milk, received from the Health Depart- ment were as follows : Colonies Per Cubic Centimeter. Raw Milk Pasteurized Formulae Modified Milk Mod. I 300 no growth II 18,000 200 III 7,400 200 IV 400 3,000 V 1 ,600 200 (3) The Formulae. In choosing its formulae, the Committee was obliged to take into consideration the varying opinions and theories of physicians in- terested in infant feeding, and to select mixtures which, because they could be made by direct dilution of whole milk, (thus avoid- ing the use of top milks), would adapt themselves to commercial preparation on a large scale. For summer work, it was also necessary that these formulae should contain a low percentage of fat.* The choice narrowed down to two sets of formulae, one prepared by Dr. Rowland G. Freeman and the other by Dr. L. Emmett Holt. Dr. Holt's set provided for five formulae as follows : Milk Lime Filtered Fat Suerar Proteid Milk 1 1. Very weak 2. Weak 3. Medium (average) 4. Strong (8-12 mos.) 5. Strong (over 1 yr.) Whole milk. Note. — Barley water, made as follows, may be used as diluent to any of the above : 4 oz. barley flour by measure to water 1 gallon ; salt to this amount — \y 2 even teaspoonfuls — grs. 90 by weight. Dr. Freeman's formulae were composed as follows : Fat Sugar Proteid Milk 1. 1.00% 6% 1.00% 1 qt. 2. 1.50% 6% 1.50% 1 qt. 19 oz. 3. 2.00% 6% 2.00% 2qts. 4 3.00% 6% 3.00% 3 qts. 5. Whole milk. Inasmuch as Nos. 2, 3, and 4 of Dr. Holt's formulae were al- most identical in their relative strengths with Nos. I, 3, and 4 of Fat Sugar Proteid Milk Sugar Water Water .50% 4.5% .54% 16 oz. 6 oz. 8 oz. 104 oz. 1.00% 4.5% •99% 32 oz. 6 oz. 8 oz. 88 oz. 2.00% 4.5% 175% 64 oz. 6 oz. 8 oz. 56 oz. 3.00% 4-5% 2.65% 96 oz. 6 oz. 8 oz. 24 oz. Milk Lime Barley Sugar Water Gruel 6V 2 oz. 7 oz. 2 qts. 25 oz. SH oz. 7 oz. 2 qts. 6 oz. 2 oz. 7 oz. 1 qt. 25 oz. 4 oz. 7 oz. 25 oz. [* The winter formulae are being made with standardized 3% and 6% milk thus ensuring proper and even percentages in the daily supply. Butter fat tests are made in the laboratory daily with a Babcock ma- chine. See physicians order blank, page 23.] Fat Sugar Proteid Milk I. • 5% 6% •5% ipt. 2. 1% 6% 1% iqt. 3- iH% 6% lV2% 1 qt.19 oz. 4- 2% 6% 2'/« 2 qts. 5- 3% 6% 3% 3qts. Lime Boiled Barley Water Water Gruel 7 oz. 3 qts. 9 oz. 7 oz. 2 qts. 25 oz. 7 oz. 2 qts. 6 oz. 7 oz. 1 qt. 25 oz. 7 oz. 25 oz. New York Milk Committee 2i Dr. Freeman's formulae, (the difference in the two sets being that Dr. Holt's set provided a very weak formula for sick infants and Dr. Freeman's set provided a medium formula to go between Nos. 2 and 3 of Dr. Holt's set), it was decided for simplicity in preparation, to add a weak formula correspond- ing to Dr. Holt's formula No. 1 to Dr. Freeman's set, making the following list of five formulae, containing, with the exception of the first, the same ingredients: Sugar of Milk 7 oz. 6^oz. 5^4 oz. 5 oz. 4 oz. (4) The Modification of the Milk. There are five men working in the laboratory, a foreman and four assistants, three of whom not only help in sterilizing and filling the bottles, but also deliver them at the different stations. These men are physically examined by a physician regularly ; they wear white suits and caps, and pay scrupulous attention to their personal cleanliness, having for their use a lavatory and shower bath on the same floor. As soon as the milk reaches the laboratory the cans are put into a long box and surrounded with cracked ice. The modifications are then made, the bottles are filled and corked, those that are to be pasteurized are put into the pasteurizer where the milk is heated at a temperature of 167 degrees for 20 minutes, and those filled with raw modified milk are cooled in water compartments of decreasing temperature, until finally they are put in the crates and covered with cracked ice. In order to avoid confusion, bottles containing the same formulae are put in the same crate. The tag- ging of these different mixtures with their varying quantities of raw and pasteurized milk for seven depots has been and is a diffi- cult undertaking. Often there are as many as twelve different quantities which, multiplied by the number of formulae