Early Death: Mortality Among Young Children in New York, Chicago, And

Journal of Interdisciplinary History, xxxiv:3 (Winter, 2004), 315–354.

EARLY DEATH Gretchen A. Condran and Harold R. Lentzner Early Death: Mortality among Young Children in New York, Chicago, and New Orleans The extremely high mortality rate among infants and young children in the na- tion’s newly expanding cities was an alarming aspect of nineteenth-century industrialization. One contemporary described the mortality of children “as fearfully high, many families having lost all their children.” More recently, Meckel described nineteenth- century cities as “infant abattoirs,” and Preston and Haines re- ferred to both the late nineteenth century and the early years of life as “fatal years.” Throughout the nineteenth century, death rates of infants and children aged one, notably high all year round, peaked in the summer months as a result of infectious diseases that had diarrhea as a major symptom and from the sequelae of diarrhea, especially dehydration. A summer peak was characteristic only of death at an early age; both infants and one-year-olds suf- fered excess summer mortality. Children who had reached age two were more likely to die (often from respiratory infections) in winter than summer. By 1920, the excess summer mortality of infants and one-year-olds and, by inference, the deaths due to diarrhea and dehydration had greatly diminished, and large numbers of deaths in the winter months dominated the mortality of these age groups, as well as that of older children.1 Gretchen A. Condran is Associate Professor of Sociology, Temple University. She is the author of “Changing Patterns of Epidemic Disease in New York City,” in David Rosner (ed.), Hives of Sickness: Public Health and Epidemics in New York City (New Brunswick, 1995); co- author, with Ellen Kramarow, of “Child Mortality among Jewish Immigrants to the United States, Journal of Interdisciplinary History, XXII (1991), 223–254. Harold R. Lentzner is an independent health researcher. He is co-author, with Barbara Mensch and Samual Preston, of Socio-Economic Differentials in Child Mortality in Developing Countries (New York, 1985). © 2003 by the Massachusetts Institute of Technology and The Journal of Interdisciplinary History, Inc.

1 Citizen’s Association, Sanitary Condition of the City (New York, 1866), 82; Richard Meckel, Save the Babies (Baltimore, 1990), 11; Samuel H. Preston and Michael Haines, Fatal Years: Child Mortality in Late Nineteenth Century America (Princeton, 1990). For previous historical work on the summer diarrhea of infants and young children in U.S. cities, see Rose A. Cheney, “Seasonal Aspects of Infant and Childhood Mortality: Philadelphia, 1865–1920,” Journal of Interdisciplinary History, XIV (1983), 561–585; Lentzner, “Seasonal Patterns of Infant and Child Mortality in New York, Chicago, and New Orleans: 1870–1919,” unpub. Ph.D. diss. (University of Pennsylvania, 1987); idem and Condran, “Seasonal Patterns of Infant and Childhood Mortality in New York, Chicago and New Orleans, 1870–1920,” paper presented

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 316 | CONDRAN AND LENTZNER The changes in the rates of early death are part of a more general decline in mortality that occurred in the early industrializing countries with accelerated speed during the last three decades of the nineteenth century. This shift in mortality is unquestionably an important part of the demographic transition, but the consensus stops there. Understanding this shift involves disaggregating multiple causes of death, each of which may be associated in different ways to multiple factors producing mortality change. Hence, the focus of this study is a narrow diarrheal disease as it affected a speciªc age group. Moreover, unlike many studies of the mortality transition that have relied on national-level data and viewed the mortality changes of nations as one transition, this study is an examination of the seasonal pattern of mortality among infants and young children from 1870 through 1917 in three large U.S. cities—New York, Chicago, and New Orleans. Moreover, for New York City, it uses data from 1820 to 1870 and additional data on deaths by month of death and month of age to illuminate the issues of breastfeeding and weaning, and the alternatives to breastfeeding, as well as their effect on infant and early childhood death. The three cities varied in climate, population size and growth, and population characteristics. In 1870, New York’s population num- bered about 950,000, compared to Chicago’s 300,000 and New Orleans’ nearly 200,000 inhabitants. In all three cities, about 10 percent of the population was younger than ªve years of age. By the turn of the twentieth century, the population of old New York (Manhattan and the Bronx) had grown to more than 2 million and the annexation of the other boroughs swelled it to 3.5 million. In 1900, Chicago had 1.6 million people and New Orleans 280,000. Somewhat more than 25 percent of New Or- leans’ population was African-American, compared to only 2 percent in the other two cities. Approximately one-third of each city’s population at the turn of the century was foreign-born.2

the data The study of historical trends in infant and early childhood mortality depends on vital statistics that are limited in a

at the meeting of the Population Association of America, Boston, 1985; Condran and Lentzner, “An Analysis of Excess Summer Mortality of Infants and Young Children, New York, 1820–1920,” paper presented at the Annual Meeting of the Population Association of America, Washington D.C., 1991. 2 United States Census Ofªce, Ninth Census, Volume 1: Statistics of Population of the United States (Washington, 1872); Frederick L. Hoffmann, “The General Death-Rate of Large

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 317 number of ways. The lack of effective birth registration in the United States until well into the twentieth century precludes the calculation of conventional infant-mortality rates. Tracing trends in a cause-of-death category, such as diarrheal diseases, is compli- cated, inasmuch as causes of death—particularly those listed for infants and young children—were commonly vague descriptions of symptoms and changed radically over time. This study uses published data on the number of deaths of infants and young children under age ªve, aggregated by month of death and age at death, to construct a monthly mortality index for three age groups—infants, children aged one, and those aged two to four. The magnitude of the summer peak in mortality for each age group is an indicator of its mortality rate from diarrheal diseases, the leading cause of death among infants and one-year-olds. Diminishing peaks represent a substantial decline in the deaths from these diseases; they account for much of the overall decline in infant and early death. The seasonal pattern of mortality at young ages is evident in the data from municipal and state public-health annual reports (the Appendix contains a detailed description and evaluation of the data sources). Ofªcial “vital reports” from Chicago and New Or- leans contain the material required for most years from 1870 to 1920; the data series for New York City begins with 1820 and, with a few exceptions, includes the 100 years to 1920. The cities, which differed in climate, size, and period of rapid growth, provide an opportunity to observe the effects of these variations on the seasonal patterns of mortality. We examined the mortality of children using an index of the seasonal peak in mortality for three age groups under age ªve. Monthly deaths were adjusted to control for the varying lengths of months. The index value is a simple ratio of actual to expected

deaths—Mi/(MY/12), where Mi is the number of deaths for month i adjusted for the number of days in the month, and MY is the total number of deaths for the year. This index of monthly mortality is less than one if the month in question had fewer deaths than would be expected with an even distribution of mortality across the year, one if the month had exactly the expected number of deaths, and a value greater than one if the month had

