lost only 99.5 babies in the 1,000, while New York lost 117. If, then, Boston's infant mortality has been reduced so much by visiting nurses, there is reason to suppose that it can be further reduced by a radical change in the institutional care of infants, as well as by new methods of caring for the poor in the maternity hospitals, and by a better control of midwives. If this is true of Boston, it is as true of all our cities. One of our best obstetricians has said that there are only a few good lying-in hospitals in the United States. Another teaches his students that every pregnant woman is in a pathological condition, and should be treated in a surgical hospital. There is evident truth in each of these statements, but without new hospitals, and even with midwives, Scandinavia has far excelled us in the saving of infants. It is probable that the average intelligence of Scandinavian midwives is far superior to that of most of our midwives, who come mainly from the countries of Eastern and Southern Europe, where their training has been far inferior to the hospital training of the Scandinavians. It is said that 40 percent of the children among our foreign population are born under the care of midwives, whose only qualifications are that they can read and write in their own language, and that they have seen six confinement cases. In England and France and Germany, where for military reasons a failing birth rate and increasing infant mortality mean national disaster3, midwives are being carefully trained and supervised, for in these countries women have for centuries been considered the natural obstetricians. By this method alone they have lowered their mortality one-third, and if we in the United States should thus deal with our midwife problem, and by so doing lower our infant mortality one-third, we should take third rank instead of fifteenth; and if, in addition, we should give premiums to mothers who nursed their babies for two months before returning to work, as Germany has done, we might further reduce our infant mortality by one-half, and thus take our place beside Sweden in the first rank of baby savers; for, naturally, proper homing of little children would be a part of these other reforms.* While paying attention to reducing our infant mortality, we should also inquire into the causes of the premature births and of the deaths of the babies who die before they have more than gasped a few times. It has been found at the Sloane Maternity Hospital that 58 percent of the deaths at term are from congenital weakness and atelectasis, 3 percent die from injuries during labor, and 4 percent are caused by congenital syphilis, besides another 42 percent born dead probably because of syphilis. This last disease claims its toll in Scandinavia as well as in America, but with the exception of tuberculosis, alcoholism, and syphilis, there is nothing in Scandinavia to cause cell deterioration in both parents and offspring, or to lessen their homogeneity as a nation and their hardiness as a race. In America we have to combat ignorance, neglect, and concealed poverty. Koplik has found that 60 percent of our deaths in earliest infancy are due to these three causes, which do not exist to any extent in Scandinavia, where, by means of governmental supervision of the people and intelligent methods of preventing extreme poverty and neglect, there is less congenital debility, and owing to almost universal breast feeding fewer cases of digestive disturbances and a much higher average of intelligence. This fact is brought out clearly in the death lists. of Scandinavian infants in a Connecticut town where only one baby dies in a year from a population of nearly a thousand Swedes. The Scandinavian infant, therefore, starts with fewer handicaps, and even if its mother gives it away or deserts it later, its digestion has not been impaired by early artificial feeding. When the Swedish Government takes care of infants in large or small homes, it continues to feed them on a diet containing at least a little breast milk, and houses them with other perfectly healthy babies, among whom there is little danger of mixed infections. Hence Sweden's 4 percent institutional mortality puts to shame our institutional mortality of 40 to 75 percent. Moreover, if our unintelligent mothers were not allowed to return to their homes from the maternity hospitals until they had lived at least two months with their babies in convalescent homes where they could learn how to care for themselves and their babies properly, as is done in a great number of cases in Scandinavia, we should not only lower our infant mortality markedly, but also improve the health of the mothers, and prevent many subsequent gynecological operations. In Stockholm alone, for instance, a city of 350,000 inhaitants, there are between fifteen and twenty co-ordinated institutions for the care of mothers with their babies under government inspection. In Connecticut, on the other hand, with its population of 1,500,000, there are in all eight county homes for orphans or degenerate children over four years old, small orphanages in the three or four largest cities, two or three small homes for unmarried mothers, a Children's Aid Society, which cares for comparatively few babies in boarding homes, and an inadequate institution for feebleminded children, none