in use, give 60 possible combinations. When one is handling 2,500 bottles daily as the Milk Committee does at present, the problem is one demanding the greatest care. 22 A. I. C. P. The prescription orders are telephoned into the laboratory by the different nurses at the close of each day. (5) Sanitary Methods at the Laboratory. In safeguarding the handling of the milk in the laboratory and in protecting from infection each object that comes in contact with it, the Committee has been indebted to the suggestions of Dr. Charles E. North, of the Lederle Laboratories. As soon as the men return from their morning deliveries, the bottles, turned upside down in the crates as they are received from the depots, are passed three times through the washing machine, receiving first a jet of soda solution, then a jet of hot water, and then a scalding rinse, all squirted into them at high pressure from below. They are then covered with cheese-cloth and, still inverted, carried to the laboratory on the third floor. No bottle, can, filler, vat, pail, receiver or receptacle used to contain milk is allowed to stand un- covered or to be exposed to the air in any way. Close meshed cheese-cloth is immediately drawn over such an article when it is not in use. Yard strips of this cheese-cloth (costing 5 cents each) are cut in halves and folded over once, making pieces a foot and a half square, which may be used for various purposes. As soon as a piece has been used it is thrown into a pail of soda solution which is always near. Each pail contains a solution of Wyandotte, two tablespoon fuls of soda to each pail. Afterwards the cheese-cloth is put into boiling water and washed, first in soda, then in hot water, after which it is wrung two or three times through a sterile wringer (not touched by hand), and hung over a line to dry. When it is used again the exposed surface is fold- ed inside. In sterilizing the vats, cans, dippers, pails, scoops, and other objects used in the modifications, the following process is observed: First the receptacle or object is scrubbed with soda solution, a wet brush being used with dry powder. Then it is scrubbed again with cold water, after which it is rinsed twice with tepid water. After that it is washed in hot water at 160 degrees F. and a steam hose is applied. It is then put into the sterilizer. No covers are used on milk cans, but a sterile cheese- 3, '* r 1 *-*!' The Bottle Filler Surgical Cleanliness in Preparing the Milk- 2 a. m. THE MILK LABORATORY Adenoids — Mouth Breathing — a bad condition that can be corrected The " Pacifier " — a bad habit that baby should not get A Well-Fed Baby Needs no Lullaby GOOD ECONOMY TO GET THEM STARTED RIGHT PHYSICIAN'S ORDER BLANK INFANTS' MILK DEPOTS NEW YORK MILK COMMITTEE, A. I. C. P. 160 Mott Street 434 East 73cl Street 73 Cannon Street 246 East 82nd Street 412 West 47th Street 202 Henry Street 146 West 100th Street PRICE PER FEEDING Yi oz. — 1 oz. - Vi cent 3% oz. — 5 oz. \Vi oz. — 2 oz. - 1 cent 5% oz. — 8 oz. 2/^ oz. — 3 oz. - 1% cents WINTER FORMULAE 2 cents 2V<2 cents Prepared from a Standarizt :d 4% and 6% Mi k No. Fat Sugar Proteid 1. 1% 6% 1.0 % 2. W2% 6% 1.4% 3. 2% 6% 1.4% 4. 2 fe 6% 1.7% 5. 2.5% 6% 2.0% 6. 3% 6V 1.7% 7. Whole Milk. Please furnish, living at with modified milk for her baby, aged. Date Form Oz. No. Per Bot. of Bot. Name of Physician Mothers whose infants are prescribed for by private physicians are expected to pay the full price for the milk. Private physicians are expected to assume responsibility for the condition of infants fed by them. Ingredients, in detail, of the formulae will be furnished on application. 