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 FOR OFFICIAL USE. 
 
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 Local Goveinment Boaid^j 
 
 Whitehall, S.W.L 
 Thursday, 6th March, 1919. 
 
 MINUTES OF DISCUSSION 
 
 AT 
 
 AN INFORMAL CONFERENCE TO CONSIDER 
 GENERALLY THE SUBJECT 
 
 OF 
 
 "PEDIATRICS." 
 
 Sir GEORGE NEWMAN, K.t.B., M.D., FRCP., 
 
 In the Chair. 
 
 rr.rn 
 
 AGENDA. 
 
 I 
 
 1. Openinj; Remarks by Cliainiian. 
 
 II. Position of Pediatrics in the United States of America and in 
 Cunnda. 
 
 III. Position in Italy. 
 
 IV. Position in New Zealantl. 
 
 V. Present demands of Examining Bodies in Pediatrics, and facilitie* 
 for teaching this subiect in Great Britain. 
 
 LONDON: 1919. 
 
LIST OF THOSE PRESENT. 
 
 Sir Geokge Newman, K.C.B., M.D., F.R.C.P., Chief 
 Medical Officer, Local Government Board, and Chief 
 Medical Officer and Medical Assessor, Board of Education. 
 
 GoL. J. G. Adami, M.D., F.R.S., F.R.C.P., Professor of 
 Pathology, McGill University, Montreal ; Canadian 
 Army Medical Services. 
 
 Capt. Richard A. Boi/i, A.B., M.D., D.P.H., Cleveland, Ohio ; 
 Chief, Bureau of Child Hygiene, Cleveland ; Instructor 
 in Pediatrics, Western Reserve University ; Welfare 
 Physician, Babies' Dispensary and Hospital, Cleveland. 
 
 Hectok C. Cameron, Esq., M.A., M.D., F.R.C.P., Physician 
 to Guy's Hospital, and Pliysician-in-Charge of the 
 Children's Department, Guy's Bospital. 
 
 Miss Janet Mary Campbell, M.D., M.S., Medical Officer in 
 Charge of Maternity and Child Welfare, Local Govern- 
 ment Board. 
 
 John S. Fairbaihn, Esq., M.A., B.M., B.Ch. (Oxon.), F.R.C.P. 
 (Lond.j, F.R.C.S. (Eng.), Obstetric Physician to St. 
 Thomas's Hospital and General Lying-in Hospital ; 
 Lecturer in Midwifery and Diseases of Women, St. 
 Thomas's Hospital Medical School. 
 
 Eardley Holla^td, E.sq., M.D., F.li.C.S., Assistant Obstetric 
 Physician to the London Hospital ; Surgeon to the 
 City of London Maternity Hospital. 
 
 F. Tkuby King, Esq., C.M.G., M.B., B.Sc. (Public Health) 
 Edin. ; Lecturer on Mental Diseases, Otago University, 
 New Zealand ; General President, Royal New Zealand 
 Society for the Health of Women and Chil Iren ; Consult- 
 ing Physician, Karitane Hospital for Babies; Medical 
 Director, Babies of the Empire Society, London. 
 
 Miss Janet E. Lane-Claypon, M D., D.Sc, Dean and Lecturer 
 in Hygiene, Household and Social Science Department, 
 King's College for Women, London. 
 
 *G. E. C. Pkitchakd, E.sq., M.A., M.D., B.Ch. (Oxon.), 
 M.R.C.P. ; Physician, Queen's Hospital for Children ; 
 Physician, City of London Hospital for Diseases of the 
 Chest. 
 
 W. R. Ramsey, Esq., M.D. ; Assoc. Professor of Disea.ses of 
 Children, University of Minnesota, U.S.A.; Visiting 
 Physician to the University Hospital. 
 
 Lieut. -Col. G. S. Strathy, Demonstrator in Clinical Medicine, 
 University of Toronto ; Assistant Physician, Hospital for 
 Sick Children, Toronto ; Clinical Assistant in Medicine, 
 Toronto General Hospital ; Canadian Army Medical 
 Corps. 
 
 S. W. Wheaton, Esq., M.D., F.R.C.P., Assistant Medical 
 Officer, Local Government Board. , • 
 
 * Present for oae session of the Conference only. 
 
G7 
 
 BIOLOGY 
 
 Minutes of Discussion at an Informal 
 
 Conference to consider generally 
 
 the Subject of " Pediatrics." 
 
 MINUTES. 
 
 MAJOR THE HON. WALDORF ASTOR, M.P. (Parlia- 
 luentary Secretary to the Local Government Board} : Ladies 
 and gentlemen, I only just want to welcome you here on behalf 
 of Dr. Addison, the President of the Local Government Board. 
 Unfortunately, he is laid up with influenza, like so many other 
 eminent persons at the present moment, and he has asked me 
 to apologise to you for his absence and to express his regrets at 
 his inability to be present here. 
 
 As yo'U koiiow, we are contemplating setting up a nev/ Miniis- 
 tiy of Health. The Bill was intioduced the othei' day into the 
 House of Comniionis, and we hope next week, if Dr. Addd&cn i.s 
 i-ecovered, to start it llu-ough the Conuiattee stage. Under that 
 .Ministiy of Health we hope to do a gireat deal in. the way of 
 improving- the conditions concerning child life, though of 
 com-se it will not be restricted to child welfare, and a Confer- 
 ence lilve this, obviously, will be of the greatest value. 
 
 I have not come hei-e really to make any speech, btit only 
 just formally to welcome you. I cannot be here for any length 
 of time, because I have to go to help finish the final draft of 
 the Housing Bill, which, incideaiitally, affects child life and the 
 health of cliildren enorniiously. We hope to Ijring that into the 
 House of Coniimonis either next week or the week after, and we 
 are just now putting the finishing touches to it. You will excuse 
 me, as I have to go to the Cabinet in addition to helping to finish 
 the draft of tilie Housing Bill, and I Avill ask Sir George Newman 
 to take the chair. 
 
 (SIR GEORGE NEW^L\N accordingly took the Chair.) 
 
 I. — Opening Remarks by Chairman. 
 
 THE CHAIRMAN : Ladies and gentlemen, I have, like Major 
 AsitO'r, very little to say by way of introduction to our conversa- 
 tion's. This little gathering had its origin some montJis ago 
 in this way. When it was learned that there would be certain 
 specialists present in this country from America and th& 
 Colonies, amd possibly from France and Italy, it was thought 
 eminently desirable that there should be an opportunity given 
 them to meet together here to talk over some of the subjects 
 
 6648 * 
 
 462 
 
•which concern maternity and child welfare in their relation 
 to the medical curriciiliim. At one time it was proposed that 
 there shoiild be a large Conference; subsequently it was decided, 
 before I came to the Local Government Board, that the Confer- 
 ence should be small and select, and that the oppoa tunity should 
 be taken of making any suggeistionis which you have in mind for 
 the new Ministry of Health. Unfortunately, owing to the 
 ravages of influenza, and to other causes, the Conference is much 
 smaller than wais arranged. It was hoped that there would be 
 some 25 or 30 representatives here, but we have received a num- 
 ber of apologies for absence on account of influenza. Sir 
 William Osier has written saying that he regi-^ts he cannot oonie 
 here to-day. Sir Tho'mas Barlow, Sir Leslie Mackenzie, and 
 Dr. Addison himself are all pi-evenited, and Dr. Lucas, one of 
 tJie principal witnesses in the caise, is unfortunately detained 
 in Paris with pneumonia, but Dr. Ranisey has come tO' represent 
 himi. 
 
 Now, ladies and gentlemen, what I suggest we should do is 
 to have a t^a-llt round the table to-day in an: informal way, follow- 
 ing the agenda, as far as may be convenient to us, and I hope you 
 will feel quite free to introduce any subject under this heading 
 which you think may be useful in the way of suggestions for a 
 Ministry of Health or for action in England. I need scarcely 
 remind you that a good deal has been done in England during, 
 the last ten or fifteen years in the way of maternity work, infant 
 welfare centres, schools for mothers, and so forth.* Undoubt- 
 edly as a partial result of that thea-e has been a reduction in 
 infant mortality : due no doubt to many factors but certainly 
 in part to that. Personally, I think a good deal of the reduc- 
 tion in the mortality is due to a wider knowledge in regard to 
 these matters, more public attention having been drawn to 
 them, so that mothers are almost necessarily more attentive 
 to the impoi'tance of these things. 
 
 Now, I think probably the best plan is for us to hear from 
 those who are present witli regard to Pediatrics in Ameiica, 
 Italy, and New Zealand, before we consider Item No. 5 on the 
 agenda. No. 5 on the agenda, as you will see, is "Present 
 demands of Examining Bodies in Pediatrics and faoilities for 
 teaching this subject in Great Britain." Again, let me remind 
 you that I am not responisiljle for this agenda; these subjects 
 have been handed down to me, but before we can really do 
 much with No. 5, I think Ave want to hear the evidence under 
 No. 2, No. 3 and No. 4. 
 
 The development of the relationship of gynecology, mid- 
 wifery and infant care in relation, to the medical curriculum is 
 in itself a very large subject. I do not propose to trouble you 
 with any detajls as to the present position in this country. It 
 
 See Appendix i., page 37 
 
differs very much in each of the 22 medical schools which we 
 have here. In some of tliem a good deal of attention is being 
 given to these subjects; in others, very little. But I would 
 venture respectfully to warn you of the fact that maternity and 
 pediatrics are in some w'ays rather akin to preventive medicine. 
 It is an extreimely difficult task to decide exactly where in a 
 medical curriculum the}' should be included. I hold the view, 
 as you know, that preventive medicine ought to pervade the 
 whole curriculum, and if you asked me where maternity and 
 pediatrics come in English medicine, I should reply, not as 
 specific stibjects only, but indirectly in a number of different 
 sections of the curriculum. And I may remind you that we do 
 not always advance a stibject by saying that we will place new 
 burdens upon tlie medical student, Ave will add a new subject to 
 the curriculimi, and we will add a new subject to the examinia- 
 tion ; we sometimes advance best by a. flank movemeoit. Many 
 of yoti are competent teachers in medical schools, and you know 
 that sort of thing quite a,s well as I do; but the result of otir 
 discussion to-day muay not necesisarily be that we have recom- 
 mendations to make to this Board or to the Boaixi of Education, 
 ■which is responsible for medical education in thi,s country. It 
 may not be tliat w^e want to add any specific subject to the 
 curriculum, but that we desire the whole curriculum to be so 
 arranged and so enlarged in this country as shall lead in the 
 result to what we d&sire. 
 
 Now as a matter of proc^duie, in order that we may get 
 through our busiitess with reasonable despatch, perhaps speakers 
 in opening a subject will speak in the first instance for a quarter 
 of an horn- only. If this is agreeable to you, I will call on 
 Dr. Eamsey to speak upon No. 2, the position of Pediatrics in 
 the United States of America and in Canada. As I said before, 
 he is here in place of Dr. Lucas, who is absent through illness. 
 
 II.— Position of Pediatrics in the United States of 
 America and in Canada. 
 
 DE. W. R. RAMSEY: Mr. Chairman, ladies and gentlemen, 
 I was informed that the subject to be discussed v>^ould be some- 
 thing regarding the status of Pediatrics in the Medical Schools. 
 It just happens that at om- Medical School at the University of 
 Minnesota, where I am Associate Professor, we have made rather 
 a definite departure from what has been usual until the last 
 few years. We have at last secured a separate Department of 
 Pediatrics, which we have been working for a long time. We 
 have our own department (with .30 beds), with a whole-time 
 professor at the he^d of it, aii as-sociate professor, and our own 
 staff of clinical assistants, most of them being what we call half- 
 time men : I am myself a haK-time man. 
 
 Perhaps I may informally just tell you a little bit about what 
 
6 
 
 led up to a separate Department of Pediatrics, or the Pediatric 
 Chair being separated from that of Medicine. Until four or 
 tive years ago Pediatrics was a separate professorship, l)ut was 
 luider the Department of Medicine. I think the first Uni- 
 versity to establish a separate Department of Pediatrics was 
 Harvard. Since that time. Haivard, being a very prominent 
 University, has been copied with great benefit to the whole 
 study of Pediatrics. 
 
 For a good while after the intitiation of scientific medicine, 
 after the great advances made by youi* Lord Lister and other 
 men, it seemed as if medicine progressed very rapidly in the way 
 of treatment and prevention of disease amongst adults, but in 
 regard to children the situation was quite at a standstill, and 
 had not improved. So a few men began studying the subject 
 more intensively. It seems to me that the important thing 
 is that we realise that child welfare is the most important and 
 the most fundamental thing in the nation, and that if we are 
 to succeed to the greatest degree possible, we must study it more 
 intensively than we iisually do. If we undertake to cover the 
 whole field of medicine, including pediatrics, the field is too 
 big, and our bread is pretty thinly buttered. We decided 
 therefore to separate the pediatrician from the medical man, 
 because, although pediatrics is a speciality in medicine, it is in 
 n)any respects quite different. And I think the sooner we 
 realise that the medical man is wrong in regarding, for instance, 
 the child as a miniature adult, the better. That was the way 
 I was taught, and I imagine a great many of you were also. 
 I was taught that the same dosage and the same things apply 
 to infants only varying in degree; that they were miniature 
 adults; and that we just had to apply a relatively smaller dose 
 and a relatively smaller kind of treatment in orcler to make it 
 possible to include the child in the same category with the 
 ■adult, But it has been found that the child has a physiology 
 and a pathology of its own, and that the question was not 
 one simply of clinical niedicinel but one of nutiition depending 
 upon an exact knowledge of feeding and general hygiene. We 
 found that the average medical' man did not study these things 
 intensively, and did not teach them intensively. The result has 
 been that the average medical practitioner throughout the coun- 
 try knows practically nothing about Pediatrics. He not only 
 does n.ot know, but he does not want to know ; and he is pi-oud, 
 very often, that lie does not know, and tells one that he does 
 not attach any great importance to these things. So it became 
 necessary to leach the students that these things were funda- 
 mental and were the very basis of child welfaore. 
 
 Now, ladies and gentlemen, if we want to teach them more 
 intensively, we must liave a special Department. Since we have 
 had a special Department of Pediatrics at the University of 
 Minnesota, our development has been very ra]>id. I am speak- 
 
ing now chieriy of teaching. I do not think that medical men 
 generally — that is to say, general practitioneis — need have a 
 very special knowledge of pediatrics, but they must have a 
 good working knowledge. In tlie Medical Schools we must have 
 for the intensive teacliing of this fundamental subject of pedia- 
 trics a very close co-operation with the obstetrician. In our 
 Department there is that close co-operation. The two depart- 
 ments are on the same floor, and as soon as the cord is tied 
 the child is passed over directly to the Department of Pediatrics. 
 From that time on there is the closest co-operation between the 
 obstetrician and the pediatrician. Also, our staff supervises 
 and uses the child for the instruction and teaching of the 
 students; and we have found the normal infant of vital im- 
 portance in otu- teaching. Now the average medical man — the 
 average general practitioner — apjaoaches the child from the 
 pathological standpoint. He is interested in whether the child 
 has pneumonia or has a heart that is dilated, or a congenitally 
 defective heart, a big liver, a floating spleen, or some dther 
 abnormal condition ; but he is not particularly interested in the 
 normal child. The normal infant is a most important thing 
 to teach the student. • If lie knows the normal infant, then of 
 course he quickly recognises the abnormal one. 
 