of these institutions being co-ordinated with the lying-in hospitals. Doubtless one State is like another in these respectshomes and asylums being under government inspectors, who make perennial visits, and report everything as in a "satisfactory condition." Recent graft disclosures in New York, however, throw some light on the high cost of maintaining such institutions. Where it is possible for a physician, not a specialist, to obtain from a New England Legislature a grant of money for removing the tonsils and adenoids from every child in an institution for orphans, it would seem possible for many other abuses to be found. Humanitarian motives, doubtless, were the reasons for founding our institutions "for poor, decayed, and impotent persons," but such institutions should be sufficiently modern, and under so enlightened a board of managers, that the inmates, young or old, should be fitted in them for life and not for death. In one of our most progressive States, for example, the infant mortality under one year of age was 37 percent until the largest cities of that State took the matter in hand. Then, by more careful housing and inspection of homes, together with the cooperation of visiting nurses and milk stations, they cut this rate down to 10 percent in their most crowded districts. But even now the infant mortality in New England is not as low as the average low figure of Norway and Sweden. Perhaps to understand the reasons why this is so, we might go more into detail as to the baby-saving methods employed in Scandinavia, beginning with the personal work of Professor Medin, in Stockholm, who revolutionized the teaching of pediatrics in the University Medical School. His foundation was laid upon the precept that no milk was like mother's milk; and as his Swedish mothers were strong, they were able to nurse their babies provided they had good food and were not overworked. Then he believed in isolating all sick babies with their mothers, and allowing no children to visit any foundling asylum because of the danger of infection. He does not believe that tuberculosis of the bovine type is ever the cause of human tuberculosis in babies", and he says that he has never seen a case of tubercular infection not of human origin. Before Professor Medin retired from his university work, at the age of 65, he was instrumental in building the Sachs Hospital for Sick Babies. Here his theories for the nourishment and treatment of sick in fants from all parts of Sweden are put into practice. The hospital has room for fifty-four babies, four wet-nurses, a resident physician, and the other personnel of such an instution. It is built on a bluff above the fjord, in a most beautiful location, isolated from all other buildings. A mother may live in the hospital with her baby if necessary, or she may visit it during the day to nurse it, according to its needs. The milk of the wet-nurses is squeezed into bowls and kept on ice until needed for some formula. No goat's milk, albumin milk, nor pasteurized milk is used in the formulæ, but cow's milk may be modified with buttermilk, flour, sugar, and human milk, these formulæ being represented graphically, in blocks of color, on a chart at the foot of each bed. There are four wards, each containing eight cribs; there are also eight single rooms provided with double doors and double windows, in order to assure freedom from noise and a constant temperature for premature babies. There is one head-nurse who prepares all the formula with the aid of servants, two ward nurses, and fourteen pupil nurses who spend three months at this hospital as part of their general training. When we consider that in a hospital for infants too ill to remain in any other institution there can be maintained a mortality of only 4 percent, we are not surprised that in the foundling hospitals the mortality is only 3 percent among 300 well infants under two years of age. This is perhaps the more remarkable to us from the fact that these hospitals are not built on a new model, the wards being dormitories where twenty-four babies sleep, or sixteen babies and eight mothers; and yet there is no "congenital debility," and there are no epidemics of measles or other contagious disease to disturb the If one visits these homes for children, one finds In a It might be asked if these statistics of the in- ing entitled, "A young mother kills her illegitimate baby in a cow shed.” The museum paid a large price for the picture, critics hung it in a prominent place, and crowds of visitors gaze at it as a work of art without apparent horror or sympathy. Most of the illegitimate babies are born in the maternity hospitals, many of which are modern and thoroughly practical. The patients enter the hospital in labor, are bathed in shower baths, examined, put to bed in the delivery room, and delivered by midwives or by obstetricians. After a few hours' rest they are taken into a ward, and the following day the baby is baptized in the presence of its father, if possible; it receives its father's name, and frequently a wedding follows this simple ceremony, the mother going to his home after two weeks. If, however, the If, however, the father cannot be induced to marry the mother of his child, it is baptized with his name, and the mother takes it to one of the many convalescent homes for a few months, where she