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28th Aug 2020

A Proper Diet for Nursing Mothers

Volunteer researcher, Anne, continues to share her findings on the growing emphasis of nutrition and the ideas put into practice through the development of a network of infant welfare centres across the city.

Mothers were encouraged to attend sessions at Infant Welfare Centres at least once a month. Apart from consulting a doctor about an ailing baby and having a baby weighed, there were sessions on the education of infant care and infant management – influencing young mothers away from the ancient customs and claims of superior experience and knowledge on the part of their grandmothers, mothers and neighbours which often prevailed. At these centres, nutritious dinners were often provided to nursing and expectant mothers.

Nursing mothers were encouraged to maintain a proper diet; the quantity and quality of the mother’s milk was dependent upon the kinds of food she ate and her general health. In Mothercraft for School Girls, 1914, published by Macmillan and Co¹, the best foods for a nursing mother were as recommended:

“Suitable foods for nursing mothers should be plain, nourishing and digestible, such as home-made brown and white bread, butter or margarine, cheese, eggs, soup, fresh fish (boiled or baked), boiled, stewed or roast meat, bacon, well cooked fresh vegetables, fresh fruit, boiled suet puddings, milk and milk puddings (such as rice, sago, tapioca, etc.), cocoa, gruel and porridge.’

“Unsuitable foods – Indigestible foods should not be taken, e.g. tinned foods, pickled foods, all kinds of sauces, all seasoned dishes, stuffing, curries, faggots, fried fish and chips, pork, new bread, new cakes, beer, stout, spirits, and too much tea. All these are liable to produce indigestion, alter the quality of the milk and upset the baby.’

¹ Mothercraft for School Girls, 1914 by Florence Horspool, published by Macmillan and Co – The Wellcome Library

Anne Hornsby

3rd Aug 2020

Sir Leonard Gregory Parsons, (1879 – 1950)

In this week’s blog, Alison looks at one of the many leading contributors in the field of paediatrics.

Parsons was born and brought up locally and attended the King Edward VI Grammar School in Birmingham. He initially studied zoology at Mason College in Birmingham, but graduated with a University of London external degree in medicine in 1903. Parsons was soon working at the Children’s Hospital in Birmingham as a clinician and researcher, and later a lecturing post in the diseases of children and paediatrics was created for him at the University of Birmingham. Following service in Salonica in World War 1, he returned to resume duties at the Children’s Hospital.

Sir-Leonard-Gregory-Parsons — *Sir Leonard Gregory Parsons by Walter Stoneman, bromide print, 1946 – with kind permission from the National Portrait Gallery.*

In 1932 Parsons was the first to use synthetic Vitamin C to treat scurvy in children. Acknowledged widely within his profession, Parsons was knighted in 1946 and elected a fellow of the Royal Society in 1950.

Alison Smith

24th Jul 2020

The Importance of Sleep and Fresh Air

To reduce excessive infant mortality, theories about mothercraft were being taught to teenage girls. Practical lessons in mothercraft, held in nurseries and infant welfare centres, were attended by girls aged between twelve and fourteen (the school leaving age). Classes not only helped older girls in the day-today dealings with their younger siblings, but directed their instincts and emotions towards future motherhood. Infant welfare superintendents taught the lessons, using babies – rather than a doll.

‘Mothercraft for School Girls’ 1914¹, published by Macmillan, covered a range of topics.

On the importance of sleep and fresh air, it was suggested that a baby should sleep alone in a cot from the day it is born since a baby might be suffocated through overlaying in a bed with its parents. A baby sleeping alone rests and sleeps better because it is not disturbed by other people moving. Baby should never be rocked to sleep; it should be put in its cot and left alone; it will soon get into good habits and go to sleep.

It was noted that cots and cradles were relatively cheap, but some mothers could not afford these, so a banana crate, which was the ideal shape of a cradle was suggested, and could be bought from a fruiter for as little as 2d. The banana crate could be made into a very pretty cradle for very little money; two and half yards of green and white muslin as covering, at 2d a yard, and two yards of unbleached calico at 3d could be stitched up and filled with finely chopped straw. This would make a comfortable, clean soft bed, and could be renewed every week by emptying out the old straw, washing the cover, and filling it freshly with straw. In this way the bed, which was likely to be wetted, could be kept sweet. A banana cot was cheap, light and easy to carry up and down the stairs, where it could be placed on two chairs close to the mother’s bed at night.

