Improvement in child welfare has occurred as the sanitary and social progress of the country has advanced. Whereas in the decade 1871-80, when money began to be spent more freely on elementary sanitary reform, the expectation of life or mean after-lifetime at birth of males was 41.4 years and of females was 44.6 years; in the years 1910-12 these had increased to 51.5 and 55.4 years respectively. The greater part of the saving of life which this addition of ten years to the average duration of life was the result of reduced mortality in children under five years of age.
The first direct steps towards the reduction of infant mortality were directed against epidemic or summer diarrhœa. Medical officers of health have always been required in their annual reports to summarize the vital statistics in their districts; and since 1905 a more detailed statement of infant mortality during each part of infancy has been required. Annually, therefore, as well as when they received the weekly returns of deaths from the local registrars, there was forced upon their attention the fact that deaths of infants under one year of age formed a high proportion of total deaths at all ages (12.9 per cent. in 1917), and that of these infantile deaths a large proportion were caused by diarrhœa, the number varying with the temperature and the deficiency of rainfall in the summer months. In 1912, a year of relatively small mortality from diarrhœa, this disease caused 8.1 per cent. of all deaths under one year of age.
For many years past it has been customary for medical officers of health to issue warnings as to summer diarrhœa, to arrange for the distribution of leaflets of advice concerning the disease, and to urge the necessity of more thorough cleanliness both municipal and domestic during the summer months. Even before the early notification of births became obligatory, in many areas the addresses of infants were obtained from the registrars of births and special visits were made to the mothers of infants during the months of June and July and especially to the mothers of those infants who were known to be artificially fed.
The reports of medical officers of health of many of the large towns from 1890 onwards show that much valuable work was being accomplished, and the way was being prepared for more general measures against infant mortality.
The importance of municipal sanitation in aiding the elimination of diarrhœal mortality is illustrated in the experience of many towns, and strikingly by the comparative experience of Leicester and Nottingham. The chief difference between the sanitary condition of the two towns was that in Nottingham in 1909 pail closets still served more than half the houses, while Leicester had abandoned this system entirely, substituting water-closets. Between 1889-93 and 1909 the diarrhœal mortality in Leicester had declined 52 per cent.; in Nottingham it had only declined 4 per cent.
Diarrhœa is not the only disease of infancy which can be greatly diminished by improved public health administration. Tuberculosis and whooping cough and measles figure largely in the infantile death returns. Over 21 per cent. of the total deaths in infancy are due to these three diseases and to diarrhœa. The amount of syphilis appearing in the death-returns is small; but its actual amount is much greater than the figures show. If pneumonia and bronchitis, which account for 19 per cent. of the deaths in infancy, be regarded—as they should—as infective diseases, then it may be said that the problem of saving child life and securing the correlative improvement in the standard of health of children who survive to higher ages, consists very largely in the prevention of infections, including diarrhœal diseases and acute respiratory diseases.
It follows from this that even if the limited and erroneous view be taken that Sanitary Authorities are concerned only with the prevention of infectious diseases, the reduction of infant mortality is a duty devolving on these authorities, and cannot be effectively carried out without their coöperation. Voluntary effort must therefore always, in large measure, be directed towards stimulating local authorities to perform their duties.
The influence of diarrhœal summer mortality on the progress of child welfare work is further shown by the fact that among the earliest efforts were those to provide pure cows’ milk to infants. In England official Milk Depots for this purpose were never numerous; and little voluntary effort went in this direction. There now remain very few such Milk Depots; but many local authorities provide milk, more particularly dried milk, to infants for whom it is specially prescribed at Infant Consultations. Early investigations at Brighton and elsewhere showed that the mortality of infants fed on condensed milk,—chiefly of the sweetened variety,—was greater than that of infants fed on fresh cows’ milk, and directed attention to the supreme importance of domestic cleanliness in the prevention of summer diarrhœa. The Milk Depots and the concurrent agitation for purer cows’ milk served a useful purpose; though it cannot yet be said that the cows’ milk ordinarily supplied in England is satisfactorily clean.
It became evident ere long that the broadcast distribution of instructions as to how cows’ milk might safely be stored and prepared for infants had but a limited utility, and that the directions given were liable to be misinterpreted by mothers as an encouragement to abandon breast-feeding; and there is reason to believe that these directions did sometimes have this effect. Hence the importance of the work initiated by the late Dr. Sykes at the St. Pancras School for Mothers, which brought into relief the importance of encouraging breast-feeding by every possible means. In towns in which the aided supply of milk was continued, advice as to its use was also initiated; and thus gradually Infant Consultations, in which the main element was the giving of individual advice and treatment as required, superseded Milk Depots, and were established in very large numbers where Milk Depots had never been started. These had educational as well as medical and hygienic activities; and there need be no dispute as to the relative value of these two aspects of the work of Infant Consultations (also known as Schools for Mothers, Child Welfare Centres, Baby Weighings, Mothers’ Welcomes, etc.); for whether advice and instruction are given to the individual mother or to mothers collectively,—or as is advisable in both ways,—it should be exactly the advice which a physician skilled in the hygiene of infancy as well as in the treatment of infantile complaints would give to his individual patient. In this sense it remains true, as Professor Budin, the distinguished founder of Infant Consultations said: “An infant consultation is worth precisely as much as the presiding physician.” This is true whether it is possible to arrange for a physician to be present at each meeting of a Child Welfare Centre; or whether, as has happened during the Great War in England, nurses or health visitors trained under such a physician have given hygienic advice in his absence.