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1,000 children begin school with "running ears," and 1,200 have their hearing so defective as to interfere with their education. Chronic bronchitis is met with in about 3 per cent. of the cases, which means that about 2,500 children have bronchitis when they begin schooling. In the burghs generally after-effects of rickets are noticeable in about 9 per cent. of the entrants. It is estimated that nonpulmonary forms of tuberculosis have a percentage incidence of o ̊4. Finally, it seems justifiable to conclude that at least 42.5 per cent. of the children entering school suffer from defects and diseases which are largely preventable. The results of limited examination of only a certain proportion of entrants fail to indicate the prevalence of disorder, disease, and defectiveness among the children of Scotland. Thus to take the death records of such a preventable disease as tuberculosis In the year 1915 some 2,238 chilticularly timely and serviceable section is that which deals with schemes of maternity and child welfare, and in which details are given of experiments and enterprises in various parts of Scotland. Finally, Dr. Leslie Mackenzie welcomes the possibility of the establishment of a great National Institute of Maternal and Child Welfare. The trustees of the Carnegie United Kingdom Trust have intimated that they are "prepared to consider favourably the cost of the acquisition or erection of a suitable building in London for the housing of a central bureau or institute of a national character to serve as a co-ordinating agency for all its various local and other organizations connected with infant and maternal welfare in England and Wales, and of a similar central institute for Scotland." And it appears "the purpose of the proposed central institutes would be to assist the various voluntary and statutory bodies engaged in the subject in England and Scotland respectively; it would not supersede them or encroach upon their proper spheres of local interest." This munificent offer is dictated by real statesmanship and is based on patriotic sentiment and scientific knowledge. We sincerely trust that ways and means will speedily be found whereby this splendid offer may be materialized. Dr. Leslie Mackenzie indicates something of the lines on which
such a Commonwealth centre for mothers and children might be founded: "A National Institute of Maternal and Child Welfare should represent all aspects of the problems we have here discussed or suggested. If established on the generous lines contemplated by the Carnegie United Kingdom Trust, it might serve as a central bureau of information, where any student could have access to books, reports, monographs, and studies of every phase of mother and child life. It would also be so equipped as to provide special direction on lines of study and research, to organize or arrange such researches as those already indicated, to be a central meeting place for discussions by experts, and to promote from all standpoints scientific investigation of the conditions most affecting the lives of mothers and children. It would also serve as a place where courses of instruction could be made available for unattached social students; where special courses could be provided for officials employed in various departments of the health service; where officers of the various branches of maternal and child welfare service could be trained through a full curriculum. To this work, now so clearly called for, the institute might add provision for the organization of popular instruction by way of local exhibitions, or travelling exhibitions, or lectures or demonstrations, or the loan of teaching appliances, such as lanterns, or slides, or diagrams, or models or other wanted equipment. It might arrange with the medical schools and colleges for technical courses in the various aspects of child welfare, so becoming to that extent an associated part of the medical schools. It might, too, arrange with the arts or law faculties in the universities to provide expositions of the legal and economic principles that underlie the various administrative proposals. Finally, it would naturally provide for the holding of periodic conferences and congresses of all the authorities and organizations concerned with the welfare of Scottish mothers and children." Such a dream is fascinating in its possibilities for the creation of a realizable Utopia, the coming of the Rule of a New Kingdom of Righteousness. We sincerely trust that Mr. A. L. Hetherington, the Secretary of the Carnegie United King