Where there was a choice of rooms for the baby to sleep in, it was recommended that the room should be the most airy and sunny room in the house, and the windows of the room should always be kept open. It was essential for babies to have plenty of fresh air –“… like plants, they thrive in sunshine and air!” ¹

¹ Mothercraft for School Girls’1914, published by Macmillan.

Anne Hornsby – Born in Birmingham 1914-24 Project Volunteer

5th Jun 2020

Elizabeth Exell – the first matron of the Carnegie Infant Welfare Centre

Sandra has been concentrating her research on the Carnegie Infant Welfare Centre. The first Matron to be appointed was Elizabeth Exell.

The first Matron to be appointed at the Carnegie was Elizabeth Exell.

Born in Thornbury, Gloucestershire in 1885, Elizabeth first trained as a nurse at The Bath Royal United Hospital.

At the start of WW1 she joined the British Expeditionary Force as a nursing sister and was posted to the Hotel Claridge in Paris, and then later to a hospital in Wimereux near Boulogne.

These hospitals were unique at the time as they were run entirely by women because it was felt at the time that women were acceptable as nurses but not as doctors or surgeons! In fact many people thought that ‘hysterical women’ would be seen as a liability on the front line. A group of wealthy suffragettes banded together to raise money to enable them to form The Women’s Hospital Corps. With the help of the French Red Cross, a newly built but empty Hotel Claridge in Paris was acquired for their hospital. The women wasted no time; they acquired the building on 16 September 1914 and within 2 days were up-and-running with the operating theatre in full use, which was in good time to accept casualties from the Battle of the Marne, which took place from 6th – 10th September 1914. The Women’s Hospital Corps was so successful in running the hospital, that Royal Army Medical Corps commissioned the Women’s Hospital Corps to set up another hospital in Wimereux near Boulogne.

Elizabeth returned to England in 1917 and worked at the Endell Street Military Hospital in London also run by the Women’s Hospital Corps. Elizabeth was decorated with the British Victory Medal and the 1914 Star for her service in WW1.

After leaving the army Elizabeth moved to Birmingham as Matron at the Pype Hayes Convalescent Home in Birmingham.

The Carnegie Infant Welfare Centre, Hunter’s Road, Handsworth

In 1923, Elizabeth was employed as Matron by The Carnegie Institute for Child Welfare situated at Hunter’s Road, Handsworth. Elizabeth worked tirelessly and was respected, loved and admired by colleagues and patients alike. During her time at the centre, Elizabeth became a member of the Royal College of Nurses.

Sadly, Elizabeth died in 1933 at the age of 48 – she was found at the Carnegie Infant Welfare Centre where she lived; she suffered an aneurysm in an artery.

In November 1934 a brass statuette of a child holding a flower was unveiled in the entrance hall of the Carnegie Infant Welfare Institute in Handsworth. It was carved by William James Bloye of the Birmingham School of Art and intended to show Elizabeth’s love of children and of flowers. On the pedestal of the statue was written: ‘To Remember Elizabeth Exell 1923 who gave ten years of love and service to children’. It stood in the entrance hall of the Carnegie Infant Welfare Centre for several decades.

20200605_131218 — “Childhood” by W. Bloye (1934)

Sandra has been assiduous in attempting to track down its current whereabouts – she’s getting close but if you know where it is please do let us know.

Sandra Flynn

26th May 2020

Early training of health visitors and the development of the professional body

Birmingham was one of the pioneers of maternity care and infant welfare provision prior to the War, when health and infant welfare were delivered through a combination of voluntary and municipal schemes. Project volunteer, Jan, has used some research from the Wellcome Foundation Library to chart the development of the the professional bodies affiliated to health visiting.

At the dawn of the 20th century there were many improvements in the health of the nation, but infant mortality was still unacceptably high. There was involvement with Sanitary Inspectors but it became clear that there was a need for a professional worker who could go into homes as a friend and work with mothers and focus on child care. Health Visiting developed as a branch of Sanitary Inspection.