partly supports herself by working as laundress or by sewing. The Government only allows about $10 a year for the support of the woman, the rest she must earn. In a country like that, where mothers nurse their babies, milk stations are not so necessary as diet kitchens and school dinners, such as are provided in all the cities of Scandinavia; for it is recognized that if a mother is to nurse her baby, she must have nourishing food; and if a child is to grow strong and robust, it must have a well-proportioned diet. In the villages, on the other hand, the problems are more serious. The government, while receiving little revenue from many of its isolated communities, is obliged to provide doctors and midwives for the inhabitants, as well as schools and churches, and employment for women whereby they may earn money during the long winters. In Northern Sweden there is one State-paid midwife to every 6,046 persons. Her salary is 300 kronor a year (about $84) plus two kronor for each new baby. In the more populated places in the south of Sweden there is one midwife to every 3,274 persons, at twice the salary. In Norway the doctors and midwives in the country undergo great hardships during the long winters, for the distances between farms or settlements are great, and travel by water or around the mountains is slow and cold. Were it not for the hardiness of the inhabitants of the seashore and dark valleys the mortality would be very great, for it is diffi cult to obtain medical help in emergencies. But where human beings are aggregated together for warmth, like sheep, in closely shut cottages, tuberculosis thrives. Hence the need for the philanthropic May Flower Society, and its intelligent care of the pre-tubercular cases, as well as of those who have the disease. 50 percent during his working years, but he could not obtain the low figures of Sweden, because his government was not awake to its responsibility in the matter, and the farmers preferred to export all of their dairy products, while the mothers were obliged to work hard on the farm and eat poor rations. Where mother's milk and cow's milk were lacking, and where cholera infantum was endemic, the difficulties in saving the babies were great. A tea made from blueberries, and a soup made by boiling bread. in beer, could not remedy an original loss of digestive function in a child. Hence the wonder is that Denmark's infant mortality was as low as 15 percent when that of Germany was 19 percent. Now, however, Copenhagen has a great new hospital with an up-to-date pavilion for children, as well as pavilions for all the other departments of a university hospital and medical school. Under Professor Bloch the students are obliged to take a course in pediatrics, and to work out percentage and caloric formulæ. The city has its milk stations and its cottage homes for foundlings, so that one easily understands why its infant mortality has now dropped to 10 percent. When There are several inferences to be drawn from the preceding brief accounts of the factors concerned in lowering the infant mortality in Scandinavia, one being the evident superiority of the institutions in those northern countries over many of the American institutions. one visits the hospitals or clinics in the large cities, one is impressed with the greatness of their surgeons and doctors, and with the team work of the faculties as a whole. Many of these men have international reputations, among whom we might mention Rovsing and Hirschsprung, of Denmark; Johannessen and Strumm, of Christiana; John Berg and Oskar Medin, of Stockholm-each of whom gives, or has given, his best hours to the university or hospital, and to the public what remained of strength and enthusiasm. Evidently, then, a paternal government and a high rate of taxation, by means of which the rich are compelled to care for the poor, have been successful in improving the health of the Scandinavian people. It is, moreover, evident that neither the size of the hospital nor the number of beds in a ward, nor midwives, nor maternity hospitals, nor pasteurized milk, have been the cause of the low infant mortality; but the lessons for Americans are essentialy the following: We must have intelligent, healthy mothers with breast milk for their babies. We must train our midwives to care for the poor in their homes. We need better teaching in pediatrics and obstetrics in our medical schools. And we should build more sanitary small homes for our foundling infants, or see that those who are boarded in families are cared for properly. When we shall have achieved these reforms, we shall find our economic conditions improved, and with lessened expense we shall have a much lower infant mortality. Besides these lessons for the saving of infants, Scandinavia teaches one the necessity of more rational methods of administering charity as well as laws. Where a government supervises the building of homes for workmen, it prescribes the THE WOMAN'S MEDICAL JOURNAL rate of interest which may be taken from the rent of such homes, and keeps the prices of dwellings within the reach of the laborers. The parks and the waterfronts of the Scandinavian cities are kept clean and attractive for the good of the people as a whole. Doctors and hospitals are provided for the poor, as well as school teachers and priests. Women of the higher