SAMUEL S. ADAMS, M.D., Washington.-We must draw a distinction between the methods of farming out babies in the time of which Dr. Jacobi speaks and the present time. The present-day method is backed up by means and intelligence; by means that can buy intelligence. They can afford to have competent nurses and skilled physicians. They do not simply board them out, ast they did in those days, to some darkey with five or six children who, as I have often seen, would bring them to the hospital surprised that they could not keep "pot-liquor" on the stomach. Now in my city we have a Board of Charities, a board of children's guardians, who watch over the children and they are better supervised. They only give a limited number of children to one person to be cared for.

In regard to the fresh air treatment I have gotten as good results as those mentioned and have been surprised how even the ignorant show a willingness to carry out this treatment. To illustrate this an incident occurred recently; I was called in consultation to see a case in an Irish locality known as "Holy Hill." When I went up to the house the doctor said, "I know what you are going to suggest, but it will not do up here." The child was in a room 10 X 12, with the usual stove, cat and dog, and coal-oil lamp and there were about twenty people in the two rooms. The child, eighteen months old, was lying on a sofa with a temperature of 106° and evidently in a dying condition. I suggested to them that the child would die if kept where it was and that it might possibly be saved if the mother would take it upstairs, wrap up well and sit by the open window with it all night. She said she would. The doctor said he knew she would not and advised me not to be seen in that neighborhood for the next thirty days. Three or four days afterward I inquired about the child and was told that they couldn't get the woman away from the window and that the baby was living and doing well.

F. S. CHURCHILL, M.D., Chicago.-I think people are very ready to carry out this treatment much more willingly than the profession at large think. This is true not only among intelligent people, but among all classes. I have no difficulty whatever in private practice. In my dispensary practice I have had great assistance by having one of the nurses of the Visiting Nurse Association follow up the cases, going directly into the homes and looking after them.

P. J. EATON, M.D., Pittsburg.-The question of the adaptability of the nurse has much to do with it. Dr. Northrup's famous paper, entitled "23," gave me the inspiration to teach the fresh-air treatment to nurses. I lecture to nurses in four different hospitals and I have found that since giving them such instructions we have a much better chance with the treatment. We now have a corps of nurses who carry out intelligently what we desire along this line.

Discussion of Papers by Drs. Northrup, Graham and Chapin. 149

J. LOVETT MORSE, M.D., Boston.-We have heard a good deal today about fresh air and cold air for sick babies. I only want to remark that they do no harm to well ones.

A. JACOBI, M.D., New York.-Dr. Adams has suggested that the time of which I spoke was different from the present time—that a good deal of my ill success must have been due to that circumstance-but I beg to remind him of the fact that it is hardly forty years ago and at that time a good many of the principles of good infant feeding were known. I taught the same thing at that time that I still teach and which has proved so successful, and there are a good many of my pupils and friends who have come to my way of thinking. So that these babies appear to have been fed correctly. Moreover, the tendency was at that time not to send. the babies out with a negro nurse, in droves, but to send them out one by one to farmhouses just as we are doing now. The Department of Charities had commenced for several years to board out children one by one, and if the example had been followed everything would have been well, but at that time it was the wish, as it always is of people in power, and ladies particularly, to control as many subjects as possible, and they wanted. everyone under their roof, and they had to bury everyone. As has been said to-day, that is the result in institutions to-day, and it was then. I am glad to have lived long enough to know that common sense is beginning to prevail, and evidently it is prevailing, for Dr. Chapin has proved it today.

E. E. GRAHAM, M.D., Philadelphia (closing discussion).—I pointed out in my paper that in the early part of the nineteenth century it was appreciated by a few that fresh air was an absolute necessity. We have never had a foundling hospital in Philadelphia, and I think the reason is that in 1871 a number of prominent medical men and others got together and discussed the advisability of erecting one. Dr. Jacobi was quoted at that meeting in 1871 as being decidedly opposed to the foundling hospitals, and the records of the foundling hospital in New York, where such a large percentage of children died, were brought up. At that meeting the idea suggested by Dr. Chapin to-day, of farming out, as they called it then, was advocated. In other words, what we are discussing to-day has been talked about for nearly a century, and boarding out, as suggested by Dr. Jacobi and such as was the unanimous verdict of these medical and legal men was endorsed then. These methods have been practiced by a few men for a great many years, but it seems to me that we are only now beginning to get out ourselves and preach it. If we as a body will be as enthusiastic about this matter of boarding out children and the securing for them of fresh air as we were in our campaign for pure milk we will get excellent results.

WILLIAM P. NORTHRUP, M.D., New York (closing discussion). I would emphasize a point that Dr. Graham has men

tioned that we have raised the standard of quality of milk. Now, by paying equal attention to this other hygienic measure, we will bring it into more prominence and greater usefulness. See what has been done in creating a better quality of drinking water by agitating the matter. Air is too cheap; we do not appreciate things until there is a dearth of them.