American Cities, 1871–1904, Journal of the American Statistical Association, LXXIII (1906), 29– 44; New York Department of Health, Annual Report of the Board of Health of the Department of Health of the City of New York (New York 1913).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 318 | CONDRAN AND LENTZNER recorded deaths in excess of the expected number. Since the mortality index, unlike conventional infant-mortality rates, is not affected by the coverage of the birth and death registration systems, it is an unbiased measure of infant and early childhood mortality.3

the seasonal pattern of early death The values of the monthly mortality index for infants in New York during the 1870s, shown in Figure 1a, reveal that the number of infant deaths in July was often twice the number expected if deaths had been evenly distributed throughout the year. For each year in the decade, the monthly index value declined quickly to an average level by September. A similar, but somewhat more pronounced, seasonal pattern of deaths is evident for infants in Chicago (Figure 1b); in New Orleans (Figure 1c), however, the summer peak in infant deaths was less extreme and its timing less predict- able than in the other two cities. The same three graphs show a similar seasonal pattern in the mortality of children aged one in both New York and Chicago. In New York, the summer peaks were less pronounced for one-year-olds than for infants; in Chi- cago, peaks of mortality had about the same amplitude for the two age groups. The summer mortality peak for those aged one in New Orleans was more pronounced than that for infants, but summer index values are still lower and less consistent than in New York or Chicago. The mortality of older children, those who died between the ages of two and ªve, also shown in the three graphs, was slightly higher in the winter or early spring months than in the rest of the year in New York and Chicago and displayed no discernible seasonal pattern in New Orleans. It is noteworthy that during the decade from 1870 to 1879, infants and young children in New Orleans did not experience the unusually high rates of mortality that occurred during the summer months in the two larger cities. Summer peaks of mortality emerged in the next two decades but continued to be less pro-

3 For a previous use of this index, see Daniel Seiver, “Trend and Variation in the Seasonal- ity of U.S. Fertility, 1947 to 1976,” Demography, XXII (1985), 89–100. Like Seiver, we also calculated an index using a twelve-month moving average of deaths in the denominator. This moving average removes the trend from the index and is therefore preferable on theoretical grounds. The two methods of analysis produced similar results, and because the use of the moving average is particularly affected by missing data, we have not used it in this analysis. It should be noted that the index produces underestimates of the seasonality inasmuch as the excess mortality in the summer is distributed across the year.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 1a Monthly Mortality Index, by Age, New York, 1870–1879

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 1b Monthly Mortality Index, by Age, Chicago, 1870–1879

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 1c Monthly Mortality Index, by Age, New Orleans, 1870–1879

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 322 | CONDRAN AND LENTZNER nounced than in New York and Chicago even during the 1890s, by which time the summer excess mortality in the two larger cities was subsiding (see Figure 2). New Orleans differed from New York and Chicago both in the timing of its growth and its climate; both factors probably affected the seasonal pattern of early death. Excess summer death was a concomitant of urbanization. New Orleans did not have this typical urban mortality pattern until late in the nineteenth century. Even at that late date, the lower peaks likely reºect less variability in temperature throughout the year in New Orleans than in the two northern cities. Causes of Summer Death Nineteenth-century physicians and public health ofªcials identiªed diarrheal diseases as accounting for the excess summer mortality. Classiªed for most of the nineteenth century primarily as cholera infantum, these diseases appear in vital records under dozens of other names, including summer diarrhea or summer complaint. Although deaths cross-classiªed by cause of death, as well as by both age and month of death, are not sys- tematically available for the three cities, data for a limited time period in New York City show the large impact of diarrheal diseases on the summer peak in mortality for children under age ªve (see Figure 3). Diarrheal diseases had an extreme summer peak; removal of them from the overall childhood mortality eliminates the summer peak. Other causes of death to which infants succumbed generally had no seasonal pattern, as in the case of prema- ture birth or congenital anomalies, or occurred more frequently in the winter or early spring, as in the case of respiratory diseases. The effect of diarrheal diseases is even more apparent in data from 1875 to 1880 on cause of death by age and month of death for infants in Chicago. Removing deaths attributed to cholera infantum considerably dampens the distinct peaks in summer deaths (see Figure 3).4 The Effects of Temperature on Infant Death That many babies did not survive the summer induced nineteenth- and early twentieth-century health ofªcials to single out hot weather as a source of disease. Indeed the publishing of weekly or monthly weather data and the collection of death statistics by month reºected their general interest in the relationship between environment and disease.

4 There were a number of other vague causes of infant deaths that showed a high summer peak. The most notable were convulsions, which often followed dehydration brought on by diarrhea.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 2 Monthly Mortality Index, Infants, New Orleans, 1870–1879, 1880–1889, 1890–1899

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Contemporaries attributed high infant and early childhood mortality to the ravaging heat of summer, although they did not always articulate the mechanisms by which heat translated into elevated mortality levels, and mechanisms, when identiªed, varied over time. In July 1870, the New York Times described a direct inºuence of heat on the mortality of infants: “The summer solstice is invariably productive of great distress and illness among the infantile portion of our City population and the present season has proved no exception. The stiºing heat during the night hours of the past four or ªve weeks gave the little treasures of the house-

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 325 hold no opportunity for the refreshing sleep so necessary for growth and well-being of children. The consequence has been a frightful increase in the mortality among children.”5 Both public-health ofªcials and physicians, however, also suggested less direct links between heat and early death. Before the general acceptance of germ theories of disease, explanatory frame- works often included the poisoning effect that rising temperatures had on the general atmosphere. High temperatures caused the rapid decomposition of sewage and other organic refuse, producing atmospheric toxins especially harmful to small children already stressed by summer heat. Increasing acceptance of germ theories turned attention to the connection between summer heat and the growth of bacteria in drinking water, in food, and, especially, in cow’s milk.6 Our analysis of the mortality indices in the three cities sup- ports the notion that temperature, whether directly or indirectly, was an important inºuence on the relatively higher mortality of infants and young children during summer compared to the rest of the year. The peak in mortality—early summer in New Orleans and mid- or late summer in Chicago and New York—coincided with a year’s ªrst sustained period of high temperatures. In New Orleans, May was usually the ªrst month with an average temperature over 70 degrees Fahrenheit; in New York and Chicago, temperatures did not tend to reach that average until July. The nineteenth-century data show a positive association between a month’s average temperature and the size of the mortality index, but the relationship is not linear. Low mortality indices are associated with a wide range of cool temperatures, whereas sig- niªcant rises in the mortality index occur within a narrow band of hot temperatures. This pattern reºects a dramatic increase in the number of deaths when the temperature ªrst reached a high threshold and a decrease in deaths before the end of the summer, even if temperatures remained high. Although temperature levels were often higher in August than in July, before the turn of the century the peak of summer deaths occurred when

5 New York Times, 7 July 1870, 3. 6 For a more extensive description of the late nineteenth-century views on the relationship between heat and infant mortality, see Condran, “Early Death: The Construction and Uses of the Infant Mortality Rate in the Nineteenth Century,” paper presented at the meeting of the Population Association of America, Washington, D.C., 2001.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 326 | CONDRAN AND LENTZNER temperatures ªrst reached a critically high level. The late summer decline in the peak may well reºect a shortage of susceptible infants and young children remaining in the population—that is, those who had neither succumbed to the diseases nor developed short-term immunities through exposure before the summer heat subsided. Our analysis of month/temperature interactions found that when New York and Chicago in July or August and New Orleans in May or June were hotter than usual, the mortality rate among infants was especially high. This association is strong from 1870 to 1900 in New York and Chicago, and in New Orleans after the turn of the twentieth century. One-year-olds, however, showed no discernible month/temperature interaction effects.7 The Ages of Summer’s Victims Both the relationship between summer mortality and temperature and the causes of death accounting for excess summer mortality suggest that contaminated food and/or milk was a major source of high infant and early childhood summer mortality; the age pattern of summer deaths adds considerably to that view. Although the pathogens responsi- ble for the nineteenth and early twentieth-century summer diar- rheas of children remain undetermined, many of the likely agents—E. coli, shigella, or salmonella—were carried in water, milk, and food supplies and grew more rapidly in hot weather. Ex- clusively breast-fed children would have had limited exposure, whereas children who were bottle-fed or whose breastfeeding was supplemented were more likely to be exposed to these pathogens. Whether particular children contracted diarrhea depended, to some extent, on their general state of health. Both the current medical literature and contemporary descriptions of these diseases, however, suggest that, although poor nutrition may have lowered a baby’s resistance, diarrheal diseases also affected well-nourished infants and children. Deaths occurred regularly to children who were otherwise healthy. The quality, rather than the quantity, of the food and milk seems to have been the culprit. Gastrointestinal diseases, often taking their toll as their victims dehydrated, were most devastating to infants and one-year-olds,