 But certainly it is true that a very careful and exact know- 
 ledge of the technique of breast feeding is most important ; but 
 I do not know of any more difficult thing. Each child "is a 
 law unto itself," and each must be studied individually. Cer- 
 tainly the man who knows the technique of breast feeding, and 
 insists upon breast feeding, will probably save ten times more 
 cliildren than the man who knows how to diagiiose pneumonia 
 or a right-sided heart. 
 
 The welfare of the race depends fundamentally upon pre- 
 natal care, upon breast feeding, and upon the technique which 
 is brought to bear in tlie first years of life. There is not any- 
 thing in the whole field of medicine that requires more judg- 
 ment, more experience, and a more thorough analysis than the 
 question of feeding infants. A few years ago we had gotten 
 down in America to sucli a position that probably not more than 
 30 or iO per cent, of oin- women were rmrsing their cliildren. 
 The country was flooded with literature on patent foods whicli 
 was sent to women, not onlv after the baby was born, but Ions: 
 before; they were told hoAv much easier it was to feed their 
 babies artificially, and that all they had to do was to add water 
 and serve. The result was that doctors became contaminated 
 with the idea, the nurses they taught, or did not teach, were 
 imbued with the same opinion, and as a result the public thotigiit 
 that breast feeding wtis practically an impossible thing. It has 
 be^^n very interesting for me to notice the development of the 
 change of opinion. I was among the first in the Middle West 
 to limit my practice to Pediatrics, and the very best doctors 
 
8 
 
 were quite disgiisted. They could not see any sense in it. 
 When I talked to some of the best obstetricians in the com- 
 munity, they said that it was quite impossible that the great 
 majority of the better-class women could niu'se their babies. 
 They said, '' It is impossible. We try it ; we give them a per- 
 fectly conscientious trial, and when after a proper time they do 
 not succeed, we wean them as a matter of course." That they 
 were wrong about it has certainly been demonstrated by the fact 
 that in_very many communities 75 to 80 p.er cent, of the women 
 now nurse their babies. 1 mean the well-to-do people, the people 
 of fashion ; the people wlio before thought it was a disgrace t^i 
 nm-se their babies are now very proud of it; it is quite the 
 thing to do ; they discuss it at their circles and their card parties, 
 and go home promptly to nurse their babies. 
 
 Now, Sir, that has all \)eeu done by propaganda, by the 
 doctor being properly educated, and as a result the nurse being 
 properly educated. But there is a tremendous lot to do yet in 
 the way of educating the doctor. The average doctor to-day 
 in the city and in the country has about the same traditions as 
 the average midwife or the average grandmother regarding the 
 care of children. I propose to give you, by way of illustration, 
 some of the fallacies which are still prevalent. The doctor 
 believes, and the nurse backs him up, that the baby must be 
 bathed immediately after birth. The result is that the baby 
 may be exposed for half an hour or more in a room of low 
 temperature, and many of them die as the result of the loss 
 of heat so caused. Then there is another thing which I know 
 from my own experience is still prevalent in America. It is a 
 very common thing to wash or swab out the baby"s mouth daily, 
 a proceeding which accounts for many of the cases of stomatitis 
 in young infants; it brushes off the epithelium and thrush 
 follows. Certainly a large percentage of the bad dyspepsia in 
 young infants is due to the classic dose of castor oil being giver. 
 on the third day. I have observed that in hospitals where the 
 ilose of castor oil wa.s givt'ii. digestive disturbance in the ncv - 
 bom was the rule. 
 
 Then, again, the belief in and the practice of frequent feed- 
 ing is still in existence. I have in my pocket here an analysis 
 of 300 charts of new-born infants in our hospital. All of them 
 were fed by four-hour feeding, and only five feedings in the 24 
 hours. They were weighed every day before and after each 
 nursing during the ten days they were in the hospital, and a 
 complete analysis was made of everything pertaining to each of 
 them. Mortality amongst them was extremely low, and they 
 thrived better and gained weight better — not in the first ten 
 days, because only a quarter of them had regained their normal 
 ])irth weight at the end of the ten days, but after that time 
 they went on much better than children who were frequently 
 
fed. Alsio we discovered this interesting fact in regard to the 
 number of stools. The normal number of stools in tlie 2i hours, 
 as given in most of the English, German and American text- 
 books, is from three to six a day, but ■with only five feeding-s 
 in the 24 hours the average numljer of stools per day was two. 
 We had no iicute dysjiejisia, the children thrived, they slept all 
 night, and the mothers slept all night too. It certainly is tioie 
 that the frequent feeding of young babies and the waking of 
 the mothers at night is the reason why a great many cases 
 are not breast fed ; the mother becomes nervous, loses her sleep 
 and her milk gradually disappears. 
 
 We a.rrived at the conclusion that Rubner's and Ileubner's 
 allowance of 100 calories per kilo was not applicable to the first 
 two weeks. Our 300 series of new-born infants gained most 
 satisfactorily on from 45-70 calories per kilo, and had only two 
 movements daily, and when we tried increasing the amount to 
 100 calories per kilo tliey tended to have dian-hoea. 
 
 Now, Sir, tiiose are fundamental matters, and those conclu- 
 sions were oome to us by a close, careful, and intensive study of 
 Pediati-ics by speciaJists who are devoting their time to the 
 subject. One could go on indefinitely regarding, for instance, 
 the facilities that still exist in the minds of the doctors, 
 the nurses, and the public. Heresies handed down from time 
 immemorial still exist, and if we are going to do anything funda- 
 mental ill regard to infant and child welfare we must get the 
 doctors properly educated, we must get the nurses properly 
 ed'ucated, and then the public -will get properly educated ; or 
 else we nuist educate the public first, and they will compel the 
 doctors to get educated. (Laughter.) That is sumetimes neces- 
 sai7, you know ! 
 
 THE CHAIliMAN : I think your remarks have been moiSt 
 interesting, Dr. Ramssey. I think the general point about the 
 importance of the subject of teaching medical students, then 
 the nurses, and then the public, we shall all absolutely agree to.. 
 The question of the fallacies Avhich exist is a very important 
 one, and I am not sure that we could not arrive at some usieful 
 conclusions about that to-day. Then the whole question of 
 breast feeding is one with which we ought to deal, so as to see if we 
 have some common denominators. I will now call upon Lieu- 
 tenant-Colonel Strathy, of Toronto. 
 
 LIEUT. -COLONEL STRATHY: Air. Chairman, ladies and 
 gentlemen, the teaching of pediatrics in Toronto has changed 
 considerably in the last decade. I have been away for over four 
 yeai's and cannot speak of the recent conditions there. Ten years 
 ago we had no pediatrician, and pe-diatrics was taught by the 
 medical department. Consequently no progress was maxle. 
 About ten years ago the teaching of pediatrics was put in special 
 hands and now we have several specialists in the subject. The 
 teaching has been taken up from two points of view, the teaching 
 
10 
 
 of medical people, and tlie teaching of the public. The former 
 is divided into two parts, tJie teaching of the medical student 
 and the teaching of the practitioner. A large miajoi-ity of the 
 men who for the next twenty years will be attending babies 
 are men whoaii we cannot reach through the University at pre- 
 sent; therefore we had to adopt other means of edu- 
 cating them. The student course up to the present has 
 been five years, but from now on it is to be six years. 
 In the fifth year of that co'urse — the fifth year is 
 all clinical work — he has practically no lectures to attend ; his 
 time is all spent in the wards and the laboratories Each student 
 gave three montJis to speciaJities, and six weeks of that time he 
 gave to pediatrics. He attended for two hours a day on 
 three days a week, lout it has probably been lengt^hened since, 
 because I know it was not conisidered enough. In Toronto we 
 have a large children/ s hospital with 150 beds, 50 of thean being 
 for infaints under one yea.r". The student is closely connected 
 with these. Some of the students live in the hospital, 
 and a-ssist the hoiise staff in their Avork. All the stu- 
 dents attend out-patient climes, and there are usually only 
 about four to six students ini a clinic, so tliat they see the cases 
 very intimately; they Aveigh the babies from week to week, and, 
 if necessary, they follow them out to their own homes. The 
 doctor holding the clinic may say to a student: "I want you 
 to go down to that bab}' and see it each da}^ until I see it again 
 next week." That is the teaching of the studemt; but even that 
 is considered insufficient to render him capable of doing 
 much in the way of feeding babies and of securing such progres'S 
 as there has been in eye and eair work, and in the variouis other 
 specialties. There was, I believe, vei-y little progress in thoise 
 things until they were made sjvecialties, and our idea iiS that 
 pediatiics must be made a specialty. Moireover, I am of O'pinioTi 
 that the physician in chai'ge of the pediatrics department of a 
 .teaching hospital should spend three to four hours daily in that 
 department. 
 
 There is the question of the overlapping between the Pedia- 
 trics Division and the Medical Division. A difference of opinion 
 exists as to time, some believing that 18 months should be the 
 time for the baby to be under the pediatrician, and others, three 
 years. The arrangement at the Hospital for Sick Children with 
 which I am associated is that the Pediatrics Division hais the 
 children from birth until 18 months, and the Medical Division 
 has them from 18 months to 14 years. I may say I am on the 
 Medical Division. 
 
 Then we were confronted with the question of educating the 
 piactitioners, and this was done largely in association with the 
 municipal authorities. In Toronto we have only one University, 
 and we have a children's hospital which is practically the Uni- 
 
11 
 
 versity liospital. The Children's Hospital is the sick centre for 
 it, and the care of all the sick children in the town who are in 
 public care comes under the Children's Hospital. The Associated 
 Board of Charities will not allow a grant of public money to be 
 made to any other institution in that City which treats sick 
 children. 
 
 The healthy babies are looked after by means of what we 
 call milk depots, of which there are 16 in Toronto, and for which 
 the municipality is responsible. These 16 milk depots cover 
 a population of half a million. Our great diflficulty has been 
 to get enough well-trained practitioners, but as time goes on, 
 and we are training more men in the hospital, we will have less 
 difficulty in getting men for those depots. To each of those 
 depots there is a practitioner, avIio is there, I think, twice a 
 week. Every depot is for a district, of course. The part that 
 the City authorities took in it was to supply places for the clinica 
 to be held, to supply nurses for caring for those places, and 
 for following up the children. That is done in this way. Within 
 ten days of the birth of a baby, it does not matter how wealthy 
 the family is or how poor, the nurse from the City Hall — a City 
 nurse — calls at that house, saying she is from the City Hall. 
 If the mother wants any help in any way in looking after her 
 baby, or wants any advice how to do it, the nurse is very glad 
 to give it at any time. In most of the poorer districts the nurse 
 is immediately welcomed and brought in to see the baby, and 
 they ask her to call again. She is very glad to do it, and she 
 usually calls round every week or so for the first few months. 
 She encourages the mother to go to the depot and have the baby 
 weighed each week. We find now that the mother can go to 
 the depot and have her baby weighed without hurting the feel- 
 ings of the practitioner who is looking after that baby. We had 
 to be careful at first not fe> tread on the toes of the local prac- 
 titioners. But the mothers went there, had their babies weighed, 
 or if the nurse saw that a baby was not doing well, she would 
 advise the mother to take the baby to the nearest depot. As 
 long as the baby was looked on as healthy, and that it was just 
 a matter of feeding, it was treated at the depot, but no sick 
 baby was allowed to be treated at any of those depots, but was 
 sent into the children's hospital with a card. There is a card 
 index, of course, for all these babies. A baby might be treated 
 as an out-patient at the hospital, and when it was well enough 
 to go back to the depot, its card showing all its treatment went 
 with it. 
 
 Then again, in regard to the welfare side of the work. 
 Whoever is holding a clinic — it does not matter whether it is a 
 baby clinic or an older children's clinic — there is alw^ays a City 
 Hall nurse in the clinic room, or the doctor can have her out- 
 side the door; she is, however, usually at his right hand. He 
 will turn round and say to her, " I would like to have a report 
 
 6648 
 
 «* 
 
12 
 
 oil that home," and she can always give him a report on the 
 home conditions, whether the child is getting enough to eat. 
 whether the mother drinks, and so on. So that one can get a 
 full report of the home conditions if it is wished. If a baby 
 comes into the out-patient clinic, and it is required, for instance, 
 that its stomach should be washed, and the mother does not 
 know how to do it, all the doctor has to do is to say to the 
 nurse, "I want that baby's stomach washed every week." Of 
 course, I only give that by way of illustration. That instruction 
 goes into the City Hall to the head nurse, and a nurse is in- 
 structed to go and do it. We have about 150 nurses who have 
 mostly graduated at the Children's Hospital itself. 
 
 THE CHAIRMAN : I will now call on Colonel Adami. 
 
 COLONEL ADAMI : Mr. Chairman, ladies ajid gentlemen. 
 Tlie veiy fact tluit I am not a professional pediatiician makes nie 
 rather nei'vous of speaking here, but I may say a few words 
 about our Canadian provisions in general. Canada, has always 
 held a half-way position, through having partly British and partly 
 United States influence acting upon it, and being sensitive to 
 both. 
 
 In regard to the general teaching in oui* medical schools, 
 evei" since McGill University was founded in 1824, the medical 
 school has followed the British system of having the free 
 entry of the students into the wards. Bedside teaching in 
 maternity work, as well as in medicine and surgery, has been 
 a striking characteristic. This was only introduced into the United 
 States long years afterwards when the Johns Hopkins Hospital 
 was opened. On the other hand, in regard to special maternity 
 work, we have been acutely influenced by the States, and as a 
 result om- teaching of pediatrics has been, I think, considerably 
 l)eyond anything in tliis countiy. I have brought tlie McGill 
 Calendar for the 85th Session, 1916-1917, with me, and briefly 
 this is the story. In pediatrics we have a professor, A. D. 
 Blackader, three lecturers, and two demonstrators. The size 
 of the staff is due to the fact that we have out-patient clinics for 
 children at both of the two main hospitals attached to the Uni- 
 versity, the Royal Victoria and the Montreal General Hospitals, 
 as well as at the Maternity Hospital. In all these three we have 
 the teaching of pediatrics. The demonstrators have a special 
 relation to the Maternity Hospital, and both of them have an 
 attachment to one or other of the main general hospitals. Foiu- 
 years ago, therefore, we had a considerable staff there, and I 
 think still have, though, as Colonel Strathy told you, I have 
 not been there for some time. We are putting on now an extra 
 year, and there will be still more work done in pediatrics. Per- 
 haps I may just read this short paragi-aph from the Calendar : — 
 
 "A didactic course on the diseases of infancy and childhood, 
 including the feeding of infants, is given during the session to 
 students of the fourth year. CUnical apd didactic lectures are 
 
13 
 
 given on diseases of the new born at the Montreal Maternity 
 Hospital. In the Montreal General and Royal Victoria Hospitals, 
 weekly clinical lectures and ward demonstrations on diseases of 
 childhood will be given to students of the fifth year, and groups 
 of students in rotation will be assigned work in connection with 
 the out-patient children's departments of both hospitals. The 
 new Foundling and Baby Hospital, which has recently been opened 
 with a capacity of 100 beds, will be utilised during the session for 
 a series of demonstrations in infant feeding." 
 