24 A. I. C. P. cloth is fastened over them with clothes pins. No part of any receptacle over which the milk passes or which comes in contact with the milk is touched with the naked or gloved hands or is allowed to touch any object which is not scrupulously clean. Each morning after the milk has been prepared each foot of floor space is sterilized with steam. These and other precau- tions give some idea of the care taken at the laboratory, in spite of which, as has already been explained, the bacteriological count of the raw milk, during the early stages of the work, was very high. (6) The Location of the Depots. In locating its depots the Committee took the following facts into consideration : (a) Density of population. (b) Nationality. (c) Relation to cooperating social and philanthropic agen- cies. (d) Relation to other milk dispensing agencies. The idea was to find districts which not only needed milk depots, but which, as respected living and racial conditions, would make fair comparison possible for experimental purposes. Let- ters and literature sent out in advance to many churches, settlements and charitable associations secured offers of personal services, money and rent — in fact there was some little competition on the part of various agencies to secure the depots. In each instance the needs of the community and the opportunity of securing the best results were the only factors considered. Several offers of rooms splendidly equipped but poorly located had thus to be passed over. In one instance a set- tlement (the East Side House), whose offer was declined, itself organized a movement to cooperate with the Committee, and con- tributed generously to pay the rent of a store situated more ad- vantageously, in which the Committee is now carrying on its work. Conforming to the Committee's experimental program, pas- teurized milk was sold from three, and raw milk from four, of BAftffOw 5T.V BOROUGHof/WNH/WT/IN Showing Denjtftj ofPopulah'fatS«nSrr«ii«f • DUWtakm An'«. © Good Swnlin D.^ 26 A. I. C. P. these depots, the milk in both groups coming from the same dairy. The depots were located as follows : Selling modified pasteurized milk: 160 Mott Street, Italian dis- trict. (Joint depot with the Diet Kitchen Association; located in a store, Committee's share of rent $12.50.) Selling modified pasteurized milk : 262 East Broadway, Jewish and Italian district. (Retail store of Sheffield-Farms-Slawson- Decker Milk Company, rent free, salary of nurse paid for sum- mer months by Henry Street Settlement.)* Selling modified pasteurized milk: 412 West 47th Street, Irish and American district. (Basement room in the Hartley House Settlement, rent free. Expenses of installation and salary of nurse provided by Mrs. W. V. S. Thorn for the first three months.) Selling modified raw milk: 73 Cannon Street, Jewish district. (Basement room in the Alfred Corning Clark House, rent free.) Selling modified raw milk: 434 East 73rd Street, Bohemian district. (Store; rent, $16.00 a month, provided for the first three months by the social workers in the neighborhood.) Selling modified raw milk: 246 East 82nd Street, Jewish dis- trict. (Basement room in the Yorkville Dispensary, rent free.) Selling modified raw milk: 146 West 100th Street, Irish and American district. (Front room in Bloomingdale Guild, rent free ; Riverside district of the Charity Organization Society pledged $1,000.00.) (7) The Engaging of the Nurses. The nurses for the depots were chosen with care from a group of about forty candidates. Few of them had had social or field experience, so that the main determining factors were : (a) A knowledge of infants. (b) A personality which would attract and hold mothers, and (c) Some apparent fitness for social work. [*This depot is now located at 202 Henry Street] New York Milk Committee 27 The personality of the nurse is a most important factor, for no matter how intelligent and capable she may be, if she lacks sym- pathy and kindness, her work, from the social point of view, cannot be either thorough or efficient. Language is another important factor. When it began its work the Committee was unable to find nurses who could speak certain of the foreign languages. This difficulty was partly over- come by securing interpreters, who were provided in two cases by cooperating settlements. The nurses also nearly always found someone in the family who spoke English, but they missed the ad- vantage of language, without which it is difficult to gain admis- sion into the lives of foreign speaking peoples. (8) The Preparatory Work of the Nurses. Although the depots did not begin to sell milk until June 17, all the nurses were put into the field June 1, in order that they might