7 Lentzner and Condran, “Seasonal Patterns,” and Lentzner, “Seasonal Patterns,” 85–87, contain descriptions of the models used in the analysis of the effects of temperature and the month/temperature interactions. We analyzed the month/temperature interactions only for the period from 1870 to 1917 for all three cities.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 327 who were likely to dehydrate more quickly than older children. The summer heat not only multiplied the bacteria in the environment but also increased the likelihood that young children would die from losing ºuids through perspiration; replenishing ºuids, in the nineteenth century, often introduced new pathogens through contaminated water. Presumably, one-year-olds who contracted diarrhea and died from it were weaned late or in the winter, thus passing their ªrst summer weaned after their ªrst birthdays. Children who had reached the age of two had probably experienced and survived their ªrst exposures to the prevalent diarrheal diseases and had achieved body weights large enough to withstand subsequent bouts of illness without dehydrating. For selected years in the 1870s, data showing both infants’ month of death and the age at death in months in New York City provide further evidence that these mortality patterns were related to weaning. The data, contained in Figure 4, separate infants by whether or not they resided in institutions at the time of death. Institutions—in this case comprising the Infant’s Hospital at Randall’s Island, the Ward’s Island Hospital, the Nursery and Child’s Hospital, and the Foundling Hospital—had various methods of feeding the infants in their care, including both wet nursing and artiªcial feeding. Artiªcial feeding of infants was more common in institutions than in noninstitutional settings, and it was less dependent on age; nearly all children received it. For infants in the general population, the index of summer deaths increased with the age of the infant up to age eight months, no doubt corresponding with an increase in the number of weaned infants at older ages. After noninstitutionalized infants reached eight months of age, the amplitude of the summer peaks declined slightly; older infants were less likely to succumb to diarrhea, although presumably the proportions weaned were greater than at earlier ages. Institutionalized babies, in general, show less summer excess in mortality than the noninstitutional population. Their mortality levels were extremely high but did not vary across seasons of the year as much as those of infants who were not in institutions. Nor did the summer peak among institutionalized infants change in amplitude with the increasing age of the child, presumably because the method of feeding these babies was not dependent on age.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 4 Monthly Mortality Index, Infants by Age at Death in Months, by Residence in Institutions, and the Rest of New York City, Selected Years, 1871–1879

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 4 Continued

note Data for years 1871, 1874, 1875, 1878, 1879 combined.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 330 | CONDRAN AND LENTZNER changes in the seasonal pattern of early death By the second decade of the twentieth century, the seasonal patterns of early death had shifted dramatically. For all three cities, the index values for infants during the summer months were well below those at the end of the nineteenth century, and the pattern of fall/winter peaks in early death, typical of low mortality regimes, had emerged. The data show similar declines in the summer mortality of one-year-olds in New York and Chicago, although summer deaths for this age group remained high through the last decade of our analysis in New Orleans. In order to examine the changing patterns of seasonal mortality, the mortality indexes of infants and one-year-olds were regressed on dummy variables for months within each decade from 1870 to 1917. The intercept of the re- gression equation derived from this analysis estimates the average value of each decade’s mortality index for the omitted month— July for New York and Chicago and May for New Orleans—and the coefªcients for each month are interpretable as deviations of the average index value from the reference-month value.8 Table 1 contains the average mortality index throughout the decade for four summer months (June through September in Chicago and New York and May through August in New Orleans), derived by adding the coefªcient for each month to the intercept value. For New York, the average July value changed little in the nineteenth century and steadily after the turn of the twentieth century. The August values declined during both time periods. July and August combined show a regular decline in summer mortality across the whole time period. Chicago shows a more consistent decline in the summer mortality of infants than New York. The average July index value dropped fairly regularly from 1870 to 1917 for one-year-olds in both New York and Chicago. Some of the decline in the July value during the ªrst decade of the twentieth century was offset by an increase in the average August index, indicating a shift in the timing of the

8 Because the mortality of those aged two to ªve never showed the summer peak in mortality, we have not continued the analysis of this age group. We ended our analysis in 1917 because the shift in the seasonal pattern of death caused by the inºuenza epidemic of 1918 overestimates the decline in the summer index. Earlier epidemics, no doubt, also affected the seasonal patterns producing unusually high or low values in some years, but their effects would have been small compared to that of the 1918 inºuenza epidemic.

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Table 1 Decadal Average Monthly Mortality Index by Age, New York, Chicago, and New Orleans infants 1870–1879 1880–1889 1890–1899 1990–1909 1910–1917 new york June 1.11 1.27 1.13 0.95 0.85 July 2.16 2.21 2.04 1.68 1.14 August 1.64 1.30 1.28 1.45 1.37 September 1.11 1.04 1.07 1.19 1.12 July/August 1.90 1.75 1.66 1.57 1.25 chicago June 1.00 0.95 0.91 0.72 0.78 July 2.63 2.14 1.73 1.17 1.10 August 1.89 1.53 1.36 1.45 1.29 September 1.05 1.04 1.01 1.16 1.11 July/August 2.25 1.84 1.55 1.31 1.20 new orleans May 1.33 1.62 1.76 1.59 1.28 June 1.32 1.53 1.55 1.45 1.13 July 1.17 1.15 0.97 0.98 0.90 August 0.96 0.82 0.78 0.86 0.99 May/June 1.33 1.57 1.66 1.52 1.21 Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on27 September 2021

Table 1 Continued one year olds 1870–1879 1880–1889 1890–1899 1990–1909 1910–1917 new york June 0.98 1.01 1.03 0.96 1.08 July 1.49 1.47 1.41 1.29 1.16 August 1.55 1.12 1.15 1.17 1.15 September 1.29 1.01 1.03 0.99 0.89 July/August 1.52 1.29 1.28 1.23 1.15 chicago June 0.67 0.87 0.80 0.80 July 1.94 1.67 1.48 1.17 August 2.60 1.65 1.47 1.36 September 1.60 1.21 1.25 1.28 July/August 2.27 1.66 1.48 1.26 new orleans May 1.23 1.61 1.50 1.47 1.66 June 1.61 1.72 1.76 1.40 1.13 July 1.29 1.38 1.29 1.11 0.86 August 1.10 0.99 0.91 0.79 0.96 May/June 1.42 1.67 1.63 1.43 1.40 EARLY DEATH | 333 highest mortality value during the year. In general, however, the index values for July and August combined declined over time and show little or no excess mortality in the summer for either age group during the last years of our analysis, 1910 to 1917, in these two cities. The pattern of change for New Orleans is different. The average decadal May and June index values for infants and one-year-olds increased for each decade before the turn of the century. It then declined for infants but remained high for one- year-olds throughout the entire period. Timing the inception of the decline in mortality more precisely than the decade averages is important in illuminating the causes of the shifting mortality pattern. Figure 5 shows the highest index value for each year from 1870 to 1917 for Chicago and New Orleans and the longer series from 1820 through 1917 for New York. This analysis uses the values of the monthly mortality index for infants and one-year-olds combined because of shifts in the age pattern of summer mortality and in the timing of deaths before or after the child’s ªrst birthday that affect the trends for each age group observed separately.9 The early data for New York City produce monthly mortality indexes that indicate no clear trend from the 1820s through 1855 and then rise until the mid 1870s. A downward trend in the size of the peak occurred after 1875; by the turn of the twentieth century, excess summer mortality had signiªcantly reduced. In Chicago, the decline in the highest index value for the two young age groups combined was already underway by 1870 and continued steadily thereafter. In New Orleans, the decline delayed until the early 1890s and was interrupted signiªcantly by high values until the 1910s. The data presented herein are consistent with the general notion that the growth of cities adversely affected the life chances of young children, but that rapid improvement in health conditions during the last quarter of the nineteenth century considerably altered the picture for the two larger cities. The picture of mortality change presented herein inspires more conªdence than of that which would emerge with the use of cause-of-death data to trace the course of diarrheal deaths in

