THE CHILD.

A MONTHLY JOURNAL DEVOTED TO CHILD WELFARE.

No. 12.

SEPTEMBER, 1918.

Vol. VIII.

THE FACTORS OF INFANT MORTALITY.

By C. W. SALEEBY, M.D., F.R.S.E., F.Z.S.

WE who are concerned with the Protection of Baby life have to face an extremely complicated problem; we have to consider all the causes of death and of damage at a certain period of life. This has some advantages, because it brings to our help people who have special interests, but it constantly leads to the danger that we may be emphasizing one thing too much and another thing too little. It would be very good if we had, as I think few of us have, a kind of diagram in our minds as to what are the biggest things and what are the smaller -perhaps relatively trivial-things, which we are out to prevent. We want statistics, and we need to bring to the statistics a particular kind of mind which is not easily going to be prejudiced or allow itself to be run away with by some particular part of the whole truth.

The Causation of Infant Mortality.

What kills babies? Does poverty? Most certainly and positively poverty kills babies; we have all seen it do so, and we all know why it does so. Babies and their mothers do not get their needs suppliedsuch as food or adequate medical attention, or rest, or fresh air, or, most notably, cleanliness. Therefore poverty kills babies. But it is no less absolutely certain that prosperity kills babies. Take a map of our country and observe where the wealth is made. The great wealthmaking industries have their centres very largely in the industrial North. Take, for instance, the great, worthy, and extremely prosperous woollen industry. Nothing could be a more legitimate or valuable industry, second only to the creation of food, and it produces

1 Substance of a lecture delivered to speakers on June 17, 1918, in connection with the work of the National Baby Week Council, 27A, Cavendish Square, London, W.1.

enormous wealth. Consider the cotton industry, of which quite so many good things cannot be said. Now make a map of the infant mortality rates, and you will find that those two maps coincide, so that where there is most wealth made most babies are killed. We owe this dreadful and fundamental observation to Sir Arthur Newsholme.

It is perfectly certain that poverty kills babies, and it is also perfectly certain that prosperity kills babies. If we are going to insist on the first statement as the whole truth, we shall have to try to dispose of poverty, and will expect infant mortality to disappear. If we are going to insist on the second statement as the whole truth, we might have to endeavour to dispose of the industries which make our national wealth. There is something here which we have not yet discerned. We must supplement sight with insight. Let us call upon statistics, and see if they can afford us any help. We must seek to resolve the antinomy between these two positively true statements-that both poverty and prosperity kill babies.

I want to direct attention, first, to the problem as it was in 1902, when I began the public exposure of infant mortality by writing and by lectures, with "One in Seven," now happily no longer true, as my slogan. That was sixteen years ago. What, then, were the big things to discuss what were the main things, as it were, to anathematize? There was the very large, scandalous, salient fact that in every third quarter of the year, if there was a typically warm summer, there was a regularly recurring holocaust of babies in all our big towns. Dividing the year into four quarters, there was a high mortality in the first quarter, coming down markedly in the second, jumping up to much the highest point in the third, and then falling again in the fourth. That was typical of the seasonal incidence of infant mortality. There was this horrible destruction in the third quarter of the year, and one used to talk about it as the "deadly third quarter." To-day that phenomenon has disappeared. It may return, for it must be held at bay every summer; but not since 1911 has there been a diarrhœal year. The deadly third quarter that was has gone, that shameful third figure has been reduced by a third or so, and in the last two years our babies have thrived best in the nice, warm weather. This great improvement has been effected by giving the infants safer food instead. of food which simply murdered them, by preventing the infection of their food by flies-thanks partly to the substitution of the motor-car for the urban horse-by the disappearance in a large measure of the long tube feeding-bottle, and of the maternal ignorance which used

such a bottle, was indifferent to flies, and fed babies on murderous milk.

The medical problem, therefore, furnished by epidemic diarrhoea is beginning to disappear, and the credit for this is largely due to the remedying of ignorance, to the raised standard of infant feeding, to those who have done the all-important work of the making and preserving of safe food for infants, and to our devoted infant welfare workers everywhere. The general milk supply is bad enough still. That matters less for you and me; we can go on because we have some degree of immunity. But infants are not fed in anything like the abominable manner in which they were fed sixteen years ago. The best thing to be able to say would be, of course, that there had been a great resuscitation of breast-feeding, and that, whatever kind of milk. was available here or elsewhere, infants were safe because their mothers fed them. That has not happened; if it had the figures would be better still. But, so far as seasonal incidence is concerned, there has been a profound alteration in the last half generation-an alteration which has transposed the comparison between the "deadly third quarter and the first quarter-the hot and the cold period. This seasonal reversal of the mortality, dependent upon questions of food, education, sanitation, flies, and type of feeding-bottles, shows that the most gross and palpable of the medical problems of infancy is being disposed of. As mainly a consequence of this, we may briefly say, in round figures, that during the last half generation infant mortality in this country has been reduced by one-third.

