The infant, the parent, and the state; a social study and review

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INTRODUCTION BV PROF. G. SIMS WOODHEAD xi

CHAP.

Introduction

Are we as citizens doing our duty by the citizen of the future ? might very well be taken as the type of question that, fortunately, is now being very widely asked in our communities. It is a question not to be lightly answered ; it deserves careful consideration. Many are now trying to answer it. Some of those who have made an effort to collect materials on which to found their answer have been astonished at what has arisen out of their search, with the result that it has been driven home very forcibly that as regards the child, even before it was born and for some time after birth, conditions have grown up and have been allowed to continue which, if properly understood, would, ere this, have been got rid of at almost any cost.

Some recent attempts to improve the condition, physical, mental and moral, of the children of the poor have been described xii INTRODUCTION.

as socialistic in their tendency. Without quarrelling about words and definitions, may it not be accepted that it is true economy to ensure healthy surroundings for the child, both before and after birth ? To put it on its very lowest plane, is it " good business " to waste money on the teaching of halfstarved children ? to allow, unrestricted, the formation of criminals and degenerates through overcrowding, through evil surroundings, through malnutrition and through drink ?

In the work before us I find evidence of an honest attempt to gather together information on these matters, to be placed at the disposal of those who are not able to collect it for themselves. In each of the eight chapters in which Dr. Heath deals with different parts of the subject we have ample evidence that not only has he studied what other people have said and done, but he has garnered much and valuable experience, facts and statistics for himself; and anyone who goes through these pages carefully and conscientiously will have a very different sense, not only of his individual, but of his communal responsibility.

INTRODUCTION. xiii

Whether the author is dealing with facts and statistics as to child mortality, with those ante-natal and post-natal conditions that play such an important part in determining the welfare of the child and of the adult in after life, or whether he is writing of the milk supply, or of the agencies and organisations of importance to infant life, one is always impressed by the thorough mastery he has of his subject — where h6 explains, he is explaining out of the fullness of his knowledge, and where he criticises he has good grounds for his criticisms.

Some of the facts brought forward are of a most startling character, and as interesting as they are startling; as, for example, that the number of infants dying in a large provincial town in the first week of life is so great that were it to continue at the same figure for forty-two weeks every infant born alive would have succumbed within such period. And again, the striking evidence that the unborn child may suffer through the imperfect nourishment and overwork of the mother. Can nothing be done to remedy this ? It appears from the statistics as though the loss to the nation in this way xiv INTRODUCTION.

may be infinitely greater than if all the women who now act as wage-earners were fully pensioned and allowed to attend to their proper duties. \

On the question of the present defects of our milk supply the author speaks strongly, but not one iota too strongly, and his chapter dealing with this matter is to be heartily commended to those who take an interest in this very important matter.

Philanthropists have a tendency to become people of one idea ; but Dr. Heath, as a scientific man, as one interested in the Public Health, and as an investigator, offers food for thought to all. He indicates how important to the Public Health is each factor with which he deals, and that there is work for all, for the Educationalist, for the man interested in the housing problem, for the Temperance Refornier, and finally for the Legislator. Every man who is desirous to help his fellows may have a share in bringing about some reformation in our methods of dealing with the early and high infant mortality. How much work there is is well indicated in the quotation, " Mortality statistics show'us the dead but are silent as to the maimed,"

INTRODUCTION. xv

— ^and what an oppressive silence it is to those who think and see !

Physical degeneration and deterioration are terms to conjure with in these days, but they raise no new problems. Let us make the most of them, however, whilst they are still potent. The Mayor of Huddersfield and his colleagues are now being taken seriously, and the question of the prevention of infant mortality has come to be one that before long will exercise more of the best minds of the country and will take its position as one of the most important with which social investigators and legislators have to deal.

This work may be commended to every parish, district, town and county councillor, to every Member of .Parliament, and indeed to all interested in social problems ; it will supply powder and shot to them all, just as the chapters on Health, Temperance and Thrift in Miss Eglantyne Jebb's work on "Cambridge: a brief study in Social Questions."

