JOHANN HOFF'S MALT EXTRACT IS PUT UP IN THIS STYLE ONLY. This has been the first Malt Extract made in Europe or America (1847), and has been constantly improved in conformity with the advance of science. No preparation of "MALT" has been so long and so extensively employed as a Medical Food and Nutrient. "As a large number of patients lack the necessary power to digest solid food, and would through the use of stimulants be merely excited and weakened, therefore I regard it of immense value to the practitioner to bring to his aid a nutritious tonic and remedy like the Johann Hoff's Malt Extract, which will act not only as a tonic but as a nutrient as well, and which is less exciting than wine, ale or porter as a stimulant." -PROF. PIETRA SANTA, Paris. "I have used Johann Hoff's Malt Extract for the past five years in my private practice, and have found it to be the best health-restoring beverage and tonic nutritive known. I have found it especially good for persons convalescing from fever in cases of dyspepsia, for nursing mothers, and in cases of weakly children, and also in lung troubles. My attention was drawn by the immense importation semi-monthly, and about million of bottles imported by you have passed my inspection in the Custom House satisfactorily for the past five years." W. W. LAMB, M.D., InsgA a chief Drug Inspector, U. S. Port, Philadelphia, CAUTION: A preparation BOTTLED IN NEW YORK is being sold as "Hoff's" Malt Extract. Hoff's" Malt Extract. To obtain the genuine, original article, please specify "JOHANN HOFF'S MALT EXTRACT, imported by EISNER," which will prevent substitution of immitations. EISNER & MENDELSON CO., Sole Agents, Office, 6 Barclay Street, New York. The Dietetic Gazette, Målthusian meaning and profess to regard it as one. HE most exalted function of the physician is to maintain health rather than to remedy disease. That chair which, in the curricula of the colleges, is most deserving of dignity and, still is most commonly conspicuous by its absence, is the chair of Preventive Medicine. The business of our profession is the con- servation of human life, and yet upon the very threshold of the task we encounter one of the most perplexing of vital problems-the fact of infant Few of us, I fancy, appreciate to their full, the ex- tent and meaning of this fact. We entertain a general idea that infancy is hedged about with seemingly in- evitable dangers, while we have but a vague notion of the relative activity and the ultimate origin of those influences which determine the fatal results. And if we seek to prosecute anything like an analytic inquiry into the causation of infant death, we find the effort of her finished work. She scatters seeds by the mil- lion to the wind, where but a thousand take root and germinate. She hatches out one fish where the possibilities of hundreds have been spawned. She matures a score of Graafian follicles in the human ovary for every ovum that is fructified and fully developed. But at that point-the point of birth— the parallel stops. With the appearance of the indi- vidual existence, the worth of life begins and reaches its highest standard in the human. Endangered it is from "foes without and foes within," but Nature immediately strives to throw around her completed product every protective influence. From birth, the vis medicatrix naturæ become not merely a latent but an actual force. Thereafter every new life, with its freight of possibilities, has an economic value; every sacrifice of it is an economic loss. But a still more serious obstacle bars the progress of the inquirer into the causation of infant mortality, viz.; the poverty of our vital statistics. gard the Old World is immeasurably in advance of tabulating death causes are in most chaotic state. There is no uniformity among them. We permit ignorance to hide behind such unscientific terms as inanition, infantile debility, marasmus, asthenia, dentition, indigestion, scrofula, heart-failure and the like. We confound methods of dying with causes of death. We commonly overstep the physiological bounds of infancy-limited naturally, by the complete evolution of the deciduous teeth, to three years-and include children up to the age of five in the records of infantmortality. In fact, only thirty American cities pay any attention even to this artificial boundary line of years in making up the sum-totals of death; while only nine cities consider the element of the.age of the decedents in tabulating the returns of individual death-causes. The American Public Health Association would do a signal service to the public if it should appoint a Committee to frame a satisfactory table of mortuary statistics and to secure the adoption of the same by State and Local Boards of Health. It goes without saying that accuracy, in such an inquiry as this, is thwarted by these failures in the official returns of death. We are confined, of necessity, to the larger group of statistics I have noted, for a discovery of the percentage of infant mortality in the gross and are forced, even, then, to accept the returns for the first five years of life instead of for the first three, while, in the endeavor to determine the individual diseases which result fatally in infancy, we are restricted to the smaller group of nine cities. In a recent address, which he had the honor to deliver before the Minnesota Academy of Medicine, the writer succeeded in approximating some degree of accuracy in the returns from twelve American cities, but, in order to secure an absolutely correct estimate, it has proved necessary to narrow down the present summary still more. While it is measurably true that the death-rate of cities is modified to some extent by that of the country-districts, yet population is concentrating itself so rapidly in great centres, that this is less true than in earlier times, and, for all practical purposes, the urban statistics are a safe index to the facts. A study of these statistics in the thirty selected cities to which I have referred, shows that, during the year 1888, 155, 208 deaths occurred in these places. Of this number 40,715 or over 26 per cent. were under one year of age, while 33,776 more, or over 15 per cent. were under the age of five, making a total of 64,491. or 41.5 per cent. After a fair estimated subtraction for the number of decedents, who ranged between three and five years of age, we can safely estimate that 35 per cent of this sum