An early example of training was a two year course at Kings College in London. The first year included, introductory science, a study of the function of life and household science. The second year focused on hygiene, sanitary law and building construction, and practical work among infants or hospitals. There were other qualifications acceptable at this time:

Sanitary Inspectors
Midwives – Certificate of Midwives Board (CMB) often at own expense
Fully trained nurse with or without CMB
District Nurses often with only a few months hospital training

In addition, there were people who had degrees and some who were judged by their letters and grammar.

Many Health Visitors were so poorly paid in some instances that they had to take other jobs such as writing articles, lecturing or coaching students for exams.

The history of the professional body began in 1898 with the founding of the Women’s Sanitary Inspectors Association. It was based in London where there were 7 sanitary workers. By 1906 there 63 workers and an invitation to join went out to the provinces. Its aims have remained constant :

To safeguard the interests and improve the status of women public health workers and to promote the interchange of relevant and technical knowledge.

It was renamed in 1915 as the Women’s Sanitary Inspectors and Health Visitors’ Association to reflect the increase of health visitors who had joined.

In 1908, The Royal Sanitary Institute began to set examinations in Health Visiting.

In 1912, the first Provincial Centre of the Association was founded in Birmingham. It was affiliated to the National Union of Women Workers in 1918.

In 1922, the Association initiated a course of training and an examination for the Board of Education Diploma for Health Visitors.

The Ministry of Health became responsible for the training of health visitors in 1925.

In 1930, the Women’s Public Health Association was formed to reflect numbers of others working in the Public Health field. It also shared connections with parallel professions such as nursing, social work, district nursing and midwifery.

The Health Visitors Association was formed in 1962. By now the health visiting role had extended to the health of the whole family, with social as well as medical aspects.

Jan Wright

References:

Welcome Foundation Library – Manual for Health Visitors and Infant Welfare Workers. Edited by Edith Eve, formerly Chief Health Visitor and Sanitary Inspector, Holborn 1921

19th May 2020

Giving birth at the Workhouse Infirmary

Last week’s blog looked at an article in the Birmingham Gazette of 9th March 1920 linking the problems of overcrowding and poor housing to the fear faced by many young women at the prospect of having to give birth at one of Birmingham’s Workhouses. In a follow up article a couple of days later the Gazette looked at the reality of the maternity ward within one of the workhouse infirmaries.

The Infirmary at the Kings Norton Union Workhouse was opened in 1897 and in addition to general wards there was separate provision for maternity cases. Although operated by the Guardians of the Poor the infirmary was separated from the Workhouse itself by a dividing wall and they were run as separate establishments. This Gazette article of Thursday 11 March 1920 provides a detailed description of the Maternity wards and is transcribed here in full:

CARE OF MOTHERS AT INFIRMARY.

Ideal Conditions for Maternity Cases.

They speak of the need for a municipal hospital, but what, after all, is this infirmary but a municipal hospital? Why people should think it less derogatory to go to a hospital supported by voluntary contributions, where they are really receiving charity, than to come to the Selly Oak Infirmary, which they themselves have been helping, to support by the rates they have paid for years. I cannot imagine,” said Dr. Martin, the infirmary’s chief medical officer, when I talked over with him yesterday the question of the housing shortage and the consequent need of more maternity hospital accommodation.

There can be no doubt that many of the expectant mothers, much as they resent the idea of being sent on to the Infirmary after having arranged to go to the Loveday-street hospital. settled down in a wonderful way when they find what the Infirmary is really like, and express their appreciation of the care and attention they receive from the trained staff there.

Restful beauty.

I have never seen a more beautiful part of any hospital than the large maternity ward at Selly Oak, which I was privileged to visit yesterday. The bright outlook, the windows arranged to catch every gleam of sunshine, the mothers’ beds and babies’ cots, with their dainty white drapery, the banks of flowers arranged on tables down the middle of the room, combined to give a sense of restful beauty. There were polished floors, the walls were painted in soothing tones of green and fawn. Nurses in their pretty uniforms moved up and down the ward., and happy looking young mothers lay in bed, with their babies in the cots by their sides. In a second ward I saw a group of expectant mothers, sitting round a table making swabs and dressings of cotton wool.

“Any work of that sort that they do is quite voluntary.” said the doctor. “but most of those who come in a few days before the birth of their baby prefer to occupy themselves in some quiet way during their waiting time.

Paying Patients.