familiarize themselves with their neighborhoods, open and fit up their stations, and make sure by home visitation of a cer- tain number of mothers. Announcements of the proposed "classes for mothers" were made from several pulpits, and various settle- ments sent out notices. In the East 73rd Street depot a corps of physicians was or- ganized and pledged to instructional work before June 1st, but in each of the other neighborhoods the nurses had to act as organ- izers, personally calling upon physicians and securing the offer of their services for instructional classes or consultations. These physicians, who began work with the opening of the depots, were selected largely on the recommendation of social workers or of other physicians interested in the neighborhoods. Some had had wide experience in infant feeding and some had had little ex- perience. All of them, however, spoke the language of their communities, which largely compensated for the lack of such knowldge on the part of the nurses. 28 A. I. C. P. THE CONDUCT OF THE MILK DEPOTS. No mother who comes to the depots can get the milk without first seeing one of the Committee's physicians, and making it clear that she is unable to nurse her baby. The physician then examines the child, writes a suitable food prescription, and secures from the mother a promise to return to his consultation regularly each week, bringing her baby to be weighed. If she does not do this, she is given to understand that the milk may be refused her. Each infant brought to the depot is given a separate sheet in the nurses' cash ledger, which covers its record for a year. This ledger shows day by day how many bottles of milk, what formula and what quantity of milk the baby is getting, how much the mother is paying for the milk, etc. The pages are dated uniformly in the same horizontal columns so that the daily entry for each child occurs on a corresponding line throughout the book. When a new case is started the first entry is not made at the top of the page, but in the column allotted to that date as on the other pages. If the milk is not called for, the column is left blank. This shows at once any irregularity on the part of the mother in getting the milk (thus proving a valu- able adjunct to the statistical work), and also facilitates the mak- ing of the weekly accounts. A small card, numbered to corres- pond with the ledger page is given to each mother who presents it when she comes for milk ; her page can thus be turned to readily and the necessary entries made without the necessity of asking her name, quantity of milk wanted, etc. When a woman is unable to pay the full price of the milk, a memorandum is made at the top of the page stating the amount she is able to pay and also the name of the charitable organization which has agreed to assist her. The amount paid by the woman, in accordance with her agreement, is each day entered in the col- umn "Cash Received." Any deficit on her part is entered in red ink at the end of the week under the total amount of money she has paid. A weekly bill for the balance of the account is ren- dered to the relief organization. IS. NO. NAME OF BABY WCMA/V CQN "PAY £,*-2AU Y — A ' I.C.7>. TfiYS 3f)L$/VCE ADDRESS •«»rrr irini OATE Ml LK ■ BOTTLES Age Form Oz per Feed'g No. of : eed'gs Rale Asked Total Value Cash Rec'd Still Owing Casn Rec'd Oep. Rct'd No. Owing lite. 1 ? / t'h /£ ? /// 1L / n $• Yd 1 ^ w % *0 JA n 16 // /% 4 /A $ /* n i- /6 /,? '? /o / HI 3 i! u C o! bo — — oi o o > ■5 OS a- Co* •Set: g 0) (J 3 £ 4) C ol bo t— ~-* oj ol OS £ O O S> s 03 :,d OS C« o *o dg~ -Si u, C _ c OS «1 S C 4>Tl <" 3ti D C o) M __ crj 5^ OJ > •a "v- ZZ O «> 2""c °Sc u ol « •" c *j g oS 3 £ 41 C CO M •n— =" CO crj I- O O > Sr crj 3^4, C o! bo __ OS ol a! £ O O > a- -^5 g u os 3 *j W O a -? CM ^ ■"* a v g ™ „;-S-Tcm .O'T CO CO p ( »-' OJ ""I ' -l co ' CM Q.CO CO C a a a *? o 53 ft s^ a M J ■* 2 3 IO £ CO ^ - crjS^co "".A" «-£. _ T a io o •, - 5 " 3 S s 3, a «m C_ M : C_ OJ : G_: «1 • i,'? 1 ^4>i,'gj 3 — •* c gc-o-g u " o I \Oh»I 4> e r, . c a .2 4> 3 — S £ >>ol .5 3S > °S c 4) c^ C c 8 4) aj .3 3 J2 > C^ :« : « " & ° 3— C c a 4; ai .5 3tJ > V" £^ 4) 3 • «l : ^X 4) ©g^C O " JJ 4) 4) f- •"• pEjti .a 3t; > 35 ^ C gaJU c"o !