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being carelessly handled is also always liable to contain pathogenic organisms derived from human or animal sources.

Results with Very Impure Milk Heated vs. Those with Pure or Average Milk Heated. During the summer of 1901 we were able to observe a number of babies fed on milk grossly contaminated by bacteria. In 1902, a systematic oversight of all stores selling milk was instituted by the Health Department, so that the very worst milk was not offered for sale that summer.

Table Showing the Results of Feeding During July and August, 1901, in Tenement Houses, of 112 Bottle-Fed Infants Under One Year of Age, and of 47 Bottle-Fed Infants Between One and Two Years of Age with Milk from Different Sources, and the Number of Bacteria Present in the Milk.

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(1) Pure milk boiled and modified at dispensary or stations; given out in small bottles. Milk before boiling averaged 20,000 bacteria per c.c.; after boiling 2 per c.c.....

41 3

23 41

(2) Pure milk 24 hours old, sent in quart bottles to
tenements, heated and modified at home, 20,000
to 200,000 bacteria per c.c. when delivered.
(3) Ordinary milk 36 hours old, from a selected
group of farms, kept cool in cans during trans-
port; 1.000.000 to 25.000,000 bacteria per c.c.,
heated and modified at home before using........ 18 4
(4) Cheap milk, 36 to 60 hours old, from various
small stores, derived from various farms, some
fairly clean, some very dirty; 400,000 to 175,000,000
bacteria per c.c....

(5) Condensed milk of different brands. Made up
with hot water. As given, contained bacteria
from 5,000 to 200,000 per c.c...........
(6) Breast Milk..

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The observations upon the impure milk of 1901 are of sufficient importance to be given in detail, although already mentioned in this report in the observations upon infants of both summers which were fed on "store milk." A group of over 150 infants was so divided that 20 per cent. were allowed to remain on the cheapest store milk which they were taking at the time. To about the same number was given a pure bottled milk from Briarcliff Farms, sent to their homes free of charge by Mr. Walter W. Law. A third

*This infant died from enteritis and toxemia.

This infant died of pneumonia. There had been no severe intestinal disorder noted.

One of the four had pertussis, the remaining three died from uncomplicated enteritis.

group was fed on the same quality of milk as the second, but sterilized and modified at the Good Samaritan Dispensary. A fourth group received milk from an ordinary dairy farm. This milk was sent to a store in cans and called for by the people. A few infants fed on breast and condensed milk were observed for control.

In estimating the significance of the observations recorded in the tables, one should bear in mind that not only do different infants possess different degrees of resistance to disease, but that, try as hard as the physicians could, it was impossible to divide the infants into groups which secured equal care, and were subjected to exactly the same conditions. It was necessary to have the different groups in somewhat different parts of the city. It thus happened that the infants on the cheap store milk received less home care than the average, and that those on the pure bottled milk lived in the coolest portion of the city. Certain results were, however, so striking that their interpretation is fairly clear. It is to be noted that the number of infants included in each group is small.

There is nothing in the observations to show that fairly fresh milk from healthy cows, living under good hygienic conditions and containing, on some days, when delivered, as many as 200,000 bacteria per c.c., had any bacteria or any products due to bacteria that remained deleterious after the milk was heated to near the boiling point.

On the other hand it is possible that certain varieties of bacteria may, under conditions that are unsanitary, find entrance to milk and survive moderate heat or may develop poisonous products resistant to heat in sufficient amount to be harmful, even when they have accumulated to less than 200,000 per c.c.

Turning now to the results of feeding with milk which has been heated, and which before sterilization contained from 1,000,000 to 25,000,000 bacteria per c.c., averaging about 15,000,000, though obtained from healthy cows living under fairly decent conditions and kept moderately cool in transit, we find a distinct increase in the amount of diarrheal disease. Though it is probable that the excessive amount of diarrhea in this group of children was due to bacterial changes which were not neutralized by heat or to living bacteria which were not killed; yet it is only fair to consider that the difference was not very great and that the infants of this group. were under surroundings not quite as good as those on the purer milk.

Finally, we come in this comparison to the infants who received the cheap store milk Pasteurized. The milk had frequently to be returned because it curdled when boiled, and contained, according to the weather, from 4,000,000 to 200,000,000 bacteria per c.c. In these infants the worst results were seen. This is shown not only by the death rate, but by the amount and the severity of the diarrheal diseases, and the general appearance of the children as noted by the physicians. Although the average number of bacteria in the milk received by this group is higher than that received by the previous group, the difference in results between this group and the previous one can hardly be explained by the difference in the number of bacteria. The varieties of bacteria met with in this milk were more numerous than in the better milk, but we were unable to prove that they were more dangerous. Probably the higher temperature at which the milk was kept in transit and the longer interval between milking and its use allowed more toxic bacterial products to accumulate.