In the first English book ever written on infant mortality,1 Sir George Newman shows by a diagram the principal causes of infant death in England and Wales in 1903. The second column, diarrhoea and enteritis, reminds us of what we have just been discussing. The first and longest column is called "prematurity and congenital": good polysyllables which might mean any mortal thing. Then the last column but one-a tiny column-is labelled syphilis. That was before the discovery of the parasite of syphilis and of the Wassermann reaction. To-day we know that syphilis is responsible for much of the height of the first column. The medical problem of infant mortality was especially syphilis (had we known it) and summer diarrhoea. The chief medical problem to-day is syphilis, and we must know it.

1 Published twelve years ago in my "New Library of Medicine," issued by Messrs. Methuen and Co.

In order to understand this, let us look at the facts in yet another statistical way. Let us study the age incidence of infant mortality: take the mortality curve of not the solar but the infantile year. The mortality is very high at first, and very rapidly diminishes thereafter. What is the relation of the improvement we have effected-a magnificent. improvement, so that we must go about saying not "one in seven " now, but "one in eleven "-upon this age incidence of the mortality? The answer is all-significant.

Briefly, we are saving the older infants-those in the last half of the infantile year, the infants that mostly died of summer diarrhoea, or, more generally, of alimentary disorders. But, looking at the younger infants, we find that we have accomplished much less, and when we get to the very young infant indeed, but there is very little to show for half a generation of work. This is not a new phenomenonit is old. In Glasgow, during a period of thirty-two years, from 1870 to 1902-the year from which I am thinking, the year when my own observation and public work began-infant mortality was steadily improving all the time. There was during that generation, which is twice the length of the period we are considering now, no less than a 30 per cent. reduction in the last six months age-period, a 16 per cent. reduction in the second quarter, but no reduction in the first quarter. After those thirty-two years of progress, though so many of the older infants in Glasgow were saved, in the first three months after birth they died as fast as ever. Those young infants are dying not much less fast than ever throughout our country now. We have achieved something great and splendid in saving a third of all the babies that died; but as for the very young infants we have signally failed. Like our prosperity-poverty puzzle, this must mean something fundamental; perhaps they both mean the same thing.

:

We will call the infant, during the first month after birth, a newborn baby, and will call the mortality among these new born the neonatal mortality. This is going to be our problem with regret we acknowledged that with this we have hitherto practically failed. This mortality at the beginning of the infantile year is going to be the main business of those of us who are fighting against infant mortality. The problem has changed. In 1918 the proportions, nay, the very nature, of the problem are seen to be not at all what they seemed in 1902. In that year we might be content to think of the problem as essentially medical-a medical problem of infancy, and, very flagrantly, an epidemiological problem of infancy.

Medico-Sociological Aspects of Motherhood.

To-day, more than ever, the problem of infant mortality is not a medical problem of infancy; it is a social problem of motherhood. It has always been really a social problem of motherhood; when we failed to solve it, there arose the medical problem of infancy. This last problem, which should never have arisen, we have partly solved, by unnatural methods, during the present century; except for the illegitimate infant, whose appalling mortality, and that of its mother, prove to the hilt my main contention.

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As for the neo-natal mortality, in especial, and much of the later mortality, let us cease to use such terms as prematurity and congenital"; let us say that the causes are maternal and ante-natal, arising mostly from what I call the racial poisons.

Let us now look at the recent history of one of the ways-doubtless the least important-in which one of them, alcohol, kills babies. Thanks to the Liquor Control Board, to which I am indebted for figures, and to the Ministry of Food, convictions of women for drunkenness have lately been very much reduced-one of the innumerable refutations of the familiar fuddled falsehood that you cannot make people sober by Act of Parliament. I said last year1 that Lord D'Abernon was hoping to be able to supply me with figures for over-lying, confirming my teaching ever since I left the Edinburgh Maternity Hospital in 1902. Here are the figures he promised me-704 in 1917, as compared with 1,348 in 1912. There were several hundreds of infants saved last year because women drank less. The factor here is, proximately, toxicological; but, ultimately, it is social and maternal.

That is a mere illustration in passing. But now look again at the age-incidence curve. If there is this tremendous mortality at birth and immediately after, and it drops with such great rapidity down to the end of the first year, will it not occur to anyone who thinks that the beginning of the curve is really a continuation of an earlier curve? Indeed it is. We have deliberately blinded ourselves to the continuity in the development of the infant by our obsession with the fact of birth. It is more than an obsession-it is deliberate, if not calculated, stupidity. I was this morning at the Registrar-General's Office. I have been trying for a long time past to get information for this lecture about still-births, and this morning was one more last attempt. I knew that still-births are now notified to medical officers of health by doctors,

1 See "Saving the Future," published by the National Baby Week Council.