As to the causes for this decreased rate, opinions seem to vary cording to the view point of the person expressing the opin- ion. For example, the Board of Education officials were inclined to attribute it to the greater educational advantages enjoyed by the mothers through the establishment of their infant welfare centres. Improved sanitation is considered by others to have had great effect. Others again consider that the national campaign against venereal disease had probably had a considerable share in it ; others the lessened employment of women in factories, and yet others the weakened strength of alcoholic beverages. Practically all these sug- gestions, as anything more than simply contributory to causation, are discounted by the fact of 1912 being so much lower than the years preceding and following it up to 1919.
The mortality rate in the case of illegitimate is very considerably higher than in the case of legitimate babies. In London during 1919 the total deaths of legitimate babies in 1,000 births was 77; in the case of illegitimate babies the total number was 233. This was the case in every area in the United Kingdom as the following table shows :
Infantile deaths from all causes in proportion to 1,000 births.
London County Boroughs . Other Urban Districts . Rural Districts All Urban Districts
All Infants
Legitimate
Illegitimate
85-30 98-62 85-69 80-46 9I-25
76-57 92-56 81-88
76-57
85-48
232-91
I95-27 I53-6I 136-16 182-68
This higher rate of mortality is maintained in practically every cause of death, the exceptions being that in London and other urban districts fewer deaths from whooping-cough occurred in the ille- gitimate babies, and in country districts fewer from tuberculous meningitis.
If we take the three main reasons for infantile death-rate, viz. : diarrhoea and enteritis, syphilis, and premature birth, we find: Deaths from diarrhoea and enteritis, proportion per 1,000 births.
London County Boroughs . Other Urban Districts . Rural Districts All Urban Districts
All Infants
Legitimate
Illegitimate
12-49
8-96
6-51
4-74 8-46
52-96
28-55 18-89 9-91
27-82
Deaths from syphilis.
London County Boroughs . Other Urban Districts . Rural Districts All Urban Districts
All Infants
Legitimate
Illegitimate
2-IO 2-56
1-37 0-86 1-99
1-18 1-84 0-91 0-48 1-35
I7-58 14-03 8-42 5-41
12-12
The infantile mortality from syphilis in 1919 was still higher than before 1917, when it underwent a sudden and considerable increase, though it was still not so high (at 1-76) as in 1917, when it reached 2-03 per 1,000 births.
Taking birth conditions generally in 1919, i.e. injury at birth, congenital malformations, premature birth and atrophy debe, and marasmus, we find :
London County Boroughs .... Other Urban Districts Rural Districts ..'... All Urban Districts ....
Legitimate
Illegitimate
7-86 9-28
8-77
8-57 8-85
20-51 17-47 H-75 14-64 16-74
The rates for illegitimate children followed the same lines roughly as the legitimate ones, viz. : the death-rate increased from south to north, being generally lowest in the residential towns of the south, and highest in the industrial towns of the north. For infants of both sexes jointly the mortality varied during 1919 from 108 deaths per 1,000 births in the county boroughs of the north to 64 in the rural districts of the south. In rural districts, however, it is quite common for infant mortality during the first four weeks of life to be higher than the urban mortality. This is of course because environment conditions other than those of birth itself have not had time to tell. This increased rural mortality is very rare after the first month of life. The birth risk in the rural districts of the north was certainly at its maximum, for much the highest rate for the first day was re- turned by those areas. There was a similar rural excess during 1919 in Wales, though not in other parts of England, so that if defective midwifery in remote districts is the cause, it does not seem to apply to the Midlands and the south of England. In 1917, on the other hand, first-day mortality was in excess in all the rural districts with the excess still greatest in the north.
Two former causes of infantile deaths that have been tending to disappear altogether, are rickets and tuberculous meningitis.
Indeed the marked fall in the mortality of age period 0-5, which necessarily includes mortality of children under one year, from tuber- culosis generally, is very noticeable, and was greatly accelerated during 1919. Formerly it was the highest at any age, but it is now exceeded by most of the adult life periods.