There was a balcony outside each large ward overlooking the beautiful garden where masses of flowering currant were bursting into bloom. Even on a cold March day the air was pleasant in these sheltered nooks, with their south aspect, and I found one or two expectant mothers resting contentedly there. ” I very much prefer having my bed out here to being indoors,” said one of these, who chatted with me very cheerfully and told me she had been a tram conductress during the war. Of the forty cases in hospital this week almost all are paying patients.

“Their payments vary, of course,” the matron informed me, “but no distinction whatever is made. The nursing, the food, and the dress are the same for all.” Every patient, when she enters the hospital, has to change her own dress for the pink uniform of the infirmary. The dresses are a pretty shade of pale pink, and look fresh and clean, but it seemed to me rather a pity that they should be insisted on. To see one patient after another dressed exactly alike spelt “institution” more than anything I came across.

” Daddy Longlegs ” type.

The small separate room where each birth actually takes place is fitted up almost like an operating theatre—the white tiles, ample hot water supply, and special lighting and heating arrangements giving all the comfort and safety possible. I was introduced to the well-stocked library of clean, nicely bound novels. “These are kept entirely for the maternity wards.” the matron told me. “and we buy just what we think our patients would like to read. You see we have quite a number by Charles Garvice and Ethel M. Dell, and they like Rider Haggard and the ‘Freckles’ series ` and books of the ‘Daddy Longlegs’ type. I don’t accept presentation volumes for this library of ours. Spurgeon’s sermons? No, thank you!”

Each floor had its own bathrooms and linen storerooms, and it’s own small supplementary kitchen, where tea could be made or milk heated at a moment’s notice. All the maternity wards are shortly to be moved to the top floor of the hospital, where an entire reconstruction is taking place, and every room is being made as perfect and up to date as it can possibly be.

Met by Proud Husbands.

The food supplied to the patients is excellent. Never have I tasted more delicious bread than that which is made in the infirmary’s own bakery. Most of the mothers and babies, I found, were able to leave at the end of a fortnight when a proud husband and father probably arrives to escort them home. I left with the impression of having spent the afternoon in a hospital of an ideal description. And yet I felt that, as the old deep-rooted prejudice against going into a Poor Law institution can never be eradicated, it would solve the problem if we could change the name of the infirmary, and, instead of patients having to apply to the relieving officer for admission. have it run as a municipal hospital under the Ministry of Health.

C. H. C.

14th May 2020

Impact of overcrowding on maternity care

‘Homes fit for heroes’ was one of the rallying cries of the working class across Britain after the First World War and housing was one of the major political issues in the General Elections of 1918 and 1920s and the local elections too. But lack of housing and high rents had an impact on maternity services too as highlighted in this emotive article from the Birmingham Gazette of 9th March 1920.

Birmingham Daily Gazette - Tuesday 09 March 1920 — Birmingham Daily Gazette – Tuesday 09 March 1920

‘Why should my baby be born in the workhouse? I don’t care how well I’m looked after there, or how kind the nurses see. I simply hate the thought of it.” This was the cry of a young married woman who, because she and her husband were among the thousands of young couples unable to get a house of their own. had arranged to go to the Maternity Hospital in Loveday-street, only to find when the time came for her to enter the hospital that there was no bed vacant, and that the authorities could do nothing but draft her on to the workhouse infirmary. She is only one of dozens similarly situated who have no choice in the matter.

Landlady Gives Notice.

“We are sending young married women to the workhouse as paying guests all the time,” an infant Welfare Superintendent told a Gazette woman. ” Many of them find the idea of going there almost unbearable, but there is nothing else to be done. Their landlady—if she is the usual kind of landlady and not an exceptionally considerate one—gives them notice, to leave their rooms as soon as she finds that a baby is expected. They find it impossible to obtain new lodgings; the high fees of the private nursing homes are beyond their means.; the maternity hospital is crowded out; so the only thing left for people who would gladly pay a doctor and a nurse, if only they could find a home of their own is the workhouse.”

Very Pathetic.

The Gazette representative then asked Mrs. Sidney Walker, chairman of the maternity hospital committee, whether anything was being done to relieve the pressure there. “We are doing what we can,” she said, ” but things are very bad indeed, and a great deal more must be done. Even the workhouse is getting crowded out. There is only room for 30 bode at Loveday-street, and it is appalling to think that that is all the provision made for a great city like Birmingham. ”

A house at Erdington has just been taken over, and one in another suburb will probably be taken shortly, where normal cases can be sent, to relieve the pressure at the maternity hospital. But there will only be room for twelve in each of these, so a great deal more accommodation will have to be found somehow.”