 I may say that we make an extraordinarily strong point of 
 infant feeding. The Maternity Hospital is an old in- 
 stitution, which has recently been wholly rebuilt. It has a large 
 number of beds. The method that has already been described 
 is in vogue there of the children being taken away from their 
 mothers as soon as they are born, aiKl those infants are looked 
 after mainly by the pediatricians. So much so that one of our 
 leading obst-etricians absolutely refuses to see the child. 
 He adopts the " by-product " idea, and says that his whole con- 
 cern is with the mother, to see that she is well through 
 maternity, and that the child should be, from the first moment 
 of its life, in tbie hands of the physician who is going to look 
 aftea* it during the next two or three years. As a teacher I 
 recognise that there are two broad groups of students who are 
 going into general practice in the country, who must be taught 
 to regard the infant as being of equal importance as the mother, 
 and who A^-ill have to care for both of them, and the students who 
 are going to specialise. The City practitioner can specialise, 
 but in the country one man has to undertake both branches. 
 
 ^Vbile I have been away they have been developing, as a 
 separate department in the University, the Social Service 
 Depai'tment ; the last news I have had about it in a 
 letter from Montreal is that they are getting the Social 
 Service Department and the Child Welfare section of 
 it closely into touch with the Medical School, and are trying 
 to interest the students in the ordinary healthy child. 
 
 DR. CAMERON : From your experience as an examiner, do 
 you think that it would be possible to conduct suc-cessfully 
 examinations in Infant Hygiene and Management for students? 
 Do you think these studies adapt themselves sufficiently w^ell to 
 the limitations of examinations? As you know, we in this coimtrv' 
 are in a position different from you in this respect. We are in 
 the hands of outside examiners who have had no opportunity of 
 seeing and valuing the previous work of the candidates. That 
 may be changed, and w^e hope it will be, but at present we are 
 dependent upon outside Examining Bodies. Now it is not diffi- 
 cult to test a student's knowledge of Medicine or of Pathology 
 and to conduct an examination in these subjects. Can the same 
 \ie said of the subjects of the Physiology, Hygiene and Manage- 
 ment of Infancy? I myself think it can. For example, the causes 
 of failm-e to nurse successfully at the breast are as definite and 
 
14 
 
 as well understood as the causes of aortic stenosis, ignorance of 
 which may mean failure to pass the examination. 
 
 COLONEL ADAMI : That is a very serious question, I 
 think the whole system of examinations an absolute curse to 
 this counto-y. The work done by the student diu-ing his courses 
 and the impression he has made upon his teachers ought to be 
 taken into account. 
 
 III. — Position in Italy. 
 
 THE CHAIRMAN: I now call upon Captain Richard Bolt, 
 Member of the Tidjerculosis Division of the American Red Cross 
 im Italy. 
 
 CAPTAIN BOLT: Mr. Chairman, unfortunately Dr. Ran- 
 degger, who was to present the position in Italy, is unable to be 
 here, so that it devolves upon me to outline briefly some of the 
 tindings of a Commission Avhich was sent to look into the tuber- 
 culosis situation in Italy. This Commission was part of the 
 American Red Crosis in Italy. We found that tuberculosis was 
 \ery closely related to other problems, and our Report* is simpl}^ 
 the result of somewdiat extensive investigation wiiich the Com- 
 mission has made with particiUar reference to the child welfare 
 aspect of the problem. I have a complete list of the Commission 
 here, but the chiefs of the Bureaux are as follows : — 
 
 Major W. C. White, Director; Major R. H. Bishop, Junr., 
 Associate Directoi" ; Major J. H. Lowman, Chief of the Medical 
 Staff; Miss Maxy S. Gardner, Chief of the Public Health Nursing 
 Staff; Capt. Knud Stounian, Statistician: Capt. E. A. Peterson, 
 Medical Inspection of Schools; Capt. R. G. Paterson, Public 
 Healtli Education; Capt. R. A. Bolt, Child Hygiene. 
 
 What I am going to state now is simply the child welfare 
 phase of the Tuberculosis Commission. In order to gain an 
 adequate conception of child welfai'e in Italy, it is necessai-y 
 to take into consideration not simply the conditions during the 
 last few years, but the pre-waj- condition of the children in that 
 coinitry. 
 
 Prior to the war Italy wais undergoing considerable eooniomiic 
 development, especially in the north. Hand in hand with in- 
 dustrial prosperity the infant mortality rate was gradually being 
 lowered, especially in those places where. seiious efforts in cliild 
 welfare had been made. The birth-rate in Italy has always been 
 considerabty higher than in northern Europe and in America, and 
 although there had' been a slight decrease in the birth-rate just 
 prior to the' war, it was still sufficiently high to assure a good 
 margin of births over deatlis. Befoa-e the war a considerable 
 amoimt of work for infants and children had already been done. 
 The Italians realised the need for the skilful treatment of children 
 
 See Appendix II., page 44. 
 
15 
 
 and developed tha-ougli their pediatncians a system of institu- 
 tions which, in most plaoes, met tlie immediate needs foa- sick 
 children. They have also recognised for some time the neces- 
 sity of assuring a good milk supply for growing children, and 
 of providing, through a system of marine and mountain colonies, 
 I'w^reation anxi out-door life for tho'se who are weak and predis- 
 ]>osed to tuberculosis. These, however, were largely run duiing 
 the summer months only. In a number of the medical centres 
 of Italy, prior to the war, special instruction was given in 
 pediatric clinics ; but only in a few was the socio-economic side 
 of child welfare work emphasised, and opportunity given to the 
 students to do practical work in millc stations, consultations, or 
 infant welfare centres. The need for co-ordinating all of this 
 work was recognised by a few of the leading pediatricians, and. 
 one of them, Dott. M. Flamini, had gathered together in 1909 a 
 complete list of institutions and schemes for child welfare in 
 Italy. At the IX. Congress of the Italian Pediatric Society in 
 June, 1918, Prof. V. Tedeschi presented an exhaustive report 
 based upon his study of child welfare conditions in Italy. At 
 the request of Prof. Bereiiini, Minister of Public Insfcnjction, 
 Prof. Tedeschi outlined a plan* for a law "For the Co-ordination 
 of the Study of Pediatrics with the National Child Welfare 
 Work." In Italy breast feeding of infants has always been in 
 favour, and it might be said that in the north from eighty-five 
 to ninety per cent, of the children are breast-fed for one year 
 at least, and in the soutJi from ninety to ninety-five per cent. 
 The institution of midwives to look after normal obstetrical work 
 is a long standing one in Italy, and in co-operation with the 
 well-trained obstetricians do, generally speaking, good obstet- 
 rical work. The midwives are required to take a two years' 
 course of training in medical centres, after which they receive a 
 diploma. On the whole these women understand the necessity 
 for cleanly obstetrics, for the care of the puerperium and the 
 care of the new born infant's eyes, so that in Italy we find the 
 incidence of puerperal infection comparative!}^ small, and the. 
 amoimt of ophthalmia neonatonim relatively so. 
 
 At the outbreak of the war practically the whole male popu- 
 lation was mobilised and a niunber of the physicians, including 
 some of the obstetricians and pediatricians, were drafted into 
 war sen'ice. A number of tlie cliildren's hospitals were utilised 
 foi- war purposes, and in those which were not completely taken 
 over they were limited to one or two wards. The effect of the 
 war upon the birth-rate was not immediately seen, and, as 
 Prof. Gini has recently sho^vn, there was rather an increase up 
 to nine months -after mobilisation of the various age groups, 
 but since that time there has been a steady, and, in some places, 
 an alarming decrease. The national birth-rate, which stood at 
 
 See Appendix III., page 48. 
 
16 
 
 about 30.5 pei- tliousaud population at tlie outbreak of the waj-, 
 lias dropped to something like 18 or 16. In sevei-al of tlie 
 industrial centres, the rate has fallen to about 10 during the 
 past year. With this decrease in birth-rate, there has been an 
 increase in infant mortality. The increase in infant moTtality 
 became manifest somewhat before the decrease in birth-rate 
 began, but since that time theie has been a steady increase in 
 infant mortality. In a group of the larger cities (Rome, 
 I'lorence, Bologna, Ravenna, Milan and Turin) thei'e ha-s not 
 been an alarming increase during the war period, but on the 
 other hand a number of cities along the Adriatic (Fano, Pesaro, 
 IJrbino, Foggia, and Bari) show a vei-y high rate of increase, 
 especially in the deaths from congenital weakness, debility, et<;. , 
 and from the gastro-intestinal diseases. It has been particulaiiy 
 noted that the increase in infant mortality has taken place in 
 the winter months January, Febiuary and Ma,rch, and in the 
 summer months, June, July and August. While the infant 
 mortality rate of children under one year of age has greatly 
 increased it might be said tliat the death-rate of children 
 froim t)ne to' five has advanced miich more i-'apidly. I 
 think this is a veiy importajit point. It has been attributed 
 to the fact tliat at the weaning jieriod, which is later in Italy 
 than in England and America, food unsuitable to young children 
 has been given, and, on account of high prices, suitable food 
 has not been obtainable in any large quantity foa- the middle 
 and lower classes. 
 
 The recent influenza epidemic has had both a dii-ect and an 
 indirect effect upon the infant mortality of Italy. While the 
 death-rate of babies and young children from influenza has not 
 Ijeen very high, when such children have been deprived of 
 maternal nursing or ci"owded together in institutions, tlie death- 
 rate has gone up considerably. For example, in the Hospital 
 .SantiL Maria Degl' Innocenti (foundling asylum) of Florence, the 
 death-rate of babies who acquired the disease was 47 per cent., 
 mostlv from complications of bronchial pneimionia ; while in the 
 pediatric clinic of tlie sa:me city, wliej'e the conditions for medi- 
 cal care were better and a greater number of legitimate babies are 
 taken, the death-rate was only 13 per cent. During the epidemic 
 a considerable portion of the case« were of young women l)etween 
 twenty and thiity years of age. The mortality among this 
 gj-oup was quite high, although it is difficult to state the definite 
 percentage. It was seen in Italy, as in America, that pregnant 
 women wntli influenza aborted very readily, and that tlie death- 
 rate among such women was considerably higher than among 
 non-pregnant women, so that the effect of this scourge will not 
 be entirely manifest until the birth returns for 1919 have all 
 been received. It should be pointed out that the number of cases 
 of influenza in Italy was incredibly high. The number of deaths 
 from this disease or its connplications has been variously estim- 
 
17 
 
 at«d from five hundred thousand to (Hie million, exclusive of 
 the military population. 
 
 In viewing the child welfare problems of Italy, one is led 
 to think of them, not as a finished picture with harmonious 
 colouring, but rather a,s a mosaic made up of some sixty -nine 
 different provinces grouped together into regions where the tem- 
 perament, progressiveness and economic conditions of the people 
 differ considerably in the various parts. In the north there has 
 been considerable piogress in the organisation of child welfare 
 woik and, although the biii:h rate is lower than that of the 
 Adriatic coast and in the south, they have managed in the larger 
 centres to reduce the infant mortality rate, so that there the 
 actual saving in life has probably been greater. This region 
 also represents the great industrial centres. It is also the seat 
 of most of the great universities. Along the Adriatic the child 
 welfare conditions appear to have been most affected by the war. 
 Many of the smaller towns have suffered tremendously on account 
 of the cutting off of trade and fishing and of tiie influx of the runil 
 [x>pulation into the cities. The region, being largely agricultTiral, 
 Ijegan to show the eft'ects of the removal of the men from the fields 
 somewhat earlier than other parts where industries pre- 
 vailed. The women were drawn to the larger centres into in- 
 dustries such as munitions and silk factories, paper and tobacco 
 manufactories, very often leaving their children to be looked 
 after by those who did not know how to direct the feeding pro- 
 perly. The result has been a considerable increase in deaths 
 from gastro-intestinal diseases in the provinces along the 
 Adriatic coast from Rimini to Lecce. With the advent of tho 
 war, precautions against malaria were somewhat relaxed. The 
 quinine prophylaxsis coidd not be kept up adequately, the screeai- 
 ing was not re])aired, and comparatively little attention was jwiid 
 to sm-face drainage. As a result, malaria has considerably in- 
 creased in the South of Italy and in Sardegna. There has also 
 been a considerable increase of malaria in the regions around 
 Trieste and Venice, on account of the soldiers who had become 
 infected in previous campaigns in Gallipoli, Macedonia and 
 Albania. The.se men, returning to their homes in distapt parts 
 where anopheles are allowed to breed, will undoubtedly convey 
 infection to their vicinities, and, in tm-n, the babies and wives 
 will l)ecome infected. 
 
 During the war there has also been a considerable increase 
 in the number of deaths from tuberculosis, which has mani- 
 fested itself in practically all the large centres of population. 
 With the coming of peace and the retm^n of prisoners from 
 Austria, a considerable number of whom have become infected 
 with tuberculosis, tuberculosis is being carried into the very 
 homes of these men. Although attempts are being made to 
 segregate the cases, it will easily be understood how impossible it 
 is strictly to enforce regulations, and how these men will come 
 
18 
 
 into their homes despite all efforts and become centies of in- 
 fection. From persoaial discussions with pediatricians in the 
 north, I have been informed that tuberculosis among children 
 imder ten yeairs of age is also' oiu the increase. Von Pirquet 
 tests applied to children in clinics in large cities in the north 
 (Bologna, Milan, Padua) give it positive in from 50 to 60 per 
 cent, of the cases under ten years of age. Tlius, childrein 
 infected eai'l'y, and without sufficient nourisliment, l>ecom!e 
 prey to this dread disease. Outside the invaded areux 
 there does not seem to be very great lack of food, 
 alit.hough along the Adriatic coast, where it was almost 
 impossible to obtain milk or eggs at any reasonable price, the 
 children did seem to be more under-nourished than in the north. 
 Those who have travelled widely in Italy, and who have reported 
 to us, state that the condition of the children between two and 
 six years of age is, generally, I'aA'ouirable, but that at the 
 period between one and two, which includes the weaning period 
 and the adjustment to new kinds of food, the children have 
 exhibited worse conditions, and in this gioup the death rate 
 has been relatively higher. In the larger centres of population, 
 among the well-to-do and even in the middle class, wet nursing 
 was at one time in great vogue. During the war the wealthier 
 class were still able to obtain wet nurses, but at gi'eatly in- 
 creased cost, w^hich has prohibited the middle class from ob- 
 taining the same service. Of course the wet mu'ses' own babies 
 liave always suffered fi-om the withdrawal of their nouaishment, 
 a.nd the de'atli rate among them has accordingly been high. 
 
