of the eye, and a slight disturbance in the middle ear, which disturbs the pressure in the internal ear, are the two most frequent causes. The latter disturbs the nerve endings of the auditory nerve that have to do with space perception.

THE PRESIDENT: Is there any more discussion of this paper? If not, I will call on Dr. McKendree to close the discussion.

DR. CHARLES A. MCKENDREE (Cromwell): Dr. Haskell seems to have obtained the impression that lumbar puncture in my experience is not a procedure to be recommended because of disagreeable subsequent results. As a matter of fact, I consider it, and think it is considered by most men, to be the most valuable adjunct that we have to the treatment of persistent aural vertigo. Babinski, who has done valuable work on this point in recent years, holds this view and is supported in this country notably by Blake and Putnam. Their results have been remarkable and I would take the opportunity of emphasizing here the importance of lumbar puncture in the treatment of persistent vertigo. Lack of time did not permit me to do so when reading my paper

Dr. Fitzgerald spoke of chronic suppurative otitis media. In the discussion I was not at any time dealing with a suppurative condition, and therefore, a radical mastoid operation before a labyrinthotomy should not be considered in this connection.

Dr. E. Terry Smith brought out the importance of disturbances within the nasopharynx. I had expected to create some discussion on the point that ocular vertigo is caused by a paresis of a nerve supplying the ocular muscles. A great many men believe that ocular vertigo is caused by muscular defect and also due to errors of refraction. However, I believe that the greater number of the most recent investigators hold that it is never due to refractive error, nor to anything but a nerve lesion.

The Work of the Infant Welfare Association

of New Haven.

JOSEPH I. LINDE, M.D., NEw Haven.

"One thousand babies that should live, die every day in the United States" (1) was a statement which appeared in one of our popular magazines a few months ago; to this statement can be added that most of these babies are under one year of age and generally born with normal physique. This and many other similar statements which have appeared within the last few years in various lay articles have been the world's recognition of the terrible mortality of children under one year. Prophylactic medicine has made wonderful strides during the last two decades, but only within the last ten years has any united effort been made in the reduction of infant mortality.

The first attempts towards the reduction of infant mortality were made by the establishment of milk depots, or milk stations, where pure milk could be obtained for the babies.

One of the first of these to be established was the Hamburg depot, in 1889, followed shortly by another establishment in the same year by Dr. Koplick at the Eastern Dispensary in New York. In 1892 Dr. Pierre Budin of Paris, impressed by the high death rate of infants and the low birth rate in France, organized in connection with his clinic at the Charité Hospital classes or conferences for mothers, at which class instruction was given as to the care of the infants. Shortly after this Dr. Variot of Paris and Dr. Dufer at Fecamp organized the "Goutte de Lait," or milk depots. These were established primarily, of course, to supply pure milk to artificially fed babies, but as in Dr. Budin's classes, instruction was one of the important aims of the work. About a year later in this country the Straus Laboratories were founded and the very excellent work which Mr. Straus has accomplished by this philanthropy is not new to any of us. Since that time all civilized countries have made

rapid strides in the endeavor to reduce infant mortality. In 1903, France, the pioneer in this line of work, called an international conference, which has been followed by international congresses held in Brussels and in Berlin. In November, 1909, at a meeting held in our own State, the American Association for the Study and the Prevention of Infant Mortality was founded.

The mortality statistics of the registration area of the United States in 1910 show that 19 per cent., or about one-fifth, of all deaths were under one year of age, and it is interesting to note that of these deaths, 29 per cent. were due to diarrhœa and enteritis, 13 per cent. due to premature birth, and 10 per cent. due to wasting diseases, as marasmus, and to lack of care (2). These three causes show the highest percentages of deaths and surely some of these deaths are preventable, yes, I might say one-half of these deaths are preventable.

Improper feeding, lack of personal cleanliness, flies and dirty milk usually cover the etiology of diarrhoeal diseases; to be sure, weather conditions have some effect on the death rate due to enteritis, but it is almost negligible when these other conditions are considered.