Some of the cases which have lately been turned away from the crowded maternity hospital have been very pathetic. Respectable people. who deeply resent having to live and bring up their children in one cramped room, plead hard to be taken in. One of these the other day was found to have only been able to get one room for herself. her husband and five children: the hospital would have admitted her if it possibly could, but there was no possibility of finding room. Another was sharing a room with a sister and a brother of 18; even she could not get into the hospital.

Piggott Street Lee Bank c.1910 — Typical back-to-back housing in Piggott Street, Ladywood c.1920

Seven in One Room.

Other astonishing cases of overcrowding which the Gazette representative came across in the course of her inquiries showed what Birmingham people are having to endure in these house less days. There was a family of seven living in one furnished room, for which they were paying 30s. a week; the family consisted of parents, three daughters of 19, 17 and 15, and two younger boys.

Birmingham Daily Gazette - Friday 01 December 1922 — Birmingham Daily Gazette 1 December 1922

A suburban house, in which there are only three upstairs rooms, is being shared by four married couples. “I do feel so for all these young people.” said Councillor Mrs. Mitchell who is also a member of the Maternity Hospital Committee. “Some of them have waited years to get married, only to find that it is still impossible to get a home. It is a shame that a city like Birmingham should have nothing better than the Workhouse Infirmary. to offer so many young mothers As a mother I can realise how terrible it must be for them for the treasured first baby to be born in a workhouse. I want to see a municipal maternity hospital established as soon as possible. To provide the housing we need is going to be a costly business but prevention is better than cure, and no matter what the houses cost it will be cheaper in the end to build them than to cope with all the disease and crime which must inevitably follow continued overcrowding.”

In our next blog we can see another article from the Gazette which follows on from this piece by looking in detail at the maternity provision at one of Birmingham’s Workhouse Infirmaries.

4th May 2020

“THE GLAXO BABY BOOK” dedicated to everyone who loves a baby

These illustrations are from the Fifteenth Edition of the Glaxo Baby Book published in November 1922. The frontispiece states that since its first publication in 1908, more than one million copies of the book had been issued. This edition runs to 150 pages, is well-indexed and includes many photographs of ‘bonnie Glaxo boys and girls’.

The story of Glaxo began with Joseph Nathan, the son of a London tailor who emigrated to Australia in 1853, at the age of 17. After a few years, he moved to New Zealand and joined his brother-in-law in a general merchandising business, becoming a partner in 1861.

In 1873, after the partnership was dissolved, Joseph Nathan and Co. was established. Strong trade links with London continued and an office there was opened in 1876.

Skimmed milk was a by-product from the Nathan dairy business in New Zealand – already successfully shipping butter to the UK – and proved a breakthrough for the family business. A purpose-built factory in New Zealand produced milk powder that was sold mainly in bulk for catering and military customers. But with the growing use of the powder as an infant food, the Nathan family changed the name of the product from Defiance Dried Milk to Glaxo brand of milk powder, a name registered in 1906.

To manage the UK promotion of the new product, Joseph Nathan brought back from New Zealand the youngest of his three sons, Alec Nathan, but it was not until 1911, during a health scare involving liquid milk, that the powdered variety was seen to be a safer alternative for the bottle feeding of babies.

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In 1908, The Glaxo department of Joseph Nathan and Co opened in London and the first “baby book” was published. The “Glaxo Baby Book” was a unique publication that aimed to answer questions from mothers about infant feeding and care. The book, which continued until the 1970s, provided practical advice from nursing staff and reflected the advances in medical and nutritional science. “Glaxo – the Food that Builds Bonnie Babies” became a familiar slogan in advertising campaigns of the time.

World War I increased the demand for dried milk and concern for the quality, safety and consistency of dried milk led to technical control improvements. In 1924, the vitamin D preparation Ostelin became Glaxo’s first pharmaceutical product following the obtaining of rights to a process of extracting vitamin D from fish-liver oil.