 From the data we have gathered, it cannotibe shown that 
 during the war there lias been any distinct increase in the num 
 ber of foundling asylums and illegitimate babies. The mor- 
 tality among this class, however, has been about twice as great 
 as among the legitimate children, and under the best conditions 
 in fovmdling asylums the mortality has been oven higher. Some 
 local reigulatioi'iis, pawsed within the last year, which prohibited a 
 mother from placing her baby in a foundling asylum before it 
 wais four montlis old, have, of course, given the appearance of a 
 vediuced-mortality iu' mch institutions. Where the babies survive 
 institutii^iinal treatment^ and a,re placed in the coaintry after one or 
 two years a number of them live if they get careful treatment 
 and supervision, but it seems to be the experience diu-ing the 
 war that the care given such babies has not been adequate and 
 sufficient supervision has not been maintained, with the result 
 that the death-rate of babies placed out in countiy homes has con- 
 siderably increased. The Italians themselves have attempted to 
 meet these problems and with the resources at hand have done as 
 much as they coidd. Milk-distributing stations and economic 
 kitchens have been established in every large centi-e, and con- 
 siderable amoaints of condensed milk have been distributed by 
 the Red Cross. Clothes aaid institutional care have also been 
 
19 
 
 provided, but tliere lias never been in Italy any enthusia.sni fur 
 health visitoavs, and wp to the present time the jjeople neither 
 understand nor appreciate the importance of trained healtli 
 visitors. But dmdng the war, a considerable number 
 of intelligent, well-to-do women entered the nursing servdce 
 in the Army with the Italian and American Red Cross 
 in one capacity (n- another, and these wumen have 
 hiid their eyes opened to the needs of the civil population, 
 especially to the care of the babies. From this group of women 
 it is hopetl to gather nuclei here and there for instruction in 
 public health nursing. The co-ordination of all the child welfare 
 iictivities in various centres must also take place, and in order 
 to become effective a national organisation, with an executive 
 committee representing various types of work for children, 
 should be organised. 
 
 The condition in Italy is more hopeful than one would 
 imagine from a mere cursory examination of the birth and 
 infant mortality rates. Since the signing of the armistice there 
 has been a decided revival of Italian spirit. There is consider- 
 able activity in the industrial centres "of the north. The birth 
 rate Avill rebound immediately when the men return from the 
 front; there is practically no birth control in the south, and it 
 is going out of vogue in the north. Breast feeding is almost 
 universal for at least a year ; only in the north does one meet 
 with serious attempts, at artificial feeding. Above all, there 
 is growing a healthy idealism for maternity and child welfare. 
 The men and women with childien are looked upon as having 
 real assets, economic, social and religious. 
 
 THE CHAIRMAN : Now will you add to that, Captain Bolt, 
 what your Commission has done to meet the problem, because 
 that is really an account of the present position in Italy? 
 
 CAPTAIN BOLT : Yes, I will briefly outline it. In the first 
 place, I might say that the Commission was constituted of people 
 interested in tuberculosis, specialists in infant welfare, publicity, 
 jiublic health education and public health nursing. We decided 
 that the thing to do Avas not to go down there and attempt to 
 show the Italians how to run their institutions, or, in fact, to 
 attempt to show them liow to do anything, bnt first to make a 
 thorough study of the health situation. Accordingly our first 
 step was to divide our Commission up into small groups, consist- 
 ing of a. medical man, a social worker and an interpreter. We 
 divided up the whole of Italy, largely on the compartment or 
 the provincial principle, and in each district we made first-hand 
 investigations of their existing institutions as to what changes 
 had taken place during the war and the outlook, gathering 
 definite statistics from each region we visited. Now, apropos of 
 child welfare to-day, I made out a special form indicating what 
 should be looked for in a community with respect to child 
 welfare. Also, in collaboration with the statistician of our 
 
20 
 
 {'oinmission, I worked out a simple form for statistics eo that 
 we could obtain from each locality what was happening there. 
 We found it Avas very difficult to obtain from the authorities at 
 Rome exact statistical information of recent date. They claimed 
 that the war had swept things aside, so that they were not getting 
 information, or when it came in it Avas hard to compile, so we 
 went out to the individual communities and got it there. How- 
 ever, we made a study of the whole situation, and pooled our in- 
 formation in regard to what was taking place in Italy. We found 
 the best thing to do was not to attempt to cover the whole 
 field, but to pick out those parts of Italy which were most likely 
 to respond to what we had to give, the next step being the formu- 
 lation of what each one of us could give in our special line of 
 work. For instance, in child welfare I was asked : " What can 
 you do for us?" I formulated a simple outline: We can go into 
 that district and help them to investigate their child welfare 
 conditions more exactly; we can help them to compile statistics ; 
 we can help tliem to establish welfare centres ; we can furnish 
 them with expert advice on any of these matterB if they want it. 
 A similar line of effort was ])ut forth by those interested in tuber- 
 culosisi, in publicity and public health nursing, and so on. Then 
 we picked out foiu- of the most likely places, the province in 
 which Geneva is situated, the province of Perugia, the provinces 
 of Sardegna., and the province of Palermo, Sicily. This gave us 
 a wide latitude, but at the same time we could concentrate on 
 those places. Then we said to the leaders of representative Com- 
 mittees : " You get together and formulate a programme as to 
 what you think ought to be done in each district to co-ordinate 
 all our forces, and we will see Avhat we can do to help." They 
 came to us with their programme. We compared it with our 
 resources, and said we can give you certain things. In all cases 
 we insisted on an executive secretary for each of these regions. 
 We made an effort to correlate oui- child welfare work with the 
 tul>erculosis work. The result of that now is that in these 
 districts we have helped them intensively with nurses, publicity, 
 secretarial help, and so on, not giving money to institutions — 
 that was the first great temptation, to respond to the large 
 number of appeals from institutions. Italy is well supplied with 
 institutions for all types of work. It simply means an adapta- 
 tion of what they have to their needs. So we stai-ted in Genova, 
 Perugia, Sardegna, and Palermo with these centres, and we hope 
 to get them to come out into a national scheme for tuberculosis 
 and infant welfare. Now, hand in hand with this. 
 I got into personal touch with the leading pediatricians 
 of the country, because I felt that urdess you get the pediatricians 
 behind you, especially in the Medical Schools, the effort in Italy 
 would not come to very much. The education of the masses is 
 difficult thei'e; it is very difficult for the public health officers 
 to introduce infant welfare into the schools, but it is not diffi- 
 
21 
 
 cult to get a certain amount of supervision, and get them to 
 understand the lines upon which we are working. We hope that 
 at a Pediatrics Congress this summer they will adopt some sort 
 of a plan such as Prof. Tedeschi has outlined. In other words, 
 we think we ought not to interfere in any way, but, if possible, 
 to assist in their technical organisation, and that is as far as 
 we have gone. Our statistician, at the same time, has compiled 
 all the data and statistics which I have brought here; he has 
 made out an account from the statistical side, and I feel that 
 rhat is a very important part. In the work which has to be 
 done, you must have some place to correlate your knowledge, 
 otherwise you go off at a tangent. We work slowly and sys- 
 tematically. When you consider it in detail, it does not look 
 as if we have gathered very much, but I feel that when we leave 
 Italy we shall have left with the Italians a method or system 
 that they will find useful. 
 
 THE CHAIRMAN : Comparing your experience in Italy with 
 your experience in America, do you think you have any sugges- 
 tions to make to us here? 
 
 CAPTAIN BOLT : In the first place, I ought to say that I 
 appreciate very much the courtesy that has been extended to me 
 here in England dmnng the past five weeks. During that time 
 I have studied your child welfare situation. I have come in con- 
 tact with many governing bodies, with yoiu voluntary organisa- 
 tion, with yoiu' educational authorities, and have made 
 somewhat extensive trips, picldng out just the essential centres 
 which seem to represent the different types of work. Having 
 thought it all over and summing it up, it appears to me there 
 are three things that will have to be done. The first and fore- 
 most, and the most important of these, it seems to me, is the 
 education of the medical student to the needs of infant welfare 
 work through your pediatiic departments. That was discussefl 
 this morning to some extent, and will be discussed at greater 
 length later on. The next need is the training of your health 
 visitors along broad lines, not necessarily very intensive lines, 
 but along ample social, economic and nursing lines. They shouhl 
 go all the way through a cross section of your coimtry where 
 the infant work occiu-s. The next thing to do is to educate your 
 growing generation of mothers to the necessity for this type of 
 work, and I would suggest that this can most easily be done 
 in the upper grades of your schools. In Cleveland, about ten 
 years ago, we got into touch with the educational authorities 
 along this line, and they introduced into the 7th and 8th grades 
 of public schools somewhat elementary courses on infant hygiene, 
 school nurses taking one course and the domestic science 
 teachers taking the other. That has been carried on now 
 for ten years, and, as a result, we can see that breast feeding 
 is C/oming more and more into vogue in Cleveland. The mothers 
 are the most enthusiastic supporters of the infant welfare centres, 
 
22 
 
 and the community is more interested. Then the propa- 
 ganda side has already received a great deal of attention both 
 here and in America. That is important, but I think propa^ 
 ganda shoukl be guided by men and women who understand 
 the fundamental principles of child welfare. All the schemes 
 should be co-ordinated and brought before the public. If these 
 three things w-ere done, it seems to me that Great Britain will 
 stand as the foremost nation in Maternity and Child Welfare. 
 I feel at present that you have worked this thing out from a 
 Governmental point of view as has no other nation, and that 
 you will now be able to put it over and be a shining light to 
 the rest of the world. 
 
 DR. JANET CAMPBELL: I should like to know from 
 Captain Bolt how he thinks the teaching of mothercraft in 
 scliools ought to be done ; whether he would agree with om* view 
 as to how it should be done. I should like to hear from him 
 who he considers should teach it, and when it should be taught. 
 
 CAPTAIN BOLT : I believe that it should be taught not by 
 your regular day-school teachers, but by those who are especially 
 familiar with the health side of child problems. The liealth 
 visitor can teach the importance of proper feeding and the 
 proper care of the milk ; she can impress upon the school chil- 
 dren why the babies are dying ; she can urge the necessity for 
 the breast feeding of babies. All those simple elementary 
 pediatric steps are more familiar to the public health visitor than 
 tliey are to the ordinary school teacher. On the other side there 
 is the domestic science teacher. I think the teaching should ])P 
 given in what we call the 7th and 8th grades; that is to say, 
 between the ages of 12 and 14. This view may not perhaps be 
 pedagogically correct, but it is at least psychologically correct. 
 l)ecause these girls will have dropped their interest in the dolls 
 and furbelows of their childhood period ; they come on to the 
 verge of puberty, and it gives them something to think about 
 that is going to appeal to them later on. They may forget about 
 it until they are married, but it then comes back to them vividly. 
 It ought to be a compulsory subject. The Avay it may be done 
 is by the systematising of the school curriculum by the head 
 nurse, by means of school nurses, and so forth. In Cleveland 
 there is a definite programme for each lectm-e, which takes 
 about 40 minutes, definite questions asked, and suggested 
 answers given ; every school nurse and every domestic science 
 teacher is asked to follow this out ; it is correlated and sys- 
 tematized, and they know to what end they are working. Each 
 year the group of nurses meets with the Director of Child 
 Hygiene, and he goes over this outline with them. If there 
 have been any changes or any advances, he suggests those 
 changes in their teaching, and they are incorporated in the sys- 
 tem, which is thus kept up to date. 
 
 There is a great deal of practical training to be done. The 
 
23 
 
 childi-en are asked to bring their baby brother or sister into 
 the school- room, and they are made to go through the demon- 
 stiation of the use of the bottle and tlie nipples, how to clean 
 a bottle, and simple things of that kind which can be done in 
 the class-room by demonstration. 
 
 THE CHAIKMAX : It is a crucial point in this country 
 whether we should require this kind of education to be given by 
 the systematised teacher who knows, we will say, relatively 
 little, but perhaps enough ; or whether it should be attempted 
 by, say, a school nurse or a doctor coming in from outside with 
 greater knowledge possibly, but with no understanding of the 
 child mind and with no practice in teaching. What do you say 
 to that ? 
 
 CAPTAIN BOLT : I ^lll.uld say the same thing could be ob- 
 tained by training your school teachers in normal schools in 
 these fundamental child hygiene principles. 
 
 DK. LANE-CLAYPON: I would rather like to ask what 
 you include under a thorough training 1 
 
 CAPTAIN BOLT : Up to the present time we have felt that 
 the health visitor should have a thorough training in general 
 nursing before she went into her public health duties; that is 
 to say, every one of the nurses we have at the present time in 
 Cleveland connected Avith the Health Department has had a 
 general hospital training first. On top of that, they have had 
 special training in tuberculosis dispensaries, sanatoria, and so 
 forth, or in infant welfare centres, children's hospitals, dispen- 
 saries, making it a rather long and complicated process, and 
 we have discovered this — that in some of the cases, perhaps 
 more than a few, the preliminary training which they have had 
 In the hospitals has not been altogether conducive to the best 
 results in their training as health visitors. They have to change 
 their attitude of mind veiy much, because they have been used 
 to looking at the pathological side, and it is difficult to get 
 them to see how to keep the baby well. From an infant wel- 
 fare point of view, social service should receive more stress than 
 this long preliminary training in hospital. I do not refer- to 
 the well-trained hospital graduates, but even in their case it is 
 a question whether it is wise to allow them to devote so many 
 years of their life in this way, when other types of work would 
 probably make them more efficient in the long run. 
 
 DR.' W. R. RAMSEY : I would like to make a suggestion in 
 connection with what Captain Bolt has said about propaganda. 
 As you are going to have a Minister of Health, this question of 
 propaganda is tremendously important, but what we found was 
 mast important was to proceed on uniform lines. There are so 
 many opinions among medical men about feeding, the care of 
 children, fresh air, and so forth, that in one institution a man is 
 taught one thing and in another institution sometliing difltei^nt. 
 ^Yhat we have found to ])e newssary, and what we finally did in 
 
24 
 
 the United States of America, was to appoint a Commission of re- 
 presentative pediati-icians — a representative from each University, 
 say — and we asked those men to formulate something that they 
 could all subscribe to. They liad some difficulty, I assure you, 
 but they finally got down to it and subscribed to a small pam- 
 phlet, which was then issued by the Government in many hun- 
 dreds of thousands. Since these men were representative men, 
 their findings are now accepted as the basis for a uniform propa- 
 ganda for child feeding and general hygiene to be applied to 
 children. 1 would suggest that that is the most important 
 thing to do in connection with your propaganda. 
 
 IV.— Position in New Zealand. 
 
 DR. TRUB'Y KING: After what Ave ha,ve heard from the 
 various speakers I think it is not essential for me to give my 
 views in detail on the question of the education of the medical 
 student, the education of the health visitor and the education 
 of the mother. We are agi-eed that all these things need atten- 
 tion and consideration. I will speak only with regard to their 
 order of importance. In New Zealand we have devoted our 
 attention more particularly to the direct education of the com- 
 munity, the parents and especially the mothers of all classes. 
 Of course our ultimate objective is the same, the obvious ideal 
 being to make every woman the competent executive in her 
 own household. She is on duty all the time ; we, as doctors 
 or as nurses, are only there at intervals. As I have s-aid, how- 
 ever, I do not propose to dwell upon the points of education of 
 the medical student or the education of the health visitors, mid- 
 wives or maternity nurses. I am entirely of opinion that^ the 
 subject should be regarded a,s of the first importance in the 
 medical oiu-riculum ; it should be thoroughly taught by compe- 
 tent people, and students should be required to show competency 
 in it. It is a subject of cardinal importance in the training of 
 doctors, and nothing would do more good in oiu- own country 
 and in all the Overseas Dominions than if a. strong lead were 
 given from here. 
 