dom Trust, and his colleagues will hasten the coming of this creation for the advancement of the fundamental interests of our Great Commonwealth. Dr. Leslie Mackenzie forcibly presents the case for action here and now in his epilogue to this epoch-making volume-and we venture to quote it in its entirety: "The war cloud dims our vision of the facts at home. But in war or peace, there is this constant struggle for a living and a life. To-day, it is the mother in her distress that needs help and care; to-morrow, it is the infant newborn; the third day, it is the talking and walking child. For, wherever the one or the other is found, the tale of inadequate service, of danger, of damage, of disease and death, is nearly the same, varying a little in local colour but never in substance. This is what our rapid survey of Scotland suggested and what our analysis demonstrates. The need is permanent and creates its own administrative instrument-the common services. By these the mother secures direction in her critical hours and the child multiplies his chances of life. The laws that supplement and support the innumerable impulses of philanthropy are not measures that can be formulated, passed, and enforced once for all; they are themselves the means and symbol of a progressive and continuous organization of the social energies, adjusting them in kind and in degree to all the phases of distress, disablement, and disease. The full development of all the powers written in the law this generation will not see, but it is in this generation that they have taken their new form. In all the varying phases of these national problems-the concentrations of the peoples, the growth of institutions, the use of new organizations and agencies-there is visible always one uniting principle: the need to preserve the life of the newborn child. Men ask
me, not for the first time," Is it all worth while?" The question finds many echoes, but no answer. If, in this long pleading, I have failed to convince, nothing I can say now will satisfy; but, perhaps, in these days of a common sorrow, the cry of every mother's heart for her dead son will keep us to our duty:
"For as lone as thou liest in a land that we see not, When the world loseth thee, what is left for its losing?"
The Carnegie United Kingdom Trust (Incorporated by Royal Charter) have just issued from the headquarters of the Trust at East Port, Dunfermline, the "Fourth Annual Report (for the Year ending December 31, 1917)." It is a record of beneficent work wisely planned and ably carried out. The Report intimates that "the Committee have determined to erect and equip buildings for six infant welfare centres in urban areas in the United Kingdom." The Report contains reference to work for the physical welfare of mothers and children, the support of a travelling welfare exhibition for Scotland, play centres, and other enterprises for national betterment. The Report is published in Edinburgh, at the University Press, by Messrs. T. and A. Constable.
An illustrative catalogue of shrines and memorials likely to be of interest to public schools and other institutions has been issued by Messrs. Strange and Sons, Ltd., 34, London Road, Tunbridge Wells.
Under the title of "An Explanation of Colour and Colour Vision," Mr. Charles R. Gibson, F.R.S. E., has issued through Mr. Alex Macdougall, 70, Mitchell Street, Glasgow, a most interesting and sugges tive brochure, which we commend to the notice of all science masters.
CHILD WELFARE AND STATE SERVICES.
In this section are inserted records of the progress of Child Welfare Work as carried out by various State Services dealing with Health, Education, Industry, Delinquency, Defectiveness, and other questions relating to the care and control of the young. We shall be glad to receive copies of reports and all other official publications as soon after issue as may be possible.
ENEMIES OF CHILD LIFE.
Sir Arthur Newsholme, K. C.B., M.D., Chief Medical Officer to the Local Government Board, has contributed a notable article on The Enemies of Child Life" to the Nineteenth Century for January. This informing and stimulating communication should be studied by all workers for maternity and child welfare. could wish that it might be reprinted in booklet form and distributed throughout the length and breadth of the land. As far as our restricted space will permit we propose to attempt a concise abstract of the essentials of this illuminating and authoritative paper. "Every society is judged and survives according to the material and moral minima which it prescribes to its members." In this precise phrase Mr. Asquith has summarized a great social truth, which all workers for human betterment should ever remember. Each child of the nation may not irreverently be viewed and treated as a Holy Child, and the protection of mother and child is to be counted as a Holy Service. The enemies of child life attack in two ways: (1) Through agencies and influences affecting the infant chiefly through the mother during her pregnancy and during the weeks immediately following childbirth; and (2) by factors arising during the remaining periods of infancy and the early years of childhood up to 5 years. A child's prospect of health is very largely determined by its environment in the first weeks after birth and the maternal environment before birth. The oft-quoted statement that all infants are born in a fairly equal state of health is now known to be incorrect. Syphilis prevails very unequally, and is an important cause of illness in the mother and of still-birth of the infant and also of serious disease in infants born alive. The statement that infants at birth "start fair" receives no support from the statis