classes are appointed inspectors of the poorer districts, and these inspectors are in reality friendly visitors who give advice and alms when they find it necessary. Deaconesses, many of whom are trained nurses, go about among the poor, caring for the sick and infirm as they do in this country; but their charges for nursing are within the means of all but the poorest, for there are State pensions waiting for them in their old age and comfortable homes provided by the government. Their nursing is more of a mission than a means of livelihood. Moreover, the public schools are possibly the greatest part of this entire system, for there not only is the mind of each child developed to its particular capacity, but from its teeth to its feet the child is cared for; its physical needs are satisfied by food which it learns how to prepare, and its body trained by gymnastics. Children study harder, play better, obey more promptly, and eat much more simple food than American children. For these reasons the health of school children is more uniform than it is here, and their death rate is half that in the United States. It must be admitted that there is a great deal of insanity in Scandinavia, and a deplorable amount of tuberculosis; but, apparently, neither the infant birth rate nor the mortality is influenced by these diseases, for the men and women in general are healthy, and their out-of-door life. keeps them strong. And yet, ten years ago the infant mortality was double what it is now, although the adults were seemingly as robust then as now. The net result, therefore, of this survey of the causes of a low infant mortality in Scandinavia points once again to the quotation with which this article was begun, and which, in two words, means "health education." REFERENCES. 1 Dr. Rowland G. Freeman says he believes that the mortality of well-cared-for babies is scarcely more than one-half of 1 percent. Not one baby in 120 consecutive cases in his private practice died during the first year. Moreover, he finds that a group of children from intelligent parents grows heavier and taller than similar groups of institutional children who are well cared for, but not well born. (Am. Jour. of Diseases of Children, November, 1914.) This fact is brought out by Prof. K. Stolte, of Berlin, who believes that the treatment of a baby must be individualized and that some one must act as its mother, playing with it and sometimes even nursing it before its time if it seems hungry. This is a surely a scientific heresy, although emanating from a German. (Jahrbuch für Kinderheilkunde, Berlin, 1914.) In 1914, in England and Wales the number of births was 23,000 less than the average of the five preceding years. In Berlin there were 3,500 fewer births in 1914 than in 1913, and 1,600 more infant deaths. in 1914 Germany's infant death rate was higher than In fact, that of any other country of Europe except Russia. These facts are given by Dr. Alice Hamilton in the Survey, January, 1916. It has been found in Germany, that during August only forty-two breast-fed babies died, as against 260 bottle-fed babies. Miss Lathrop, of the Children's Bu 15 reau, recently verified these figures by an investigation Other excellent authorities estimate that 25 percent Starch and Table Salt Sold as Neosalvarsan. The recent indictment by the Federal Grand Jury A most serious feature of this matter is the discov- A further investigation showed that during July, 1916, Strangaard had 15,000 ampules made in Jersey City, which upon his instructions were filled by the glass blower with either starch or salt. A remarkable coincidence is that during August and September, and as recently as the time Strangaard was arrested in New York, physicians and drug stores all over the Middle West and the East were approached by women trying to sell, on the one pretense or another, the frauds made for Strandgaard. These spurious products were put up in imitation of either the German or particularly the English package, as marketed by the German manufacturers in England before the war, in square pasteboard cartons. They did not appear in round aluminum packages, like the American package. They are very cleverly executed, and their outside appearance even led experienced physicians to be deceived. The product has been sold in New York, Chicago, Milwaukee, Cincinnati, Peoria, Kalamazoo, Detroit, Terre Haute and Mobile, and other Western and Southern cities, and is undoubtedly still being peddled on account of the great profits accruing to the saleswomen. There is no need to call the attention of physicians to the dangers connected with the use of such frauds. In view of the serious and possibly fatal results which would follow the administration of these fraudulent salvarsans, it is incumbent upon medical men who have any information about the distribution or sale of these frauds to communicate with Chief Inspector E. R. Norwood, U. S. Customs House, New York, at their earliest opportunity, or, in case of emergency, with the local police authorities. The Woman's Medical Journal sultants, only one of whom is a woman. of four chiefs and twenty-four assistant con A Monthly Journal Published in the Interests of Women Physicians Published by THE WOMAN'S MEDICAL JOURNAL 3437 Mooney Ave., Hyde Park Cincinnati, Ohio SUBSCRIPTIONS: Domestic-$2.00 per annum in advance. Foreign- $2.50 per annum in advance. REMITTANCES should be made by check, draft, registered letter money or express order. A subscriber should notify the publishers promptly of any removal, giving Old and New address. that there may be no break in the service of the Journal. In order to discontinue a subscription, notice must be sent direct to THE JOURNAL and all arrears paid in full to date. COPYRIGHT.