 We initiated the teaching of the public in New Zealand at 
 Dunedln, which is our University centre. From the first, we 
 liad the sympathy of some of the leading men in the University, 
 the Professor of Gynecology and the Professor of Sm-gei\y, 
 for instance, and latei- most of the other Professors became 
 identified with it, so we got a good backing. We established a 
 small hospital solely as a baby hospital, and we trained nurses to 
 fit them for teaching and for the care of mother and child through- 
 out the whole country. We then used the hospital for the 
 clinical teaching of the medical students, and the teaching of 
 the domestic science students at the University : we also used 
 it for the teaching of the general public by encouraging them 
 
25 
 
 to come as visitors to the institution, allocating special uiu'ses 
 for this purpose. There was also a general propaganda by 
 means of lectures, regular weekly articles in the newspapers, 
 and so forth; books were ^^Titten, some of which were printed 
 by the Government and issued by the Public Health Depart- 
 ment, not only to every expectant mother but for all mothers. 
 In this way, being a small country, we were able to give uniform 
 authoritative advice. There was unity in the matter, and, 
 though our Society for the Health of Women and Children was 
 started as a purely voluntary organisation, I happened to be a 
 public servant and have come to act towards the Society partly 
 in that capacity. There are between 70 and 80 Committees — 
 Committees of from 10 to 25 representative women — all 
 governed by rules and laws which are ratified and extended about 
 every two years by a central meeting. Montldy reports are 
 issued to the Public Health Department, and the Society has 
 worked in loyal co-operation with them. There has been a 
 growing recognition upon the pai-t of the Public Authority. At 
 first there was no grant towards the voluntary funds of the 
 Society, but we have now reached the position of the Govern- 
 ment contributing 24s. for every pound raised voluntarily for the 
 salaries of our mothercraft nm-ses, and in addition the Govern- 
 ment grants generous annual subsidies towards the support of 
 the hospitals established by the organisation. Fm-ther, the 
 Government allows our nurses to travel free of cost over the 
 State-owned railways, and the Municipalities give them free 
 travelling over the Mimicipal tramways. So that while the 
 work is nominally voluntary the Government and the Munici- 
 palities take more and more cognisance of it, and in that way 
 it has a growing status. 
 
 With regard to tlie teaching of the medical students it is 
 only about seven or eight years since children's diseases Avere 
 separated from the general teaching of medicine. Since then 
 the subject has been under the Pioncipal Doctor at the Babies' 
 Hospital, and he has taken a veiy keen interest in pediatrics. 
 He has seen to the teaching of the students by means of the 
 Special Baby hospital, by means of his ward in the Dunedin 
 Hospital into which children are received, and by access to the 
 Government Maternity Hospitals. At the same time I should 
 explain that our poisition with regard to the teaching of pedia- 
 trics is not to be compared with the status of this subject at the 
 California University, for instance. At the best American 
 Universities there is infinitely larger expenditure, there is an 
 infinitely larger amount of research being carried out, and much 
 more is expected and required of the medical students. It 
 seems to me that that is entirely in the right direction ; the 
 subject is a most important one and the fate of the race largely 
 depends on it. 
 
 In addition to what has aheady been said regarding the 
 
26 
 
 fundaineutal importance of breast feeding, I should lilve to stale 
 emphatically that I am satisfied that the main damage to the 
 baby often has its origin in the first fortnight of life. The 
 common mistake is iiTegularity and undue frequency of feed- 
 ing; and the after difficulties are largely due to indigestion 
 caused through this over-feeding in the first fortnight of life. 
 The facts and figures contained in Dr. Ramsey's rec-ent paper, 
 stating the conclusions formed at the University of Minnesota 
 from the exhaustive study and investigation of 300 cases, show 
 that the average quantity of mother's millv on which the baby 
 really thrives at ten days of age is only about 13 ounces. The 
 German standard, arrived at by Ileubner, Camerer and others, 
 which has been so largely followed, is 18 ounces at ten days. 
 The difference is enormous. We find here in London, both in 
 our Baby Hospital and in the home, as we found in New Zea- 
 land, that many cases where the mother fails in the early stages 
 and where the child is subjected to early weaning are due to 
 the fact that the child has had too much and not too little from 
 the breast. There has been an over-supply during this early 
 period, with the result that owing to indigestion and restlessness 
 thus caused, the mother's milk supply begins to fall off. In such 
 cases it is the habitual practice to recommend that a bottle be 
 used, and that is the beginning of the end with regard to the 
 giving up of nursing. That, at any rate, was the conclusion 
 which was forced upon us in New Zealand and which is borne 
 out by all the experience which I have had here. About 13 
 ounces of mother's milk is, in my opinion, the average food 
 requirement at ten days. This is what we show on our Feeding 
 Charts, and the figures coincide with those arrived at by Prof. 
 Marfan, in Paris, and consistently advocated by him. With 
 regard to the need for the adequate teaching of students for the 
 medical and nursing pi-ofessions and for enlightening the laity. 
 I should like simply to endorse the statements made, especially 
 by Dr. Bolt, as to the relative importance of these vanous 
 factors. I do not think it matters much at which end we com- 
 mence. Pediatrics ought to be taught thoroughly and should 
 be given an important place in the examination of medical 
 students. I have felt so strongly on this subject that I have 
 proposed that my own lectureship (Mental Diseases) should be 
 cut down to a half to make some room. 
 
 THE CHAIRMAN : Now, before we take the next subject I 
 think it would be well if we could agree upon one or two quite 
 general positions. I have got various notes doAvn which come 
 under four headings, and I think it would be well if we could 
 decide whether they are the four main points on which we should 
 now concentrate. The heading which I happen to have down 
 first is breast feeding. We ought to try and arrive to-day at 
 some sort of conclusion, if we can, on breast feeding, with par- 
 ticular reference to its importance and to the four hour question. 
 
27 
 
 The .second subject whicli has aii.seii is the education of the 
 medical student. The third is the education of the school girl 
 in niothercraft or infant hygiene, and the fourth is the educa- 
 tion of the public, to be achieved, possibly, by a uniform pre- 
 sentation of the elementary facts to be drawn up by a Com- 
 mission of medical experts. The subjects we have discussed 
 appear to be capable of division into those four categories. Is 
 anybody impressed \nth any other subject which does not come 
 within those four and which has arisen, directly or indirectly, 
 in the discussion? 
 
 DR. TRUBY KING: Might I suggest that perhaps sufficient 
 emphasis has not been placed by any of us on the subject of the 
 iutliieuce of the maternity nurse and midwife? She ha.s para- 
 mount power; she is the first in contact. It is a matter of 
 supreme importance. Many of these women who have been 
 authorised, and who may be authorised in the future, but mainly 
 those authorised in the past, principally on the ground that they 
 have been practising, are very misleading in what they teach. 
 They get in first, and it is difficult for doctor or nurse to bring 
 reason to bear. 
 
 THE CHAIRMAN' : 1 think you are right: training the niid- 
 nife, the monthly or nutternity nurse, and the health visitor. 
 We all agree that the training of these people is also of para- 
 mount importance. This, therefore, is a fifth subject. 
 
 V. — Present Demands of Examining Bodies in Pediatrics 
 and facilities for teaching this subject in Great Britain. 
 
 DR. H. C. CAMERON : Mr. Chairman, Ladies and Gentle- 
 men, in what I say I shall speak from two points of view. I 
 was for some yeai-s Dean of the Medical School at Guy's Hospi- 
 tal, and therefore I have some knowledge of the general ques- 
 tion of the education of medical students. I am also in charge 
 of the Children's Department at Guy's Hospital, which was 
 opened in 1911. I feel strongly that a Children's Department 
 in a Medical School should be concerned not only with the treat- 
 ment of disease, but also with the study of the social and 
 economic side and with the preventive aspect of the problem. 
 
 I think we may look upon Medicine as l>eing divided into 
 two parts. First, there is the study of growth and development, 
 which must be based on physiology ; the child is a living 
 physiological model always to hand. Secondly, there is the 
 study of decline, degeneration and decay, work which nmst be 
 intimately connected with the study of Pathology and Morbid 
 Anatomy. Now almost all the teaching which medical students 
 receive is concerned with this second aspect of medicine. Even 
 in the teaching about children, the emphasis is laid too exclu- 
 sively upon diseased conditions. The children's physician is 
 
28 
 
 apt to have the same attitude as the general physician, the only 
 difference being that hie patients are below a certain age. In 
 order to correct this faiilt as far as possible, the Governors 
 of Guy's Hospital have accepted a scheme which I laid before 
 them for a complete Children's Department. In some respects 
 the war has caused a vexatious delay. All the buildings are 
 not yet complete, but everything has been agreed to. I should 
 like, if I may, to describe our plans. 
 
 The children's wards, containing about 50 cots, will be in 
 close proximity to a lying-in-ward of 20 beds. The infants born 
 in the lying-in-ward will be under the care of an assistant, 
 who will act imder the joint control of the obstetric surgeons 
 and myself. The Salomon's Centre for Infant Welfare is 
 housed in a building adjoining the hospital, and is approach- 
 ing completion. It will be conducted by assistants acting under 
 my control. The Centre will undertake the ante-natal care 
 of the two to three thousand expectant mothers who apply each 
 year to the hospital for assistance in child-birth. These births 
 are attended in part by the students of Guy's Hospital, and in 
 part by the Pupil-Midwives of the Midwifery School attached 
 to the hospital, in each case under the necessary supervision. 
 The mothers all live in an area which is situated in the Boroughs 
 of Bermondsey, Southwark and Lambeth, and our arrangements 
 have the approval of the Medical Officers of Health concerned. 
 In this area there are some twelve other Infant Centres at work, 
 and the Salomon's Centre has entered into arrangements with 
 these Centres to cover the whole area completely, so that every 
 child is sent to the Centre which is most conveniently situated 
 to its home. The Salomon's Centre, therefore, although it con- 
 ducts the ante-natal work for the whole area, restricts its post- 
 natal work to a small district in the immediate neighbourhood 
 of the hospital. 
 
 The Out-Patient Children's Department has made arrange- 
 ments to place the resources of the Hospital both for diagnosis 
 and treatment at the disposal of all these Centres. In the Salo- 
 mon's Centre there will be a resident superintendent and six 
 resident health visitors. They will be assisted in the work by 
 the pupil-midwives, and ultimately, it is hoped, by students 
 working for a Diploma in Infant Welfare. The medical students 
 of Guy's Hospital will have opportvmities of studying the work 
 and appreciating its methods and objects. I hope that this 
 scheme will soon be in working order. At present it exists in 
 precis, and there are still gaps caused by delay in the necessary 
 building. An arrangement has just been made by which all 
 students will spend three months in the Children's Department, 
 passing into it immediately after three months spent in the 
 special study of midwifery and the diseases of women, and I feel 
 that with these arrangements it will be possible to make the 
 insti-uction sufficiently comprehensive so that it may include the 
 
29 
 
 study of the newly-born and of the normal child as well as the 
 .study of sick children. 
 
 But with all these advantages I feel tliat I shaU be apt to 
 fail in my attempt to give all students a sufficient training in 
 pediatrics if the subject is still a voluntaiy one, so far as the 
 student is concerned, and if there is no set examination of his 
 knowledge as part of the Final Examination. At the present 
 time in the various examinations there is often a single ques- 
 tion set on some one of the classical disorders of childhood, 
 and as Dr. Fairbairn has said, occasionally, or even usually, 
 a question is set on some point of infant management or hygiene. 
 If this important subject is not to be neglected by many stu- 
 dents, who naturally enough have their examination requirements 
 constantly in mind, the training must be compulsory and an ex- 
 amination must be held which will demand that the student does 
 not answer scrappily or with vague generalities, but goes into 
 detail and shows the same Iviiowledge that is expected of him in 
 liis answers on morbid anatomy or on clinical sjTiiptoms. 
 
 I know that the curriculum of the medical student is over- 
 crowded. Nevertheless, I do not think that there should be 
 difficulty in providing for a three-months' study of a subject 
 which is not a narrow speciality, but which forms the founda- 
 tion of almost all that the student learns elsewhere. It is neces- 
 sary for his understanding of many disorders of later life, and 
 is of supreme practical importance for him in after life. In 
 the first place, I think that relatively too long a time is spent 
 in the study of anatomy. Of the five years of medical study, 
 tlie greater part of two years is devoted to memorising anatomi- 
 cal nomenclature. Within a very short time the whole fades 
 from the student's memory ; only general outlines survive and 
 those details which he learns often for the first time from his 
 studies in medicine and surgery. Of the two or two-and-a-haJf 
 years devoted to clinical study, a very large part of his time is 
 spent in Avatching or assisting in surgical procedures of various 
 sorts. Now the development of modern surgery has led in a 
 direction away from the requirements of medical education. 
 These special surgical procedures are really objects for post- 
 graduate study. Having completed his training in the broad 
 jtrinciples of physiology, pathology and medicine, the student 
 may decide after gi-aduation to perfect himself in some particu- 
 lar manipulation. Some surgical teaching and experience is 
 essential, but the time spent in this way should be less than 
 that spent in the study of medicine. From this point of view 
 much surgeiy is the work of a narrow speciality. It is no 
 more than a form of treatment, and its educative effect is not 
 to be compared with that of the study of infancy and cliildhood. 
 I think that the time devoted to pediatrics might be spared 
 from the time devoted to anatomy and siu-gei-y. 
 
 THE CHAIRMAN : You are going to relieve the me<lical 
 
30 
 
 cuniculaim ; we know tliat is what you have to do before you load 
 up. You propose to relieve the cun-iculum on the anatomical 
 detail side and on the surgical assistance side. Is that all, or can 
 youi help us anywhere else ? If you have any more points in your 
 mind as to how we can relieve the cura-icuhmi, you are going to 
 help everybody round the table. There ha.ve been a good 
 many letters from other coimtnes asking for advice on 
 how to unload the curriculum, and we do not yet know what 
 advice to give at home, let alone abroad. I am always ti-ying 
 to discover ways in which we can fairly reduce the burden on 
 the student's memory and get a much better trained man than 
 one wlio ha.s merely memorised his facts. You h'ave given 
 us two examples; are you prepared to increase the number? 
 
 DR. CAMERON: No, I think not. Unless I add that I 
 sometimes see a tendency to demand a very close familiarity with 
 bacteriological technique. It is right that students should under- 
 stand the principles of bacteriology, but we need not demand too 
 great a knowledge of a technique that is consitantlj' changing. 
 