tics of still-births. On an average there are about 3 still-births for every 100 live births, but the proportion is as high as Enormous varia7 or 8 in some towns. tions exist in the incidence of illness and deaths of mothers during pregnancy and in child-bearing. In many Welsh counties 7 die for every 1,000 infants born, while in London only 3 are lost. In towns like Dewsbury, Rochdale, Huddersfield and Oldham, 6 to 8 mothers; while in Poplar, Shoreditch and West Ham only 2 to 3 mothers, die in every 1,000 infants born. And it must be remembered that these deaths are associated with a lamentable amount of sickness and weakness in mothers who survive, often protracted over many months; it is inevitable that excessive sickness and mortality of mothers should mean at least a corresponding excess of sickness and deaths of infants both before and after birth. The effect of maternal malnutrition on the unborn infant is difficult to estimate. There is probably a relation between malnutrition in the mother and an excess of still-births. Even if it were assumed that severe malnutrition of the mother during pregnancy had no detrimental effect on the health of the unborn infant, its harmful effect on the mother's capacity to suckle her infant is demonstrated by repeated experience. Anything which diminishes the ability of a mother to nurse and tend her infant after its birth must be regarded as an enemy of home life. The mortality statistics for the first week and the first month after birth display most clearly the error of the assumption of an equal start in life at birth for all children. Mortality statistics, it must never be forgotten, are merely an index of the much larger amount of sickness which may or may not end in death. The general conclusion is that many infants are condemned to death before birth; that a large proportion of these deaths
can be prevented, and that of the infants who survive to be born alive a large number are handicapped from birth by their unfavourable ante-natal environment and by the evil circumstances in which they were born. Statistics regarding the variations in vitality of infants in the first month after birth go to show that much of the infantile mortality now existing is preventable. The experience of five groups of population in London has been collected by Dr. W. H. Hamer, the groups being arranged in accordance with the percentage of children in each borough who were scheduled for education in the Council schools and varying only from 82 to 97 per cent. The deathrate under one week in these five groups varied from 18.3 to 22 per 1,000 births (a difference of 12 per cent.), and under one month from 28.7 to 34 per 1,000 (a difference of 12 per cent.). Between the death-rates under one month in Hampstead and Shoreditch the difference was about 25 per cent. Returns from Brighton, prepared by Dr. Forbes, show a difference of 40 per cent. between the death-rate of infants under one month in the poorest families and in the well-to-do, but the two rates are identical in the first week after birth, a result which is not surprising in view of the fact that in Brighton midwifery and medical attendance are of exceptional high quality, and the death-rate of mothers from diseases and accidents associated with pregnancy and confinement is only 3 per 1,000 births, as compared with 6, or even 8, in some other parts of the country. According to the returns of the death-rates in 1907-10 of infants under one month, the following conspicuous variations occurred: Workington, 61; Blyth, 58; Batley, 57'7; Dewsbury, 56'7; Todmorden, 54°7; Watford, 259; Hornsey, 271; Penge, 27°2; Reigate, 27'9; Holborn, 28. The following returns for urban areas and counties of death-rates during the first week after birth deserve consideration. In Durham and Northumberland out of every 1,000 infants born nearly twice as many die in the seven days after birth as in Hereford and Kent. In Workington out of every 1,000 born 41 die before reaching the end of the first week; in Hornsey only 16; in Dewsbury 41, as compared with 18 in
Hampstead, 38 in Batley, only 17 in Heywood, and so on. Similarly the deathrate from premature birth and congenital defects varies within wide limits, as, for instance, between 43'6 per 1,000 births in Todmorden and 14.6 in Watford. In 1911, omitting a few unclassified cases, there occurred 843,293 births in England and Wales; 207,295 (246 per cent.) of the total births occurred under circumstances involving a sacrifice during the first month after birth of nearly 5 per cent. of the infants born; while for 20,931 (over 2 per cent.) of the total births the corresponding sacrifice was only 2 per cent. of those born. The total loss by death of 105,130 infants in England and Wales in 1911 was distributed as follows:
Of the total deaths in infancy, nearly one-third occur in the first month, and about one-fifth in the first week after birth. When the deaths during the first week or during the whole of the first month after birth are taken as the test, there are enormous variations in mortality. To regard the greater part of the mortality at these ages as inevitable is contrary to the teaching of our current national experience. Improvement in social service, the provision of skilled assistance and domestic aid for the mother during the lying-in period, subsidization of maternity, and much else making for maternal and child welfare are essential if further progress is to be made. Continued and increased effort is called for so that the mothers who suffer unnecessarily and whose infants die soon after birth in excessive numbers have standards raised to the level of their more favoured sisters. To bring this about the combined efforts of doctors, midwives, hospitals, health visitors, monthly nurses and home helps are required. Local authorities must recognize their responsibilities in regard to the protection of human life. Under existing conditions the lot of the unmarried mother and the illegitimate infants calls for special consideration.
In 1915 the births of 36,245 illegitimate infants were registered in England and Wales. Of this number one-fifth died during the first year after birth, or double the number among a corresponding number of legitimate births. It is a grave reflection on our social organization, a responsibility shared in varying degree by the majority of voluntary agencies for helping unmarried mothers and their infants, by lying-in hospitals, and by the Poor Law-that such help as is given implies most often that the mother is separated from her infant, and that thus the infant loses its most favourable means of health, and the mother loses the buttress against lower moral fall, which the personal care of her infant would give. The factors influential in the life of a child are personal and environmental. The personal elements in so far as they consist of infection, malnutrition or injury during intrauterine life are environmental. Before, as well as after birth, circumstances and personal factors are so closely interrelated as to make it folly to minimize the influence of one or the other in the making of the home. After birth infection is certainly the greatest enemy of child life, and the larger part of deaths due to infections are preventable. More than half of the total deaths in childhood are caused by communicable diseases. The following table indicates the proportion of total deaths at ages 0-5 in England and Wales:
and climatic conditions which are indistinguishable show great variations in child mortality. Industrial towns within the same county, and sometimes within a few miles of each other, show widely divergent child mortality rates. Equally marked differences in child mortality rates occur in contiguous wards of the same town. The experience of dwellers in the Peabody Block Dwellings in London show that the infant mortality occurring in these "model dwellings" is markedly lower than in the homes of the surrounding population. Attempts to ascribe the whole evil to one cause must fail, because they are not consistent with all the facts of a complex social problem, in which functional and structural obstacles to health in each household are intermingled. Insufficient wages, alcoholism, thriftlessness, ignorance, lack of pure milk, all bear their part in varying proportions in different instances; but the chief difference between urban and rural life is in housing, especially in regard to overcrowding and in opportunities for human organic poisoning and infection. Out of a given number of families more than six times as many live in one-roomed tenements in towns as in rural districts, and an excessive proportion of urban families live in tworoomed tenements. Nearly one-seventh of all the families in towns occupy only one or two rooms, and every function of domestic life, including birth and death, is carried on under these cramped circumstances. The amount of crowding in these rooms, furthermore, is much greater in towns than in the country. To the general depressing influence of town life is added the deleterious influence of crowded rooms. But when all is said and done, the fact remains that the chief enemies of child life are within the home itself, and they may be classified as functional and structural, though in practice these must be considered together. To attach exclusive importance to persons or to conditions is to invite failure in social reform. Often the chief enemies are the parents themselves, and their default is vitally serious, as they are responsible for bearing as well as for rearing their children. Among personal faults in the parents responsible for a large portion of the total excessive child sickness and