9 The highest index value for the year occurred in either July or August in Chicago and New York and in either May or June in New Orleans. The highest value reºects the timing of the decline better than the decadal average monthly index values that can be affected by changes from year to year in the month in which the peak occurs.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 334 | CONDRAN AND LENTZNER Fig. 5 Highest Monthly Index Value, Infants and Children Aged One and Two Combined

young children. Changes in the categorization of these deaths— especially the movement of deaths from several general categories (for example, inanition, debility. and marasmus to the more spe- ciªc categories of diarrheal diseases), during the course of the nineteenth century—affect the observed trends. The addition of deaths that at an earlier time would not have been counted as diarrheal deaths to that category masks any decline in these causes of death that occurred during the late nineteenth century. A major shift in nosological schemes in the early twentieth century exacer- bates the problem. The earlier decline suggested by our data has important implications inasmuch as it precludes many of the explanations for decline that have been frequently proffered. Filtration of water supplies, pasteurization of milk, and the child hygiene movement in large cities postdate the beginning of the decline in mortality exhibited in the seasonal mortality index. However, they may have had important effects on the rapid decline in diarrheal disease in the later period.10 Changes in the Age Pattern of Excess Summer Mortality Figure 6 plots the highest monthly mortality index by year separately for infants and one-year-olds in each of the cities. The data for the long series in New York are especially interesting. The degree of excess mortality during the summer varied from year to year 10 Lentzner, “Seasonal Patterns,” 333–352.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 6 Highest Monthly Index Value, Infants and Children Aged One

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 336 | CONDRAN AND LENTZNER for both age groups early in the century, but the peaks for one- year-olds were consistently higher than those for infants. A crossover occurred in the 1860s after which the peaks for infants regularly exceeded those for one-year-olds; the peaks for infants increased from 1860 to 1870, whereas those for one-year-olds showed little or no change. The decline in the size of the summer peaks began for both age groups during the 1870s but was more rapid for one-year-olds than for infants. For infants, the rapid decline in the peaks began during the 1890s and continued after the turn of the twentieth century. Because the data for Chicago and New Orleans begin in the 1870s, whether a similar crossover in the age pattern occurred there remains unknown. However, in the limited data for Chicago, the slightly higher mortality indexes for one-year-olds in the 1870s and the more rapid decline in one- year-olds’ index values suggests that a crossover like that in New York may have occurred. A more vivid representation of the shifting age pattern of peak summer mortality is contained in Figure 7, showing the index of mortality for those aged one and younger in New York City for selected years from 1820 to 1902. During the ªrst half of the nineteenth century, the amplitude of the summer peak in mortality was greater for one-year-olds than for those under age one. The previously noted reversal in the age pattern of the summer peak for the two age groups, however, is apparent. By the 1880s, the index values for summer months were higher for infants than for one-year-olds. This age pattern persisted throughout the remainder of the period. By the last few decades of the nineteenth century and into the early twentieth century, living through the summer clearly became more problematical for infants than for one-year-olds. The change in the age pattern of the peak in summer mortality suggests new weaning patterns—namely, a general decline in the age at which babies were weaned and consequently an increase in the number of those weaned or given supplementary food before their ªrst birthdays. Bottle feeding and artiªcial foods put an infant at risk of early exposure to the bacteria causing diarrheal diseases; early weaning increased the likelihood that the outcome would be dehydration and death. These data suggest that the mortality of infants and young children was inºuenced not only by the macro-environment of large cities but also by the child-care

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 337 Fig. 7 Monthly Mortality Index, by Age, New York, Selected Years

practices of their inhabitants and the complex intersections of the two. Although these trends suggest a relationship between infant and early childhood mortality from diarrheal diseases and weaning practices, a number of contradictions complicate this interpreta- tion. Declining summer peaks imply a reduction in diarrheal mortality and in infant mortality more generally. Yet, both the relative speed of the decline in summer peaks of mortality for infants and one-year-olds and the crossover of peak mortality from one- year-olds to infants imply that weaning and/or the introduction of artiªcial food occurred at an earlier age during the last half of the nineteenth century than it had previously. The simulta- neous decline in diarrheal mortality and breastfeeding contradicts a well-established link between artiªcial feeding and high mortality. A reconciliation of these results must lie in the changing alternatives to breastfeeding and their impact on the life chances of infants. the relationship between changes in feeding practices and early death The Mortality of Breast-Fed and Artiªcially Fed Babies By the end of the nineteenth century, practitioners of the new medical

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 338 | CONDRAN AND LENTZNER specialty of pediatrics consistently advocated breastfeeding to pro- tect infants and young children from diarrheal diseases. However, the relationship between feeding and infant death had been observed for years before. The high death rates among foundlings and institutionalized babies, many of whom were artiªcially fed, provided early evidence that babies deprived of mother’s milk were not likely to thrive. Throughout the nineteenth century, books and pamphlets providing advice on infant care noted the tenuousness of the lives of infants who were not breast-fed by their mothers. Although concerned about the more general envi- ronmental conditions affecting infants in cities, Smith, for example, argued before the New York City Board of Health in 1866 as a physician to foundlings, “it was seldom that an artiªcially fed infant under the age of six months or even ten months, residing within the city limits, escaped the summer diarrhea.” According to Smith, nurses believed that all foundlings would die. Indeed, one foundling was regarded “as a curiosity since it had been several months in the institution, and was still alive.”11 Holt claimed that in many European and U.S. cities, there was a close connection between the incidence of diarrheal disease and methods of feeding. “Hope of Liverpool has shown that in 1,000 breast-fed infants under three months there were only 20 deaths from diarrheal diseases; while of 1,000 bottle-fed infants under three months there were 300 deaths. Of 1,000 fatal cases of diarrheal disease investigated by the New York Health Depart- ment in 1908, only 90 had previously been entirely breast-fed.