Observations Upon Milk Feeding in Institutions.-During the summer of 1901, observations were made by Dr. Long in nearly all the institutions for children situated in New York City. He found, with three exceptions, that no particular care was taken to secure a supply of pure milk. Samples taken from the supply of the other institutions showed that the milk averaged over 1,000,ooo bacteria per c.c. when delivered, and at half of them it averaged over 10,000,000 per c.c. The cream frequently contained 60,000,000 bacteria per c.c. The milk at two places contained at times over 100,000,000, At several special hospitals for young children the milk and cream contained on different days from 26,000,000 to 157,000,000 bacteria per c.c. Formaldehyde was also occasionally found, especially in the cream. Samples of milk were taken weekly from most of the institutions and examined as to the number of bacteria, and in some cases also as to the varieties present.

As a rule to the children who were over three years old the milk was given raw, while for those under two it was heated (sterilized). For those between two and three years, it was sometimes heated, sometimes not. In only two institutions was it possible to trace any epidemic of diarrhea among the infants and older children, and in these, the particulars of which are given below, the results cannot be reasonably attributed to the milk.

The first epidemic of diarrhea occurred at the New York Infant Asylum during June and July, 1901. There were in the institu

tion 86 infants; 30 of these were bottle-fed and 56 were on breast milk. Of the 30 bottle-fed infants, 22 suffered from diarrhea. Of the 56 breast-fed infants, only 7 were affected. The epidemic was mild in character, only 2 infants dying.

This epidemic, which occurred during and after a period of very hot weather, at first glance might be ascribed to the milk. The fact, however, that 7 cases occurred among the breast-fed infants, that the cases occurred from time to time, not simultaneously, and that the milk used had been previously heated, points rather to an infection communicated from the sick to the well than to one conveyed by the milk, unless it was true that the milk had been contaminated in the wards.

In another institution an epidemic of moderately severe diarrhea occurred during the winter, in which at first all the cases came from one ward, and then later from a second ward. In this epidemic, infection through the milk was not conceivable, since the bottle-fed infants in the wards where no illness occurred received milk from the general supply.

General Conclusions.-In addition to the statistical reports of their observations, the different physicians who watched the infants in their homes were asked to state their own conclusions regarding the general problem of infant-feeding in the tenements. These general impressions are most suggestive and cannot fail to be of interest to all who are working at this difficult problem.

It was practically the unanimous opinion that the most important factor in securing good results is intelligent care. This covers much clean bottles and nipples; the willingness and ability to carry out directions as to methods of feeding, quantities, frequency, the stopping of milk at the first signs of serious diarrhea, etc.; proper care of the milk itself while in the house, and methods of sterilizing; suitable clothing and cleanliness of the children, and as much fresh air as possible.

Most of the physicians stated that, leaving out the very worst store milk in summer, the results were much less affected by the character of the milk than they had anticipated, and distinctly less than by the sort of care the infants received.

The surroundings alone had much less influence on results than was anticipated. For not only were breast-fed infants found doing well under the most unfavorable surroundings, but those also who received only the bottle as a rule did well, provided they received intelligent care and good milk.

The depressing effects of great atmospheric heat, i. e., a temperature in the neighborhood of 90° F., or over, were very marked in all infants, no matter what their food. Those who were ill were almost invariably made worse, and many who were previously well became ill. A bad method of feeding, or, rather, a feeding without any method, was responsible for many failures when the milk itself was of good quality. Common mistakes were, feeding an infant every time it cried; giving it a full bottle, no matter what the age of the child, and letting it take as much as it would; preparing a large bottle of food at one time, and warming it over from time to time until the child had taken the whole of it, or allowing the milk to turn sour in the feeding bottle. Quantities proper for single feedings were almost invariably disregarded. Proper washing of feeding bottles was seldom seen in a tenementhouse. Such matters as these are closely connected with intelligent care, which has been already considered.

The importance of the matters just mentioned raises the question of how much can be accomplished by the distribution of printed slips of directions. It was the observation of the physicians that comparatively little can be accomplished by these alone. Such printed circulars are often treated by the tenement-house mother very much as most of us treat the printed advertisements which are left at our doors-seldom read and soon thrown away. Mothers are often anxious and willing, but ignorant and stupid. Many cannot read and many more have not the wit to apply in practice what they read. When, however, such printed advice was preceded or accompanied by personal explanation, it was found of great assistance. Personal contact is the only sure way to influence these people, and this must be frequently repeated to influence them permanently; as an aid to this, printed slips are useful. Printed directions, however, should be as simple as possible in statement, few in number, and touch only the most vital matters, telling the mother always what she is to do, not what she is not to do.

Summary. The observations here recorded were made upon the groups of infants for periods of about three months only, and the conclusions drawn relate especially to the more immediate effects of the milk.

1. During cool weather neither the mortality nor the health of the infants observed in the investigation was appreciably affected by the kind of milk or by the number of bacteria which it contained. The different grades of milk varied much less in the

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