G. SIMS WOODHEAD.

Cambridge.

January, 1907.

THE INFANT, THE PARENT, AND THE STATE.

Chapter I. Infant And Child Mortality

In the year 1904, England lost 137,392 of her children before they had reached the short span of twelve months of life.

The deaths of these infants constituted 25 per cent, of all the deaths in England and Wales during the year we are considering.^

During the years 1900 to 1904 inclusive, 670,666 children died under one year of age, and a total of 970,749 children died before seeing their fifth birthday.

Thus, during the last five years for which complete statistics are available, nearly 1,000,000 children died in these very early years of life. We know that the two extremes of life — infancy and old age — will demand a heavier death toll than the

> Geneva has kept registers of births, marriages, and deaths since 1549. In the sixteenth century their infant deaths constituted 25-9 per cent, of their total deaths at all ages.

I.P.S. B intervening periods, but a waste of this character is very distressing.

These hundreds of thousands of deaths are not alone as the evidence of child sacrifice in our midst, for the untoward influences which caused the deaths affected adversely at least three times the number among the living. This is probably under the figure, but leaving it at this, it is an unhappy reflection upon our conditions of life for three million children — to consider these years only — to bear upon or within them the evidence of having battled with inimical agencies.

The conditions that are unfavourable to the life and health of the child are very varied in kind, as also in their time of action. In one instance it may be a condition of the past though the impress is seen in a life lost to-day ; in another it is a condition purely of the present with a full and immediate remedy at hand.

Professor Arthur Thomson says : —

"An organism's start in life is vigorously determined by its parents and ancestors ; not only specific characters but trivial idiosyncrasies; not only physical qualities but mental as well ; not only the normal but the abnormal may be transmitted."'

And further, to quote the teratologist, Dr. Ballantyne : —

" The individual is, as it were, the meeting-place of two long lines of spectral forms, stretching away back into the past and melting into an army of shadows each of which in its time was a living being, with

1 " Heredity," " Encyclopedia Medica," vol. iv.

habits good and bad, with health or disease, with structures stoutly normal or defectively abnormal ; the infant at birth is the living gsnglioii towards which many lines of influence converge and in which they meet, with effects which we cannot foretell, but about which, when we see therti, we say " heredity determined them."»

The follovving table illustrates some of the ill results attendant upon parental influence of an adverse character.

Disease in tlie parents, or untoward conditions acting througli them resulting in

Non-development of the germ. (Sterility.)

Imperfect or

ill-development

of the germ.

Disease in the fcstus.

Malfor- Death of the Death of the

mations. embryo. foetus.

(Abortion or (Miscarriage

miscarriage.) or still birth.)

Deficient vitality of the fcetus.

Premature birth.

Still-birth.

Death shortly

after birth from

inability to live

a separate

existence.

Death of the

fcetus. (Miscarriage or still-birth.)

Premature birth.

Birth at normal time.

Disease in the infant.

Immaturity,' as a cause of infantile mortality, is increasing, and it is to be noticed that this change is coincident with a decline in the birth rate.

Darwin referred to the early deaths of children among certain races in the following words:

• " Ante-natal Pathology and Hygiene," vol ii., p. 648..

* Included in this term are : premature birth, congenital malformations, atrophy, and debility.

B 2

" This has been attributed to the neglect of the children by the women, but it is probably in large part due to innate weakness of constitution in the children in relation to the lessened fertility of their parents."^

The causes of immaturity may be roughly classed as being due to : —

(i) The action of certain poisons upon the reproductive cells and organs of one or both parents. These are various and are associated with alcoholic excess, lead and other metal poisoning, syphilis, tuberculosis, and other diseases. The most common are the first, second, and third.

(2) The unhealthy environment of the parents, including insanitary dwellings and workshops, injurious trades, insufficient food, excessive and prolonged work for women during pregnancy.