11 William H. Davis, “Statistical Comparison of the Mortality of Breast-Fed and Bottle-Fed Infants,” in Transactions of the Fifteenth International Congress on Hygiene and Demography (Wash- ington, D.C., 1912), 184–190; L. Emmett Holt, “Infant Mortality and Its Reduction Espe- cially in New York City,” Journal of the American Medical Association, LIV (1910), 682–691; idem, “Infant Mortality, Ancient and Modern: An Historical Sketch,” in Transaction of the Fourth Annual Meeting (American Association for Study and Prevention of Infant Mortality) (Washington, D.C., 1913), 24–55; George Kober, “Impure Milk in Relation to Infantile Mortality,” Journal of the American Medical Association, XXV (1895), 983–987; Herman Schwarz, “Nursing Statistics Derived from the Study of the Infancy of 1500 Children, and a Contribution of the Cause of the Summer Infant Mortality,” Transactions of the First Annual Meeting (American Association for Study and Prevention of Infant Mortality) (Baltimore, 1910), 207–215; J. Lewis Smith, “Causes of the Great Mortality of Young Children in Cities During the Summer Season, and the Hygienic Measures Required for Prevention,” in Sanitary Care and Treatment of Children and Treatment of Their Diseases (Boston, 1881), 239– 263; Victor C. Vaughan, “Infantile Mortality: Its Causation and Its Restriction,” Journal of the American Medical Association, XIV (1890), 181–185; Smith, “Causes of the Great Mortal- ity,” 257.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 339 Newsholme gives almost identical ªgures for England, viz.: 10 per cent. of deaths from diarrheal disease in breast-fed infants and 90 per cent. in bottle-fed infants.” Davis estimated that in 1910, artiªcially fed children in Boston had a mortality rate of 218 per 1,000 children aged two weeks to one year, compared to only 94 per 1,000 for those who were breast-fed. The contrast is even more striking for the speciªc cause of death, diarrhea and enteritis. Only 36 per 1,000 breast-fed babies aged two weeks to one year died of diarrhea and enteritis; the rate for bottle-fed babies was nearly three times higher.12 Although “scientiªc” studies carried out in the ªrst two decades of the twentieth century conªrmed the notion that mortality rates among breast-fed babies were much lower than among those artiªcially fed, the relationship between type of feeding and mortality was certainly changing during the period, as alternatives to breastfeeding improved. Increasing attention to the quality of the milk supply, as well as to the cleanliness of the bottles and appropriateness of the foods used to feed infants who were not breast-fed, surely reduced the differential mortality of breast-fed and artiªcially fed babies. The mortality data by type of feeding, however, are not sufªciently comparable to establish the extent of this reduction. The Children’s Bureau Studies of infant mortality, conducted from 1914 to 1920, reported that artiªcially fed infants had signiªcantly higher mortality than those who were breast-fed. Indeed, according to Woodbury’s summary of data for eight cities, deaths among bottle-fed infants aged nine months and younger were nearly ªve times higher than those among the breast-fed; the deaths of partly breast-fed babies were nearly double the number among those who received only breast milk.13 The Extent of Breastfeeding Although many studies documented the relationship between infant mortality and type of feeding, few provided data on the extent of breastfeeding and the changes therein throughout the nineteenth and early twentieth centuries. The contemporary literature on infant care directed to mothers and textbooks for physicians strongly recommended breastfeeding, on the grounds that the composition of mother’s

12 Holt, The Diseases of Infancy and Childhood (New York, 1897); idem, “Infant Mortality and Its Reduction,” 686; Davis, “Statistical Comparison,” Table V, 189. 13 Robert M. Woodbury, “The Relation Between Breast and Artiªcial Feeding and Infant Mortality,” American Journal of Hygiene, III (1922), 668–687.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 340 | CONDRAN AND LENTZNER milk, designed by nature, met the nutritional needs for infants better than any alternative. Not even cow’s milk, with its various additives, could approximate it. By the end of the nineteenth century, the rationale for breastfeeding invoked germ theories of disease. Mother’s milk was not contaminated by the disease- producing organisms found in milk that had made the long jour- ney from a less than pristine dairy farm to a city shop. There the milk might have sat without refrigeration for several days before being sold, arriving ªnally at a baby’s home where it was often im- properly stored for several more days before being used. Advice about how long a mother should breastfeed and, just as important, how long breast milk should be the exclusive food of an infant, varied during the nineteenth century. Early nineteenth- century domestic medical literature advocated a relatively long period of breastfeeding, though rarely more than a year, but also recommended that supplementary feeding begin as early as the third or fourth month of a baby’s life. The abundant literature at the end of the nineteenth century gradually decreased the recommended age at weaning and continued to advise supplemental feeding. By the second decade of the twentieth century, the Children’s Bureau’s child-care pamphlets proposed weaning at six months and supplemental feeding even earlier.14 Although these manuals increasingly extolled the virtues of breastfeeding, or “natural feeding,” by the end of the century, they also increasingly questioned the ability of mothers to carry out the prescription. In 1906, Holt noted that the capacity for maternal nursing had diminished over the course of the nineteenth century: “Among the well-to-do classes in New York and its suburbs, of those who have earnestly and intelligently attempted to nurse, less than 25 per cent, in my experience, have been able to continue satisfactorily for as long as three months. An intellectual city mother who is able to nurse her child successfully for the entire year is almost a phenomenon.”15

14 William Buchan, Domestic Medicine: Or, A Treatise on the Prevention and Cure of Diseases by Region and Simple Medicines (Halifax, N.C., 1801); Charles E. Rosenberg (ed.), Reprint of 1818 Edition of The Maternal Physician (New York, 1972). For descriptions of the late nineteenth- century accounts, see Rima D. Apple, Mothers and Medicine (Madison, 1987); Meckel, Save the Babies; Children’s Bureau, Infant Care (Washington, D.C., 1914); Children’s Bureau, Infant Care (Washington, D.C., 1921). 15 Holt, Diseases of Infancy and Childhood (New York, 1906).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 341 Advice literature is a poor substitute for data on actual breastfeeding practice, which, unfortunately, are limited for the nineteenth- and early twentieth-century United States. In 1910, Holt emphasized the difªculties of obtaining accurate information on the extent of breastfeeding: “From data collected through various agencies, the Health Department estimates that at present about 85 percent of the infants in New York are breast-fed and about 15 per cent. are bottle-fed. These data are gathered chieºy from the tenement districts and seem to me rather low for the artiªcially fed. I believe that for the entire population, 18 to 20 percent. would be nearer the truth.”16 A survey by Davis produced lower estimates of breastfeeding for infants in Boston at that time—only about 65 percent of infants aged two weeks to one year and approximately 75 percent of those under age six months. Davis’ Boston data showed wide variation by ethnicity; of babies aged two weeks to one year, born to native-born mothers, 59 percent were breast-fed compared to 83 percent of babies with Italian mothers and 79 percent of babies with Russian and Polish mothers.17 The surveys of infants, conducted by the Children’s Bureau during the second decade of the twentieth century, are the best available source of infant feeding practices of U.S. mothers. The Children’s Bureau studies divided method of feeding into three categories—exclusive breastfeeding, mixed feeding, and exclusive artiªcial feeding—and analyzed their extent by a number of other variables, including mother’s ethnicity, father’s income, and mother’s work status. In his summary of the data for eight cities, Woodbury describes substantial differences in the length of exclusive breastfeeding for women of different ethnic origins; in general, immigrant mothers, especially those from eastern and southern Europe, breast-fed longer than mothers born in the United States. Employed mothers supplemented or stopped breastfeeding earlier than those who were not employed.

