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9
Report of the County Medical Officer—General.

In order to gauge correctly the precise character of the change which the figures relating to the
years 1903 to 1914 (shown in the table at the top of page 8), represent, it is desirable to eliminate from
them, as far as possible, the causes of death which, while varying greatly in incidence from
year to year, do not in the main imply any corresponding periodical changes in the
healthiness of the children; the principal causes of death thus eliminated are deaths from infantile
diarrhoea or "summer diarrhoea" (which is influenced by the summer temperature), and the common
infectious diseases, the incidence of which among infants varies, of course, mainly with the ever-changing
prevalence of epidemics among older children.
These diseases having been eliminated, the remaining causes of death may be roughly classified
into such as can be more immediately attributed to pre-natal (or natal) influences, and those which
may rather be regarded as acquired or developed after birth. In the pre-natal group there is comprised
premature birth, congenital malformation, atelectasis, syphilis and injury at birth, and also (as
probably resulting from unhealthy condition of the mother) want of breast milk, atrophy, debility
and marasmus. In the second group, the stated causes of death are tubercular disease, rickets, meningitis,
convulsions, bronchitis, pneumonia, suffocation and overlaying; finally there is a group of
less important unspecified causes of death.
The years covered by the table may be divided into two periods, namely 1905-1908, when the
decline in the infant mortality after elimination of the causes of death above referred to was scarcely
noticeable, and 1909-1913, when it was very marked*; it will then be found that the causes of death
here regarded as mainly pre-natal show a relative increase, being 48 2 per cnt. of the total in the first
period, as against 514.per cent, in the second, while other specified causes declined from 42.4 per cent,
to 39.7 per cent., and the miscellaneous unspecified causes from 94 per cent, to 8.9 per cent.
The figures do not show any very striking differences when the vagueness of some of the terms
under which the deaths are certified are borne in mind; yet so far as they gor they seem to indicate
that there had, up to 1913 at any rate, been a somewhat greater improvement in the post-natal influences
affecting the health of infants, than there had been in the circumstances affecting their condition at
birth.
A further point relating to the assignation of the cause of death deserving of special notice is the
remarkable change in the number of deaths assigned to premature birth which has occurred since 1871.
The death-rate from premature births per 1,000 births recorded in London in successive periods of
five years has increased from 103 in 1871-1875 to 18.7 in 1906-1910, and the mortality rate from
atrophy and debility has almost correspondingly diminished.
The question thereupon arises, has there been an increase in prematurity, and has the mortality
from this cause risen in consequence, or is the increase shown merely due to gradual change in assignment
of the cause of death ? A prematurely born child is undoubtedly very liable to die from atrophy
or debility, and a decision as to whether the prematurity of birth or the subsequent atrophy was the
initial cause of death must largely be a matter of personal opinion or local practice. In a lesser degree
the same doubt may arise in regard to other causes of death which follow prematurity It seems to
be a matter of great doubt as to whether premature births are proportionately more frequent new than
formerly, or have since 1871 undergone any such change in frequency as might be deduced from the
deaths recorded under this heading.
Since 1910 two circumstances affecting the statistics relating to infant mortality have, moreover,
to be taken into account. Firstly, the adoption in 1911 of the International Code for classification of causes
* The year 1914 is omitted, as the European War may in some measure have affected the continuity of the
figures.
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