§S T3 CJJ, = So OCS o h c c 4) 3 •Sis g ac a ?> * o o > a 2 ■ico -iJ • ^J )0 a $ % a lot* a^2oo 1,"- ■ — < "t> - 00 S 1 a "X C^j w : ^^•^ 4) 3-r ? c S a ^•^ 4) 2>«i gc-^-o e 2>>3 gc-^-g oC-g Ills .5 35> o x-ot; 4>-§ c 36 A. I. C P. THE STATISTICAL SIDE OF THE WORK. In planning the statistical side of the work, the determining fac- tor was the necessity of obtaining facts which would tell a defin- ite and concrete story. To say, for instance, that of fifty babies fed at a certain depot, fifteen did well, twenty did fairly, ten did poorly and five died, signifies absolutely nothing unless it is known exactly in what condition those babies were when they were first taken in charge. Were they in perfect condition ? Then the report was one deserving severe criticism. Were they in dying condition? Then it was excellent. To overcome this difficulty and to secure, as nearly as possible, uniform employment of the same descriptive terms among the Committee's physicians, it was decided, after much deliberation, to use a record chart, the revised edition of which is inserted on the following page. In this chart, it has been assumed that there are seven physical classifications in which a child, brought to the depots, may be placed. A numerical estimate has been given to each of them as follows: Moribund, from o — io Bad, 10—25 Poor, ' 25—50 Fair, ' ' 50—65 Good, ' ' 65—80 Excellent, ' 80-^5 Perfect, ' 95— 100 In estimating a baby's physical condition, the doctor's judgment is thus limited by the value of the descriptive term, chosen with respect to all the others and to the upper and lower limits of zero (death) and 100 (perfect health). This still leaves a considerable range for the personal equation, but as the Committee found in experiments made before the adoption of the chart, the "esti- mates" of physicians, trained in infant feeding, seldom vary more than from 10 to 15 points. With less trained workers there is likelihood of a wider discrepancy, but even among these, experi- ence indicates, the variation can be minimized by uniformly hold- ing certain chief characteristics in mind. 1 J „0 FORMU • 1 it(l < ^ ■t 1 f 1 1 ■A-t.'t n E f_ rr -i » T - ■r : •: 'i r * ;. :, Z»^ "\ «CE < ! i s , ■ p ,1 ': ~ n V. ... a i 1. ., -: E * ■ .V ■i al »| J. s» ss r>| 37 ;. -. -| 1" n 10 III 170 Ss -- 1 £ D , r/. ,:t I 5- idp J s; ">j [ j r j >3 i t 6 ii ■/ en i, a U 5 i * s, £ 1 -^ o '4 - -i ^ jj I -J 8 . i I ■£ j H f, h W 1 . - J j rf ^ * \ i] - V \ * 1 -i - i» * ^5 ., -d ■ v, ■0 «s if •i 1 1 S3 11 1 3 i -- - J =K L i ' r : 1 ^ jfi N 4 - 3 b. k, 2 >-. W || • • T ^ - - 3 • ^ -' 5 > c I J ' ill >> « 5 •* < « !<■ / f ||* '- ^ — ... - / a ^ d, It u ■5 ! H ; V >j * Is - - - •5 - i: ! • '- v t hi no V- 10 ONE BABY'S HISTORY As told by the Committee's record charts. On June 5, Barry O'Shea, 12 weeks old, came to the depot in Bloomingdale Guild on the point of death. Almost the only thing he had not been fed on was mother's milk. Instead of putting him on the Committee's modified milk, Dr. Wile, senior physician at the depot, persuaded the mother to increase her own nourishment and nurse Barry herself. By so doing the Com- mittee lost a customer but saved the life of Barry O'Shea. Observe (a) that Barry weighed only six pounds and 14 ounces when brought to the depot whereas he should have weighed n| pounds; (b) that his life line rose immediately when his mother began to nurse him and to come regularly to the Committee's classes; (c) that he now is in "perfect health." Moral: — Modified Milk Stations are not to win customers but to lose them. The best milk is mother's milk. New York Milk Committee 27 In order to standardize the curve of general vitality the Associ- ation of Physicians, working in connection with the depots, has recently issued the following instructions: [Appendix A.] In determining the value of work done by the physicians em- ploying the accompanying chart, the plotting of the curve showing the relative general vitality of the child from week to week is im- portant. This curve, which is designed to show in graphic form what would take many words to describe gives a comparison of the child under