16 Idem, “Infant Mortality and Its Reduction.” 17 Davis, “Statistical Comparison,” 186. Davis had no separate classiªcation of Jewish mothers, but they likely dominated the Russian category in Boston in 1912. The exception- ally low mortality of Jewish immigrant mothers has been noted and discussed in the context of breastfeeding in a number of previous studies. See, for example, Preston and Haines, Fatal Years,” 28,107; Condran and Ellen Kramarow, “Child Mortality Among Jewish Immigrants to the United States,” Journal of Interdisciplinary History, XXII (1991), 223–254.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 342 | CONDRAN AND LENTZNER Although substantial but unexamined interrelationships probably obtained between variables in the studies, each variable had a large univariate effect on infant feeding practices.18 Exclusive breast-feeding was deªnitely on the decline by the turn of the century at least, despite the increase in immigrant populations, in which breastfeeding occurred longer than in the native-born white population. Changes in the ethnic composition of U.S. urban populations during the nineteenth and early twentieth centuries should have increased the proportions of breast-fed infants and lowered infant mortality rates from diarrheal diseases. The increases in the numbers of mothers working away from home, however, would have had the opposite effect. Our data on summer mortality suggests that the length of breastfeeding decreased even as the proportions of New York City’s late- weaning ethnic population (Italians, Russians, Jews, and Poles) increased from about 1 percent of the population in 1870 to nearly 30 percent of the population in 1910. This shortened length of breastfeeding, which appears to have moved the high levels of summer death to an earlier age, continued later in the century despite the entry of a large number of immigrants into cities. At the same time, the peaks of summer mortality were diminishing. Understanding the transition in infant-mortality rates requires reconciling these seemingly contradictory ªndings and disentan- gling the signiªcant relationships between explanatory variables that are not yet evident. Public Health Activities, Alternatives to Breastfeeding, and the De- cline in Early Mortality A detailed history of the public-health activities in three cities is beyond the scope of this article, but three speciªc public-health initiatives were likely to have affected directly the care and feeding of young children and hence their mortality—the provision of clean water, improvements in the system of human waste disposal, and regulation of the milk supply. By reducing the contamination of foods given to young children as alternatives or supplements to breast milk, each of these public- health activities had the potential to change the long-standing and well- documented relationship between artiªcial feeding and the likelihood of early death. Moreover, all three cities made major changes in the provision of water, the disposal of human waste, 18 Woodbury, Causal Factors in Infant Mortality: A Statistical Study Based on Investigations in Eight Cities (Washington, D.C., 1925), 99–101.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 343 and the regulation of milk supplies. The question is, Did these developments have any bearing on the decline of summer mortality?19 Late nineteenth- and early twentieth-century interest in public water supplies focused on both the quantity and quality of the water available to households in the cities. In the 1870s, New York, Chicago, and New Orleans each had major difªculties supplying their populations with water, but the nature of their problems differed. In New York, the Croton aqueduct provided water that was probably less contaminated than that in the other two cities. But the growing population had already outstripped the available water supply, and per capita consumption was low, especially in the city’s tenements, where households on the upper ºoors had no water because of low pressure in the pipes. In Chicago, the water from Lake Michigan was adequate to meet the population’s needs, but during the 1870s, the lake grew increasingly polluted as the city grew. Both the quality and the quantity of water were problems in New Orleans, which depended largely on rain catch stored in wooden cisterns above ground.20 Both New York and Chicago made efforts to improve their water supplies before the turn of the century. By the 1880s, the municipal government of New York City was worried about the presence of sewage in the water and began chemical testing for organic matters in 1888. Interestingly, the results showed no greater problem in summer than in winter. The opening of a new aqueduct in the 1890s increased the per capita supply, although some city ofªcials argued that it was not getting to the citizens in need. Bacteriological testing in 1891 actually showed higher bacterial counts in winter than in summer. More dramatic changes in both the quantity and the quality of the water supplied to New

19 Lentzner, “Seasonal Patterns.” Isolating these three factors from the other likely inºuences on general mortality levels and early childhood mortality more speciªcally simpliªes our analysis but probably under-represents the interaction among many independent variables affecting mortality in the same direction. Our representation of this overdetermined model is necessarily incomplete and limited by the available data and analyti- cal tools. In this article, we summarize Lentzner’s extended account of these public-health initiatives and focus on their relationship to the observed changes in infant and early childhood mortality. 20 Merchant’s Association of New York, The Water-Supply of the City of New York (New York, 1900).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 344 | CONDRAN AND LENTZNER York’s population occurred after the turn of the century. Between 1900 and 1919, the quantity of water, as well as water pressure, increased to alleviate the shortage in tenements. Bacteriological testing of water samples continued to show higher colon bacteria counts in winter than in summer, but the counts fell between 1900 and 1909. Improvement ceased, and reversed, after 1909 until chlorination, initiated in 1915, substantially reduced the number of contaminants in the water.21 In conjunction with attempts to improve the quality of water contaminated with sewage, the cities also attempted to improve human waste-disposal systems. In New York, the focus was on replacing privies with water closets or, lacking them, with “school sinks” (privies connected to sewer lines). In the 1870s, the construction of 100 miles or so of sewers increased the system by 43 percent. Gradually from 1873 to 1900, the number of privies declined, but school sinks, rather than the more effective water closets, replaced many of them. Although the New York Department of Health reported that by 1891, the privy vault had been nearly abolished, a federal study of slums published in 1894 indicated that more than half the tenement households were still using privies. Sanitary inventories from the ªrst decade of the twentieth century show a dramatic decline in the number of privies: In 1903, Manhattan had 6,800 school sinks, privies, and latrines, and all of the boroughs except the Bronx had 9,200. By 1909, a tenement-house survey found that only 1,920 privies and school sinks remained in the city’s 102,000 tenements. Another survey reported in 1917 that privies were extinct.22 The efforts to deal with the contamination of Chicago’s plentiful water supply from Lake Michigan from 1870 to 1899

21 New York City Department of Health, Annual Report (New York, 1890); Merchant’s Association of New York, Water-Supply; New York City Department of Health, Annual Re- port (New York, 1893); idem, Annual Report (New York, 1905); idem, Annual Report (New York, 1909); New York Department of Water Supply, Gas, and Electricity, Annual Report (New York, 1910); idem, Annual Report (New York, 1916). 22 Sewer-connected privies, known as “school sinks’ because they ªrst appeared in the public schools, allowed the eventual movement of waste through the sewers and eliminated the need for manual removal. They represented little improvement over regular privies, since ºushing was infrequent, and the amount of water used was inadequate to eliminate all the waste. Tenement House Department of the City of New York, First Report (New York, 1902/03); New York City Department of Health, Annual Report (New York, 1891) 31; Carroll D. Wright, Seventh Special Report of the Commissioner of Labor (Washington, D.C., 1894); Tenement House Department of the City of New York, Tenement House Census (New York, 1909); idem, Ninth Report (New York, 1917).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 345 consisted of two engineering feats—the establishment of cribs in 1867, 1874, and 1892 to pump water from a part of the lake considered to be less polluted and the building of conduits to keep the dirty water from the Chicago River out of the lake. The ªrst such conduit was built in 1880; the second, a canal, was built in 1900. However, if the typhoid-fever rate can serve as an index of water quality, neither of these efforts substantially reduced contamination. The construction of more intercepting sewers during the ªrst decade of the twentieth century appears to have reduced contamination. By 1908, only a few communities north of Chicago were dumping sewage into Lake Michigan. Reports of the “safety” of the water, based on chemical and bacteriological testing, indicated that in 1906, only 2.2 percent of samples were unsafe. In 1907, only .2 percent were classiªed as unsafe, and levels of colon bacteria were low. The introduction of the disinfectant, calcium hypochlorite, from 1912 to 1916 further reduced bacteria counts signiªcantly.23 Sketchy evidence of the history of sewage disposal in Chicago indicates that it lagged behind that in New York regarding the replacement of privies with water closets. In 1894, 74 percent of the tenement families surveyed were using privies and in 1899, 40,000 privies remained in the city. Legislation passed in 1901 requiring water closets in all new construction reduced the number of privies, though it went largely unenforced in tenement housing. In 1910, however, a survey revealed 14,407 privies in the city; the number reduced to 6,000 in 1918.24 The rain water that the inhabitants of New Orleans collected in cisterns was both limited in supply and contained a great deal of sediment, the measure of pollution on which ofªcials relied in the absence of either chemical or bacteriological testing in the nineteenth century. Although ofªcials were convinced that much