Poor heredity, unsanitary housing and ignorance are the chief causes of the wasting disease, while poor heredity and ignorance of the pregnant mother would cover most of the deaths due to premature birth.

The furnishing of clean milk alone will not correct all these causes; the constant supervision of these babies and the education of the mothers, the fathers, and the whole families in the fundamental rules of hygiene and cleanliness, as well as careful prenatal supervision of the mother, the encouragement and the instance of breast feeding wherever possible, are fully as important as pure milk. In fact, one of our most noted workers on the reduction of infant mortality has said "the solution is 20 per cent. pure milk and 80 per cent. training of the mothers," (3) and Abraham Jacobi in his address before our parent society in 1912 said: “By breast feeding you will save 100,000 babies that now die or become invalids from no other

cause but unnatural feeding" (4). Innumerable statistics show that breast-fed babies stand the battle many times better than artificially fed infants, but I will not bore you with the figures.

In the summer of 1906 it was my good fortune to assist Dr. Bartlett in his work on the bacteriology of the milk supply of New Haven. This was the first systematic bacteriological work done in New Haven on milk. Previously very careful inspection, fat content estimated, and tests for preservatives had been made by the Board of Health; soon after this the city began to examine the milk supply bacteriologically, and although not absolutely conclusive, the following figures compiled by Dr. Wright, Health Officer of New Haven are interesting.

The mortality statistics of diarrhoeal diseases in New Haven under five years of age (the increase in population is about 2,500 a year):

The Board of Finance of New Haven for the first time has made an appropriation to the Board of Health for the employment of nurses for instructing and educating mothers and householders in the proper care of milk after it has been delivered, and in the care of children and infants during the summer. The appropriation, although small, is a start, and I sincerely hope that in time the closest coöperation of the work of the Infant Welfare Association and the city will take place, as has taken place in New York, where these individual societies and the Board of Health have joined for the following reasons:

1. To prevent duplication of the work.

I.

2. To establish some uniform system of record keeping.

3. To render information in the possession of one group available to all.

4. To conduct a publicity campaign in the interests of the reduction of infant mortality (5).

We have the Health Officer's assurance of his Board's coöperation and plans have already been formulated so that the work will be carried out to the best advantage of all concerned.

In 1909 a committee was appointed from the Consumer's League to dispense pure milk to babies. The milk was modified in the laboratory and then dispensed to the mothers at the lowest possible price. Standardized formulæ were used; two years' whole milk modifications were used, and one year percentage modifications. In exceptional cases special formulæ were made up.

In 1912 the Pure Milk Committee withdrew from the Consumer's League and began its work as the Infant Welfare Association. Although much good had been accomplished by the milk stations, to quote from the President's report, the system of dispensing milk already prepared has grave faults:

"In the first place it is very expensive, and though this is perhaps an argument to struggle against if the method is otherwise perfect, it must be given serious consideration. Secondly, it has no educative value, and makes even the best mother absolutely dependent on the existence of the station; and thirdly, even more vital, it may become a center for the spread of the moral weakening that ensues when one is relieved of his natural responsibilities, among which the care of one's children ranks first. It was quite too easy for the average parent to send a little sister or brother with eight cents and receive the bottles of milk all prepared for the next twenty-four hours. The nurse took the responsibility; the nurse did the work; all the mother had to do was to provide the baby. So one by one the cities have changed their methods, and now we are putting the work on the mothers, where it belongs, but teaching and watching them, and sometimes in special need preparing it for them, and it has been really wonderful to see how they have responded to it. We did not make the change ourselves without most careful consideration, for it seemed almost inconceivable that the modification of milk and sterilizing of the utensils, which is at first alarming to the best trained of us, could be managed successfully by an Italian or Polish mother in a two or three-room tenement. But New York, Chicago, and Baltimore assured us of their success, and Fall River, also, which has a very low class of foreigners, and we persevered" (6).