the first and fourth quarters, and 10 for the second and third; in 1920 they were 16 and n respectively. The fact of expert patholo- gists very rarely finding overlying a cause of death, but some other quite different cause, such as pneumonia, lends some support to Dr. Brend's contention.
Housing is a most important condition of infant mortality. Where there is most overcrowding, there is the highest death-rate. Of all children who die in Glasgow before they complete their fifth year, 30 % die in houses of one room, and not 2 % in houses of five rooms and upwards.
Vital Statistics of Large Towns: London. We find that the London infant mortality rate in 1919 was 85 compared with 108 in 1918. The birth-rate was 18-2 compared with 16 in 1918.
The following table published in the report of the Medical Officer of Health for London shows very clearly one great cause of lessened infantile mortality in cool summers and mild winters :
1911
1912
1913
I9H 96
79 127 109
1915
1916
1917
1918
1919
ist quarter . 2nd "
^ .',' ' ' 4th
108 89 203
"3
95
82 81 103
116 81 105 "5
in 93
113 126
92
73 82
i3
"5 85 88 114
125 90
85 "7
118 7 72 76
The high figure in the first quarter of 1919 was due to influenza. The third quarter was the lowest ever recorded and may usefully be compared with the third quarter of 191 1 when the heat in the latter part of the summer was almost tropical. The factor which mainly contributed to the low death-rate was the remarkably small number of deaths from measles and whooping-cough, which were 55 and 72 respectively as compared with 276 and 498 for 1918. Diarrhoea however showed an increase, there being 1,217 deaths, as compared with 970 in 1918, which was due to a period of high temperature late in the summer.
The number of deaths of nurse infants during 1919 was only 51 as compared with 103 in 1918. Foster-mothers were encouraged to take their children to infa/it welfare centres, and visitors followed up to see if the advice given had been carried out.
It is interesting to study the incidence of infant mortality in the different boroughs of the County of London. For example, the highest rates in 1919 were in Kensington, Shoreditch and the City of London with 102, 106 and 115 respectively. The lowest three were Lewisham with 62, Wandsworth with 72 and Battersea with 74, the rest varying from 81-99 per 1,000 births.
The deaths from enteritis and diarrhoea were greatest in Kensing- ton, Hammersmith and Bethnal Green with 30-5, 29-8 and 26-5 re- spectively, and lowest in Lewisham, Woolwich and the City of London with 5-6, 6-6 and 7-2 respectively. The highest birth-rate was in Poplar with 24-7 per 1,000 of population, and lowest in the City of London with 9-6. These two districts had very nearly the same infantile death-rate, 14-5 and 14-3 respectively.
Birmingham. The infantile mortality-rate in 1919 was 84, and in 1920 even lower, viz.: 83. This diminution is most striking in the poorer parts of the city. Thus St. Mary's Ward, which for many years held the record for a high infantile mortality, had a mor- tality of 103, or a drop of 80 as compared with the rate for the years 1912-18 of 183.
An interesting table showing the total infantile mortality rate and the rate with diarrhoea and enteritis taken out is given below. It is really put in to show that the diminution is not due only to cool summers, but it is a very striking evidence of that atmospheric effect as a contributory cause. Thus in 1911 there was a mortality rate of 47 per 1,000 from this cause, and in 1912 a rate of 9 only this was a year with a very cool summer. It is true that this rate was exceeded every year since, though it never approached 1911, till 1919 when we have a further drop to eight.
Total
mortality
rate
Infant mortality less diarrhoea and enteritis
Deaths from diarrhoea and enteritis per 1 ,000
1911 1912
1913 1914
1915
1916
1917 1918 1919
ISO in 129
122
118 104
IOI
99
84
103
102 100
IOO
95 90
89
84 76
47 9 29
22 23 H 12
' 8 5
There can be little doubt that after the appalling rate of 191 1 all varieties of infant welfare work were pushed forward and were sub- sequently beginning to tell, but it seems impossible to doubt that the absence of tropical heat must certainly be given credit for part of it. It remained to be seen what would happen in the event of great sum- mer heat occurring again. The illegitimate death-rate was 177 com- pared with 84 amongst the total births, i.e. over a double rate, very much the same as is shown in most other tables. An analysis of the figures of total deaths in infants under one year shows the effect of the colder parts of the year.