Alison Smith

28th Apr 202028th Apr 2020

Our Baby for Mothers and Nurses

The Royal College of Gynaecologists heritage Collections Blog shows details of one of the period babycare manuals for mothers: Our Baby for Mothers and Nurses

The book itself can also be seen in it’s entirety here in the Wellcome Collection: https://wellcomecollection.org/works/duazcum5

I’ve had a bit of a delve into the author – she was born Annie Martha Everard in Ramsden, Suffolk in 1861, eldest daughter of a Church of England Vicar, Rev George Everard and his wife, Martha. She married Joseph Langton Hewer, a surgeon in July 1886.
Annie’s entries in the Nursing Registers show that she trained at the Workhouse Infirmary in Manchester in 1881-2. And her entry in the Central Midwives Board Register shows that she was first registered in Nov 1904 (when Registration first started) & indicates that she qualified by virtue of having passed the London Obstetric Society examination in Oct 1883.
She published ‘Antiseptics – a handbook for nurses’ in 1888.
Her continued entries in the Nursing & Midwives registers show that she kept her registrations up. But did she continue to practice?
She died in 1940 in Kent and her husband Joseph in 1945.
Their son, Christopher Langton Hewer became an anaesthetist – his case is in the Wellcome Collection and can be viewed here: https://wellcomecollection.org/works/tzf9jqg5

Liz Palmer

20th Apr 2020

Infant Mortality Rates Birmingham 1913-24

We’ve become accustomed to hearing from the Chief and Deputy Officers of Health for England on a regular basis over the last few weeks. But did you know that each local authority also has a Medical Officer of Health (MoH) and that the first one for Birmingham was appointed back in 1872? The Annual Reports of the MoH make fascinating reading. Printed copies of the Birmingham MoH reports (& those of the School’s MoH) can be viewed on request at the Library of Birmingham when it is open, but they can also be found online at the Wellcome Collection http://search.wellcomelibrary.org/ – Simply search for “medical officer of health birmingham” and the year of interest between 1873 and 1973 and lose yourself for a few hours.

David Low, one of our volunteer researchers and an retired paediatrician made extensive use of the MoH reports in his research on the Infant Mortality Rate during our period of study. This is a summary of some of his findings:

Why so much emphasis on Infant Mortality Rate [IMR], deaths under 1 year of age per 1000 live births?

Dr John Robertson Medical officer for Health submitted his report of “Child Welfare in 1913” to the Public Health and Housing Committee in May 1914.

“the extent of Infant mortality in Birmingham…and the amount of permanent damage to young children done by the ignorance and carelessness on the part of parents is still so great …to consider whether something further cannot be done to prevent this unnecessary waste of human life”. In 1913 4257 [33%] of all deaths were in children under 3 and 3070 [23.7%] under 1. He considered that half were preventable, noted that areas of “careful artisans” had an IMR half that of areas of poverty and the resulting inefficiency & carelessness. His ward maps demonstrated the relationship of infant mortality to the gradient of socio-economic deprivation [my words not his], between the Central, Middle and Outer Wards.

He considers that much of the inefficiency of adults has its origin in their own preventable childhood illnesses. This equates with the concerns of the Infant Welfare Movement and its emphasis on physical development and the quality rather than the quantity of the population in an era of declining birth-rate.

He states that the real object of the report is “to suggest further methods of imparting information to adults as to the rearing of young children and to suggest methods of dealing with the health of parents so that a healthy stock may be produced”.

Was he successful?

The yearly MOH reports contain a plethora of statistics. As a retired Consultant Paediatrician, I have recalculated and reinterpreted them to try and answer the question

In 1913 86% of deaths under 1 could be classified as due to either Perinatal causes [38%] or Infection [48%].

Perinatal causes were classified as “largely due to some defect on the part of the mother” and were mainly responsible for deaths in the first week or first month of life; premature birth, congenital malformations and a complex heading of debility, atrophy and marasmus. Marasmus is derived from the Greek, meaning to waste away and is generally applied to the undernourishment of the child.

Despite the expansion of the Maternity and Infant Welfare Centres and their staff, and the increasing emphasis on improving antenatal care, there was no improvement in the IMRs for premature birth and congenital malformations by 1924. However, I think we can attribute the 50% fall in IMR for debility, atrophy and marasmus to the education on feeding in those centres and the referral from them to defined beds in Barnt Green in 1916 and later to Witton Babies Hospital in 1921, where 102 marasmic babies were admitted with “good results”.