23 Chicago Bureau of Engineering, Ofªcial Report to the Commissioner (Chicago, 1925). For a description of the use of the typhoid-fever rate as an index of water quality, see Lentzner “Seasonal Patterns,” 198–199. Research in Philadelphia attempting to link the quality of the water supply to infant and childhood mortality and typhoid-fever rates found that the latter declined consistently with the ªltration of water in sections of the city, though the infant and early childhood death rates did not. Condran and Cheney, “Mortality Trends in Philadelphia: Age- and Cause-Speciªc Death Rates 1870–1930,” Demography, I (1982), 97–123; Condran, Henry Williams, and Cheney, “The Decline in Mortality in Philadelphia from 1870 to 1930: The Role of Municipal Services,” Pennsylvania Magazine of History and Biography, CVIII (1984), 153–177. 24 Wright, Seventh Special Report; Chicago Department of Health, Report of the Department of Health of the City of Chicago (Chicago, 1918), 665.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 346 | CONDRAN AND LENTZNER of the city’s water was unsafe, they took no action to improve it until after the turn of the twentieth century. A comprehensive water and sewer system, begun in 1903, was helping only a small number of households in 1906. By 1911, 40 percent of the city’s households were connected to it; by 1917, nearly 88 percent of them were connected; and by 1920, nearly all of the city’s households were on the sewer and water system. New Orleans may have trailed New York and Chicago in the provision of water and sewage disposal in the nineteenth century, but by the ªrst decade of the twentieth century, it had incorporated disinfecting procedures that the two larger cities had not yet introduced.25 The efforts to clean up the milk supply in these three cities is a complex story; municipalities were not the primary suppliers of milk, as they were of water and waste disposal. Regulation of the milk supply required expansion of the mandated authority of the boards of health over private businesses. Because cow’s milk was the most likely alternative to breast milk in the feeding of babies, the hypothesis of a direct link between bad milk and infant mortality was, and is, compelling. In both New York and Chicago, early attempts to improve the quality of milk focused on reducing the amount of water and other substances added to milk and on regulating a milk supply that, from 1870 to 1900, came increasingly from dairies outside the cities’ jurisdictions. Both cities adopted ordinances, established inspection teams, and initiated chemical testing of milk. New York’s municipal code prohibited the entry and sale of “any unwholesome, watered or adultered” or “swill” milk during the 1870s. Effective enforcement of the ordinances, however, was still years away. Among the modest accomplishments in New York City during the 1880s were the passage of an amendment to the city code allowing the city to seize and destroy adulterated milk and an increase in the number of health inspectors employed. By the end of the 1880s, the ªrst published statistics related to milk inspections indicated that the examination of 63,240 specimens resulted in the destruction of 6,000 quarts of milk. A year later only 3,700 quarts were destroyed as a result of the inspection of

25 Louisiana Board of Health, Annual Report of the State Board of Health (New Orleans, 1874); idem, Annual Reports (New Orleans, 1883); idem, Biennial Reports (New Orleans, 1890/ 91); Board of Health for the Parish of Orleans and the City of New Orleans, Biennial Reports (New Orleans, 1919).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 347 97,040 specimens. Representing only about 1 percent of the milk supply, these statistics say little about the milk supply more generally.26 Although attention in the early 1890s shifted from the adulteration of milk to its bacterial contamination (the board of health established a division of Pathology, Bacteriology and Disinfection in 1892), routine testing of the general milk supply for levels of bacterial contamination did not begin until after the turn of the century. The nineteenth-century reorientation, however, resulted in efforts to produce, test, and make available at low cost better quality milk to needy mothers. In 1893, the pure milk stations established by Nathan Straus began dispensing modiªed and pasteurized milk—at this point amounting to only a small percentage of the city’s milk supply, which remained unpasteur- ized until after the turn of the century. General systematic testing of milk for bacterial contamination began in the ªrst years of the twentieth century. It revealed two facts about milk contamination that are relevant to the issues in this study: (1) that bacterial counts were higher in the summer than in the winter and (2) that the milk available in tenement districts was worse than that in better neighborhoods. Tests of the milk produced counts not of known pathogens but of all bacteria in the milk. Although the latter may have been an indicator of the former, the pathogens resulting in infant and early childhood diarrhea remained a puzzle throughout the ªrst two decades of the twentieth century; reduction of overall bacterial counts, not of speciªc pathogens, remained the goal during the ªrst two decades of the twentieth century. The number of milk stations supplying milk to poor infants and young children grew signiªcantly between 1908 and 1917. But the most dramatic changes in the milk supply came during the second decade of the twentieth century with legislation making the pasteurization of milk mandatory. The proportion of the milk supply that was pasteurized in New York rose from 15 percent in 1911 to 50 percent in 1912, to 75 percent in 1913, to 90 percent in 1915, and to 98 percent in 1918.27

26 New York City Department of Health, Annual Report (New York, 1873); idem, Annual Report (New York, 1889). 27 Manfred J. Waserman, “Henry L. Coit and the Certiªed Milk Movement in the Devel- opment of Modern Pediatrics,” Bulletin of the History of Medicine, XLVI (1972), 359–390.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 348 | CONDRAN AND LENTZNER The history of milk regulation in Chicago mirrored, with some time lag, that in New York. Chicago shared New York’s problems of regulating a milk supply that came from dairies outside its city limits, and Chicago’s Board of Health also focused on the adulteration of the city’s milk supply. There was little progress in regulating the milk supply until the 1890s, however, when a detailed set of ordinances mandated inspection of the milk that came into the city, established speciªc chemical standards for milk, and required the vendors selling inside the city limits to be licensed. The authority to regulate dairies outside the city limits entered the city’s code in 1895. Although the last decade of the nineteenth century brought an interest in bacterial contamination of milk, routine testing did not begin until 1905. During the ªrst two decades of the twentieth century, Chicago was delivering sanitary milk to poor infants. Its introduction of pasteurization came a little later than New York’s.28 Throughout the nineteenth century, New Orleans’ milk supply, unlike New York’s and Chicago’s, came largely from dairies within the city limits, sparing the city’s authorities the problems associated with transport and jurisdiction. As in the two larger cities, however, the major concern in New Orleans was the adulteration of milk. Legislation prohibiting the adulteration of milk in the 1890s did not end the practice of diluting milk with contaminated well water. A growing awareness of the problem of bacterial contamination led to a recommendation that consumers sterilize their milk before using it. When a member of the New Orleans Board of Health traveled to New York to meet with Straus and returned with sterilization equipment, the board endorsed a plan to operate a plant to sterilize milk for distribution to the needy. The program languished until 1907 when sponsors were found. Consequently, New Orleans’ efforts to supply good milk to poor infants came much later than those of New York and Chicago. During the ªrst decade of the twentieth century, about 40 percent of New Orleans’ milk came from outside the city and the rest from inside the city limits. Bacteriological examinations in 1907 revealed that the milk originating within the city was less