(3) The marriage of the unfit.

These causes, accentuated in part by others of post-natal origin, are responsible for the larger proportion of infant deaths during the first three months after birth.

The chief causes of the mortality of infants between the third and twelfth months after birth are due to : —

(i) Poverty of the parents with the attendant evils.

(2) Ignorance of parents in the feeding and care of infants.

(3) The mothers' employment in factories.

(4) Public supply of impure milk, and lack ot care in the storing of it in the home.

(5) A remnant of those children whose ill development prior to birth renders them unduly susceptible in the struggle for existence.

A special sub-committee made a report through the Public Health Committee for Preston in 1902, and among their conclusions were the following : —

(i) Many deaths taking place during the first month of life, which are returned as due to premature birth, immaturity, congenital debility, and convulsions, may be ascribed to female labour in the mills.

(2) The diminished stamina of the parents is a cause especially associated with the increase in infantile mortality.

In Preston, as in the older manufacturing towns, where there is little importation of fresh blood, there is a risk in the intermarriages (often at an early age) amongst persons of the same class, and a danger of the offspring becoming more and more enfeebled.

(3) The alarming increase in the consumption by young women and mothers of alcoholic beverages exercises a baneful effect on the constitution of the child before birth, but more especially leading to carelessness and neglect of the child after birth.

The term "infantile mortality" refers to the deaths of children under one year of age, and it is expressed as in proportion to each i,ooo births ; at all ages above one year the mortality is expressed as in proportion to each i,ooo of the population.

There has been a marked decline in the general death rate of the community during the last fifty years, but the infantile mortality rate has not shared proportionately in this decline ; in fact, particularly during the first trimester, the death rate of infants is more or less stationary, or even in some places shows an increase..

The rate of infantile mortality in England and Wales in 1904 was 145 : this was for the whole of the first year of life.

If we divide the first year into three age periods we see the greater rate of mortality in the first three months.

Infantile Mortality Rate in England and Wales, 1904.

Whole Year Rate.

— 3 Month Rate.

3—6 Month Rate.

S— 13 Uonth Rate.

Again, if we divide the first year into yet lower age periods, we see how heavy is the death toll in the very early days after birth. The following table is based on an investigation, made by the writer, of the ages of infants dying in a large provincial town during a recent decennium.

Age Period.

Under 2 days . „ I week . „ 2 weeks

3 weeks

4 weeks

Of 100,000 bom alive, tliere would die :

1.432 2,410

9.756 10,646

11,590 12,493

13.219 13.830

14.454 15,160

The mortality rate is so high during the first week, that were it to continue at the same figure for forty-two weeks every infant born alive would have succumbed within such period.

The mortahty among male infants is greater than among female. In 1904 in England and Wales, the rate for male infants was 159, and for female 131.

Industrial centres lose a greater proportion of their children than do rural districts; this is markedly seen during the first year of life. The

INFANT, PARENT, AND STATE.

higher rate is maintained throughout this period, but the excess varies greatly.

In 1904 the Lancashire infant mortality rate exceeded that of Wiltshire by 85 per cent. For infants under three months of age the excess was 38 per cent. ; among those three to six months it was 137 per cent. ; and among the infants aged six to twelve months it was 172 per cent.

From an analysis of the deaths of infants in the three agricultural counties of Dorset, Wilts, and Hertford, and in three counties containing great centres of industries, Durham, Lancashire, and Staffordshire, during the three years 1901-2-3, we can construct an elementary life table.

Of 100,000 children born alive, the number surviving at each age will be : —

Age Period.

Rural Group.

Urban Group.

At birth . ,, 3 months „ 6 months „ 12 months .

We see from the above table that of 100,000 children born alive, there will die under twelve months of age, 9,147 of the rural infants and 15,817 of the urban.

An extension of the analysis showed that 13,027 of the rural and 23,693 of the urban born, failed to reach their fifth birthday.

INFANT AND CHILD MORTALITY.