Infectious Diseases. The infectious diseases which influence the infantile death-rate are measles, scarlet fever and whooping-cough. With regard to measles, the death-rate of 1919 was by far the lowest ever recorded. It was much the greatest in the north of England, and since 1912 it has been noted as being the greatest in the large towns. Thus Cumberland, Durham, Northumberland and the North Riding, all in the north, showed the highest mortality, and in spite of the low mortality-rate in the country generally, Middlesbrough and Rother- ham remained very high. The total deaths from measles in children under one year in 1919 was 650, or 1-05% of the infantile deaths.
In the case of scarlet fever, the same high mortality occurs in the north in all areas whether country or town, compared with the south and with Wales; Birkenhead, Bootle, St. Helens and Liverpool head the list as they did in the previous year. The total deaths from scar- let fever in infants under one year for 1919 was 32, or -051 % of all infantile deaths.
The death-rate from whooping-cough was the lowest ever re- corded. There was a marked excess in the case of females, which is constant. The proportion of infantile deaths to the total number of deaths from whooping-cough naturally fell with the diminished birth- rate, but it is a curious fact that it was higher in rural districts than in small towns, and in small towns than in county boroughs. The cause of this persistent characteristic it was impossible at present to discover. It was not shared by measles, which was the only other infectious disease causing infantile mortality to any marked extent. The total number of deaths from whooping-cough under one year was 1,054, or I '7 % of all infantile deaths.
Enteritis and Diarrhoea. Diarrhoea as a cause of death is grad- ually disappearing from the British returns. This is also the case with tubercle and convulsions. The mortality ascribed to tubercle in 1919 was less than one-third, and convulsions less than one-half of that so returned 14 years earlier. In the case of these two latter diseases it is probably very largely one of nomenclature, whereas in that of diarrhoea it presumably represents in the main an actual decrease of mortality. During 1919 there was a lower infant mor- tality from diarrhoea and enteritis than ever before, except in 1912, when there were remarkably favourable weather conditions, even better than those in 1919. In 1911, a year with an almost tropical summer, the infantile deaths from these causes were 3 1 ,900 compared with 6,039 in 1919, the total infantile deaths being 1 14,600 and 61,715 respectively.
Syphilis shows a steady decrease compared with the startling rise in 1917, but it had not yet in 1919 attained its pre-war level as a cause of infantile mortality. As in the two previous years, mortality from syphilis was in considerable increase in the north.
Developmental and Wasting Diseases, notwithstanding an increase in 1919 in the first month, showed in that year the mortality of 10-3 per 1,000 births, the lowest ever recorded for England and Wales. By far the most important increase was that due to premature birth. This accounted for 59 % of the total increase of mortality during the first four weeks of life. Injury at birth also showed a considerable rise, which increase was entirely confined to male infants, whose mortality had risen from I -II to 1-34, whereas that of females had remained stationary at 0-85. As the British Registrar-General says : " It looks as if the infants born during 1919 were for some reason exceptionally susceptible to death within the month." This cause of infant mortality was, like so many others, excessive in the north of England, and mainly in the rural districts where it caused a mortality of 1-91 as compared with l-ll for the country at large. Rural mor- tality from birth injury was high, and as the health and general condition of the mothers is likely to be better than in towns, it looks as if defective midwifery might be at least a contributory cause. As higher mortality is attributed to premature birth in the north as a whole than elsewhere, the facts of the greater industrial employment of married women in the north might be pointed to as a cause, but mortality from this cause declined during the early part of the war, reaching a minimum in 1916, and increased after the war together with the increased employment of women. Speaking generally, it looks as if a baby born north of the Wash had less chance of sur- viving than if it were born in the south.
" Overlying." This cause of infant mortality deserves separate mention. It was very much lower in 1919 than it had ever been be- fore, being 0-76 per 1,000 births, or less than half of what it was a few years before the war. But Dr. W. A. Brend throws some doubt on this as a genuine cause of death. See Health and the State, 1917, as well as Inquiry into the Statistics of Deaths from Violence, 1915, in which he shows that there is no connexion between overcrowding and deaths from overlying, and that the seasonal variation follows that of bronchitis and pneumonia, being considerably higher in the first and fourth quarters of the year than in the second and third. This is borne out by the figures furnished by the Medical Officers of Health for Liverpool and Birmingham for 1919 and 1920. Thus in Liverpool in 1919 there were 18 deaths from this cause in the first and fourth quarters, and 7 in the second and third; and in 1920, 17 and 6 respectively. In Birmingham in 1919, the figures were 23 for