 Before concluding I should like to state again our difficulties. 
 We are not masters in our house. We .cannot ourselves mani- 
 pulate the cun'iculum so as to make the changes we desire. We 
 have tO' follow- Examining Boards and I^niversities. It is a great 
 satisfaction to me that the Governors of Guy's Hospital have done 
 what they have for pediatrics and yet at present I find that only 
 a few students — and these I think are generally the best students, 
 the best trained and with th.e keenest intellects — will throw them- 
 selves heart and soul into the study of the individual child to 
 detect how it differs from the normal and wherein it falls short of 
 the ideal development of which it is capable. The work is not 
 easy. It is difficult both to leara and to teach. It is much easier 
 for the student to be keen on the removal of adenoid vegetations 
 than to understand why they come and how they can be pu-e- 
 vented. The educational effect is, however, veiy different. 
 Incidentally I may say that I hope that the difficulties which have 
 hitherto stood in the way of post-graduate instruction in London 
 are about to be surmounted and that we shall soon, have arrange- 
 ments which will permit of the satisfactory study of special sub- 
 jects by post-graduates from this country and abroad. Lastly I 
 think that we might at least urge that the University of London 
 should grant an M.D. degree in the special subject of Pediatrics 
 as is done now, I think, in ^lidwifen' and Diseases of Women. 
 
 THE CHAIRMAN : If I may say so without presumption, the 
 case has been very clearly put by Dr. Cameron on these three 
 jioints. First, he suggests that a pediatric department is neces- 
 saiy in eveiy medical school ; secondly, that in this depai-tment 
 every student shall be taught compidsorily for three months ; his 
 third point is that eveiy student shall have a special and separate 
 exaniination in pediatrics. 
 
 DR. WHEATON: I would like to sav that we had a con- 
 
31 
 
 ference liere last summer about the question of providing beds 
 for childien in centres and since then the Board have made grants 
 for this pui-pose, but we havelim^ited theiiuiiiber of the beds which 
 we have provided in every individual centre. An appeal is now 
 pending, and we are hoping that the hospitals themselves will 
 take this subject up. and that they will provide these beds as paii: 
 of their nut-patient department. That is one reason why we 
 limited the number of beds which we have provided in a volun- 
 tary centre to eight, because we thought at that time it was a 
 pity this work should be lost to the medical student. It is im- 
 possible to imagine medical students wandering around a great 
 number of small centres in London, but we were told at that 
 time that the hospitals could not take this up at all; it would 
 mean an expenditure by Governors which they were not pre- 
 pared to meet, and therefore we consented with reluctance to 
 the voluntary centres having these beds and supporting them, 
 but we are lioping in addition to the voluntary efforts, that all 
 the large hospitals will have an observation ward. 
 
 DR. CAMERON : I think this is a matter of great importance, 
 because yoimg cliildren will not remain in health except in 
 buildings which are especially oonstmcted for the purpose. The 
 crowding of infants into houses turned into hospitals may lead to 
 very disastrous results. I take a child into hospital with great 
 rehictance. Often the infant dies of the complaint which he con- 
 tracts in hospital, not of that for which he was admitted. 
 
 DR. RAMSEY : The child should be treated in its home and 
 the health visitor trusted to do the work. 
 
 DR. FAIRBAIRN : I have a few points 1 should like to bring 
 out, and I should Vjegin with the examination. I should 
 like to emphasise that we cannot impi-ove the teaching 
 of pediatrics unless the examination system is brought 
 into line, because it is the first hurdle in front of the men, and 
 they cannot look further ahead than that. You cannot expect, 
 with the curriculum overloaded as it is, that the men will devote 
 themselves to a subject that has no examination value whatso- 
 ever. One is constantly finding that we are up against this 
 problem. I might explain to our visitors that we are in a specially 
 difficult position in London because in the London Medical Schools 
 we are not only not our own masters, but we have to cater for 
 Oxford, Cambridge, London University, and three or four dif- 
 ferent Examining Bodies. They are quite independent of ns, 
 so that any suggestions to be effective would have to come from 
 headquarters. By "headquarters," I mean the General Medical 
 Council. If we wish to achieve anything for pediatrics with 
 the new generation, we must have the examination system 
 brought up to date. I do not think we can leave the examination 
 entirely to the teacher, because teachers vary very much in theii- 
 estimate and judgment of men. It would have to be done with 
 the help of assessors. I think it would be a very good tiling if 
 
32 
 
 we could introduce something based on the system they have in 
 Canada. 
 
 1 have already spoken of the necessity for a complete 
 maternity centre in connection with each hospital; I am quite 
 sure it is not at all a difficult thing to arrange. I think it Ib 
 essential that any hospital that is given a grant or recognised as 
 a medical school should have a complete centre of its own. I 
 would specially urge that the teaching of the student should 
 begin with the pregnant woman. Imbue the student with the 
 idea that he is really dealing with two patients, the mother and 
 her parasitic foetus, and that he has to anticipate the time 
 when there will be the health of two individuals to deal with. 
 That should be the aim and object of the obstetric side — to get 
 a healthy baby without injury or damage to the mother. The 
 pediatric side should carry on the training, and there should be 
 a complete fusion of the two sides from the start to the finish. 
 I think everybody here is perfectly agi-eed about that. I have 
 spent a good deal of time on the rather academic point as to 
 where the teaching of the obstetrician should be divided from 
 that of the pediatrician, and I feel very strongly that there ought 
 to be a time when both teachers are sharing the teaching together 
 at one and the same time. 
 
 Finally, in regard to the social side of the subject. For some 
 years our social work at St. Thomas's Hospital has been extend- 
 ing and om- students are getting a new idea of their work by 
 being given some insight into the social side. Before my 
 obstetric clerks go out into the district they have an interview 
 with the Lady Almoner and her chief visitor ; they are told that 
 there are certain things they have to look out for in the home, 
 and they do so and report. That is very useful training. 
 
 My jjoints would be that the examination system should 
 be arranged to meet the new conditions of things; that 
 every Medical School should have a complete centi'^; that tli^e 
 student should take the midwifeiy com-se and, if pvo&siible, go 
 stiraight on, as Dr. Cameron has suggested, from midwifery into 
 pediatrics, watch the life and health of the infant whose intra- 
 uterine development and birth have hitherto been his care 
 through its breast-feeding and weaning. If the student does 
 that he gets a complete pictiu-e of the whole thing from the pre- 
 ventive medicine point of view. As Dr. Ramsey said, it is the 
 normal infant that should be taught to the student. The pedia- 
 trician shoidd approach the subject from the standpoint of 
 physiology rather than of pathology. 
 
 ■ DR. EARDLEY HOLLAND: There are one or two points I 
 should like to say a few words about. T am not so much inter- 
 ested in the infant. I do not know much about the infant and I 
 am not ashamed of my ignorance, because if I had studied the 
 infant intensively, then I should not have studied so intensively 
 other things that I feel I ought to know more about, such as 
 
33 
 
 pregnancy, labour, gj'necological disease and so on. I think the 
 infant wants intensive study, but I am convinced that the 
 obstetrician and gynecologist has not the time to give the 
 infant that study. Therefore I am most sti-ongly in 
 favour of the infant being handed over to the pediatrician 
 for the purpose of teaching and research. I mean, of course, 
 in the hospitals and medical schools. It comes to this, tlmt if 
 the obstetrician has to look after the infant and to study it 
 intensively, then he must give up g^-necologj'; he cannot do both. 
 He mlist either be an obstetrician and pediatrician, or he must 
 be an obstetrician and gj^necologist. But obstetrics ought not 
 to be separated from gynecology. It is, I think, agree<"l that 
 they are inseparable subjects. 
 
 Another point I wish to mention is the teaching of obstetrics. 
 The teaching of obstetrics at the present time is exceedingly 
 badly done, except in a fe-w chosen places. One of those places 
 is St. Thomas's Hospital, where it is entirely due to the efforts 
 of Dr. Fairbairn that students are well taught. I consider that Dr. 
 Faii'bairn is one of the pioneers in London of the better teaching 
 of obsteti-ics. As a matter of fact the midwife has ousted the 
 student. Nearly all the lying-in beds for teaching are allocated 
 to the teaching of the midwife, and the student is left out in 
 the cold. It is absolutely essential that hang-in beds in the 
 general hospitals should be established, and that it should be 
 made obligatory upon the student to do lying-in work in a 
 ward. I mention this because it is closely connected with 
 pediatrics ; for it means the study of the foetus, the 
 causes of foetal death, the relation of the foetus to the 
 infant, -injuries I'eceived by the foetus and the diseasas trans- 
 mitted to the foetus during pregnancy. I feel that as obstetri- 
 cians we have verv little more interest in the infant than is in- 
 cluded in its foetal stage. The part that shonld be played ba- 
 the obstetrician in infant welfare is to look a.fter the foetus ; to 
 preserve it during pregnancy from transmitted disease, and to 
 preserve it during labour from the injuries it may receive during 
 its passage through the birth-canal. As soon as the establish- 
 ment of pulmonary respiration has announced the fact that the 
 metamorphosis from foetus to infant is complete, he will hand 
 over the infant to his pediatric colleague, asking the latter to 
 ' notelTiat it has been delivered to him in good condition. 
 
 Those really are the only two points I wish to speak on, the 
 point of view of the obstetrician qua the infant, and the teach- 
 ing of obstetiics. 
 
 THE CHAIRMAN : I have these five points in front of me. 
 First, breast feeding; second, education of medical students 
 and practitioners on pediatrics and obstetrics ; third, tlie 
 education of girls in the public elementary schools; fourth, 
 the education of the. public; lastly, the training of the 
 midwife, the maternity nurse and the health \-isitOir. I 
 
34 
 
 think, if I may suggest it, what we want to do is to put oiu- 
 conclusions in simple, general terms. If we get at the deep 
 roots of the subject Ave sliall probably agree; if we get on the sui- 
 face of the subject we shall find a great many details on which 
 we can differ. We have been discussing questions to-day which 
 have deep roots. If now we say to the Government, "We are 
 all agreed round this table on four or five broad principles," we 
 are much more likely to get action than if we try to narrow down 
 our points. If we can get something specific, say, one sentence 
 on ea-ch of these points on which we are agi-eed, it would be most 
 useful 
 
 After some discussion the Conference unanimously 
 resolved : — 
 
 That every effort should be made to impress on the whole 
 community the supreme importance of breast-feeding, for 
 the sake of both mother and child ; that at present over-feeding 
 of the baby, especially in the first fortnight of life, is one of 
 the commonest and most serious mistakes of nursing mothers, 
 often upsetting the child and leading to the eaiiy abandon- 
 ment of suckling. 
 
 That this tendency can be best counteracted by a general 
 recognition of the benefit of greater regularity and lessened 
 frequency of feeding than is customary. 
 
 That with very few exceptions nui'sing only every four 
 hours from birth is best for mother and child, thougji in a 
 few cases more frequent feeding may be desirable. 
 
 That in general there should be an interval of seven or 
 eigjit hours between the last feeding at night and the first 
 feeding in the moiTiing. 
 
 That every medical student preparing for a registrable 
 qualification shall receive adequate teaching in the subjects of 
 infancy and childhood in health and disease; that attendance 
 in a department where instruction is given in these subjeots 
 sliuuld be compulsoiy for a period of not less tha.n 
 three months ; and that some special part of the final examina- 
 tion in medicine shoiild be devoted to these subjects. 
 
 That, as far as practicable, tliis study shall follow upon, 
 and be co-ordinated with, a satisfactory coiu*se in obstetrics 
 and gynecology, and should be made available for post- 
 graduate students; further, we are convinced that the present 
 training in obstetrics leaves much to be desired, especially in 
 i-egard to the lack of facilities for bedside teaching in mid- 
 wifery. 
 
35 
 
 That we consider gieat public advantage would result 
 from a larger measure of imiformity in the advice given by 
 Public Authorities and others in respect of maternity, infant 
 a ad child welfare; the only way in which we think this can 
 be secured is by obtaining a w^'itten statement from a body 
 of experts. 
 
 That both practical and theoretical instruction in infant 
 hygiene should form a part of the training of midwives and of 
 ail persons engaged by Public Authorities in infant welfare 
 work. 
 
 That maternity nursing should only be luidertaken by 
 competent arid adequately trained peisons, preferably by 
 qualified midwives. 
 
 THE CHAIRMAN : I have to thaiik you veiT much for your 
 attendance here to-day. The responsibility of this Coinlerejice 
 has been upon you ; it is n(nv foi- me to place its reconuneiidations 
 before tlie Local Government Boai^d. 
 
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APPENDIX I. 
 
 MATERNITY AND CHILD WELFARE IN ENGLAND AND WALES. 
 
 I Schemes for Maternity and Child Welfare in Kughnid 
 
 and Wales are organised by the Metropolitan Borough Councils in 
 London, by the Councils of most Borought, and Urban Districts 
 with a population over 20,000, and for the rest of the coiiutiy 
 for the most part by the Comity Councils. All Local Authoritie's 
 have power to make such aj-rangements as may be sajictioned by 
 tlie Local Government Boai-d for attending to the health od" 
 expectant and nursing mothers and of ciiildren under five who are 
 not being educated in schools recognised by the Board of 
 Ediication. • 
 
 2. The distinctive features of these schemes are the employ- 
 ment of Health Visitors and the estabhshment of Maternity and 
 Child Welfare Centres. Health Visitors are women Avith ike 
 qualitication either of a trained nurse, a midwife, or a sanitarv" 
 inspector, often with more than one of these qualifications and 
 with a diploma given by a training school after a special course 
 in the work of a Health Visitor. The Government are now con- 
 sidering the question of prescribing a special cun-iculum and a 
 standardised examination for Health Visitx)rs. 
 
 3. The chief duty of a Health Visitor is to visit the infants 
 in her district inmiediately after birth. Every birth is now 
 required to be notified to the Local Authority -n-ithin 36 hours, 
 but where there is a doctor or a trained midwife in attendance 
 the Health Visitor does not usually visit the infant until after 
 the first ten days. Health Visitors have no power of entry into 
 a house, and their visits can only be made \rith the good-will of 
 the mother. They usually ask on their first \dsit whether their 
 services ai-e desired, and in practice it is fotmd that they are 
 generally well received. They are even invited in, some districts 
 to some of the better class houses in which infants are bom, 
 which they do not usually visit except on request. 
 
 i. Their function is to assist the mother generally in 
 the ca.re and managemeint of the child. They supervise 
 it as a i-ule until it is five years old, when it goes to 
 the Elementaiy School and comes under the care of the 
 School Medical Officer and School Nm-se. They try to get 
 the mother to bring it to tlie Centre at regular intervals, 
 see that it has proper and adequate nourishment and clothing, 
 advise the mother how to keep it in health, and what to do if it 
 becomes ill. They make special visits to cases of measles and 
 other infectious disease in young (Children, inquire into the 
 
38 
 
 ciiTuiiistances of still-births and deaths of young children, and 
 also visit expectant nwvthers in some cases to give them hygienic 
 advice and to induce tliem to attend the Maternity Centre. 
 
 5. It has been found that a Health Visitor giving her -whole 
 time to this work can projierly supei'vise a child population repre- 
 seaited by about 400 births a year, and oiii tlhis standard about 
 2,000 Health Visitors are needed in England and Wailes. At 
 the present time upwards of 1,450 whole time Healtli 
 Visitors are at work. About 3,000 women altogether are 
 engaged in Health Visiting, but many of them act also as School 
 Nurses, Tuberculosis Nurses, District Nui^es, Midwives, and 
 Sanitary Inspectors. 
 