In 1919 during the 1st quarter of the year 554 infants died. " " 2nd " 291 "
" " " 3rd 315
" 4th " 470
1,630
Liverpool had in 1919 a considerably higher birth-rate than the average of the great towns, being 23^9 per I, coo of population com- pared with 19, and at the end of 1919 the birth-rate was going up. The infantile death-rate varied from 136 to 81, giving an average for the city of no. Examination of the figures for the first 20 years of the century shows in common with all other figures examined in other places a marked drop in 1912, with a slight rise in 1913, 1914, and 1915, and a distinct fall for 1916, 1917, and with a slight rise for 1918, and a still lower rate (by far the lowest on record) for 1919.
The statement is made, and is often borne out, that a high birth- rate means a high infant mortality rate. This is not so in certain districts of Liverpool. For example, in the Everton district there were 3,240 births with a death-rate per 1,000 births of 109, whereas in the Exchange district, with 922 births, the death-rate was 127. On inquiry we find that the Everton district is the most densely populated district of the city, containing 176 persons to the acre, but the inhabitants are of the respectable artisan type, such as railwaymen, carters, painters, etc. The houses, although small and closely aggregated, 'generally contain six rooms with a small back- yard, and are of a better type than those found in Exchange district, which is one of the oldest districts in the city, and is closely populated mostly with persons of the labouring class. The men are employed to a great extent about the docks and many of the women are hawkers and such like. Nearly 40 % of all infant deaths takes place within the first four weeks.
There has been a marked decrease in drunkenness among women, due in part to restricted hours, but probably also to the weaker nature of the beverage, as well as to better wages which mean better food and improvea conditions generally. No woman is noted as having died from excessive drinking in 1919, whereas 50 died in 1914, and 38 in 1915.
Speaking generally, it is the experience of the United Kingdom that infant mortality, though steadily going down, was in 1921 still far too high, but there was probably an irreducible minimum which might be taken as somewhere about 30 per 1,000 births, and might be regarded as accidental and to a large extent unavoidable. In Liverpool, for example, the deaths noted in 1919 under congenital malformation were 56 out of a total number of births of 2,055, or death-rate of 27 per 1,000.
The lines on which we may expect further diminution are many, and cannot be regarded as due to any one cause, or group of causes, such as sanitary improvements or climatic conditions. The quicken- ing of late years of the public conscience upon the subject, as well as the increased value put on all infant life owing to the immense loss of life during the war, have a very large share in the diminution of infant mortality.
REFERENCES. Report on the Physical Welfare of Mothers and Children (England and Wales), vols. i. and ii., Carnegie United Kingdom Trust; Reports of the Medical Officers of Health for the Cities of Birmingham, Liverpool and London, 1919; Report of the Registrar General of Births, Deaths and Marriages in England and Wales for /pip (Cd. 1017); Report on Food Conditions in Germany with Memoranda on Agricultural Conditions and Statistics, 1919 (Cd. 280); Princess Bliicher, An Englishwoman's Life in Berlin during the War; W. A. Brem, Health and the State; W. A. Brem, An Enquiry into the Statistics of Deaths from Violence; Maternity and Child Welfare, vol. iv., 1920; Annual Report of the Chief Medical Officer of the Board of Education, 1919 (Cd. 995) ; Sir George New- man, An Outline of the Practice of Preventive Medicine (Cd. 3631); Maternal Mortality in Connexion with Childbearing and its Relation to Infantile Mortality (Cd. 8085). (J. WA.*)
UNITED STATES
Although accurate statistics of infant mortality in the United States were lacking until recent years, practical interest in the subject was shown as early as 1893, when Nathan Straus estab- lished infant milk stations in New York City for the purpose of providing pasteurized milk for infants. After that time there were sporadic efforts in various parts of the country to protect infants. Municipal or state effort was unknown until 1908, when the City of New York established the Bureau of Child Hygiene. On April 9 1912 the U.S. Government established the Children's Bureau under the U.S. Department of Labor, one of whose functions was to investigate matters relating to infants' welfare. Between that time and the end of 1921 35 states established bureaus or divisions of child hygiene, and such municipal organizations for the same purpose became common. In addition to these Governmental enterprises, private and semi- private organizations did excellent work in many communities.