total come within the physiological limits of infancy. This figure accords very closely with the reckoning of a number of other statisticians and coincides curiously with the calculation that nearly thirty-five, out of every hundred babies born, die in infancy. These cities are sufficiently varient in size, climate. and geographical situation to afford a fair average in death-rate and to establish, beyond a question, the truth that modern preventive medicine has not reached a remedy for the excessive loss of infant-life. This fact duly recognized, the more difficult task awaits us of determining the immediate and ultimate causation of this mortality. It will not be enough to discover the names and relative fatality of the diseases which destroy the human race in its earliest years. This is a comparaively simple thing to do, even in the face of our statistical failures. But the weightier question remains and hides the solution of the whole problem of infant mortality. Why is infancy peculiarly liable to the destructive influence of these immediate deathcauses? In the correct reply to this important query rests the final recognition of the ultimate causation of infant-death in its present overwhelming excess. The road to the last analysis of the problem must, of course, lie through a primary analysis of the immediate causes. The nine cities, whose published reports enable us to determine the classified age of their decedents in each individual death-dealing disease, are New York, Baltimore, Boston, San Francisco, Cincinnati, St. Louis, Newark, Hartford and Minneapolis. In the year ending October 1st, 1889, the combined statistics of these cities give a death-total of 22,092 infants under one year and of 12,883 children between the ages of one and five. The sum of these figures gives 34,975 so-called infants who have died within one year. The diseases which have induced these fatal results are as follows: THE DIETETIC GAZETTE. This general statement demands a brief analysis and these causes a general classification. Under "Miscellaneous Causes" we find a variety of diseases which seldom appear, and more seldom result fatally, in true infancy, while probably two-thirds of this total, in which these rarer death-causes are included, is made up of still-births and premature births, which should not be, but almost always are reckoned as actual deaths. Under the term," Congenital Malformations, etc.," are included cyanosis, atelectasis, trismus nascentium, umbilical hæmorrhage, malæna, spina-bifida, deformities and other conditions which terminate life within a few hours or days of birth. This class should probably be increased by some further contribution from the "miscellaneous causes. The small number of infant-deaths charged up to syphilis would excite surprise were it not for the well recognized fact that physicians habitually save the feelings of their patients' families by concealing the nature of this disease, as a death-cause, under the guise of some local disturbance incident thereto. It is a misfortune to the public that a cause so unquestionably potent and so frequently occurrent should be thus obscurely hidden. With the deaths attributed to hydrocephalus and to tabes mesenterica are inextricably grouped, by some statisticians, many cases of so-called marasmus, while with the latter disease are included similarly a few deaths from tabes and hydrocephalus. Admitting that it is difficult to classify these conditions and that they sometimes interact upon each other, that it is now true that hydrocephalus has a syphilitic origin and again that it has a tubercular character, it is nevertheless improper to place that large variety of conditions, which we conveniently term marasmus, in association with either the one or the other of these two well defined diseases. For convenience of future criticism, it will be well to resolve these diseases into several well defined groups, as follows: (1) CONTAGIOUS DISEASES, including diphtheria, marasmus. Total 3 This classification puts us in a position to discuss these groups of diseases in their relation both to the immediate and remote causation of infant mortality. And, first, the Contagious Diseases, which represent about 16 per cent of the entire death-rate of infancy. Over one-half of the fatalities in this group are chargeable to diphtheria and membranous croup, which may safely be regarded, so far as the statistician is concerned, as identical diseases. The significance of this percentage is enhanced when we observe that these are preeminently the fatal members of this group so far as true infancy is concerned and that scarlet fever, measles and whooping-cough find the vast majority of their victims in children between the ages of three and five. Of this remaining trio, it might be something of a surprise to the casual student of vital statistics, to find whooping-cough playing so large a part and really destroying a greater number of actual infants than scarlatina and rubeola. That measles, too, a disease ordinarily regarded in so innocent a light and rarely quarantined, should yield so large a number of fatalities as it does, deserves emphasis. Doubly true is this when we remember how common a sequel or concomitant of measles is capillary bronchitis and give due weight to the fact that a large part of the numerous deaths debited to the bronchial disease should be charged to this primary cause. And this naturally leads us on to the reflection that our second group-the Respiratory Diseases-are very definitely related as sequelae in infancy to the exanthemata. This conclusion is borne out by the fact that where the latter thrive, the former are always prevalent; and that, whenever the one group assumes a marked degree of statistical importance, the other group keeps pace with it. And, let us mark very carefully, that of both classes is it true that they appear and multiply, in occurrence and fatality, not merely in direct ratio to the increase of the population, but in direct proportion to the massing of the population within a given area. This is due not only to the opportunity which close crowding of the people gives for the spread of contagion, but also to the correlative truth, applicable to all diseases alike, that reduced cubic space per capita, involving the worst of insanitary consequences, means a reduction in the powers of resistance in the people and particularly in the infant so environed. And