 6. MateiTiity and Child Welfaa-e Centres have nowi been estab- 
 lished in most populous areas in England and Wales. The 
 tendency is for each Centre to coincide with tlie district of a 
 Health Visitor. The Health Visitor tries to get the expectant 
 and nursing mothers and children under five in her district to 
 come regularly to the Centre, Avhich is usually open one after- 
 noon a week. The Centre is attended by a doct(^r, who sees each 
 mother a:nd child as far as possible once &• fortnight O'r once a 
 montJi, and advises the mother how to keei> herself and her baby 
 in health and gives siniple treatment when they are ailing. Tht^ 
 Health Visitor makes notes of the advice given and tries to get it 
 carried out in the home. 
 
 7. Apart from the medical consultation, the Centre als(j 
 serves as a medium of instruction to the women attending it in 
 matters relating to mothercraft. Lectures and Classes are 
 held, and cooking and sewing are taught, with special reference 
 to the needs of young children. Milk and other foods are 
 generally supplied at Centres, at cost price to women who can 
 afford to pay, and at a reduced price or free of cost where 
 they cannot afford to pay cost price. The children are weighed 
 at each attendance, and a record of their Aveight and other par 
 ticulars are kept on cards. At many Centres children attend 
 imtil they are five years old, and their cards are then handed on 
 to the School Medical Service. 
 
 8. The number of Centres on the 1st April, 1919, was 1,412, 
 Most of these receive expectant mothers as well as children. 
 Several of them give treatment on an extended scale to women 
 who cannot afford to call in a private doctor. The tendency is. 
 however, to separate consultation and treatment centres, and to 
 provide one treatment centre in a town to serve a number of 
 consultation centres. Such a treatment centre is sometimes 
 established at a hospital, and is often combined with a school 
 clinic. Many consultation centres, however, provide treatment 
 as a routine matter for certain conditions, and especially for 
 dental defects of expectant and nursing mothers and children 
 up to five. 
 
 9. Maternity and Child Welfare work as now understood in 
 
39 
 
 England and Wales includes, in addition to the two services 
 described, a development of eiisting institutions for the benefit 
 of mothers and young children which had ])reviously been pro- 
 vided as a general rule by voluntary effort. Maternity Hospi- 
 tals and hospitals for infants and young children, which used 
 to be financed wholly by voluntary subscriptions, are now l)eing 
 established in many towns by Local Authorities. Moreover, 
 their scope is being extended in the case of maternity to normal 
 confinements, and in the case of infants to ailing children who 
 are not usually admitted to the older hospitals, which as a rule 
 receive only acute cases. Several centres provide an observa- 
 tion ward for children who are not thriving, and some of these 
 take in the mother as well in order to enable her by treatment 
 to feed her infant herself 
 
 10. Otlier institutions for the Avelfare of mothers and chil- 
 dren which are now being provided or subsidised out of public 
 funds are creches, day and night nurseries, convalescent homes 
 for women after confinement and for children recovering from 
 illness, and homes for childi-en whose parents cannot provide a 
 proper home for them, especially for illegitimate .children. 
 Many such homes take the mother as well as the infant and 
 endeavour to keep them together for six months or a year after 
 birth ; in some of these the women go out to work after the 
 first few^ months. 
 
 11. The maintenance of Day Nurseries is encoui'agetl and 
 assisted by the Government in order that provision may be 
 made during the day for the care of infants and young 
 children for whom adequate care cannot be provided in 
 their own homes by reason of the necessary absence of 
 the mother at work or other similar cause. The pi-imary 
 object of such nurseries is to promote the physical welfare of the 
 children placed under their care. Their usefulness was clearly 
 demonstrated during the war when special provision was made 
 for the establislmient of emergency mu'series for the children 
 of women munition workers who were thus enabled to offer 
 their services to the country at a time of national crisis. At 
 the present time some 200 day nm'series are aided by the 
 Government. 
 
 12. In most districts the Local Authority now arrange for 
 nursing to be available for expectant and nursing mothers and 
 young children, sometimes by the appointment of special nurses 
 and sometimes by contracting with a Nursing Association for 
 the services of a district nurse. The conditions for which 
 nurses are usually provided are measles and other infections of 
 young children, ophthalmia neonatoriun, maternity nursing, 
 and the nursing of puerperal fever. In a few cases the nursing 
 is done by a Ilealtli Visitor wlio is a trained nurse. 
 
 13. The quality of midwifery practice in England and Wales 
 was much improved by the Midw'ives Act. 1902, which is gradu- 
 
10 
 
 ally substituting a service of trained experts for the untrained 
 handy-woman of former times. In 1918, 61 per cent, of the 
 midwives in practice were trained and 39 per cent, were im- 
 trained. In a large number of cases midwives are subsidised by 
 Maternity Charities and Nursing Associations, and in the last 
 few years Local Authorities have not only assisted these volun- 
 tary agencies financially to maintain and improve this service, 
 but have also in between 30 and 40 cases provided municipal 
 midwives, paid by salary out of the rates. Of the 11,450 
 practising midwives in 1918, about 1,500 were employed by 
 Nui'sing Associations in rural districts, and about 350 by such 
 Associations or by Maternity Charities and other Institutions 
 in urban districts. Midwives are being employed more and 
 more as ante-natal visitors tO' give hygienic advice to the women 
 who engage them, and to help at Materpity Centres. The 
 quality of maternity nursing is also being improved by the em- 
 ployment of trained midwives to nurse women who have en- 
 gaged a doctor for their confinement. 
 
 14. Though Local Authorities are now organising compre- 
 hensive schemes for Maternity and Child Welfare, comprising 
 many uf the services above described in nearly every dis- 
 trict in England and Wales, a great many of these services are 
 still mianaged and largely financed by voluntary societies. The 
 work of these societies is co-ordinated with the w'ork of the 
 Local Authority, and is generally supervised by the Medical 
 Officer of Health of the Local Authority. 
 
 15. The accompanying chart indicates the Maternity and 
 Child Welfare services in respect of which the State now make 
 a grant of half the net expenditure, whether incurred by Local 
 Authorities or by voluntary societies. The amount of this 
 grant during the last financial year was about £230.000; dur- 
 ing the present year it is estimated at £400,000. 
 
 16. Under the National Health Insurance Acts every 
 
 woman who is herself insured as an employed contributor or wlx> 
 is the wife of an insured man is entitled to a payment of 30s. on 
 her confinement; in the case of an insured married woman the 
 amount is £3. An insured woman is entitled also to (a) sickness 
 benefit (usually at the rate of 7s. 6d. a week) dnrimg any period 
 of inca|)acity for work arising ont of her pregnancy or con- 
 finement, other than the four weeks inmiediately following tlie 
 date of confinement, and (b) to medical attendance both before 
 and after confinement, which, however, does not include attend- 
 ance in respect of the confinement itself. 
 
 17. The School Medical Service.— In ii^)07 the Educa- 
 tion (Administrative Provisions) Act was passed and tnfer alia 
 imposed on the Local Education Autlioiities — 
 
 "the duty to provide for the medical inspection of children imme- 
 " diately before, or at the time of, o-r as soon as possible after, their 
 " admission to a public eleraentary sch/;^,l, and on such other occasions 
 
41 
 
 '•as the Board of Education direct, and the power to make such 
 " arrangements as ma}- be sanctioned by the Board of Education for 
 "attending to the health and physical condition of the children 
 "educated in public eljmentary schools." 
 
 The result of this enactment has been that the School Medical 
 Service is now a national system (it may be said as complete 
 of its kind and more universal than elsewhere in the world) at 
 work in all the 318 educational areas of England and Wales, 
 in all the 21,000 Public Elementary Schools, and in many of 
 the Secondary, Preparatory, and Public Schools. In 1915^ 
 that is, before the temporary depletion on account of the war — 
 there were 855 School Medical Officers and Assistant School 
 Medical Officers engaged in the routine work of inspection and 
 treatment, and 445 Medical Officers employed on work of a 
 specialist character (ophthalmic, aural, dental, etc.), 1,300 
 medical men in all; there were 1,500 school nurses, employed 
 in 291 out of the 318 educational areas. In 1917 the mmiber 
 of Local Education Authorities which had established a school 
 dental service was 151 (comprising a school population of 
 3,458,700), employing 200 school dentists, at work in 300 school 
 dental clinic^. The number of Local Education Authorities 
 which have exercised their power of providing medical or surgi- 
 cal treatment is 279, and 512 school clinics have been 
 established. In addition to the establishment of School 
 Clinics, 95 Local Education Authorities have made arrange- 
 ments with hospitals in their areas for the treatment of school 
 children. It is estimated that on the average about 60 per cent, 
 of the children found to be defective on medical inspection are 
 now receiving treatment. Under Section 2 (1) (b) of the Edu- 
 cation Act, 1918, however, it is in futiure made the duty of 
 Local Edtication Authorities to provide medical treatment for 
 children in Pubhc Elementary Schools. Under Section 19 of 
 the Act, a Local Education Authority is empowered to make 
 arrangements for the provision of nm-sery schools for children 
 over two years of age and under five or six years of age (accord- 
 ing to the minimum school age in force in the area). These 
 schools are intended to provide for the care and training of Buch 
 children whose attendance is necessary or desirable for their 
 healthy physical and mental development. 
 
 18. The English Medical Schools include in tlieir curri- 
 culum a greater or less degree of instruction in Pediatrics. In 
 some schools the course consists of clinical work in the out- 
 patient department; in some, ward work is arranged; and in 
 others, special lectures are given on the diseases of children. 
 In several of the Medical Schools arrangements have been made 
 for including in the student's course attendance at Maternity 
 and Infant Welfare Centres or clinical work in Children's Hos- 
 pitals. 
 
42 
 
 REGULATIONS UNDER WHICH GRANTS NOT EXCEED- 
 ING ONE-HALF OF APPROVED NET EXPENDITURE 
 WILL BE PAYABLE BY THE LOCAJ. GOVERNMENT 
 BOARD TO LOCAL AUTHORITIES AND TO VOLUN- 
 TARY AGENCIES IN RESPECT OF ARRANGEMENTS 
 FOR ATTENDING TO THE HEALTH OF EXPECTANT 
 MOTHERS AND OF CHILDREN UNDER FIVE YEARS 
 OF AGE. 
 
 1 . General. 
 
 (i.) The salaries and expenses of Health V i^ntors and 
 Nurses engaged in Maternity and Child Welfare work. 
 
 (ii.) The expenses of a Centre — i.e., an Institution provid- 
 ing (a) medic^il supervision and advice : 
 
 (b) medical treatment. 
 
 (iii.) Arrangements for Instruction in the general hygiene 
 of maternity and childhood, 
 
 (iv.) The 'cost of food provided, where such pi-ovision is 
 certified by the Medical Officer of the Centre or by the 
 Medical Officer of Health to be necessary, and where the case 
 is necessitous. 
 
 (v.) Experimental health nork carried out by Local 
 Authorities or voluntary agencies with the appioval of the 
 Board. 
 
 (vi.) Contributions by the Lix^al Authority to voluntary 
 institutions and agencies approved under the scheme. 
 
 2. Expectant Mothers. 
 
 The provision for necessitous women of a doctor for illness 
 connected with pregnancy. 
 
 3. Period of Confinement. 
 
 (i.) The salaries and expenses of Inspectors of Midwives. 
 
 (ii.) The 2}''orision of a midwife for necessitous women 
 in confinement and for areas which are insufficiently supplied 
 with this service. 
 
 (iii.) The provision for necessitous women for aid during 
 the period of confinement for mother and child. 
 
 (iv.) Hospital treatment for — 
 
 (a) complicated cases of confinement or complica- 
 tions a-rising after parturition ; 
 
 (b) cases in which a woman to be confined suffers 
 from illness or deformity ; 
 
iS 
 
 (c) cases of women who cannot with safety be con- 
 fined in their homes ; 
 
 (d) such other provision for securing' proper con- 
 ditions for the confinement of necessitous Avomen as 
 may be approved by the Medical OflScer of Health. 
 
 4. NuRSiKc Mothers. 
 
 The provision of accommodation in convahscent homes. 
 
 5 Children Under 5. 
 
 (i.) Hospital treatment in cases fotnid to need in-])atient 
 treatment. 
 
 (ii.) Expenses of (■/■ar/irs and (laij nur!<eriex. and of other 
 arranp-ements for attending to the health of children whose 
 mothers go out to Avork. 
 
 (iii.) The provision of accommodation in conraleitcent 
 homes. 
 
 (iv.) Tlie yroi^ision of homes and other arrangements for 
 attending to the health of children wliose parents cannot pro- 
 vide a satisfactory home for tliem. 
 
u 
 
 APPENDIX U 
 
 NOTES ON INFANTILE MORTALITY IN ITALY DURING 
 THE WAR, BY STATISTICIAN OF TUBERCULOSIS 
 COMMISSION OF THE AMERICAN RED CROSS IN 
 
 ITALY. 
 
 It has been lepeatedly stated and emphasized by lecturers 
 aud war posters, until we became tired of the argument, that 
 the War would be won not merely on the battlefields but also 
 by the endurance and the industrial and productive power of 
 the people at home. What has not been drawn equally to our 
 attention is that also the civil population suffei'ed casualties 
 from the War, and that these losses have been not less severe 
 than those suffered by the armies at the front. In some 
 instances, the loss of life in the civil population caused directly 
 or indii'ectly by the War has exceeded the deaths on the 
 battle6eld, and these losses, probably more than anything else, 
 have determined the ability of the nations to continue in 
 the struggle. After the initial sanguinary battles of 1914, 
 the improved defence methods, the great progress of military 
 surgery, and the better organisation of hospitals and supplies 
 have kept the losses of the combatants at a lower figure than 
 could othemvise be expected. The revei'se condition has, how- 
 ever, been developing among the civil population of the 
 belligerent countries. During the first couple of jenrs of the 
 W^ar, the condition of the people remaining at home was not 
 alarming except in the iuvaded districts. During the years 1917 
 and 1918 the strain became much increased, and we find in 
 many countries evident signs of the physical strength of the 
 civil population giving way. The birth rates dwindled to a 
 hitherto unknown minimum, and the mortality from several 
 causes increased dangerously. Finally, the weakened state 
 of the population made possible the terrible influenza pandemic 
 which cai^ried away millions of people at the best age of life. 
 
 It is particularly true for Italy that the loss of population 
 at home has been greater than the direct war casualties. 
 During the last ten years before the war, there was consider- 
 able progress in economic life as well as in culture and arts ; 
 also, the sanitary conditions of the country were materially 
 improved. Malaria was being beaten down rapidly ; pellagra 
 was being eradicated ; tuberculosis brought under control ; 
 and the mortality from these and other diseases was, at the 
 beginning of the war, in no sense unusual. The general 
 
45 
 
 TOortality fi'oin all causes was, in 1914-. the lowest ever 
 experienced in Italy, that is, 17.9 pet- l.UOU population. This 
 figure is somewhat higher than the correspoudiug rates for 
 England, but it must be remembered that the proportion of 
 children under two years is very much higher in Italy, and 
 that the high mortality which is always found during the 
 first two years of life will hare a great infiueuce upon the 
 genei'al mortality rate. Standardization of the Italian mortality 
 on the basis of the age distribution of the population of 
 England and Wales would bring the rates for these two 
 •countries nearer together. In 1915 we already- see some 
 infiueuce of the War upon the general mortality, the rate 
 for that vear being 20.4. that is, an increase of 14 per cent, 
 over the previous jear. During 191ii. however, we find no 
 further increase of the general death rate, the average for the 
 Kingdom during that year being 20.0 per 1.000 population. 
 These figures refer only to the civil population and take no 
 account of the soldiers who died in the service. 
 