treatment with the normal healthy child of correspond- ing age. It is important to understand that it is not simply a weight curve, but that it connotes and denotes everything related to normal childhood. While weight is an important index to the condition of the baby, an increase in weight is not the only nor an infallible criterion of normal development. Increase in weight due to cedema of the ex- tremities (without explanatory notes), not uncommon in poorly nourished and anaemic infants, would give a false impression of im- provement to the statisician. A fat, flabby, anaemic baby, brought up on a rich carbohydrate diet would, judged by weight alone, ap- pear to be a healthy child rather than one with low resistance. And vice-versa, a very difficult feeding case might show a stationary or vacillating weight on the chart and yet gain steadily in general vitality and digestion. For these reasons, weight alone, while im- portant, is not a sufficiently true index, to the condition of the baby. Following are the chief characteristics which must be borne in mind : Weight: For easy reference, a weight curve of the normal infant under one year is printed on the chart. For practical purposes, the average weight of the normal new-born infant may be considered as 7 lbs., which is usually augmented by a pound monthly during the first year. Thus the birth weight is about doubled at six months and trebled at one year. During the second year the gain is usually less, averaging about six pounds for the year. Skin: Next to be considered is the skin; as to color, whether normal pink, or pale and with the veins showing through, or cyanotic, etc. ; as to texture, whether firm, moist, dry, harsh, wrinkled, eczematous, syphilitic, etc. Subcutaneous Fat: At the same time the amount of subcutaneous fat present should be noted; well covered bones and rounded contour standing for the normal, against the familiar thin, wizened, angular, poorly nourished child. Musculature : The development of the muscular system is very important. Under this head should be considered the condition of the muscles 38 A. I. C. P. of the extremities, whether firm, flabby or paralyzed ; the muscles of the abdomen, whether firm and normal or thin and ballooned out by the intestines; the muscles of the spinal column, whether, for example, the child can support its head on its trunk (by the 4th month), whether it can sit up alone (by the 7th-Qth month), whether it attempts to support weight on feet (by Qth-ioth month), whether it stand with support (by the nth month), whether it begins to attempt to walk by the beginning of the second year, etc. Bones and Teeth : In regard to the bony system, aside from congenital abnormalities, it is important to note the time of the ossification of the sutures and fontanelles, the posterior closing normally by the end of the second month and the anterior by the end of the second year (usually eighteenth month). Signs of rachitis are to be looked for — craniotabes, bowed legs, enlarged epiphyses, contracted chest, walls, etc. The teeth in the normal child are usually cut in a certain succession, viz. : incisors, then first molars, then canines, and last second molars. Irregularity of irruption frequently denotes disease or mal-nutrition, while dentition, delayed within certain limits without other symptoms, may be an idiosyncrasy rather than an abnormality. It is commonly agreed that the normal child should have cut six incisors by the end of the first year, sixteen teeth by the end of the second year, and all twenty by the middle of the third year. Premature decay and deformities (notched teeth, overlapping teeth, etc.) must be taken into general con- sideration. Mental Condition: Another criterion of the baby's general well-being is its mental condition and development. A well-nourished baby sleeps nor- mally and is happy and contented when its necessary wants are met. The mental development of a given child varies considerably, but, in a general way, a baby begins to notice and grasp objects by the second and third months and begins to enunciate single words by the end of the first year. "Backwardness" may be an idiosyncrasy or