Striking as these differences are, it must be remembered that the returns of whole counties have been considered; if we were to limit our observations to towns only, we should find the differences greatly accentuated. Thus, on the average of 1901-2-3, of the standard number of children born alive in Hanley, 18,400 would not reach twelve months of age ; and in Wigan 17,810 infants out of 100,000 born alive would die during the first j'ear of life.

Again, certain portions of towns have an infantile mortality greatly exceeding the mean. In Manchester in 1905 the twenty -two districts had among them a minimum rate of 82 and a maximum of 217 per 1,000 births.

If children's deaths are considered in relation to the districts in which they occur we see that the excess is largely due to what may be termed a " class " mortality.

In York, the three districts, Bootham, Micklegate, and Walmgate, vary greatly in their infant and child mortality.

The following facts are for 1903.

Bootham.

Micklegate.

Walmgate.

Infant mortality per 1,000 births.

Deaths of children under

4-45

5-57 five years of age per 1,000 living at all ages.

Premature Births and Developmental Diseases.

lo INFANT, PARENT, AND STATE.

The writer is indebted to Mr. -B. S. Rowntree for kindly sending him the following particulars of the Bootham and Micklegate districts. " These districts comprise a very mixed population. The best houses in York are distributed between the two, and they comprise also a good deal of shop property. In addition to this, however, they both comprise a good deal of artisan population. Possibly the proportions may approximate to the following in each district : Well-to-do, 10 to 15 per cent. ; shop property, 10 per cent. ; artisan dwellings, the remainder, including an undue proportion of the well-to-do artisan, the poorer artisans being in Walmgate district,"

Of the greater portion of the Walmgate district we learn from Mr. Rowntree's book on "Poverty" that 69*3 per cent, of the inhabitants are living in poverty ; there are many casual and unskilled workers, and, on the other hand, a number of artisans, many of whom would be living in better districts but for their unsteady habits. The district comprises some typical slum areas. Many of the yards and courts are unpaved; and brick ash-pits and midden privies, cleared only at rare intervals, abound.

Another illustration, this from Dublin. Sir Charles Cameron, the medical officer of health, arranges the mortality of the inhabitants according to the social position of the family in which the death occurs.

INFANT AND CHILD MORTALITY. ii

Class I is called " the professional and independent class."

Class 2 " the middle class."

Class 3 " the artisans and petty shopkeepers." Class 4 " the general service class." In 1903 the deaths of children under five years of age constituted 28*3 per cent, of all the deaths in Dublin.

An analysis of the census returns and of the mortality returns shows :—

Class I. Class :. Class 3. Class 4.

Number of living children under five years of age, expressed as a percentage of the total population at all ages in each class, at the last census.

N umber of deaths of children under five years of age, expressed as a percentage of total deaths at all ages in each class in 1903.

5-4

6-2

8-5

38-6

41 "4

In Croydon, Dr. Richards found that based on the returns of 1900-3, the mortality of infants among the more affluent of the population was 55, among the artisan section of the community, 156 per 1,000 births.

Certain fatal diseases are peculiarly associated with infancy. " Wasting diseases " was responsible for 45 deaths per 1,000 births in England and Wales in 1904 ; diarrhoeal diseases, 32 ; meningitis and convulsions, 16 ; pneumonia, 12 ;

bronchitis, ii ; tubercular diseases, 6 ; whooping cough, 6 ; and measles, 3.

" Wasting diseases " formed the cause of 56 per cent, of the deaths of infants under three months of age in this country in the year we are considering, and quite overshadows in importance the other fatal ailments.

Of the children aged three to twelve months, diarrhoea claimed a large number of victims.

Of the fatalities among children aged six to twelve months, respiratory affections — pneumonia and bronchitis — are second only to diarrhoea in their frequency, and with this, as might be expected, we find an increasing mortality from measles and whooping cough. A fatal termination to these latter diseases is not uncommonly due to exposure resulting in respiratory complications.