Dr. Griffith has raised the point that we were not definite enough in our phraseology. I have purposely made my talks concerning pneumonia and its treatment in the open air. If pneumonia can be successfully treated in the open air, other acute infectious diseases certainly can. I think the body breathes the air and needs the stimulus as much as the lungs.

As to typhoid, I am not at all sure that cold air will take the place of the bath. I have tried it a little, but have not had an opportunity to try it enough.

An old pal of Dr. Jacobi's, Dr. Oliver Wendell Holmes, said: "God lent His creatures light and air and waters open to the skies;

Man locks him in a stifling lair and wonders why his brother dies."

HENRY D. CHAPIN, M. D., New York (closing discussion).I must say that I feel very deeply on this subject, as for many years I do not think I lived up to my light, and I do not believe many of us have. We have seen hundreds of these babies slip through our hands under the usual methods of treatment in institutions. I have had the best hospital wards, roof gardens, convalescent homes especially for these cases, and yet it was the same thing; every baby under one year of age did badly if kept long. History is repeating itself, and the time has come when we who are supposed to know something about this thing should speak, and in no uncertain manner.

With regard to the boarding-out system: the plan I follow is not simply farming out; it is putting them out in a restricted area of the country, with skillful doctors and trained nurses and with people who can be watched. There are all kinds of objections. Some said you will kill these children, but it is not true, and they will all do better in this way.

ACUTE POLIOMYELITIS (AN EPIDEMIC).

BY HENRY KOPLIK, M.D.,

New York.

The epidemic of so-called poliomyelitis, which visited New York last summer, was certainly not only the most extensive known in New York, but possibly in the United States. Something over 1,200 cases were reported to the New York City and State Boards of Health. The conditions of weather and of atmosphere were not unusual, and the writer of this reference was present in New York during the whole epidemic, and his experience includes a large number of cases seen in private office work and with other physicians. The disease was certainly, in its characteristics, an epidemic one. It was quite widely distributed, being limited particularly to the city limits, with a few scattering cases in the suburbs. It cannot be said that to any extent the cases occurred in the filthy or crowded portions of the city; I have heard of cases in Tuxedo, a fashionable suburb for city residents. There were cases in parts of Brooklyn in sparsely populated districts; cases in the Bronx, where the sanitary conditions among the poor are exceptionally good; and finally, I saw cases in the crowded and filthy portions of the city. The conditions: of the streets were not unusual; they were about as clean as one can expect to find in a large, densely populated city. There was nothing in the water supply that attracted attention, and the milk supply was certainly as good, if not better, than in previous summers. Therefore, so far as external hygienic influences are concerned, the conditions were not better, and certainly not worse, than they have been in previous years; consequently, the local conditions causing the epidemic must remain a matter of speculation.

The epidemic, in its behavior and in the several cases seen by me, certainly resembled very closely what was seen by Harbitz in Sweden, and so classically described by him in his work on the pathological aspect of this question. As to the character of the disease, it affected children of all ages from earliest infancy to

adolescence; and some cases occurred in adults, but they were few and scattering.

The general characteristics of the disease can in no way be said. to resemble what has been classically understood to be poliomyelitis anterior, but it is rather a disease which hitherto has been unknown to us in many of its manifestations. Many of these cases at first resembled meningitis, and yet some of the physicians with whom I came in contact saw immediately that they were in the presence of something new, which was not meningitis, and at the same time in some cases presented many meningeal symptoms.

I think it will be best from a clinical standpoint to describe certain sets of cases which occurred in this epidemic of so-called poliomyelitis. First, there were the cerebral cases. In these cases a child in apparent health would either suddenly go into a condition of unconsciousness, or would go to bed perfectly well, awake with a febrile movement, vomiting and complaining of headache, then pass into a condition of sopor, or with a very bright sensorium would develop paralysis of all four extremities. If the case was an extreme one, the paralysis would suddenly be followed by increasing sopor, in which the patient suddenly developed symptoms referable to the bulb or enlargement of the medulla; there was difficulty in respiration due to paresis or paralysis of the respiratory muscles; difficulty in swallowing; the sopor increased to coma with increasing paralysis in some cases ending with the death of the patient apparently from respiratory failure and bulbar paralysis. In other cases these cerebral symptoms would abate and a mild condition of sopor would be replaced by a clear sensorium, but with complete paralysis of all four extremities. In some cases there would also be paralysis of the abdominal muscles, or paralysis of the thoracic muscles and abdominal muscles, and muscles of the back, in addition to the muscles of the four extremities. These patients would also show distinct signs of bulbar paralysis with a form of breathing which is purely diaphragmatic, that is, the abdomen at each respiration would be protruded, the thorax remaining inert.

In other cases a child would go to bed apparently well, and these are what I call the neuritic cases; they would awake with acute pains in the extremities, referred in many cases to the joints. So acute were these pains that the patients would cry out in the night, even if not disturbed. Gradually, in many of these cases,