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A PLAN OF DEALING WITH ATROPHIC INFANTS

AND CHILDREN.

BY HENRY DWIGHT CHAPIN, M.D.,

New York.

The problem of dealing with the sick and ailing infants of the poor must occasion much thought to those who have worked a great deal with this class. The usual forms of charity intended for their relief consist in attendance at dispensaries, day nurseries, the visits of district physicians or nurses from dispensaries and settlements, the extending of hospital accommodations to proper cases and fresh-air excursions and homes in summer. But there is one disheartening feature that constantly confronts the worker who is seeking to permanently help these children, namely, their defective vitality from the wretched environment that so often surrounds them when returned to their homes.

They frequently pass from one institution to another, each one contributing its share of effort, but really not able to do more than temporarily relieve the most urgent necessities. These poor little waifs thus pass on from hand to hand until their waning vitality is exhausted.

It may be said that the fault really lies in deficient and inefficient fathers and mothers, and much of the trouble undoubtedly is here, but, even so, better measures of relief should be sought and will often yield results that are surprising if continued long enough.

All purely institutional work for these children should be only temporary. After acute illness has been relieved, they should have other management. If they must be sent back to faulty life conditions at home after discharge from an institution, the relief afforded by the latter will often be of very temporary value. Neither is good accomplished by sending them to other institutions, as the collecting of many little children under one roof is not good for them, no matter how well managed the institution.

After a long experience with this class of cases the writer has found that relief can be much better accomplished along the lines of family life with individual supervision instead of the collective life with institutional methods. Acting on this idea, the Speedwell Society was inaugurated in 1902, and has since been in successful operation. The plan followed is the boardingout system, and the results have been remarkably good, considering that bottle-feeding has been exclusively employed, as wet nurses have never been available. The cases have been placed in carefully selected private families in the neighborhood of Morristown, N. J., which affords a very healthy location. A doctor and trained nurse have oversight of the cases. The foster mother is instructed in feeding and otherwise caring for the baby. A supervising nurse procures the children from the city and returns them to their homes when discharged from the care of the society, besides attending to many other necessary details of the work. She also endeavors to see that improved methods of care and feeding are carried on after the child is returned to its home.

The work of the society is not confined to the summer months. Children are received at any time of the year, and it is found that most valuable work can be done during the winter season. Neither is there any time limit for the keeping of the children. Each one is retained long enough to attain permanent improvement, or until it is proven that the case is hopeless. It is believed that it is better to permanently help a few than only temporarily to help many.

Most satisfactory results have been obtained in the cases of infants suffering from chronic malnutrition due to prolonged faulty care and feeding. In institutions, fed on the bottle, the vast majority of these cases will die, no matter how carefully they are nursed and fed. These babies should never be kept in institutions of any kind. The method of dealing with them should be changed. The experience of this society shows that, even on the bottle, a majority of them can be saved if a fairly good individual environment can be secured and careful oversight of the feeding maintained.

A hospital or institution of any kind should only serve as a temporary hold-up in cases of acute illness of infants, and they should always be sent out to recuperate after the acute symptoms have been relieved, and, if possible, to the country.

For the past six years the Speedwell Society has worked according to this method, with the following results: The first child was sent out March 19, 1902. The total number cared for from that date to March 19, 1908, is 817. The ages were as follows:

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There have been 103 deaths at the following ages :-
Under three months

45
From three six months

29 six to twelve

21 one to two years

8

103

21

45 .. 22

6

I

The following were the causes of death :

Marasmus or wasting
Gastroenteritis
Enterocolitis (chronic with malnutrition)
Bronchopneumonia
Acute lobar pneumonia
Tuberculosis
Diphtheria
Scarlet fever
Cholera infantum
Meningitis
Premature infants

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The results of the method, as judged by the number of deaths, may not seem very brilliant to those unaccustomed to deal with this class of cases. In glancing over the tables we see that a little over one-third of the cases under three months died; a little over one-quarter between three and six months, and one-quarter from six to twelve months died. After the age of one year there were only eight deaths among 518 cases. The heavy mortality among this class is under one year. This period is very hard to deal with in thin, badly nourished, bottle infants brought to institutions for relief.

The boarding-out method, under careful supervision in the country, is the best plan yet devised to relieve and save these infants. The first series of 121 cases would nearly all have died under ordinary methods of handling, and yet almost two-thirds of

[graphic][graphic]

Condition May 18, 1905.

Condition September 8, 1905. Fig. 1.-A case of extreme atrophy.

them were saved. They were poorly nourished from bad hygienic surroundings, with various degrees of digestive disturbance from faulty feeding on the bottle, and stationary or losing weight. A Carge proportion were restored to fair and even vigorous vitality, although kept on the bottle.

A larger proportion were saved from three to six months and from six months to one year—in the first series nearly threequarters and the second series quite three-quarters being the proportion saved. These are brilliant results, considering that artificial feeding was still of necessity exclusively employed.

In some cases of marasmus the results have been really remarkable. As an example, Esther K., aged thirteen months, was sent out from hospital on May 18, 1905, weighing 9 pounds, 8 ounces. The extreme emaciation is shown in the picture. (Fig. 1.) She was returned on September 8, 1905, weighing 18 pounds, 8 ounces. In four months of this management she had doubled her weight and was a healthy, vigorous infant.

Morris R., three months; weight 5 pounds, 8 ounces—less than birth weight, and slowly but constantly losing. He was kept from January 19, 1903, to November 20, 1903, when he was returned, weighing 25 pounds—a gain of nearly 15 pounds in ten months.

Bessie M., fifteen months, weighed 14 pounds, 12 ounces on being received, November 22, 1905. She was sent back February 15, 1906, weighing 23 pounds. (Fig. 2.)

These cases are used as illustrations and are not so exceptional as might be supposed. They show that wasted infants can often be restored to proper vigor and development if handled in the way here proposed.

While wasting in infants is largely due to faulty diet in its inception and continuance, yet when the atrophy has proceeded to a certain extent the change to a proper diet is not usually sufficient to check the downward trend. These cases require, in

[graphic]

Condition November 22, 1905.

Condition February 15, 1906. FIG. 2.- A case of atrophy with rickets.

addition, an altered environment that will furnish plenty of fresh air, good general hygiene and individual care. For this reason they never do well in institutions, no matter how carefully and scientifically they are fed. They cannot assimilate the best of food without an abundance of good air to assist in its oxidation;

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