The following table illustrates the variations in the incidence of certain fatal diseases of infancy in rural and urban counties : —

Infant Deaths per 1,000

Births, 1904.

Wiltshire.

Lancashire.

Durham.

Total infant mortality Wasting diseases .

Respiratory affections' Diarrhoea Meningitis and convul

sions .

Tubercular diseases

47 38 43

19 8

160 » 55

33 87'

S

' Whooping cough has been included .

" According to the 1901 census, in Lancashire, 167, and in Durham, 47 per cent, of the married or widowed women were engaged iu occupations.

Being in great measure a preventable disease, it is very unsatisfactory to see the large part that diarrhoea plays in swelling our infantile mortality returns, and its greater frequency of late years.

This is well seen in the following table : —

Average Deaths from Diarrhcea per 1,000 Births.

Group of

Males.

Females.

Counties.

1873-7?.

1899-1903.

1873-77.

1899-1903.

Urban Rural

22 11

36 18

39 18

19 9

31 14

35 16

We see a great increase in the cases of fatal diarrhoea in both groups of counties, but the change is more marked in the urban than in the rural counties. The increase is probably due to the greater prevalence of artificial feeding, and will be referred to later in this connection.

A lessened mortality among infants from bronchitis, meningitis, and convulsions during the last quarter of a century is to be noticed ; the increase in immaturity, and the greater fatality of diarrhoea and pneumonia are in great part responsible for the somewhat stationary position of the death rate among infants.

The increase in the deaths certified as due to prematurity, congenital defects, and injury at birth is in all probability a real and not an apparent one, but the extent of this increase is difficult to establish, because still-births are not registered in England, and it is quite possible that of late years a certain number of infant deaths are correctly returned as deaths from prematurity, etc., and are registered, which in earlier years would have been passed as still-births.

The registration of still-births, and of the occupation of mothers in all cases of child-birth would aid materially in determining more exactly the extent of immaturity, and also the association of certain conditions of life with these abnormal endings to pregnancy.

In Stockport in 1904 there were interred iig still-born children : of these, 74 were certified by medical practitioners, 16 by mid wives, and 29 were interred with no certification.

In the same year there were registered in that town 2,566 births : the proportion of still-births was therefore 46*3 per 1,000 live births. If this rate applied to the whole of England and Wales in 1904 it would mean that upwards of 44,000 lives were so lost. If to the number of still-births be added that of the abortions and miscarriages which annually occur, with what a huge array of wasted pregnancies are we faced.

Thus, in brief review we have considered the chief causes of the deaths of infants, and we have seen that for each disease there is a higher case mortality in urban than rural areas.

Further, we have seen that excessive infantile and child mortality is a class symptom, that the lower the social scale in which the parents live the greater is the proportion of deaths among their young. Such conditions are not inevitable and the remedies are known.

Chapter II. The Infant

The long period of helplessness which characterises infancy is an interval of human life which teems with possibilities. Within it we may modify much that is faulty, yet ignorance and carelessness may also controvert the normal and produce the abnormal.

It is not sufficiently appreciated that although birth is not the beginning but the continuance of life, nevertheless, it is a radical change for the infant when he ceases to be a dependent and has to rely upon his own organs for the assimilation of nutriment.

We may fairly consider the early weeks after birth as a probationary period, a prelude to future vigour or weakness, and the infant during this time demands extreme care. The infant of to-day must have greater care shown for his welfare than has been the custom of the past, for the decline of the birth rate makes each infant life the more valuable to the nation.

We do not here make any analysis of the causes of this decline, and refer to it only for the purpose of pointing out that the seriousness of it lies, not only in the actual decline and the significance of the causes, but also in the absence of a commensurate saving of h'fe amongst the infants to neutralise this lack of births.

And if it were this only that we advanced as the reason for attempting a greater saving of infant life, it is sufficient to justify whole-hearted work ; but further, the remedial measures we may adopt for the saving of life will also prevent the incidence of many of the ailments and diseases of children which, to-day, strain the resources of hospitals and charitable societies.