may, with other symptoms, point to a mental defect. Digestion : The child's digestive capacity is clearly an important considera- tion in determining its lease on life. The question of its status in relation to the food given it up to the day of each consultation; whether it is or has been breast fed; whether fed modified cow's milk or proprietary foods; how it has digested and thrived on the food given; whether it has had frequent gastro-intestinal upsets; whether the foods have had to be frequently changed, etc., must all be considered. Other things being equal, a child thriving on breast milk would be rated higher than a child thriving on modified milk or a proprietary food. In the case of a child fed on modified cow's milk, the question must be considered whether it can take care of the normal amount of fat, carbohydrate and proteid for its age and development, or whether any one or all of the elements must be considerably reduced to suit the lowered digestive New York Milk Committee 39 capacity. The question of the kind of carbohydrate and proteid also enters ; all pointing toward a delicate digestive capacity. Current Diseases and Deformities : Finally the natural resistance of the child as modified by in- herited tendencies, congenital deformities and previous and con- current diseases, must be weighed. Children delicate from birth by reason of disease of parents; children with hare-lip, cleft-palate, congenital heart disease, microcephalus, hydrocephalus, spina- bifida, etc., etc., are all handicapped. Also children suffering with rachitis, syphilis, tuberculous glands and bones, etc., have a lowered resistance. A history of frequent attacks of disease, "colds," bronchitis, pneumonia, etc., shows lessened natural resisting power. The above does not pretend to cover the ground of all that ought to be taken into the general estimation of the vitality of the child, but it ought to serve as a basis for more uniform expression of what we are trying to do. Executive Committee, Association of Physicians of the New York City Milk Depots. From a statistical standpoint, the estimate of the condition of the baby when it is received at the depot is of the utmost im- portance. Given a true estimate, an agency like the Milk Com- mittee can in a large measure determine what injury or profit the baby has received at its hands. Given a false estimate, any deduc- tion as to what has or has not been accomplished is entirely with- out meaning. In addition to the feeding history and "line of progress," the record chart originally contained other facts dealing with the question of infant mortality. Although this possessed the advan- tage of giving a full history of the child on one page, it proved confusing because the responsibility for filling it out rested joint- ly with the physician and nurse, neither of whom was under the same administrative control. Subsequently it was deemed wise to separate the statistical responsibility of the physicians from that of the nurses, leaving the record chart with its physical history to be rilled out by the physician, and adding a social card (inserted on the following page), dealing with conditions which bear on infant mortality, to be filled out by the nurse. 40 A. I. C. P. It is not supposed, in obtaining the facts on this social card, that nurses, when they visit the homes, will produce the card, read off the questions, and record the answers on the spot. Such a proceeding would arouse the suspicion of mothers and make them either refuse to answer or to answer falsely. In the first case, valuable material would be lost. In the second, the mater- ial would not be such that any truthful deductions could be made from it. With intelligent parents, the method of direct ques- tioning often proves successful, but in the great majority of cases, it is necessary to pesort to the indirect or conversational method of questioning. Any nurse, in the course of her con- versations with a mother, can, by a little exercise of tact and intelligence, touch practically upon every point covered in the record chart ; and after short practice, can easily fill in the moth- er's answers from memory. In making entries, nurses are requested to observe the follow- ing instructions : 1. Previous Children. In specifying the causes of death under this head state whether they are certified (that is, taken from the death certificate), alleged (that is, not taken from the death certificate), and unknown. In alleged causes please state source of information. 