- Matter appearing in THE WOMAN'S MEDICAL JOURNAL is covered by copyright, but no objection will be made to the reproduction in reputable medical journals of anything appearing in the columns of THE JOURNAL if proper credit be given. The Editors and publishers are not responsible for the views of contributors. NEWS.-Our readers are requested to send us items of news of a medical nature, also marked copies of local newspapers containing matters of interest to women physicians. We shall be glad to know the name of the sender in every instance. Contributions and books to be reviewed, and all business com munications should be addressed to MARGARET HACKEDORN ROCKHILL. Managing Editor, Cincinnati, While the needs and interests of women physicians are inseparable from those of men, they are by no means identical; and we earnestly hope and believe that in all questions of family life, with sanitary, moral and social problems, they will raise the tone, widen the perception and alter the attitude of the profession in general, so as to make it respond more perfectly to the needs of society, and exert a high power for good in all directions. If this be realized, it will be seen that the work of women is absolutely essential and of ever increasing importance, and the outlook for this in every respect most helpful.-Dr. William H. Welch. Hon. John P. Mitchell, mayor of the city of New York, in a recent interview, said: "I re gard the reorganization of Randall's Island as one of the greatest constructive humanitarian works of this administration." And the Commissioner of Charities, Hon. John A. Kingsbury, states: "In the care of the mentally defective, I am striving to hold up just three ideals: 1-To make their crippled lives as happy as possible under the circumstances; 2To make them as nearly self-supporting as possible; 3-By proper segregation and protection to keep them from producing their kind." This will indeed be good news to those who have deplored the conditions which existed at Randall's Island through the unintelligent and unkind rule of those in charge. The hospital and schools are now under a resident staff-medical director and assistants-and a consultant staff We are glad to publish the entire consultant staff to date from January 1, 1917, and we are pleased to note on that list some warm friends of THE WOMAN'S MEDICAL JOURNAL. Dr. Mary Sutton Macy, who has been appointed by Mr. John A. Kingsbury, Commissioner of Charities, to be Assistant Consultant in medicine to the Children's Hospital and Schools, is the first woman ever so appointed on the consultant staff. This is a most important appointment, and is rare good news for women in medicine. We congratulate Dr. Macy. A WOMAN'S CLINIC IN WASHINGTON, D. C., We have received the year book of the Woman's Evening Clinic, of Washington, D. C., which contains much interesting information regarding this splendid work. This clinic was started in a small way three years ago by Dr. Eleanor Folkmar, who succeeded in interesting some prominent women of Washington in the plan, and the development has been really remarkable. The work of the clinic, which is for white women and girls attended only by women physicians, has doubled and trebled, and now averages over 400 visits a month. The quarters have twice been outgrown, and they now need a resident in terne. The Board of Trustees has authorized an expenditure of fifty dollars per month for a resi dent physician. A room will be furnished, but not board. This can be secured at reasonable rates from the matron or near at hand. The regular hours of service will be from noon each day to nine or ten P. M., as the work requires. Here is a splendid opportunity for a young doctor who wishes to get training in what corresponds to office work where there is good modern equipment-electrical, mechanical, diagnostic, surgical. Many minor operations are performed at the clinic. The "resident" would have opportunity for practice in anesthesia and minor surgical work, and to some extent in obstetrics and major surgical work at Sibley Hospital, where they take hospital cases. The appointment would be for six months, from January 1st, and if all is satisfactory, would be renewed for another six months. The board expects to move into larger quarters with more hospital facilities next September, and would probably be able to pay a better salary the second year. They are ready to begin by giving $50 and room a month. If the resident physician registers in the District by examination or reciprocity, she could do private out work forenoons, and thus add to her income This clinic is only three years old, yet they have the largest white female service of any dispensary clinic in Washington, and have only begun to reach the many in need of such a clinic. We are indeed proud of this fine piece of work by women physicians. From all over the country we get reports of the progressiveness of the woman in medicine. |