The infant is a " bundle of potentialities," a body with unknown and unseen conditions of, and for, good or ill health.

By the time of birth forces acting prior to this have done their best or worst, and all that we can now do is to encourage the former results or to modify the latter as far as human science and art are able.

It might be thought unnecessary to point out the importance of ensuring attention to the infant at birth, yet there is a great lack of care at this time.^ To instance this in one particular, we are told that nearly one-half of the children in blind schools are suffering from loss of sight as a sequel to ophthalmia of the new-born, a disease which can be easily prevented or treated.^

' During the second quarter, 1906, 41 per cent, of the births in Glasgow were attended by " women of whose training one knows nothing" (Dr. Chalmers).

" Evidence " Inter-departmental Committee on Physical Deterioration," Q. Sag.

I.P.S. c

Of late years there has been an increasing tendency for the infant to be deprived of its natural food — the mother's milk. This is to an extent wilful, but in part owing to physical inability, and again in part due — in industrial districts — to the factory employment of married women.

Dr. Hall, of Leeds, considers that more than 80 per cent, of English mothers do not suckle their infants.^

Dr. Holt says, "Among the well-to-do classes in New York and its suburbs, of those who have earnestly and intelligently attempted to nurse, not more than 25 per cent, 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 first year is almost a phenomenon. Among the poorer classes in our cities a marked decline in nursing ability is also seen, although not yet to the same degree as in the higher social scale.""

There is no doubt that many women who do not, could nurse their babies. Thus the writer is told by M. Morel de Villiers it was found at the " Goutte de Lait " in Dijon that 70 per cent, of the children brought there between June, 1904, and January, 1905, were artificially fed. Recognising the law of nature that a mother should feed her infant, voluntary lady helpers visited the

* British Medical Journal, 1905, vol. ii. p. 932,

' " Diseases of Infancy and Childhood," Holt, p. 165.

homes of these mothers, gave advice, and appealed to the best feelings of the women, and the result was that with an increasing number of children attending the " Goutte de Lait" in the succeeding seven months only 48'9 per cent, were fed artificially.

Encouraging results have attended the efforts of MM. Blin et Blin at their works in Elbeuf. Prior to April, 1904, none of their married workwomen fed their infants at the breast. The employers then announced their intention of depositing in the savings bank 100 francs for each of their employees who would nurse her infant for twelve months. In fifteen months — that is, by September, 1905 — this venture resulted in 37-5 per cent, of the infants being breast-fed.

In an investigation of 1,008 infants among artisans in Ipswich, 62"8 per cent, were breast-fed and 8 per cent, partially so. Of 296 successive children in the lower working order 266 were entirely breast-fed, and of 202 amongst the better woi-king class 134 were breast-fed.

Dr. Richards found in Croydon, in 1903, from an investigation of over 1,000 infants under six months of age in the artisan class, 58 per cent., and in 1904, 63 per cent, were entirely breast-fed.

Enquiries at lying-in hospitals reveal the fact that probably not more than 10 per cent, of the mothers cannot suckle their children.

This is borne out by certain continental observers, who maintain that 90 per cent, of all

c 2 mothers are capable of nursing their children, at least for the first few months.^

In a letter to the writer a lady says : " I know many mothers among my own friends, I am sorry to say, who did not at first want to nurse their babies, but who, on being persuaded by their doctors to do so, were as reluctant to give it up as they had been to begin."

Human milk has a definite composition differing from that of the milk of domesticated animals, and is peculiarly suited to the needs of the infant. /

The infant, different to the adult, requires in its food the wherewithal, not only to repair waste, but also to build up new tissue; and this need varies in degree and kind, week by week, possibly day by day. To meet this varying need there are certain chemical changes in the human milk, a refinement of variation which man cannot fully accomplish in artificial dietaries with other milk as a basis. Given a healthy mother with a good supply of satisfactory human milk no adaptation of other milks can produce the same favourable result in an infant.