2. Nationality of Parents. In recording the nationality of parents use the following descrip- tive terms, noting whether persons, declaring themselves to be of one nationality, belong evidently to another; as for instance, American-German, Canadian-French, American-Jew, Canadian- English, etc. Never enter a Jew without giving the country from which he comes. ionalities. Jew ( Servian American Balkan-Slav < Bulgarian Canadian ( Croatian Bohemian French (incl. Belgian, French Slavic (Ruthenian) and Swiss) Pole Italian (North and South) Russian Spanish Finn Portuguese Lithuanian English Lett Scotch Caucasian Irish Hungarian ( Swedish Scandinavian < Norwegian ( Danish DATE-. ADDRESS: - 1 _!)ate of Birth : ^_ ~~ _ CHILD JP- Consultations O UJ £ o XindafMilkused TralmtofJIilk fVopniftFood Formula O Oz.pcfedin(r Nooffudipsri Interval a TrtatrntofMilk s| 2 f OzDcrfj«dinf 1 i Nooffadinp S|b s YEAUS?:iSWIEX5 1. % 3 4 5. 6 7 8 9 10 11. 12 13 14. 15. 16. 17. 1 8 19 20. 21 n 23 24 25 26 27 28 29 50 31 32 33 34 35 36 3/ 3ft 39 40 41 42 45 44 45 4c 47 4& 49 50 51 52 PQ > w U h K Ul :< 19 Ifi 17_ 16 15 14 11 !S 11 10 9_ A 2_ 6 ^ j|_ J_ j_j95 f V r 1? e <<- 9 $ -1 %>£ ' : VAK. 5 90 Vss F jt ~f // 'A7 f. fi tf _C W* «8o P- 2 j7» 7 J /-1 70 £ TT ?7 / 6 & ^ \c V? R ^ 65 fo ^,^*~ ^• ! "" F 1/ T rs _ ^ * ° 50 ft ^,^ §4* £ **' H40 ^5 ¥A <' F r>< ■>r P T- g 30 r uas <20 £15 P n d u '- 9 t % §10 — ^ u 5 X t% *&■ 4^ T* ^ ^ -t *— £i. >— 75 INSTRUCTIONS FOR FILLING OUT RECORD CHART. (Physicians) A line of physical progress (not a weight curve) should be drawn from week to week with dotted lines for absences, based upon the weekly numerical estimate of the general vitality of the child.* The ideal weight curve of a normal child weighing seven pounds at birth, which is placed upon the chart, is to assist the physician in i .75 per gross for its three ounce bottles; $2.45 per gross for its six ounce bottles, and $2.65 per gross for its eight ounce bottles. All the bottles were lettered "The New York Milk Com- mittee." The mould for the three ounce bottles cost $13; for the six ounce bottles $16; for the eight ounce bottles $18. The first instalment of corks cost 16^ cents per gross and the second instalment 16 cents per gross. The first instalment of crates cost $2 each and the second instalment $1.50 each. These crates are hand made of iron. To have made them by machinery would have necessitated the casting of a die costing $2,000. There are three sets of crates and bottles in use constantly (one set in the depots, one in delivery, and one in the laboratory). At time of writing, the Com- mittee is using daily, to feed 375 babies, 900 three ounce bottles, 3,600 six ounce bottles and 2,100 eight ounce bottles; 45 three ounce crates, 180 six ounce crates and 90 eight ounce crates. The cost of the other articles of equipment was as follows : one sterilizer $325; two copper boilers $125 each; one separator $86; one bottle-washer $550; one bottle-filler $1,500; 40 wire covers $24; two wire baskets $7; one hand bottle-filler $7; scales, crocks, pails, etc. $25; lumber, fittings and labor $425. The Committee uses Cereo Company's barley, sterilized, standardized and put up in one pound packages costing 12 cents each. Experience seems to indicate that barley in the barrel is likely to spoil. Milk sugar costing 12 cents a pound in 200 lb. barrels was used at first. This has been changed to cane sugar on account of the expense. Tongue Out " A Class for Colored Mothers MOTHERS ARE EAGER TO LEARN •3 tf s ** w w & BJ o. o n \\»nue and 52n \ St: TELEPHONE CONNECTION II THE J. H. PADDOCK COMPANY MANUFACTURERS OF CORKS AND CORK SPECIALTIES 82-92 THIRD STREET BROOKLYN. NY. DATE DUE nonm w An o i ?n IH IflARi UcUUI w r\\\ J 1 tU Jl • i . _ . '! '' ' I • | .., : WV Ml i cut DEMCO 38-296 COLUMBIA UNIVERSITY LIBRARIES 0041067320 ^W^^ \ >& *V> rv .