28 Chicago Department of Health, Department of Health of the City of Chicago (Chicago, 1898).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 349 contaminated than that which had come from the country. In 1919, only 30 percent of New Orleans’ milk supply was pasteurized; the city had passed no legislation making pasteurization mandatory.29 Figures 8 and 9 show the timeline of these public-health interventions in schematic form, along with the trends in the index representing the summer peak of infant mortality. Even this cursory look at the public-health situation in these three cities suggests a number of important points. First, the initiatives concerned with the provision of clean and abundant water, effective waste disposal, and regulation of milk supplies that were likely to have had the most direct impact on diarrheal diseases occurred largely during the ªrst two decades of the twentieth century. Yet, even though some of these programs coincided with declines in the index, and could have been causally related to them—especially in New York—they were irrelevant to the substantial changes in infant and early childhood mortality before the turn of the century. The sources of these mortality shifts must lie elsewhere. Moreover, even after the turn of the century, assessing the signiªcance of particular interventions is difªcult because of the number of them occurring simultaneously. Even if we grant that the sharp decline in the diarrheal death rates during the ªrst two decades of the twentieth century, as measured by the summer mortality index, resulted from improvement in the removal of human waste and the puriªcation of milk and water, we cannot ascertain the relative effectiveness of these initiatives. What we do know, however, is that they can be only part of the reason for the decline in mortality from diarrheal diseases. The failure of the mortality index to respond uniformly to such major changes and the reduction in diarrheal diseases that predated them attest to their inability to stand as the sole explanation.

Although our analysis emphasizes that individual infant-feeding practices were likely to have had an impact on infant and early childhood mortality, it also illuminates the difªculty of isolating that impact within a broader causal framework. The use, duration, and consequences of breastfeeding in the case of individual 29 Times Democrat (New Orleans), 15 June 1897; Ridgeways, 17 Nov. 1907; Louisiana State Board of Health, Biennial Reports (1919).

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 8 Highest Monthly Index Value for Infants, Related to Water Supplies and Waste Disposal, New York, Chicago, and New Orleans, 1870–1917

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 Fig. 9 Highest Monthly Index Value for Infants Related to Milk Sup- ply, New York, Chicago, and New Orleans, 1870–1917

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 352 | CONDRAN AND LENTZNER mothers depended on ethnicity, employment status, and exposure to certain technological and cognitive changes that altered the effects of various feeding practices on an infant’s health. The literature purporting to explain the mortality transition presents what are generally seen as oppositional positions. One side emphasizes broad economic changes and the inevitable effects of economic variables on the health and well-being of individuals and populations. In this view, mortality declined as a happy, but largely unanticipated, consequence of structural change. The other side focuses on the efforts of individuals, governments, and the medical community to lower mortality levels. It takes the position that public health activities became increasingly efªcacious with advances in knowledge. Declining infant-mortality rates might be attributed to general economic developments, improvements in technology, changes in the understanding of disease (for example, germ theories of disease), better sanitation, cleaner water and milk, and the individual practices of mothers in feeding their babies. Our results suggest that even though all these factors may have played a role in changing mortality levels, no single one of them is sufªcient to understand either the poor life chances of infants in nineteenth-century cities or the improvements in those chances that were in evidence by the last quarter of the century.

APPENDIX: DATA DESCRIPTION

For New York, the following sources contain monthly and weekly data on the deaths occurring to infants: Annual Report of the City Inspector from 1820 to 1865; Annual Report of the Board of Health of the Department of Health of City of New York from 1866 to 1912; Condensed Statement of Mortality, published by the Department of Health from 1871 to 1888; Annual Report of the Department of Health of the City of New York from 1913 to 1917. The data from 1820 to 1865 have substantial gaps in the 1930s. With the exception of 1875, 1889, and 1890, these reports also listed the deaths of one-year-olds and two-to-ªve-year-olds separately. Health ofªcials in New York City reported cause-of-death statistics by age and month of death in one age group only, age ªve and under. The Report of the Health Department of the City of Chicago contains monthly mortality statistics for most years form 1868 to 1917. Data from the Con- densed Statement of Mortality in the City of Chicago ªlls in a gap for the year

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 EARLY DEATH | 353 1876, and Vital Statistics of the City of Chicago contained additional data for the years 1899 to 1903. This historical record does not contain separate entries for one-year-olds and two-to-ªve-year-olds between 1906 and 1914. Cause-of-death data are available for only a few years by month of death and age. For New Orleans, a monthly series of deaths of infants, one-year-olds, and children aged two to ªve is contained in the Annual Report of the State Board of Health for all years, except 1876, 1881, and 1883.30 Although by 1900, the death registration in each of the three cities met the 90 percent coverage required for entry into the national death- registration area, the quality and completeness of the mortality record varied by city and time. Of the three cities in our analysis, New York had the earliest and most rapidly improving system of death registration; New Orleans lagged behind the other two cities largely because the death of blacks often went unreported. Although changes in coverage make estimates and comparisons of absolute levels of mortality problematical, underreporting that does not appear to have varied by month or season of the year would not have affected the seasonal patterns observed. On the contrary, age and cause in monthly patterns of deaths would hardly have been affected if the seasonal pattern resulted from seasonal variations in reporting.31 A more serious threat to our analysis arises from the fact that the date of death recorded by sextons of city cemeteries in the early returns could be either the actual date of death, the date of burial, or the date when the report was made. Later series recorded either the date of death or the date on which the death certiªcate was ªled, events that may have been separated by indeterminate and varying lengths of time. Although by the turn of the twentieth century, all three cities were reporting the date of death itself, variation in the recorded event within the earlier period of our analysis may have affected the timing of the mortality peak. The ªnal possible difªculty is that the data collected may not be entirely comparable by time and city because sometimes the reported month of death was a four-week period, the ªrst or last week of which could span two calendar months, and sometimes it was the calendar month itself. Early publications did not always indicate which deªnition of a month applied. These two approaches produced different monthly totals, particularly when the “swing week” had extremely high or low

30 Until 1889, the monthly and/or weekly series for New York includes only deaths in Manhattan and the Bronx; from 1898 onward, the time series contain deaths from all ªve boroughs of New York. 31 Rudolph Matas (ed. John Duffy), The Rudolph Matas History of Medicine in Louisiana (Baton Rouge, 1962), II. It is also important to note that because infant and early childhood deaths did not have the same seasonal pattern as recorded births, they did not reºect the latter. Seasonal patterns, which differed by age and cause of death and which also differed from that of births, argue against seasonal underreporting as the source of the monthly variation in deaths.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021 354 | CONDRAN AND LENTZNER numbers of deaths. For other times when deaths were reported by week rather than month, we constructed a monthly index by prorating the deaths in weeks that extended over two months. These problems do not alter the general seasonal pattern in any substantial way, but each could affect the observed timing of the summer peak and, hence, our interpre- tation of it.

Downloaded from http://www.mitpressjournals.org/doi/pdfplus/10.1162/002219504771997881 by guest on 27 September 2021