 The iiifiuence of the war upon the birth rate was more 
 keenly felt. The birth rate had in the years before the war 
 been decreasing, hut very slowly, and b^' no means as much 
 as in the northern countries. The birth frequency was still 
 high when compared with that of England, Holland. France, 
 Scandinavia, and Germany. During 1914 the birth rate was 
 31"1 per 1,000 population, and during 1915, SOo. it will be 
 remembered that Italy did not enter the war until May, 
 1915, and only in the following year do we see the results of 
 the mobilization in a marked decrease of 'the birth rate to 
 24-4 per l.OOO population, which means a decrease of 20 per 
 cent, from the previous j'ear. This decrease was most signifi- 
 cant in the northern provinces, because the birth rates were 
 there ali-eady very low. In 1916. a birth rate as low as 15"8 
 was recoi'ded in the region of Pietnoute, IS'o in Liguria, and 
 19"G in Toscana. The natural increase of the population of 
 Italy, that is, the excess of births over deaths, amounted to 
 131 per 1,00 » inhabitants in 1914. which figure has been 
 about the same for the previous decade. In 1915 the natural 
 increase fell to 101 per 1.000, and in 1916 became as low as 
 44 per 1,")00 population. During this year we find an actual 
 decrease in some of the northern provinces, as Torino, 
 Novara, Porto Maurizio. and in other provinces, as Como, 
 Pavia, Firenze, Pisa, and Livorno. the population was practi- 
 cally stationary. 
 
 It is to be regretted that the mortality data and birth data 
 have not as vet been compiled for 191/ for the country as a 
 whole. We have, however, been able to obtain mortality 
 statistics for some of the cities during I'.'IT and 191s. and can 
 from these s(;attored data obtain some impression of the 
 general trend of the development. The geuei'Jil mortality 
 I'ate for the countrv was evidentlv higher in 1917 than in the 
 
46 
 
 previous year, but certainly did not exceed 25 per 1,000 popu- 
 lation. We have compiled the birth statistics for the years 
 19U to 1917 for IG cities with a total population of 3.000,000. 
 The birth rate in these cities combined was 22 8 in 1914, 21'4 
 in 1915, 17-7 in 1916, and 14-7 in 3 917. For 1918, we have 
 as yet received only a few data, but the majority of these 
 indicate a further decrcrtse. In the city of Genova, for in- 
 stance, the birth late was 14 4 for 1918, as against 16"1 in 
 1917, and in the city of Padova 15"8 in 1918 as against 2'S 1 in 
 
 1917. It is probable that the birth rate for the country as a 
 whole has been not much over 18 per 1,000 during 1917, and 
 probabl}- about 16 per 1,000 population during 1918. Thi.s 
 would mean that during the three years, 1916, 1917 and 
 
 1918, about 1,200,000 fewer children were born than 'would 
 have seen life if the birth rate of the pre-war years had 
 remained. This re))resents clearly a very serious loss of 
 potential lives. 
 
 We have as yet very few definite and final data as to th& 
 actual number of deaths caused by the influenza epidemic. 
 Seve al of the best statisticians in Italy state that the loss of 
 life from this cause has been no less than 500,000 during 
 1918, which would mean a mortality from tin's disease alone of 
 about 1'5 per cent of the population. We have already 
 statistical data to show that in the cities of Firenze, Genova. 
 Milano, Padova, Perugia, and several smaller cities, the 
 moi'tality from the influenza epidemic was about 1 per cent, of 
 the population In the cities of the south and in the villages 
 the mortality from the epidemic has generally been considerably 
 higher Ihan in the cities of the noith. With the help of these 
 data we can conservatively estiniHte that nearly 1,000,000 
 people have died in Italy dui^ing the war years in excess 
 of the number which would have died if the pre-war 
 mortality rate had prevailed The total number of actual 
 and potential lives lost by the civil population is. then 
 probably four or five times the number actually killed on the 
 battlefield or died from wounds received in action oi- from 
 diseases conti-acted in the military service. This truly 
 alarming condition makes it all the more necessary to attend' 
 to the welfare of the new-boi-n children with the utinost care^ 
 and the development of the infantile mortality during these 
 years impresses still more forcibly the necessity of immediate 
 and thorough action. 
 
 The infantile mortality, that is, the mortality during the 
 fiist year of life, was not excessive in Italy before the war. 
 During the yeai-s 1910 to 1914,138 children under one year 
 died for each 1,000 living births, which is a figure considerably 
 lower than tlie corresponding rates for France, Germany, 
 Austria and Spain, but, howevei-, slightly in excess of the 
 rates foi- England, Holland, Scandinavia, and the noi'thern 
 states of America. Fi-om the beginning of the war we meet 
 
47 
 
 with an increase of the inl'iuitilo mortality. Dui'ing- JDl-i it 
 was 129-9 per 1,U00 births, and in 1915 146-0 per 1,000 births. 
 The data for 1916 or later j^ears have not as yet been compiled 
 for the country as a whole, but we have, through the courtesy of 
 several Italian statisticians and municipal health departments, 
 been able to obtain some data foi-the latest years. The city of 
 Rome shows no increase of the infant mortality up to and 
 including 1917, and also other facts indicate that the capital of 
 the counti-y had suffered less from the war than most other 
 cities up to the time when the influenza epidemic commenced. 
 Much less favoui-able conditions are met with in the large 
 industrial cities. The data for the cities of Torino, Milano, 
 Bblogna, Ravenna, Fii'enze and Palermo combined, gave au 
 infantile mortality of 107-7 per 1,000 living births in 1914, 
 which increased to lo0'7 in 1915, 143 "6 in 1916, and 171 '2 in 
 1917. This indicates an actual increase of 60 per cent, during 
 the four j^ears in view. The city of Genova shows somewhat 
 higher infantile mortality than prevailed before the war, but 
 the increase has not been as considerable as in the above- 
 mentioned cities. In Perugia the infantile mortality was 115 
 per 1,000 births in 1914; during 1915 it was 142, in 1916, 155, 
 in 1917, 217, and in 1918 as high as 269 per 1,000 births. In 
 some of the smaller towns — from 20,000 to 80,000 population 
 — on the Adriatic Coast, we meet with a still more remarkable 
 increase of the infantile mortality rate. In the city of Fano, 
 thei-e were, in 1915, 172 deaths under one ye;ir per 1,000 living 
 births, in 191t:), 258, in 1917, 424, and in 1918, 575. In the city 
 of Pesaro,tlie infantile mortality inci"eased from 161 in 1914 to 
 :^71 in 1917 and 637 in 19 L8. The infantile mortalil-y in these 
 last two cities is, of course, exceptional, bvit it proves that the 
 situation in many parts of the country is decidedly critical. The 
 general impression is that the rural districts and the small 
 towns have suffered worse than the laige cities, and I should 
 not be surprised to find, when the data are compiled for the 
 countr}-^ as a whole, that the infantile mortality had doubled by 
 the end of the war. 
 
 When the (piestion is discussed as to what Italy has lost in 
 the wai', it should not be forgotten that the tuberculosi-s 
 mortality has nearly doubled, the infantile mortality has 
 doubled, the incidence of malaria has trebled, the influenza 
 epidemic has caused the death of more than 1 per cent, of 
 the population, and the birth rate has been reduced to about half, 
 and all this through no fault of hers or through the relaxation 
 of sanitary and social measures. The privations and suffering 
 of the Italian civil population and the disease and death among 
 them should be considered equally with the soldiers who died 
 in the allied cause. 
 
 • (Signed) K. Stouwax, 
 
 Statist iciaii. 
 Jamuiry 27th, 1919. 
 
48 
 
 APPENDIX III. 
 
 OUTLINE PREPARED BY CAPTAIX RICHARD A. 
 BOLT OF A PLAX BY PROF. V. TEDESCHI, OF 
 PADUA, FOR A LAW " FOR THE CO-ORDINATIOX 
 OF THE STUDY OF PEDIATRICS WITH THE 
 NATIONAL CHILD WELFARE W^ORK " 
 
 I. A Provincial Association for child icelfare shall he esta- 
 blished in every provincial deputation of the Kingdom. 
 
 This scheme provides for the co-ordination of all the 
 child welfare work through the establishment of provincial 
 boards for child welfare, made up of the following elements : — 
 
 First. — Pj'Bsident of the Provincial Delegation. 
 
 Second. — The Piovincial Physician. 
 
 Third. — Secretaiy of the Provincial Delegation. 
 
 Fourth. — A " Medico Condotto " (county physician) 
 of the Province, delegate from the Directive Council of 
 the National Association of Executive Ph3sicians. 
 
 Fifth. — Delegate of Directive Council of the order of 
 Provincial Pliysician.-?. When these organisations are 
 formed in a place whei'e there is a medical faculty, they 
 will be represented by the following : (a) Professor of 
 Pediatrics; (b) Professor of Hygiene, and (c) Professor 
 of Obstetrics. 
 
 Sixth. — Physician for the Foundling Asylum where 
 there is such. 
 
 Sevet'th. — Two graduate nurses of the Italian Red 
 Cross who reside in the province and who, upon invitation 
 of the President of the National Delegation, are designated 
 by the Cerjtral Committee of the Red Cross. 
 
 This organisation is to carry oa in the Province, with all 
 means possible, a suitable propaganda in behalf of infancy and 
 childhood. It will give advice in all undertakings whioh it 
 deems useful for the protection of infancy, and also in case of 
 need furnish the material means for those undertakings which 
 are not merely aimed at local benefits, but which would 
 benefit the entire nrovince. 
 
49 
 
 //. The co-ordination of the teaehinn <>f Pediitrics with child 
 welfare work. 
 
 This includes : 
 
 First. — The establish nicut of practical Schools of 
 Pedology which are to be gradually organised at the 
 Royal Universities by the Minister of Public Instruction- 
 Schools of Pedology which were instituted before the 
 proposed law shall be promulgated are to be modified to 
 correspond with the new I'egulations. 
 
 Seco7id. — As a necessary condition for the establish- 
 ment of these schools, there should be formed in the same 
 place a charitable voluntary organisation composed of 
 citizens which shall correspond to societies for the protec- 
 tion of children, and which shall have as their chief aim 
 the supporting by moral and material means the pediatric 
 clinic in its educational work of a social-medical character. 
 
 Third. — Only graduates of medicine and surgery may 
 enrol in these Schools of Practical Pedology. 
 
 Fourth — Similar courses of study may be held in all 
 the pediatric clinics of the Kingdom. 
 
 Fifth. — Pediatric clinics shall have the right to use 
 the new-born of the maternity homes for their instiuctioa 
 when the mothers do not object and they have the consent 
 of the director of the institution. 
 
 Sixth. — The Minister of Public Instruction may, 
 after discussion with the Chief Council, decide that the 
 university instruction in pediatrics shall cover two years 
 and be given in the last two years of the course of 
 medicine. 
 
 Seventh. — In the Medico- Surgical Faculties, or in the 
 Foundling Asylums, the Professor of Pediatrics will take 
 part in the Directive Council and have right of discussion 
 on all questions of a technical sanitary character. 
 
 Eighth. — The Minister of Public Instruction has 
 authority to found or subsidize one or more pediatric 
 journals for the propaganda of pediatrics audits medico- 
 social phases in harmony with the present law. 
 
 Niyith. — Each provincial organization for infancy shall 
 establish a travelling school for child welfare for the 
 purpose of carrying on propaganda and education in the 
 rural districts. 
 
 Tenth. — In order to unify the scientific-social manage- 
 ment of child welfare work, the Schools of Practical 
 Pedology should be alike in details of equipment and 
 operation, and should have in common any modifications 
 which the Minister may make within the limits of the 
 rules. 
 
50 
 
 Eleventh. — The fundamental studies taken up in the 
 School of Pedology are : Pediatrics, Anthropology of 
 Infancy and Infant Psychology, Infant Hygiene, Essentials 
 of OiHhopedics, and Legislation regarding infancy and 
 childhood. 
 
 Ill Special courses hi child icelfare for inidwives. 
 
 Courses for niidwives are to be provided which consist of 
 practical teaching and demonstration in forty lessons. This 
 course is to be organised by the Director of the School of 
 Pedology where one exists ; otherwise by the Director of the 
 Pediatric Clinic. 
 
 The course will be held in the pediatric clinic which will 
 put at its disposal all the necessary means for teaching. 
 
 IV. Subsidies jor Pediatric Journdh. 
 
 First. — The Minister of Public Instruction, after- 
 hearing of the Chief Council, will give contracts to the 
 journals appointed to support child welfare work in 
 accordance with the law. 
 
 Second. — When the Minister uses other journal* 
 which are subsidized, he will have in the office of each 
 journal which is subsidized, a representative, or one of 
 the editors, who c:in be trusted to look after its interests, 
 chosen from among the members of the National Associa- 
 tion of Medical Officers and appointed by the Directive 
 Council. 
 
 V. Medals for Distinginshed Services. 
 
 Medals are proposed to be given to those who distinguish 
 themselves in national child welfare work. They are to be 
 conferred b_y the Minister of the Interior upon the proposal 
 of the president of the organisation, or by the Minister of 
 Public Instruction upon the proposal of the Society for the 
 Protection of Children, after discussion with the Prefect of the 
 Province, 
 
 Resolutions imssed at the Xinth Gougress of the Italian Pediatrie 
 Societ;/, Borne, June 3-4, 1918. 
 
 The Italian Pediatric Society in its daily congress ex- 
 pressed the following in regard to the above report : — 
 
 That it is convinced that the most useful pi'ovision 
 for social restoration rendered necessary by the War must 
 consist in reducing the infant mortality, too high even 
 before the War, and in assuring to infancy better and 
 more suitable conditions for development. 
 
51 
 
 That it is certain that sucli an end cannot he attained 
 unless a suitable National Institution for the Protection 
 of Infancy (Opera Xazionale di protezione dell' Infanzia) 
 is functioning in the country. 
 
 That it is persuaded that such an Institution will he 
 truly efficacious only if the .State takes upon itself the 
 protection of infancy. 
 
 That it expresses the opinion that the Government 
 will enact a law for the protection of infancy, which, aside 
 from establishing the fundamental principle that the care 
 of children belongs to the State, determines upon the 
 constitution for a National Institution for Infant Protec- 
 tion (Opera Nazionale di protezione dell' Infanzia) which 
 assures to every child the necessary watchful assistance; 
 submits for revision the Acts regarding abandoned infants 
 and the functioning of the foundling asylum and the other 
 institutions for pediatric assistance ; permits the applica- 
 tion of the new researches in science and hygiene to the 
 protection of children; ai-rraiges so that a popular instruc- 
 tion of puericulture and pediatric hygiene may be made 
 possible; regulates wet-nursing ; modifies and re-arranges 
 with a modern construction the other laws of the State 
 which have already been drafted for the protection of 
 infancv. 
 
 tVAh. W(.49.W7 !41/:i73. 4,001. 5,10. S.O.,F.Rd. 
 
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