here we touch the first key-note in this social discord of infant-death-the first suggestion of its ultimate causation. It is not true that infant-life under favorable averages of environment, is unequal to the task of maintaining itself against disease; but it is true that infancy, prejudiced in the unequal struggle with insufficient air-space and sunshine, easily goes down under the attack of disease. The remarkable number of deaths assigned to pneumonia, coupled with the fact that this malady, 4,350 in its true form, is not ordinarily considered a foe to infancy, gives rise to a suspicion of carelessness in diagnosis and of a probability that a large part of this total should be added to that essentially infantile disease-capillary bronchitis. It is also certainly true that a considerable share of cases reported as pneumonia are in children between three and five years, when the advancing age renders the diagnosis more probably correct, but carries the disease further outside the proper limits of the causation of truly infantile mortality. this fatality. The introduction of mechanical aids, by means of the operation known as intubation of the larynx, to which Dr. O'Dwyer, of New York, and Dr. Waxham, of Chicago, have contributed so ably, marks. I believe, an era in the treatment of the diphtheria and croup of infancy. It cannot be practised too early after the invasion of the larynx by the disease if it is to avail in averting the dangers of death by suffocation. It is matter for regret that the seat of the lesion in True pneumonia-unquestionably a germ disease-capillary bronchitis does not permit of any hope that is, so far as it affects true infancy, most prevalent in closely crowded communities and the fact re-emphasizes what we have already said upon this subject. European cities are taking long strides in the direction of providing better houses and more cubic space for their less fortunate inhabitants and the great cities of the United States must, sooner or later, grapple with the same necessity. Of design, the writer has recorded the fact that in the statistics of the nine cities under discussion, only seven cases of pleurisy, occurring and terminating fatally in infancy, are recorded within the past year. Now pleurisy is a disease to which infancy would much more probably be prone than to pneumonia, and, without doubt, it occurs with some degree of frequency. Dr. C. D. Conkey, of Larimore, Dakota, has, in a recent and timely paper, drawn attention to the somewhat frequent errors in the non-diagnosis of the disease alike in its acute and chronic form. The suggestion is, at least, worthy the attention of the profession. So far, then, we have noted three diseases which are peculiarly fatal to infancy-diphtheria (including membranous croup) whooping-cough and capillary bronchitis. Between the two latter a natural relationship exists, for in whooping-cough death usually results from complicating bronchitis. At first sight, no pathological connection of these maladies with diphtheria is apparent, but, if we pause to consider the usual mode of death in all of these conditions, as affecting infancy, we find a suggestive link which may, to a great degree, account for their common fatality and give us a clue to another ultimate agency in the mortality of this period. Death usually occurs in all of them by suffocation, rather than from exhaustion or blood-poisoning. It is in older years that the latter modes of death more frequently prevail. It is suffocation, incident to the blocking of the larynx or trachea in diphtheria, of the capillary tubes in bronchitis, with or without whooping-cough, which commonly destroys the infant. The narrow lumen of the air-passages and the inability of the babe to keep them free of obstruction, are the main factors in this result. If these points are well taken, they are valuable, because while affording another primary reason for the excessive mortality of infancy, they offer a hope of lessening similar means will prevail to lessen also the mortality of this disease. But, nevertheless, the point of relationship in the mode of death suggests new possibilities of adaptation of the old methods of treatment. No case, however desperate, should be readily abandoned to its fate. By the brief but timely aid of an emetic, by the careful use of diluted oxygen, by the admission, in the neighborhood of the child of currents of fresh air, by the stimulating effect of dashes of hot and cold water upon the chest and by the use of other agents which will promote the temporary clearance of the tubes, the mechanical obstruction which is fast destroying life, by cutting off the airsupply from the lung-cells, may be overcome and the infant-life, rapidly being choked out, may be saved. The next class of death-causes which claim attention in the order in which we have arranged them, is the group of tubercular diseases. Phthisis pulmonalis does not often develop in infancy and we frequently hear the idea of its occurrence in that period scoffed at by medical men. Other forms of tubercular disease, meningitis, tabes, and hydrocephalus, more commonly attack the infant. There is no apparent reason why the bacillus tuberculosis should not find its way into the system of the young child as easily as it does into that of the adult. Doubtless it does, perhaps remaining in a quiescent state for years, and again making its ravages upon meninges, or mesentery, where in infancy a more favorable nidus for the germ seems to exist and where the presence of tubercle quickly kills. Happily we are living in an age of wonderful progress in pathology and we have clearly established, among other things, the contagious quality of these diseases. Heredity, in their causation, is seen to be limited to predisposition or tendency; the actual disease is traced to the entry of the germs through the media of air and meat and milk. We class the tuberculoses among the preventable diseases and the fact bespeaks hope for infancy as well as for adult life. Fresh air and an abundance of it, the increased capacity of the chest, the disinfection of the products. of the disease thrown off by its victims, the inspection of animals and of meat, the application of sufficient heat to all infant-foods-these are the preventable agencies which will, eventually, lessen the ravages of "the bacillus tuberculosis of Koch." For the arrest of congenital syphilitic disease and |