These charts show the growth rate of selected babies at Carnegie Institute when specific support measures were put in place to support feeding.

Infant Mortality Rates are composed of the following: Neonatal mortality rate (deaths in the first 4 weeks of life per 1000 live births) which only fell by 13.2% [41 to 34.6], whereas the Post Neonatal Mortality rate (deaths between 4 week and 1 year per 1000 live births) fell by 45.32% [87.9 to 48.06]. This strongly suggests that the majority of the reduction occurred in infectious diseases. The death rate in the 0-5 year child population also fell by 34.8% over this period.

Infectious diseases

Diarrhoea and enteritis

This was the great success story, with deaths under 1 year reduced from 746 [25%] in 1913 to 160[11%] in 1924, and the IMR falling from 31.3 to 8.7. Dr Robertson described this as the “most easily preventable” and that “dirt in various forms is the exciting cause of the disease”. Hot weather, precipitating summer epidemics, was dreaded. Education by Health Visitors and the Maternity and Infant Welfare Centres about hygiene and feeding, especially breast feeding, was the key to this improvement. Handbills such as “Protecting Babies during Hot Weather” in 1914

and “Prevention of Flies” in 1915 were distributed to all houses in the poorest areas.

Public health issued byelaws requiring owners to provide portable galvanised dustbins, and a booklet for stable owners to remove horse dung and weekly emptying of ashbins and ashpits. Robertson also highlighted the lack of storage facilities for food and the dust from street horse dung blowing directly into many living rooms.

Nearby manure was still a problem in 1921 when Witton Babies Hospital had to cover babies with mosquito nets and empty fly traps containing 100-500 flies every 2 hours.

Measles, Whooping Cough, Scarlet Fever and Diphtheria

The burden of these diseases for all children, especially the under 5s, was immense. Between 1914-24 there were 14,383 cases of diphtheria and 89,143 cases of measles reported [underestimate], and 12961 cases of whooping cough between 1916-18. There was no change in incidence. Being highly infectious they were no respecter of class or ward and carried important sequelae for adult life. Mortality remained high, particularly for young children, and 4 or 5 times higher in the inner poorer wards. Between 1916-24 deaths under 5 years from measles were 1441 and from whooping cough 1912. From 1914 Nursing Societies were contracted to supply a visiting nurse for severe cases of measles, and then whooping cough, as expert nursing was felt to be key. Whereas all diphtheria cases were admitted to hospital, there was debate about whether severe cases of measles and whooping cough especially from dirty and poor houses should be admitted to hospital, Capacity and expense were issues and in the case of whooping cough the “high mortality” “would alarm the community” and bring “any hospital into disrepute”.

Scarlet Fever was primarily a mild disease of older children but with important sequelae. There were 23,766 cases between 1916 and 1924, with a case mortality for under 5s reduced from 6% in 1913 to 2.7 % in 1924.

Diphtheria

Dr Robertson’s 1924 report describes advances in the management of this disease. The use of high doses of antitoxin to treat cases early was introduced in Birmingham in the 1890s and this, combined with hospital admission for all cases and skilled nursing, had resulted in case mortality dropping from 29.2% [1890-93] to 14.5% [1913-16] to 8.5% [1920-23], although case mortality for the under 5s was still 17% in 1923. Immunisation of nursing staff working on diphtheria wards introduced in 1921, using a mixture of toxin and antitoxin, meant that meant no nurse had contacted the disease compared to 13 in 1918

In 1924, it was approved that all children between 2 and 5 should be immunised by 3 weekly injections.

Pneumonia and Bronchitis

The IMR remained consistently high fluctuating between 15 and 21 for this collection of respiratory illnesses. In 1924, it was the cause of 661 under 5 deaths, of which 55% were under 1.

Summary

Between 1913 and 1924 there was a very significant reduction in “the waste of human life” to quote Dr Robertson. A 35.6% fall in the infant mortality rate from 129 to 83, a similar decline in children under 5, and these declines were not interrupted by World War 1 or the post war depression. These were reflected in the three ward area categories and compared favourably with the rates of England and Wales and other large towns. In 1924 2128 [19%] of all deaths were in children under 3, 1518 [13.56 %] under 1, and there had been significant reductions in deaths from marasmus and diarrhoeal disease. However, the burden of other childhood infectious diseases remained high.

David C Low